1
|
Yozgat I, Cakır U, Serdar MA, Sahin S, Sezerman OU, Nemutlu E, Baykal AT, Serteser M. Longitudinal non-targeted metabolomic profiling of urine samples for monitoring of kidney transplantation patients. Ren Fail 2024; 46:2300736. [PMID: 38213228 PMCID: PMC10791079 DOI: 10.1080/0886022x.2023.2300736] [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: 08/29/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024] Open
Abstract
The assessment of kidney function within the first year following transplantation is crucial for predicting long-term graft survival. This study aimed to develop a robust and accurate model using metabolite profiles to predict early long-term outcomes in patient groups at the highest risk of early graft loss. A group of 61 kidney transplant recipients underwent thorough monitoring during a one-year follow-up period, which included a one-week hospital stay and follow-up assessments at three and six months. Based on their 12-month follow-up serum creatinine levels: Group 2 had levels exceeding 1.5 mg/dl, while Group 1 had levels below 1.5 mg/dl. Metabolites were detected by mass spectrometer and first pre-processed. Univariate and multivariate statistical analyses were employed to identify significant differences between the two groups. Nineteen metabolites were found to differ significantly in the 1st week, and seventeen metabolites in the 3rd month (adjusted p-value < 0.05, quality control (QC) < 30, a fold change (FC) > 1.1 or a FC < 0.91, Variable Influence on Projection (VIP) > 1). However, no significant differences were observed in the 6th month. These distinctive metabolites mainly belonged to lipid, fatty acid, and amino acid categories. Ten models were constructed using a backward conditional approach, with the best performance seen in model 5 for Group 2 at the 1st-week mark (AUC 0.900) and model 3 at the 3rd-month mark (AUC 0.924). In conclusion, the models developed in the early stages may offer potential benefits in the management of kidney transplant patients.
Collapse
Affiliation(s)
- Ihsan Yozgat
- Department of Medical Biotechnology, Institute of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ulkem Cakır
- Department of Nephrology, Acibadem University School of Medicine, Istanbul, Turkey
| | | | - Sevgi Sahin
- Department of Nephrology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Osman Ugur Sezerman
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Emirhan Nemutlu
- Faculty of Pharmacy, Department of Analytical Chemistry, Hacettepe University, Ankara, Türkiye
| | - Ahmet Tarik Baykal
- Department of Medical Biochemistry, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Mustafa Serteser
- Department of Medical Biochemistry, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| |
Collapse
|
2
|
Jung S, Lee S, Jeon H, Kim MH, Lee JS, Chang SH, Kim HJ, Jang H. Successful management of proteinuria in recurrent immunoglobulin A nephropathy after deceased donor kidney transplantation: A case report. Medicine (Baltimore) 2024; 103:e36990. [PMID: 38241588 PMCID: PMC10798750 DOI: 10.1097/md.0000000000036990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Immunoglobulin A nephropathy (IgAN) is the most common type of primary glomerulonephritis, and recurrent IgAN is common after kidney transplantation (KT). Owing to the differences in various biopsy protocols and follow-ups in each study, the recurrence rate varies from 9.7% to 46%. Although the relapse rates are high, there is no definitive treatment for IgAN recurrence. METHODS We present a case of successful management of proteinuria in recurrent IgAN after deceased donor KT. A 60-year-old man diagnosed with IgAN 20 years prior, who progressed to end-stage renal disease, underwent deceased donor KT 5 years prior and was admitted to our hospital with progressively increasing proteinuria. RESULTS The pathological examination of the kidney biopsy specimen revealed recurrent IgAN. High-dose steroid treatment was initiated, and the patient was discharged while maintaining steroid treatment. However, outpatient follow-up showed that proteinuria did not decrease while steroids were maintained. Therefore, an angiotensin receptor blocker was administered after explaining its benefits to the patient. After the addition of angiotensin receptor blocker, proteinuria continued to decrease. CONCLUSION This case report highlights the importance of using renin-angiotensin system inhibitors with supportive care in cases of suspected of recurrent IgAN after KT. It also emphasizes the need to prescribe renin-angiotensin system inhibitors when steroid therapy is unsuccessful in cases of recurrent IgAN after KT.
Collapse
Affiliation(s)
- Sehyun Jung
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Seunghye Lee
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Hyejin Jeon
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Min Hye Kim
- Department of Pathology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jong Sil Lee
- Department of Pathology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Se-Ho Chang
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Hyun-Jung Kim
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea
| | - Hani Jang
- Division of Nephrology, Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| |
Collapse
|
3
|
Ganesh K, Jayaram JK, Thomas RM, Abraham TT, Kumar JS, Simon SS, Abraham MA. Immunoglobulin A Deposits In Renal Allografts: A Prospective Longitudinal Single-Center Study. Transplant Proc 2024; 56:97-104. [PMID: 38216361 DOI: 10.1016/j.transproceed.2023.11.023] [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: 10/12/2023] [Accepted: 11/26/2023] [Indexed: 01/14/2024]
Abstract
AIMS AND BACKGROUND To describe the prevalence of IgA deposits (IgAD) in renal allografts in a cohort of renal transplant recipients and to analyze their management strategies and histopathology. To assess graft function and proteinuria after 1 year of follow-up. MATERIALS AND METHODS A prospective longitudinal follow-up study was carried out in VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, over a period of 5 years (July 2015 to June 2020). Kidney transplant recipients with allograft biopsies that reported IgAD on immunofluorescence were included in the study. Light microscopy and immunofluorescence studies were performed. Mesangial hypercellularity (M); segmental glomerulosclerosis (S); endocapillary hypercellularity (E); tubular atrophy/interstitial fibrosis (T); crescents (C) (MEST-C) Scoring was done in patients with pathogenic IgAD. Treatment strategies included increased baseline steroid dosage, rituximab administration, and plasma exchange. Clinical details and management strategies were analyzed, and patients were followed up for 1 year after diagnosis. Changes in graft function (S. Creatinine) and proteinuria (Urine Protein/Creatinine ratio) were analyzed. Clinico-pathologic correlation with the MEST-C scores was also done. RESULTS Out of 1036 kidney transplants done in the study period, 760 graft biopsies were performed. Sixty-four cases had post-transplant deposition of IgA (8%). The mean age was 45 ± 11.25SD years. The study had 51 men and 13 women. Induction immunosuppression comprised rabbit antithymocyte globulin in 29 (45%) patients and basiliximab in 35 (54%). Maintenance immunosuppression in all comprised tacrolimus, mycophenolate mofetil, and steroids. There were 2 groups: group A (pathogenic IgAD) and group B (incidental IgAD). Group A had 46 cases (71.9%), out of which 8 had "active" IgA nephropathy (endocapillary proliferation, crescents, and IgA vasculitis), and 38 had "inactive" IgAD. In patients with active deposits, 3 had cellular crescents (18%, 30%, and 23%), all 8 had endocapillary proliferation, and 2 had vasculitis. Group B had 18 cases (28.1%), comprising T cell-mediated rejections (5), antibody-mediated rejection (8), BK virus nephropathy (1), and interstitial fibrosis and tubular atrophy (4). In group A, 22 (47.8%) presented with graft dysfunction, 8 (17.3%) with isolated proteinuria, and 14 (30.4%) patients presented with a combination. Two (4.3%) patients had neither. Fourteen (30.4%) patients presented within 1 month of renal transplant. In patients of group A, at the end of 1 year of treatment, the mean S. Creatinine reduced to 1.68 mg/dL from 1.84 mg/dL, and the mean protein/creatinine ratio reduced from 1.2 to 0.5 (±1.17). In patients with "active IgA" lesions, at the end of 1 year of treatment, the mean S. Creatinine increased slightly to 1.68 mg/dL (±0.47SD) from 1.48 mg/dL (±0.52SD), and the mean protein/creatinine ratio reduced from 2.32 (±1.56SD) to 1.05 (±1.70SD). In the 16 patients with IgAD and proteinuria, at the end of 1 year of treatment, the mean S. Creatinine decreased to 1.41 ± 0.32 SD mg/dL from 1.47±0.37SD mg/dL and the mean protein/creatinine ratio reduced from 1.12 ± 1.31 SD to 0.39±0.75 SD. In the remaining 22 patients with acute tubular injury, at the end of 1 year, the mean S. Creatinine decreased to 1.920.32 SD mg/dL from 2.10.8SD mg/dL, and the mean protein/creatinine ratio reduced from 1.1 ± 1.31 SD to 0.66 ± 1.45 SD. In the MEST-C scoring analysis, all scores were 0 in 20 (43.4%) biopsies, only M1 score in 11 (23.9%) biopsies, only E1 score in 10 biopsies (21.7%), S1 in 13 (28.2%) cases. CONCLUSION Immunoglobulin A deposits occur commonly after transplant; these may represent recurrence, de novo IgA, or donor-derived IgAD. Although commonly benign, some may cause significant graft dysfunction and graft loss. IgAD can present as varying combinations of graft dysfunction and proteinuria. Active IgA pathologies may occur early in the post-transplant course, may have significant graft dysfunction, and need proactive management. There is a correlation between segmental sclerosis and proteinuria. Evidence for the efficacy of Rituximab, plasma exchange, and prolonged courses of steroids is wanting; however, some benefits are possible. Long-term follow-up is essential.
Collapse
Affiliation(s)
- Kartik Ganesh
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India.
| | - J K Jayaram
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| | - Renu Mariam Thomas
- Department of Pathology, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| | - Tena Thomas Abraham
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| | - Jithin S Kumar
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| | - Sunita S Simon
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| | - M Abi Abraham
- Department of Nephrology and Renal Transplantation, VPS Lakeshore Hospital and Research Center, Nettoor, Maradu, Kochi, Kerala, India
| |
Collapse
|
4
|
Rodrigo E, Quintana LF, Vázquez-Sánchez T, Sánchez-Fructuoso A, Buxeda A, Gavela E, Cazorla JM, Cabello S, Beneyto I, López-Oliva MO, Diekmann F, Gómez-Ortega JM, Calvo Romero N, Pérez-Sáez MJ, Sancho A, Mazuecos A, Espí-Reig J, Jiménez C, Hernández D. Tubulo-interstitial inflammation increases the risk of graft loss after the recurrence of IgA nephropathy. Clin Kidney J 2024; 17:sfad259. [PMID: 38186867 PMCID: PMC10768752 DOI: 10.1093/ckj/sfad259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Indexed: 01/09/2024] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is the most frequent recurrent disease in kidney transplant recipients and its recurrence contributes to reducing graft survival. Several variables at the time of recurrence have been associated with a higher risk of graft loss. The presence of clinical or subclinical inflammation has been associated with a higher risk of kidney graft loss, but it is not precisely known how it influences the outcome of patients with recurrent IgAN. Methods We performed a multicentre retrospective study including kidney transplant recipients with biopsy-proven recurrence of IgAN in which Banff and Oxford classification scores were available. 'Tubulo-interstitial inflammation' (TII) was defined when 't' or 'i' were ≥2. The main endpoint was progression to chronic kidney disease (CKD) stage 5 or to death censored-graft loss (CKD5/DCGL). Results A total of 119 kidney transplant recipients with IgAN recurrence were included and 23 of them showed TII. Median follow-up was 102.9 months and 39 (32.8%) patients reached CKD5/DCGL. TII related to a higher risk of CKD5/DCGL (3 years 18.0% vs 45.3%, log-rank 7.588, P = .006). After multivariate analysis, TII remained related to the risk of CKD5/DCGL (HR 2.344, 95% CI 1.119-4.910, P = .024) independently of other histologic and clinical variables. Conclusions In kidney transplant recipients with IgAN recurrence, TII contributes to increasing the risk of CKD5/DCGL independently of previously well-known variables. We suggest adding TII along with the Oxford classification to the clinical variables to identify recurrent IgAN patients at increased risk of graft loss who might benefit from intensified immunosuppression or specific IgAN therapies.
Collapse
Affiliation(s)
- Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, SpainRD21/0005/0010 (ISCIII RICORS2040)
| | - Luis F Quintana
- Nephrology and Renal Transplantation Department, Hospital Clinic, Barcelona, Spain
| | - Teresa Vázquez-Sánchez
- Nephrology Department, Hospital Universitario Regional de Málaga, Málaga, SpainRD21/0005/0010 (ISCIII RICORS2040)
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Clínico San Carlos, Facultad de Medicina Universidad Complutense, Madrid, Spain
| | - Anna Buxeda
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Eva Gavela
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Juan M Cazorla
- Nephrology Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Sheila Cabello
- Nephrology Department, Hospital Universitario Son Espases, Mallorca, Spain
| | - Isabel Beneyto
- Kidney Transplant Unit, Nephrology Department, Hospital Universitario La Fe, Valencia, Spain
| | | | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clinic, Barcelona, Spain
| | - José M Gómez-Ortega
- Pathology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Natividad Calvo Romero
- Nephrology Department, Hospital Clínico San Carlos, Facultad de Medicina Universidad Complutense, Madrid, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | | | - Jordi Espí-Reig
- Kidney Transplant Unit, Nephrology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Carlos Jiménez
- Nephrology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Domingo Hernández
- Nephrology Department, Hospital Universitario Regional de Málaga, Málaga, SpainRD21/0005/0010 (ISCIII RICORS2040)
| |
Collapse
|
5
|
Engen RM, Bartosh SM, Smith JM, Perkins JD, Harshman LA. Risk for graft loss in pediatric and young adult kidney transplant recipients due to recurrent IgA nephropathy. Am J Transplant 2024; 24:37-45. [PMID: 37595842 DOI: 10.1016/j.ajt.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/29/2023] [Accepted: 08/10/2023] [Indexed: 08/20/2023]
Abstract
IgA nephropathy (IgAN) is associated with a risk for posttransplant recurrence. Data are limited regarding graft loss attributable to recurrence of IgAN among pediatric and young adult kidney transplant (KT) recipients. This was a retrospective cohort study of patients aged 0 to 25 years from the Scientific Registry of Transplant Recipients who received a primary KT for IgAN. Patients with history of KT attributable to renal dysplasia were comparators. Outcomes included the incidence of graft loss attributable to IgAN recurrence, association with donor type, and posttransplant corticosteroid use. In total, 5475 transplant recipients were included, with 1915 patients with IgAN and 3560 patients with renal dysplasia. In a multivariable Cox proportional hazards model, IgAN was associated with higher risk of graft loss (adjusted hazard ratio [aHR], 1.35; 95% CI, 1.21-1.50; P < .001) compared with dysplasia. Graft loss was attributed to recurrent disease in 5.4% of patients with IgAN. In a multivariable competing risks analysis, patients with IgAN receiving a parental living-donor kidney were more likely to report graft loss from recurrent disease compared with patients with a nonparental living donor (aHR, 0.52; 95% CI, 0.31-0.91; P = .02). Posttransplant prednisone use was not associated with improved graft survival (P = .2). These data challenge existing paradigms in posttransplant management of patients with IgAN.
Collapse
Affiliation(s)
- Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA.
| | | | - Jodi M Smith
- University of Washington, Seattle, Washington DC, USA
| | - James D Perkins
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington DC, USA
| | | |
Collapse
|
6
|
Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
Collapse
Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
| |
Collapse
|
7
|
Bednarova K, Mjøen G, Hruba P, Modos I, Voska L, Kollar M, Viklicky O. A novel prognostic nomogram predicts premature failure of kidney allografts with IgA nephropathy recurrence. Nephrol Dial Transplant 2023; 38:2627-2636. [PMID: 37202220 PMCID: PMC10660147 DOI: 10.1093/ndt/gfad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Recurrence of immunoglobulin A nephropathy (IgAN) limits graft survival in kidney transplantation. However, predictors of a worse outcome are poorly understood. METHODS Among 442 kidney transplant recipients (KTRs) with IgAN, 83 (18.8%) KTRs exhibited biopsy-proven IgAN recurrence between 1994 and 2020 and were enrolled in the derivation cohort. A multivariable Cox model predicting allograft loss based on clinical data at the biopsy and a web-based nomogram were developed. The nomogram was externally validated using an independent cohort (n = 67). RESULTS Patient age <43 years {hazard ratio [HR] 2.20 [95% confidence interval (CI) 1.41-3.43], P < .001}, female gender [HR 1.72 (95% CI 1.07-2.76), P = .026] and retransplantation status [HR 1.98 (95% CI 1.13-3.36), P = .016] were identified as independent risk factors for IgAN recurrence. Patient age <43 years [HR 2.77 (95% CI 1.17-6.56), P = .02], proteinuria >1 g/24 hours [HR 3.12 (95% CI 1.40-6.91), P = .005] and C4d positivity [HR 2.93 (95% CI 1.26-6.83), P = .013] were found to be associated with graft loss in patients with IgAN recurrence. A nomogram predicting graft loss was constructed based on clinical and histological variables, with a C statistic of 0.736 for the derivation cohort and 0.807 for the external validation cohort. CONCLUSIONS The established nomogram identified patients with recurrent IgAN at risk for premature graft loss with good predictive performance.
Collapse
Affiliation(s)
- Kamila Bednarova
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- 1st Medical Faculty, Charles University, Prague, Czech Republic
| | - Geir Mjøen
- Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Istvan Modos
- Department of Informatics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ludek Voska
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marek Kollar
- Clinical and Transplant Pathology Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
8
|
Sani A, Movalled K, Kamanaj A, Hassannezhad S, Hosseinifard H, Rashidi Y, Ghojazadeh M, Niknafs B, Zununi Vahed S, Ardalan M. Interventions for decreasing the risk of recurrent IgA nephropathy: A systematic review and meta-analysis. Transpl Immunol 2023; 80:101878. [PMID: 37348769 DOI: 10.1016/j.trim.2023.101878] [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: 08/21/2022] [Revised: 03/28/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
Recurrent IgA nephropathy (rIgAN) is an important cause of kidney allograft loss. Till now, no proven strategies have been confirmed to prevent/decrease the rIgAN. Here, a systematic review and meta-analysis were performed on the available interventions impacting rIgAN. PubMed, Embase, Web of sciences, ProQuest, and Cochrane library databases along with Google Scholar were searched for articles evaluating the rIgAN after kidney transplantation (up to 23 February 2023). The main inclusion criteria were kidney transplantation because of primary IgAN and articles studying the rate of the rIgAN based on different therapeutic interventions to find their effects on the disease recurrence. Based on our criteria, 11 papers were included in this systematic review, two of which pleased the criteria for the meta-analysis. Meta-analysis showed that the risk of the rIgAN in the steroid-free group was 3.33 times more than that of the steroid-receiving group (Pooled Hazard Ratio = 3.33, 95% CI 0.60 to18.33, Z-value = 1.38, p-value = 0.16). Steroid-free therapy increases the risk of rIgAN in kidney transplant recipients with primary IgAN. High-quality trials with large sample sizes studies are needed to confirm the impact of the steroids on decreasing the rate of the rIgAN.
Collapse
Affiliation(s)
- Anis Sani
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kobra Movalled
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Kamanaj
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sina Hassannezhad
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Hosseinifard
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yasin Rashidi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bahram Niknafs
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Zununi Vahed
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mohammadreza Ardalan
- Kidney Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
9
|
Kawabe M, Yamamoto I. Current Status and Perspectives on Recurrent IgA Nephropathy after Kidney Transplantation. Nephron Clin Pract 2023; 147 Suppl 1:9-13. [PMID: 36966530 DOI: 10.1159/000530341] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/21/2023] [Indexed: 06/18/2023] Open
Abstract
IgA nephropathy (IgAN) is the most common form of glomerulonephritis worldwide. IgAN progresses to end-stage kidney disease in 20-40% of patients within 20 years of diagnosis. Kidney transplantation is the most effective option for patients with end-stage kidney disease caused by IgAN, but recurrence can occur in the transplanted kidney. The IgAN recurrence rate varies from 1% to 10% per year and varies according to the follow-up period, diagnostic modality, and biopsy criteria. Of note, studies based on protocol biopsies have reported a higher incidence of recurrence, which also occurred earlier after transplantation. In addition, recent data show that recurrence of IgAN is a more significant cause of allograft failure than previously believed. Little is known about the pathophysiology of IgAN recurrence, but several potential biomarkers have been investigated. Among them, galactose-deficient IgA1 (Gd-IgA1), IgG anti-Gd-IgA1 antibodies, and soluble CD89 could play a pivotal role in disease activity. This review aims to describe the current status of recurrent IgAN, including the incidence, clinical characteristics, risk factors, and future perspectives, with a focus on the available therapeutic approaches.
Collapse
Affiliation(s)
- Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan,
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
10
|
Prasad GVR, Sahay M, Kit-Chung Ng J. The Role of Registries in Kidney Transplantation Across International Boundaries. Semin Nephrol 2022; 42:151267. [PMID: 36577647 DOI: 10.1016/j.semnephrol.2022.07.001] [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] [Indexed: 12/28/2022]
Abstract
Transplant professionals strive to improve domestic kidney transplantation rates safely, cost efficiently, and ethically, but to increase rates further may wish to allow their recipients and donors to traverse international boundaries. Travel for transplantation presents significant challenges to the practice of transplantation medicine and donor medicine, but can be enhanced if sustainable international registries develop to include low- and low-middle income countries. Robust data collection and sharing across registries, linking pretransplant information to post-transplant information, linking donor to recipient information, increasing living donor transplant activity through paired exchange, and ongoing reporting of results to permit flexibility and adaptability to changing clinical environments, will all serve to enhance kidney transplantation across international boundaries.
Collapse
Affiliation(s)
- G V Ramesh Prasad
- Kidney Transplant Program, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Manisha Sahay
- Department of Nephrology, Osmania General Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - Jack Kit-Chung Ng
- Carol and Richard Yu Peritoneal Dialysis Research Center, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
11
|
Jäger C, Stampf S, Molyneux K, Barratt J, Golshayan D, Hadaya K, Huynh-Do U, Binet FI, Mueller TF, Koller M, Kim MJ. Recurrence of IgA nephropathy after kidney transplantation: experience from the Swiss transplant cohort study. BMC Nephrol 2022; 23:178. [PMID: 35538438 PMCID: PMC9088042 DOI: 10.1186/s12882-022-02802-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Recurrence of IgA nephropathy (IgAN) after kidney transplantation occurs in about 30% of patients. The relevance of recurrence for the long-term graft survival is expected to increase, since graft survival continues to improve. Methods In a nested study within the Swiss Transplant Cohort Study the incidence of IgAN recurrence, predictive factors, graft function and graft and patient survival were evaluated. Serum concentration of total IgA, total IgG, Gd-IgA1 and IgA-IgG immune complex were measured using ELISA-based immunologic assays. Results Between May 2008 and December 2016, 28 women and 133 men received their kidney allograft for end-stage kidney disease due to IgAN in Switzerland. Over a median follow-up time of 7 years after transplantation, 43 out of 161 patients (26.7%) developed an IgAN recurrence, of which six (13.9%) had an allograft failure afterwards and further four patients (9.3%) died. During the same follow-up period, 6 out of 118 patients (5%) each experienced allograft failure or died without prior IgAN recurrence. After 11 years the risk for IgAN recurrence was 27.7% (95%-CI: 20.6–35.3%). Renal function was similar in patients with and without recurrence up to 7 years after transplantation, but worsened thereafter in patients with recurrence (eGFR median (interquartile range) at 8 years: 49 ml/min/1.73m2 (29–68) vs. 60 ml/min/1.73m2 (38–78)). Serum concentration of total IgA, total IgG, Gd-IgA1 and IgA-IgG immune complex within the first year posttransplant showed no significant effect on the recurrence of IgAN. Younger recipients and women had a higher risk of recurrence, but the latter only in the short term. Conclusions Our study showed a recurrence risk of 28% at 11 years after transplantation, which is consistent with previous literature. However, the predictive value of known biomarkers, such as serum Gd-IgA1 and IgA-IgG IC, for IgAN recurrence could not be confirmed. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02802-x.
Collapse
Affiliation(s)
- Cédric Jäger
- Clinic for Nephrology and Dialysis, Cantonal Hospital Basel-Land, Liestal, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation immunology and nephrology, University Hospital Basel, Basel & Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Karen Molyneux
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Déla Golshayan
- Transplantation Center, CHUV University Hospital, Lausanne, Switzerland
| | - Karine Hadaya
- Division of Nephrology, Geneva University Hospital, Geneva, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, University of Bern, Bern, Switzerland
| | - Francoise-Isabelle Binet
- Division of Nephrology/Transplantation Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Michael Koller
- Clinic for Transplantation immunology and nephrology, University Hospital Basel, Basel & Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Min Jeong Kim
- Division of Nephrology, Cantonal Hospital Aarau, Aarau, Switzerland.
| |
Collapse
|
12
|
Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
Collapse
Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
13
|
Zanoni F, Khairallah P, Kiryluk K, Batal I. Glomerular Diseases of the Kidney Allograft: Toward a Precision Medicine Approach. Semin Nephrol 2022; 42:29-43. [PMID: 35618394 PMCID: PMC9139085 DOI: 10.1016/j.semnephrol.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The continual development of potent immunosuppressive regimens has led to a decreased incidence of acute rejection and improvement of short-term kidney allograft survival. In contrast to acute rejection, glomerular diseases of the kidney allograft are being encountered more frequently and are emerging as leading causes of late kidney allograft failure. Although data on the pathogeneses of glomerular diseases in the kidney allograft are sparse, cumulative evidence suggests that post-transplant glomerular diseases may be the result of inherited predispositions and immunologic triggers. Although studying immunologic signals and performing genome-wide association studies are ideal approaches to tackle glomerular diseases in the kidney allograft, such studies are challenging because of the lack of adequately powered cohorts. In this review, we focus on the most commonly encountered recurrent and de novo glomerular diseases in the kidney allograft. We address the important advances made in understanding the immunopathology and genetic susceptibility of glomerular diseases in the native kidney and how to benefit from such knowledge to further our knowledge of post-transplant glomerular diseases. Defining genomic and immune predictors for glomerular diseases in the kidney allograft would support novel donor-recipient matching strategies and development of targeted therapies to ultimately improve long-term kidney allograft survival.
Collapse
Affiliation(s)
- Francesca Zanoni
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Krzysztof Kiryluk
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA,Corresponding Author: Ibrahim Batal MD, Department of Pathology and Cell Biology, Renal Division, Columbia University Irving Medical Center, 630 W 168th street, VC14-238, New York, NY 10032, Phone: 212-305-9669, Fax: 212-342-5380,
| |
Collapse
|
14
|
Kavanagh CR, Zanoni F, Leal R, Jain NG, Stack MN, Vasilescu ER, Serban G, Shaut C, Kamal J, Kudose S, Martinho A, Alves R, Santoriello D, Canetta PA, Cohen D, Radhakrishnan J, Appel GB, Stokes MB, Markowitz GS, D’Agati VD, Kiryluk K, Andeen NK, Batal I. Clinical Predictors and Prognosis of Recurrent IgA Nephropathy in the Kidney Allograft. GLOMERULAR DISEASES 2022; 2:42-53. [PMID: 35450416 PMCID: PMC9017582 DOI: 10.1159/000519834] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Although IgA nephropathy (IgAN) is the most common recurrent glomerulonephritis encountered in the kidney allograft, the clinical and immunogenetic characteristics remain poorly understood. We sought to study determinants and prognosis of recurrent IgAN with special focus on HLA antigens. Materials and Methods Between 2005 and 2019, we identified 282 transplanted patients with failure secondary to IgAN from two North American and one European Medical Centers, including 80 with recurrent IgAN and 202 without recurrence. Prevalence of HLA antigens was compared to external healthy controls of European ancestry (n=15,740). Graft survival was assessed by Kaplan-Meier method and log rank test. Cox proportional hazards were used for multivariable analyses. Results Compared to external controls of European ancestry, kidney transplant recipients of European ancestry with kidney failure secondary to IgAN had higher frequency of HLA-DQ5 (42% vs. 30%, OR=1.68, P=0.002) and lower frequency of HLA-DR15 (15% vs. 28%, OR=0.46, P<0.001) and HLA-DQ6 (32% vs. 45%, OR=0.59, P=0.003); however, the frequency of these HLA antigens were similar in recurrent versus non-recurring IgAN. Younger recipient age at transplantation was an independent predictor of recurrence. HLA-matching was an independent predictor for recurrent IgAN only in recipients of living-related but not deceased or living unrelated transplants. Recurrent IgAN was an independent predictor of allograft failure, along with acute rejection. In patients with recurrent IgAN, serum creatinine at biopsy, degree of proteinuria, and concurrent acute rejection were associated with inferior allograft survival. Discussion/ Conclusion Recurrent IgAN negatively affects allograft survival. Younger recipient age at transplantation is an independent predictor of recurrent IgAN, while the presence of HLA antigens associated with IgAN in the native kidney and HLA-matching in recipients of deceased or living unrelated transplants are not.
Collapse
Affiliation(s)
- Catherine R. Kavanagh
- Pediatric, Nephrology, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Francesca Zanoni
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Rita Leal
- Nephrology department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal,Faculty of Medicine, University of Coimbra, Portugal
| | - Namrata G. Jain
- Pediatric, Nephrology, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Megan Nicole Stack
- Medicine, Nephrology, Oregon Health & Science University, Portland, OR, USA
| | - Elena-Rodica Vasilescu
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Geo Serban
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carley Shaut
- Medicine, Nephrology, Oregon Health & Science University, Portland, OR, USA
| | - Jeanne Kamal
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Satoru Kudose
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - António Martinho
- Centro de Histocompatibilidade do Centro, Instituto Português do Sangue da Transplantação, Coimbra, Portugal
| | - Rui Alves
- Nephrology department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal,Faculty of Medicine, University of Coimbra, Portugal
| | - Dominick Santoriello
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Pietro A Canetta
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - David Cohen
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jai Radhakrishnan
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gerald B. Appel
- Medicine, Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael B. Stokes
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Glen S. Markowitz
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Vivette D. D’Agati
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Nicole K. Andeen
- Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
15
|
Nakamura T, Shirouzu T. Antibody-Mediated Rejection and Recurrent Primary Disease: Two Main Obstacles in Abdominal Kidney, Liver, and Pancreas Transplants. J Clin Med 2021; 10:5417. [PMID: 34830699 PMCID: PMC8619797 DOI: 10.3390/jcm10225417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023] Open
Abstract
The advances in acute phase care have firmly established the practice of organ transplantation in the last several decades. Then, the next issues that loom large in the field of transplantation include antibody-mediated rejection (ABMR) and recurrent primary disease. Acute ABMR is a daunting hurdle in the performance of organ transplantation. The recent progress in desensitization and preoperative monitoring of donor-specific antibodies enables us to increase positive outcomes. However, chronic active ABMR is one of the most significant problems we currently face. On the other hand, recurrent primary disease is problematic for many recipients. Notably, some recipients, unfortunately, lost their vital organs due to this recurrence. Although some progress has been achieved in these two areas, many other factors remain largely obscure. In this review, these two topics will be discussed in light of recent discoveries.
Collapse
Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takayuki Shirouzu
- Molecular Diagnositcs Division, Wakunaga Pharmaceutical Co., Ltd., 13-4 Arakicho, shinjyuku-ku, Tokyo 160-0007, Japan;
| |
Collapse
|
16
|
Adebiyi O, Umukoro P, Sharfuddin A, Taber T, Chen J, Lane KA, Li X, Goggins W, Yaqub MS. Patient and Graft Survival Outcomes During 2 Eras of Immunosuppression Protocols in Kidney Transplantation: Indiana University Retrospective Cohort Experience. Transplant Proc 2021; 53:2841-2852. [PMID: 34774307 DOI: 10.1016/j.transproceed.2021.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression. METHODS We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort. RESULTS No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05). CONCLUSIONS In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.
Collapse
Affiliation(s)
| | - Peter Umukoro
- Indiana University Health Transplant, Indianapolis, Indiana
| | | | - Tim Taber
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Jeanne Chen
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Kathleen A Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
| | | | | |
Collapse
|
17
|
Ng MSY, Charu V, Johnson DW, O'Shaughnessy MM, Mallett AJ. National and international kidney failure registries: characteristics, commonalities, and contrasts. Kidney Int 2021; 101:23-35. [PMID: 34736973 DOI: 10.1016/j.kint.2021.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 12/23/2022]
Abstract
Registries are essential for health infrastructure planning, benchmarking, continuous quality improvement, hypothesis generation, and real-world trials. To date, data from these registries have predominantly been analyzed in isolated "silos," hampering efforts to analyze "big data" at the international level, an approach that provides wide-ranging benefits, including enhanced statistical power, an ability to conduct international comparisons, and greater capacity to study rare diseases. This review serves as a valuable resource to clinicians, researchers, and policymakers, by comprehensively describing kidney failure registries active in 2021, before proposing approaches for inter-registry research under current conditions, as well as solutions to enhance global capacity for data collaboration. We identified 79 kidney-failure registries spanning 77 countries worldwide. International Society of Nephrology exemplar initiatives, including the Global Kidney Health Atlas and Sharing Expertise to support the set-up of Renal Registries (SharE-RR), continue to raise awareness regarding international healthcare disparities and support the development of universal kidney-disease registries. Current barriers to inter-registry collaboration include underrepresentation of lower-income countries, poor syntactic and semantic interoperability, absence of clear consensus guidelines for healthcare data sharing, and limited researcher incentives. This review represents a call to action for international stakeholders to enact systemic change that will harmonize the current fragmented approaches to kidney-failure registry data collection and research.
Collapse
Affiliation(s)
- Monica S Y Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Kidney Health Service, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Faculty of Medicine and Institute for Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia
| | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
| | | | - Andrew J Mallett
- Faculty of Medicine and Institute for Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia; Department of Renal Medicine, Townsville University Hospital, Townsville, Queensland, Australia; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
| |
Collapse
|
18
|
Chancharoenthana W, Leelahavanichkul A, Ariyanon W, Vadcharavivad S, Phumratanaprapin W. Comparative Long-Term Renal Allograft Outcomes of Recurrent Immunoglobulin A with Severe Activity in Kidney Transplant Recipients with and without Rituximab: An Observational Cohort Study. J Clin Med 2021; 10:jcm10173939. [PMID: 34501386 PMCID: PMC8432075 DOI: 10.3390/jcm10173939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 12/17/2022] Open
Abstract
Recurrent IgA nephropathy (IgAN) remains an important cause of allograft loss in renal transplantation. Due to the limited efficacy of corticosteroid in the treatment of recurrent glomerulonephritis, rituximab was used in kidney transplant (KT) recipients with severe recurrent IgAN. A retrospective cohort study was conducted between January 2015 and December 2020. Accordingly, there were 64 KT recipients with biopsy-proven recurrent IgAN with similar baseline characteristics that were treated with the conventional standard therapy alone (controls, n = 43) or together with rituximab (cases, n = 21). All of the recipients had glomerular endocapillary hypercellularity and proteinuria (>1 g/d) with creatinine clearance (CrCl) > 30 mL/min/1.73 m2 and well-controlled blood pressure using renin–angiotensin–aldosterone blockers. The treatment outcomes were renal allograft survival rate, proteinuria, and post-treatment allograft pathology. During 3.8 years of follow-up, the rituximab-based regimen rapidly decreased proteinuria within 12 months after rituximab administration and maintained renal allograft function—the primary endpoint—for approximately 3 years. There were eight recipients in the case group (38%), and none in the control group reached a complete remission (proteinuria < 250 mg/d) at 12 months after treatment. Notably, renal allograft histopathology from patients with rituximab-based regimen showed the less severe endocapillary hypercellularity despite the remaining strong IgA deposition. In conclusion, adjunctive treatment with rituximab potentially demonstrated favorable outcomes for treatment of recurrent severe IgAN post-KT as demonstrated by proteinuria reduction and renal allograft function in our cohort. Further in-depth mechanistic studies with the longer follow-up periods are recommended.
Collapse
Affiliation(s)
- Wiwat Chancharoenthana
- Tropical Nephrology Research Unit, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
- Correspondence: ; Tel.: +66-2256-4132; Fax: +66-2252-5952
| | - Asada Leelahavanichkul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
- Translational Research in Inflammatory and Immunology Research Unit (TRIRU), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Wassawon Ariyanon
- Cardiometabolic Centre, Department of Medicine, Bangkok Nursing Hospital, Bangkok 10500, Thailand;
| | - Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Weerapong Phumratanaprapin
- Tropical Nephrology Research Unit, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
| |
Collapse
|
19
|
Uffing A, Pérez-Saéz MJ, Jouve T, Bugnazet M, Malvezzi P, Muhsin SA, Lafargue MC, Reindl-Schwaighofer R, Morlock A, Oberbauer R, Buxeda A, Burballa C, Pascual J, von Moos S, Seeger H, La Manna G, Comai G, Bini C, Russo LS, Farouk S, Nissaisorakarn P, Patel H, Agrawal N, Mastroianni-Kirsztajn G, Mansur J, Tedesco-Silva H, Ventura CG, Agena F, David-Neto E, Akalin E, Alani O, Mazzali M, Manfro RC, Bauer AC, Wang AX, Cheng XS, Schold JD, Berger SP, Cravedi P, Riella LV. Recurrence of IgA Nephropathy after Kidney Transplantation in Adults. Clin J Am Soc Nephrol 2021; 16:1247-1255. [PMID: 34362788 PMCID: PMC8455056 DOI: 10.2215/cjn.00910121] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES In patients with kidney failure due to IgA nephropathy, IgA deposits can recur in a subsequent kidney transplant. The incidence, effect, and risk factors of IgA nephropathy recurrence is unclear, because most studies have been single center and sample sizes are relatively small. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a multicenter, international, retrospective study to determine the incidence, risk factors, and treatment response of recurrent IgA nephropathy after kidney transplantation. Data were collected from all consecutive patients with biopsy-proven IgA nephropathy transplanted between 2005 and 2015, across 16 "The Post-Transplant Glomerular Disease" study centers in Europe, North America, and South America. RESULTS Out of 504 transplant recipients with IgA nephropathy, recurrent IgA deposits were identified by kidney biopsy in 82 patients; cumulative incidence of recurrence was 23% at 15 years (95% confidence interval, 14 to 34). Multivariable Cox regression revealed a higher risk for recurrence of IgA deposits in patients with a pre-emptive kidney transplant (hazard ratio, 3.45; 95% confidence interval, 1.31 to 9.17) and in patients with preformed donor-specific antibodies (hazard ratio, 2.59; 95% confidence interval, 1.09 to 6.19). After kidney transplantation, development of de novo donor-specific antibodies was associated with subsequent higher risk of recurrence of IgA nephropathy (hazard ratio, 6.65; 95% confidence interval, 3.33 to 13.27). Immunosuppressive regimen was not associated with recurrent IgA nephropathy in multivariable analysis, including steroid use. Graft loss was higher in patients with recurrence of IgA nephropathy compared with patients without (hazard ratio, 3.69; 95% confidence interval, 2.04 to 6.66), resulting in 32% (95% confidence interval, 50 to 82) graft loss at 8 years after diagnosis of recurrence. CONCLUSIONS In our international cohort, cumulative risk of IgA nephropathy recurrence increased after transplant and was associated with a 3.7-fold greater risk of graft loss.
Collapse
Affiliation(s)
- Audrey Uffing
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Division of Nephrology, University of Groningen, Groningen, the Netherlands
| | | | - Thomas Jouve
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Mathilde Bugnazet
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Saif A. Muhsin
- Renal Division, Harvard Medical School, Boston, Massachusetts
| | | | | | - Alina Morlock
- Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Anna Buxeda
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Carla Burballa
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Claudia Bini
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Luis Sanchez Russo
- Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samira Farouk
- Division of Nephrology, Beth Israel Medical Center, Boston, Massachusetts
| | | | - Het Patel
- Division of Nephrology, Beth Israel Medical Center, Boston, Massachusetts
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Medical Center, Boston, Massachusetts
| | | | - Juliana Mansur
- Division of Nephrology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Carlucci Gualberto Ventura
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Agena
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Elias David-Neto
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Enver Akalin
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Bronx, New York
| | - Omar Alani
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Bronx, New York
| | - Marilda Mazzali
- Division of Nephrology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Roberto Ceratti Manfro
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Aileen X. Wang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Xingxing S. Cheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, Ohio
| | - Stefan P. Berger
- Division of Nephrology, University of Groningen, Groningen, the Netherlands
| | - Paolo Cravedi
- Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
20
|
De Souza L, Prunster J, Chan D, Chakera A, Lim WH. Recurrent glomerulonephritis after kidney transplantation: a practical approach. Curr Opin Organ Transplant 2021; 26:360-380. [PMID: 34039882 DOI: 10.1097/mot.0000000000000887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review will provide a practical approach in the assessment of kidney failure patients with primary glomerulonephritides (GN) being considered for kidney transplantation, focusing on high-risk subtypes of immunoglobulin A nephropathy, focal segmental glomerulosclerosis, idiopathic membranous glomerulonephritis and membranoproliferative glomerulonephritis. RECENT FINDINGS Recurrent glomerulonephritis remains one of the most common causes of allograft loss in kidney transplant recipients. Although the epidemiology and clinical outcomes of glomerulonephritis recurrence occurring after kidney transplantation are relatively well-described, the natural course and optimal treatment strategies of recurrent disease in kidney allografts remain poorly defined. With a greater understanding of the pathophysiology and treatment responses of patients with glomerulonephritis affecting the native kidneys, these discoveries have laid the framework for the potential to improve the management of patients with high-risk glomerulonephritis subtypes being considered for kidney transplantation. SUMMARY Advances in the understanding of the underlying immunopathogenesis of primary GN has the potential to offer novel therapeutic options for kidney patients who develop recurrent disease after kidney transplantation. To test the efficacy of novel treatment options in adequately powered clinical trials requires a more detailed understanding of the clinical and histological characteristics of kidney transplant recipients with recurrent glomerulonephritis.
Collapse
Affiliation(s)
- Laura De Souza
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Janelle Prunster
- Department of Renal Medicine, Cairns Hospital, Cairns North, Queensland
| | - Doris Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Rajasekaran A, Julian BA, Rizk DV. IgA Nephropathy: An Interesting Autoimmune Kidney Disease. Am J Med Sci 2021; 361:176-194. [PMID: 33309134 PMCID: PMC8577278 DOI: 10.1016/j.amjms.2020.10.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. It is a leading cause of chronic kidney disease and progresses to end-stage kidney disease in up to 40% of patients about 20 years after diagnosis. Additionally, IgAN is associated with significant mortality. The diagnosis currently necessitates a kidney biopsy, as no biomarker sufficiently specific and sensitive is available to supplant the procedure. Patients display significant heterogeneity in the epidemiology, clinical manifestations, renal progression, and long-term outcomes across diverse racial and ethnic populations. Recent advances in understanding the underlying pathophysiology of the disease have led to the proposal of a four-hit hypothesis supporting an autoimmune process. To date, there is no disease-specific treatment but, with a better understanding of the disease pathogenesis, new therapeutic approaches are currently being tested in clinical trials. In this review, we examine the multiple facets and most recent advances of this interesting disease.
Collapse
Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Bruce A Julian
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Dana V Rizk
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
23
|
Bobart SA, Alexander MP, Bentall A. Recurrent Glomerulonephritis in the Kidney Allograft. Indian J Nephrol 2020; 30:359-369. [PMID: 33840954 PMCID: PMC8023028 DOI: 10.4103/ijn.ijn_193_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/05/2019] [Accepted: 10/30/2019] [Indexed: 01/05/2023] Open
Abstract
Renal transplantation is the preferred form of renal replacement therapy in patients who develop end-stage kidney disease (ESKD). Among the diverse etiologies of ESKD, glomerulonephritis is the third most common cause, behind hypertensive and diabetic kidney disease. Although efforts to prolong graft survival have improved over time with the advent of novel immunosuppression, recurrent glomerulonephritis remains a major threat to renal allograft survival despite concomitant immunosuppression. As a result, clinical expertise, early diagnosis and intervention will help identify recurrent disease and facilitate prompt treatment, thus minimizing graft loss, resulting in improved outcomes. In this review, we highlight the clinicopathologcal characteristics of certain glomerular diseases that recur in the renal allograft.
Collapse
Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
24
|
Kawabe M, Yamamoto I, Yamakawa T, Katsumata H, Isaka N, Katsuma A, Nakada Y, Kobayashi A, Koike K, Ueda H, Tanno Y, Koike Y, Miki J, Yamada H, Kimura T, Ohkido I, Tsuboi N, Yamamoto H, Kojima H, Yokoo T. Association Between Galactose-Deficient IgA1 Derived From the Tonsils and Recurrence of IgA Nephropathy in Patients Who Underwent Kidney Transplantation. Front Immunol 2020; 11:2068. [PMID: 33013875 PMCID: PMC7494805 DOI: 10.3389/fimmu.2020.02068] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/29/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Recurrence of IgA nephropathy (IgAN) in the transplanted kidney is associated with graft survival, but no specific treatment is available. Tonsillectomy (TE) reportedly arrests the progression of IgAN in the native kidney. Thus, we conducted a single-center retrospective cohort study to evaluate the effect of TE prior to IgAN recurrence. Methods: Of the 36 patients with biopsy-proven IgAN who underwent kidney transplantation, 27 were included in this study. Nine patients underwent TE at 1 year after kidney transplantation (group 1), and the remaining 18 did not undergo TE (group 2). Results: The rate of histological IgAN recurrence was significantly lower in group 1 than in group 2 (11.1 vs. 55.6%, log-rank p = 0.046). In addition, half of the recurrent patients in group 2 exhibited active lesions, compared to none in group 1. Serum Gd-IgA1 levels decreased after TE in group 1, whereas they remained stable or increased slightly in group 2. In the recurrent cases, IgA and Gd-IgA1 were found in the germinal center in addition to the mantle zone of tonsils. Finally, mesangial IgA and Gd-IgA1 immunoreactivity was reduced after TE in some cases. Conclusion: Our data suggest that TE at 1 year after kidney transplantation might be associated with the reduced rate of histological IgAN recurrence. TE arrested or reduced serum Gd-IgA1 and mesangial Gd-IgA1 immunoreactivity. Therefore, we generated a hypothesis that serum Gd-IgA1 derived from the tonsils may play a pivotal role in the pathogenesis of IgAN. Based on these findings, we need to conduct verification in a prospective randomized controlled trial.
Collapse
Affiliation(s)
- Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Yamakawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruki Katsumata
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nao Isaka
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ai Katsuma
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuyuki Nakada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akimitsu Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ueda
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Koike
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroki Yamada
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kojima
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
25
|
Infante B, Rossini M, Leo S, Troise D, Netti GS, Ranieri E, Gesualdo L, Castellano G, Stallone G. Recurrent Glomerulonephritis after Renal Transplantation: The Clinical Problem. Int J Mol Sci 2020; 21:ijms21175954. [PMID: 32824988 PMCID: PMC7504691 DOI: 10.3390/ijms21175954] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 12/22/2022] Open
Abstract
Glomerulonephritis (GN) continues to be one of the main causes of end-stage kidney disease (ESKD) with an incidence rating from 10.5% to 38.2%. Therefore, recurrent GN, previously considered to be a minor contributor to graft loss, is the third most common cause of graft failure 10 years after renal transplantation. However, the incidence, pathogenesis, and natural course of recurrences are still not completely understood. This review focuses on the most frequent diseases that recur after renal transplantation, analyzing rate of recurrence, epidemiology and risk factors, pathogenesis and bimolecular mechanisms, clinical presentation, diagnosis, and therapy, taking into consideration the limited data available in the literature. First of all, the risk for recurrence depends on the type of glomerulonephritis. For example, recipient patients with anti-glomerular basement membrane (GBM) disease present recurrence rarely, but often exhibit rapid graft loss. On the other hand, recipient patients with C3 glomerulonephritis present recurrence in more than 50% of cases, although the disease is generally slowly progressive. It should not be forgotten that every condition that can lead to chronic graft dysfunction should be considered in the differential diagnosis of recurrence. Therefore, a complete workup of renal biopsy, including light, immunofluorescence and electron microscopy study, is essential to provide the diagnosis, excluding alternative diagnosis that may require different treatment. We will examine in detail the biomolecular mechanisms of both native and transplanted kidney diseases, monitoring the risk of recurrence and optimizing the available treatment options.
Collapse
Affiliation(s)
- Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Michele Rossini
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Serena Leo
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Dario Troise
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Elena Ranieri
- Clinical Pathology Unit and Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 71122 Foggia, Italy; (M.R.); (G.S.N.); (E.R.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy;
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
- Correspondence: ; Tel.: +39-0881732610; Fax: +39-0881736001
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto Luigi 251, 71122 Foggia, Italy; (B.I.); (S.L.); (D.T.); (G.S.)
| |
Collapse
|
26
|
Infante B, Rossini M, Di Lorenzo A, Coviello N, Giuseppe C, Gesualdo L, Giuseppe G, Stallone G. Recurrence of immunoglobulin A nephropathy after kidney transplantation: a narrative review of the incidence, risk factors, pathophysiology and management of immunosuppressive therapy. Clin Kidney J 2020; 13:758-767. [PMID: 33123355 PMCID: PMC7577761 DOI: 10.1093/ckj/sfaa060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/18/2020] [Indexed: 01/04/2023] Open
Abstract
Glomerulonephritis (GN) is the underlying cause of end-stage renal failure in 30–50% of kidney transplant recipients. It represents the primary cause of end-stage renal disease for 25% of the dialysis population and 45% of the transplant population. For patients with GN requiring renal replacement therapy, kidney transplantation is associated with superior outcomes compared with dialysis. Recurrent GN was previously considered to be a minor contributor to graft loss, but with the prolongation of graft survival, the effect of recurrent disease on graft outcome assumes increasing importance. Thus the extent of recurrence of original kidney disease after kidney transplantation has been underestimated for several reasons. This review aims to provide updated knowledge on one particular recurrent renal disease after kidney transplantation, immunoglobulin A nephropathy (IgAN). IgAN is one of the most common GNs worldwide. The pathogenesis of IgAN is complex and remains incompletely understood. Evidence to date is most supportive of a several hit hypothesis. Biopsy is mandatory not only to diagnose the disease in the native kidney, but also to identify and characterize graft recurrence of IgAN in the kidney graft. The optimal therapy for IgAN recurrence in the renal graft is unknown. Supportive therapy aiming to reduce proteinuria and control hypertension is the mainstream, with corticosteroids and immunosuppressive treatment tailored for certain subgroups of patients experiencing a rapidly progressive course of the disease with active lesions on renal biopsy and considering safety issues related to infectious complications.
Collapse
Affiliation(s)
- Barbara Infante
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Michele Rossini
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Adelaide Di Lorenzo
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Nicola Coviello
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Castellano Giuseppe
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy
| | | | - Giovanni Stallone
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| |
Collapse
|
27
|
Vock DM, Matas AJ. Rapid discontinuation of prednisone in kidney transplant recipients from at-risk subgroups: an OPTN/SRTR analysis. Transpl Int 2019; 33:181-201. [PMID: 31557340 DOI: 10.1111/tri.13530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/30/2019] [Accepted: 09/19/2019] [Indexed: 12/23/2022]
Abstract
Although rapid discontinuation of prednisone (RDP) after kidney transplantation has been successful in low-risk recipients, there is concern about RDP use in recipients at increased risk for rejection or recurrent disease. Using SRTR, we compared outcomes for RDP versus maintenance prednisone-treated recipients for all adult 1st and 2nd transplants (n = 169 479) and the following 1st transplant subgroups: African American (AA); highly sensitized; those with a potentially recurrent disease; and pediatric recipients. For all adult 1st LD and DD transplants, RDP was associated with better patient and graft survival. For all LD subgroups, RDP and maintenance prednisone were associated with similar patient, graft, and death-censored (DC) graft survival. For 1st transplant DD subgroups, RDP was associated with better patient survival in AA, those with potentially recurrent disease, and pediatric recipients; graft survival with RDP was better in AAs. For adult 2nd DD transplants, RDP was associated with worse DC-graft survival. Importantly, for all differences, the effect size was small. With the exception of 2nd DD transplants, RDP protocols can be used without decreasing patient or graft survival for subgroups of 1st DD and LD kidney transplant recipients and for 2nd LD transplant recipients, at increased risk of rejection or recurrent disease.
Collapse
Affiliation(s)
- David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
28
|
Lim WH, Shingde M, Wong G. Recurrent and de novo Glomerulonephritis After Kidney Transplantation. Front Immunol 2019; 10:1944. [PMID: 31475005 PMCID: PMC6702954 DOI: 10.3389/fimmu.2019.01944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) occurring after kidney transplantation remains incompletely understood, including whether there are differences in the outcomes and advances in the treatment options of specific GN subtypes, including those with de novo GN. Consequently, the treatment options and approaches to recurrent disease are largely extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described. Given a greater understanding of the pathogenesis of GN and the development of novel treatment options, it is conceivable that these advances will result in an improved structure in the future management of patients with recurrent or de novo GN. This review focuses on the incidence, genetics, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential disparities between “high risk” disease subtypes of IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis. We will examine in detail the management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence. Given the relative paucity of data of patients with recurrent and de novo GN after kidney transplantation, a global effort in collecting comprehensive in-depth data of patients with recurrent and de novo GN as well as novel trial design to test the efficacy of specific treatment strategy in large scale multicenter randomized controlled trials are essential to address the knowledge deficiency in this disease.
Collapse
Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Meena Shingde
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| |
Collapse
|
29
|
Barbour S, Djurdjev O, Gill JS, Dong JJ, Gill J. A propensity score matched analysis shows no adverse effect of early steroid withdrawal in non-diabetic kidney transplant recipients with and without glomerulonephritis. Kidney Int 2019; 96:460-469. [DOI: 10.1016/j.kint.2019.02.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
|
30
|
Okumi M, Okada D, Unagami K, Kakuta Y, Iizuka J, Takagi T, Shirakawa H, Omoto K, Ishida H, Tanabe K. Higher immunoglobulin A nephropathy recurrence in related-donor kidney transplants: The Japan Academic Consortium of Kidney Transplantation study. Int J Urol 2019; 26:903-909. [PMID: 31328329 DOI: 10.1111/iju.14066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 06/18/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the 10-year biopsy-proven recurrence rates and risk factors for immunoglobulin A nephropathy recurrence in kidney transplant recipients. METHODS We included 299 kidney transplant recipients from 1995 to 2015, who had biopsy-proven underlying immunoglobulin A nephropathy and underwent zero-hour biopsy. The primary end-point was recurrence of immunoglobulin A nephropathy. We compared clinical, treatment and graft failure among those with and without recurrent immunoglobulin A nephropathy. A time-to-recurrence analysis was carried out using the competing risk analysis and time-dependent Cox model. RESULTS Of 299 recipients, 80 had recurrent immunoglobulin A nephropathy (66.3% with clinical biopsy and 33.7% with protocol biopsy, post-transplant biopsy rate: 90.6%). The 10-year recurrence rate was 34.3% (95% confidence interval 27.6-41.1). Related-donor transplantation (hazard ratio 2.28, P = 0.009) and post-transplant increased proteinuria (hazard ratio 1.59, P < 0.001) were identified as potential risk factors for immunoglobulin A nephropathy recurrence. The 10-year rates were 41.5% in related donor recipients and 16.3% in unrelated donor recipients. There was no conclusive evidence that the calcineurin inhibitor, antimetabolites, basiliximab and rituximab reduce immunoglobulin A nephropathy recurrence. Immunoglobulin A nephropathy recurrence was associated with an increased risk of death-censored graft failure (hazard ratio 5.29, 95% confidence interval 1.39-20.17, P = 0.015). However, related donor itself was not associated with an increased risk of graft failure. CONCLUSIONS The present results have clinical implications in that the signs of recurrent immunoglobulin A nephropathy should be evaluated carefully in recipients receiving related-donor transplants. There is a need for further studies related to genetic and/or familial interactions in kidney transplant recipients with immunoglobulin A nephropathy and related donors.
Collapse
Affiliation(s)
- Masayoshi Okumi
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daigo Okada
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Kazuya Omoto
- Department of Urology, Toda Chuo General Hospital, Saitama, Japan
| | - Hideki Ishida
- Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Departments of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | |
Collapse
|
31
|
Moroni G, Belingheri M, Frontini G, Tamborini F, Messa P. Immunoglobulin A Nephropathy. Recurrence After Renal Transplantation. Front Immunol 2019; 10:1332. [PMID: 31275309 PMCID: PMC6593081 DOI: 10.3389/fimmu.2019.01332] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/28/2019] [Indexed: 12/28/2022] Open
Abstract
IgA nephropathy (IgAN) is the most common primary glomerular disease worldwide. The disease generally runs an indolent course but may lead to ESRD in 20-30% of patients in 20 years or more after diagnosis. Patients with IgA nephropathy are ideal candidates for renal transplant because they are generally relatively young and with few comorbidities. Their graft survival is better or comparable to that of controls at 10 years, though few data are available after 10 years of follow-up. Recurrence of the original disease in the graft is a well-known complication of transplant in IgAN and is a significant cause of deterioration of graft function. Recurrent IgAN rarely manifests clinically before 3 years post transplantation. Recurrence rate is estimated to be around 30% with considerable differences among different series. Despite these factors there is no certain recurrence predictor, young age at renal transplant, rapid progression of the original disease and higher levels of circulating galactose-deficient IgA1 and IgA-IgG immune complexes are all associated with a higher rate of recurrence. Which pathogenetic mechanisms are responsible for the progression of the recurrence to graft function deterioration, and what therapy can prevent or slow down the progression of the disease in the graft, are open questions. The aim of this review is to describe the clinical outcome of renal transplantation in IgA patients with attention to the rate and the predictors of recurrence and to discuss the available therapeutic options for the management of recurrence.
Collapse
Affiliation(s)
- Gabriella Moroni
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Frontini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Tamborini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
32
|
Martín‐Penagos L, Benito‐Hernández A, San Segundo D, Sango C, Azueta A, Gómez‐Román J, Fernández‐Fresnedo G, López‐Hoyos M, Ruiz JC, Rodrigo E. A proliferation‐inducing ligand increase precedes IgA nephropathy recurrence in kidney transplant recipients. Clin Transplant 2019; 33:e13502. [DOI: 10.1111/ctr.13502] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Luis Martín‐Penagos
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Adalberto Benito‐Hernández
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - David San Segundo
- Immunology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Cristina Sango
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Ainara Azueta
- Pathology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Javier Gómez‐Román
- Pathology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Gema Fernández‐Fresnedo
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Marcos López‐Hoyos
- Immunology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Juan C. Ruiz
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| | - Emilio Rodrigo
- Nephrology Service University Hospital Marqués de Valdecilla‐IDIVAL, University of Cantabria Santander Spain
| |
Collapse
|
33
|
Sofue T, Suzuki H, Ueda N, Kushida Y, Minamino T. Post-transplant immunoglobulin A deposition and nephropathy in allografts. Nephrology (Carlton) 2018; 23 Suppl 2:4-9. [PMID: 29968406 DOI: 10.1111/nep.13281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/16/2022]
Abstract
Post-transplant immunoglobulin A (IgA) nephropathy (IgAN) in the allograft is the major cause of allograft loss. Using a protocol biopsy, latent mesangial IgA deposition (IgAD) can be detected in the allograft. Latent IgAD is distinguished from IgAN by the absence of urinary abnormalities, although IgA is observed in the mesangium. However, the pathophysiology and most appropriate treatment strategy for latent mesangial IgAD in the allograft remain to be fully determined. Importantly, it is unknown whether all cases of post-transplant asymptomatic IgAD progress to symptomatic IgAN; indeed, IgA deposits disappear in some cases. The differences in allograft prognosis between asymptomatic IgAD and IgAN have also not been determined. Non-invasive methods of diagnosis of IgAD in the allograft using serological and pathological biomarkers are being developed. Possible serum biomarkers include serum galactose-deficient IgA1 (Gd-IgA1), Gd-IgA1-specific IgG and Gd-IgA1-specific IgA, and its immune complexes. Immunofluorescence analysis using Gd-IgA1 monoclonal antibody may provide a pathological biomarker. These serological and pathological biomarkers may be suitable for the characterization of the stage of IgAD. However, there is insufficient information regarding whether serological and pathological biomarkers can predict the progression of asymptomatic IgAD to symptomatic IgAN. We propose that the pathogenesis of IgAN can be defined through the clinical study of IgAD in the allograft using protocol biopsies conducted by nephrologists involved in clinical kidney transplantation.
Collapse
Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobufumi Ueda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshio Kushida
- Department of Diagnostic Pathology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuo Minamino
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| |
Collapse
|
34
|
Agrawal V, Singh A, Kaul A, Verma R, Jain M, Pandey R. Utility of Oxford Classification in Post-Transplant Immunoglobulin A Nephropathy. Transplant Proc 2018; 49:2274-2279. [PMID: 29198660 DOI: 10.1016/j.transproceed.2017.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND With increasing graft survival, post-transplant immunoglobulin A nephropathy (IgAN) has emerged as an important cause of chronic graft dysfunction in renal allograft recipients. We studied the clinico-pathological features of post-transplant IgAN regardless of the primary disease. The aim was to study the usefulness of the Oxford classification in predicting survival. METHODS Indication graft biopsy specimens (n = 915) were received during a 10-year period; 27 biopsy specimens from 22 patients were diagnosed as IgAN. RESULTS Post-transplant IgAN was seen in 2.6% of biopsy specimens. Mean time to occurrence was 71.6 ± 47.6 months (range, 6.8 months to 16 years), occurring most commonly 4 to 8 years after transplant. Associated rejection was present in 4 biopsies; 72.7% (16/22), 91% (20/22), and 31.8% (7/22) presented with rise in serum creatinine, proteinuria, and hematuria, respectively. Four (21%) patients had nephrotic range proteinuria. Mesangial hypercelullarity (M1), endocapillary hypercelullarity (E1), segmental glomerulosclerosis (S1), and tubulo-interstitial fibrosis (T1-2) was present in 36.6%, 22.7%, 54.5%, and 31.8% biopsies, respectively. The most frequent Haas class was III (n = 7; 29.1%), followed by classes IV and I (n = 5; 20.8% each). The 2- and 5-year graft survival rates were 75% and 56%, respectively. High serum creatinine, low estimated glomerular filtration rate, E1 and T lesions, and degree of interstitial inflammation predicted graft survival. Interestingly, percentage (>25%) of segmentally sclerosed glomeruli and not S1 correlated with graft outcome. CONCLUSIONS The Oxford MEST scheme is useful in predicting graft survival in post-transplant IgAN. The degree of interstitial inflammation is also an important feature for determining graft outcomes in post-transplant IgAN.
Collapse
Affiliation(s)
- V Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - A Singh
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - A Kaul
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - R Verma
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - M Jain
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - R Pandey
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
35
|
Kofman T, Oniszczuk J, Lang P, Grimbert P, Audard V. [Current insights about recurrence of glomerular diseases after renal transplantation]. Nephrol Ther 2018; 14:179-188. [PMID: 29706414 DOI: 10.1016/j.nephro.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recurrence of glomerular disease after renal transplantation is a frequent cause of graft loss. Incidence, risk factors and outcome of recurrence are widely due to the underlying glomerular disease. Graft biopsy analysis is required to confirm the definitive diagnosis of recurrence and to start an appropriate therapy that, in some cases, remains challenging to prevent graft failure. Increased use of protocol biopsy and recent advances in our understanding of the pathogenesis of some glomerular diseases with the identification of some relevant biomarkers provide a unique opportunity to initiate kidney-protective therapy at early stages of recurrence on the graft. This review summarizes our current knowledge on the management of many recurrent primary and secondary glomerulonephritis after kidney transplantation.
Collapse
Affiliation(s)
- Tomek Kofman
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Julie Oniszczuk
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Lang
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Grimbert
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Vincent Audard
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
| |
Collapse
|
36
|
Allen PJ, Chadban SJ, Craig JC, Lim WH, Allen RDM, Clayton PA, Teixeira-Pinto A, Wong G. Recurrent glomerulonephritis after kidney transplantation: risk factors and allograft outcomes. Kidney Int 2018; 92:461-469. [PMID: 28601198 DOI: 10.1016/j.kint.2017.03.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/08/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022]
Abstract
Recurrent glomerulonephritis after kidney transplantation is a feared complication because it is unpredictable and may have a negative impact on graft outcomes. To better understand this we collected data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry accumulated over 30 years. The incidence, risk factors, and outcomes of recurrent glomerulonephritis in transplant recipients were determined using adjusted Cox proportional hazard and competing risk modeling. A total of 6,597 recipients with biopsy-proven glomerulonephritis as the primary cause of end-stage kidney disease were followed for 51,871 person-years (median duration 7.7 years). The four most common types of glomerulonephritis were IgA nephropathy in 2501 patients, focal segmental glomerulosclerosis (FSGS) in 1403, membranous in 376, and membranoproliferative (MPGN) nephropathy in 357 patients. Among these four types, recurrence was reported in 479 of 4637 patients, and of these, 212 lost their allograft due to recurrence. Older age at transplantation (adjusted hazard ratio [per year increase] 0.96 [95% confidence interval 0.95 - 0.97]) was associated with a lower risk of recurrence. Significantly, the five-year graft survival was 30% for recipients with recurrent MPGN and 57-59% for recipients with FSGS, IgA, and membranous nephropathy. Transplant recipients with recurrent disease were twice as likely to lose their allografts compared to those without recurrence (adjusted hazard ratio 2.04 [1.81-2.31]). Thus, recurrent glomerulonephritis remains a significant cause of graft loss in transplant recipients.
Collapse
Affiliation(s)
- Penelope J Allen
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia; ANU College of Medicine, Biology and Environment, Australian National University, Canberra, Australian Capital Territory, Australia.
| | - Steve J Chadban
- Transplantation Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Australia and New Zealand Dialysis and Transplant Registry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gardiner Hospital, Perth, Western Australia, Australia
| | - Richard D M Allen
- Transplantation Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; Department of Renal Medicine, Westmead Hospital, New South Wales, Australia
| |
Collapse
|
37
|
Cordeiro Cabral DB, de Sandes-Freitas TV, Medina-Pestana JO, Mastroianni-Kirsztajn G. Clinical Features, Treatment and Prognostic Factors of Post-Transplant Immunoglobulin A Nephropathy. Ann Transplant 2018. [PMID: 29519995 PMCID: PMC6248017 DOI: 10.12659/aot.907167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Initially described as a relatively benign condition, recent studies report graft loss in up to 50% of the patients with post-transplant IgA nephropathy. There is no evidence for the best therapeutic approach, and prognostic factors remain to be elucidated. Material/Methods Single center retrospective analysis of patients >12 years old, with clinically relevant post-transplant IgA nephropathy (proteinuria ≥1.0 g/g and/or graft dysfunction) and ≥6 months follow-up after diagnosis (n=47). Results Living donor transplants represented 85% of cases. Dysmorphic hematuria (100%), blood pressure elevation (95.7%), renal dysfunction (70.2%) and subnephrotic proteinuria (60.6%) predominated at presentation. Using the Oxford Classification, mesangial proliferation was the main histological lesion (91%). Treatment consisted mostly of blockade of the renin angiotensin system (89.4%) and modification of immunosuppression (85.1%), mainly by increasing oral steroids dose (83%), with venous pulse therapy in 63.8% of cases. Partial and complete remission occurred in 48.9% and 17% of cases, respectively. One patient died (sepsis) and 15 patients (31.9%) lost their grafts due to nephropathy. The percentage of decrease in glomerular filtration rate at diagnosis was independently associated with partial remission (HR 0.97, 95% CI 0.94–0.99, p=0.01) and graft loss (HR 1.13, 95% CI 1.06–1.20, p<0.001). Deceased donor (HR 28.04, 95% CI 4.41–178.39, p<0.001) and donor age (HR 1.1, 95% CI 1.04–1.16, p=0.001) were also risk factors for graft loss. Conclusions Despite treatment, most patients with post-transplant IgA nephropathy in this cohort study presented unfavorable outcomes, and graft dysfunction at diagnosis appeared to be the main prognostic marker.
Collapse
Affiliation(s)
| | - Tainá Veras de Sandes-Freitas
- Transplantation Section (Nephrology Division), Federal University of São Paulo (UNIFESP) and Hospital do Rim, São Paulo, SP, Brazil
| | - José Osmar Medina-Pestana
- Transplantation Section (Nephrology Division), Federal University of São Paulo (UNIFESP) and Hospital do Rim, São Paulo, Brazil
| | - Gianna Mastroianni-Kirsztajn
- Glomerulopathies Section (Nephrology Division), Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| |
Collapse
|
38
|
Di Vico MC, Messina M, Fop F, Barreca A, Segoloni GP, Biancone L. Recurrent IgA nephropathy after renal transplantation and steroid withdrawal. Clin Transplant 2018; 32:e13207. [PMID: 29345747 DOI: 10.1111/ctr.13207] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 01/19/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis; the reported recurrence rate of IgAN after renal transplantation is as high as 13%-50%. The impact of immunosuppressive therapy and steroid withdrawal on the risk of recurrence of IgAN is still under debate. We performed a retrospective single-center study, selecting 123 kidney transplants (rtx) in 120 patients, between January 1995 and December 2012, with IgAN on the native kidney. In 51 of 123 transplants, at least one post-transplantation biopsy for clinical indication was performed; in 28 of 51 transplants, IgAN recurrence (IgANr) was demonstrated. This group (G1; N = 28) was compared with a group without IgANr (G2; N = 23). In our study, clinically evident IgANr rate was 54.9% (28/51) on biopsied patients. At discharge, the use of the immunosuppressant drugs (tacrolimus, cyclosporine A, mycophenolate mofetil, azathioprine, mTor inhibitors) was not associated with an increased risk of IgANr (P = NS). At discharge, all patients were steroid treated. Neither the use of tacrolimus, mycophenolate mofetil, nor mTor inhibitors (mTori) at biopsy time were associated with IgANr. However, IgANr was significantly higher in patients who experienced steroid withdrawal at any post-transplantation time (OR 7.7 P = .03). The median time to recurrence after steroid withdrawal was 59 months (min 4.18, max 113.2).
Collapse
Affiliation(s)
- Maria Cristina Di Vico
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Maria Messina
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giuseppe Paolo Segoloni
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Luigi Biancone
- Department of Medical Sciences, Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| |
Collapse
|
39
|
Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. Recurrence of primary glomerulonephritis: Review of the current evidence. World J Transplant 2017; 7:301-316. [PMID: 29312859 PMCID: PMC5743867 DOI: 10.5500/wjt.v7.i6.301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/24/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023] Open
Abstract
In view of the availability of new immunosuppression strategies, the recurrence of allograft glomerulonephritis (GN) are reported to be increasing with time post transplantation. Recent advances in understanding the pathogenesis of the GN recurrent disease provided a better chance to develop new strategies to deal with the GN recurrence. Recurrent GN diseases manifest with a variable course, stubborn behavior, and poor response to therapy. Some types of GN lead to rapid decline of kidney function resulting in a frustrating return to maintenance dialysis. This subgroup of aggressive diseases actually requires intensive efforts to ascertain their pathogenesis so that strategy could be implemented for better allograft survival. Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis after renal transplantation was evaluated using data from various registries, and pathogenesis of individual glomerulonephritis is discussed. The following review is aimed to define current protocols of the recurrent primary glomerulonephritis therapy.
Collapse
Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
| |
Collapse
|
40
|
Snead CM, Crockett SC, Bailey PK. Non-infectious aortitis in an immunosuppressed renal transplant recipient with IgA nephropathy. BMJ Case Rep 2017; 2017:bcr-2017-221136. [PMID: 29054943 DOI: 10.1136/bcr-2017-221136] [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] [Indexed: 11/03/2022] Open
Abstract
A 54-year-old woman presented with atypical chest pain, fever and malaise. She was immunosuppressed with three agents following a living-donor kidney transplant 1 year previously. Her native kidney failure was secondary to biopsy-demonstrated crescentic IgA nephropathy, with systemic involvement. A CT pulmonary angiogram revealed an inflammatory cuff of soft tissue around the descending thoracic aorta suggesting aortitis. Inflammatory markers were elevated. Given her immunosuppression, the patient was screened extensively for infective causes and was empirically commenced on intravenous meropenem. After 72 hours of no clinical or serological response to antibiotic therapy, negative microbiological investigations and worsening inflammation on serial imaging, she was commenced on high-dose methylprednisolone for presumed inflammatory aortitis. Symptoms and inflammatory markers rapidly normalisedand the patient was discharged home on oral prednisolone. A clinical diagnosis of IgA-related aortitis was made. Imaging 3 months later showed complete resolution of the aortitis.
Collapse
|
41
|
Leeaphorn N, Garg N, Khankin EV, Cardarelli F, Pavlakis M. Recurrence of IgA nephropathy after kidney transplantation in steroid continuation versus early steroid-withdrawal regimens: a retrospective analysis of the UNOS/OPTN database. Transpl Int 2017; 31:175-186. [PMID: 28926143 DOI: 10.1111/tri.13075] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/24/2017] [Accepted: 09/14/2017] [Indexed: 11/27/2022]
Abstract
In the past 20 years, there has been an increase in use of steroid-withdrawal regimens in kidney transplantation. However, steroid withdrawal may be associated with an increased risk of recurrent IgA nephropathy (IgAN). Using United Network of (Organ Sharing/Organ Procurement and Transplantation Network) UNOS/OPTN data, we analyzed adult patients with end-stage renal disease (ESRD) due to IgAN who received their first kidney transplant between 2000 and 2014. For the primary outcome, we used a competing risk analysis to compare the cumulative incidence of graft loss due to IgAN recurrence between early steroid-withdrawal (ESW) and steroid continuation groups. The secondary outcomes were patient survival and death-censored graft survival (DCGS). A total of 9690 recipients were included (2831 in ESW group and 6859 in steroid continuation group). In total, 1238 recipients experienced graft loss, of which 191 (15.43%) were due to IgAN recurrence. In multivariable analysis, steroid use was associated with a decreased risk of recurrence (subdistribution hazard ratio 0.666, 95% CI 0.482-0.921; P = 0.014). Patient survival and DCGS were not different between the two groups. In the USA, ESW in transplant for ESRD due to IgAN is associated with a higher risk of graft loss due to disease recurrence. Future prospective studies are warranted to further address which patients with IgAN would benefit from steroid continuation.
Collapse
Affiliation(s)
- Napat Leeaphorn
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Neetika Garg
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eliyahu V Khankin
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Francesca Cardarelli
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Martha Pavlakis
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
42
|
Kim Y, Yeo S, Kang S, Park W, Jin K, Park S, Park U, Kim H, Han S. Long-term Clinical Outcomes of First and Second Kidney Transplantation in Patients With Biopsy-Proven IgA Nephropathy. Transplant Proc 2017; 49:992-996. [DOI: 10.1016/j.transproceed.2017.03.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
43
|
Berthoux F, Suzuki H, Mohey H, Maillard N, Mariat C, Novak J, Julian BA. Prognostic Value of Serum Biomarkers of Autoimmunity for Recurrence of IgA Nephropathy after Kidney Transplantation. J Am Soc Nephrol 2017; 28:1943-1950. [PMID: 28255003 DOI: 10.1681/asn.2016060670] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/20/2016] [Indexed: 11/03/2022] Open
Abstract
A prognostic biomarker for IgA nephropathy (IgAN) recurrence after renal transplant is lacking. We followed 96 consecutive first renal transplant recipients with native kidney IgAN (79 men; 92 deceased donors; mean age =48.1 years) on calcineurin inhibitor-based immunosuppression over 10 years for death, allograft failure, and clinicopathologic recurrence (CPR; clinically evident and biopsy-proven). Using time-dependent Cox regression analysis and receiver operating characteristic curves, we assessed prognostic significance of levels of galactose-deficient IgA1 (Gd-IgA1; autoantigen) and Gd-IgA1-specific IgG and IgA autoantibodies in serum obtained at time of transplant or native-kidney IgAN diagnosis (30 patients only). Overall, 13 patients died, 34 kidneys failed (17 due to CPR), and 34 patients developed CPR after a mean interval of 5.8 years. Compared with healthy controls (n=30), patients had significantly elevated serum Gd-IgA1 levels at diagnosis and transplant, but levels did not associate with any outcome. Patients also had significantly elevated levels of normalized (but not total) serum Gd-IgA1-specific IgG autoantibodies at diagnosis and transplant, and the level at transplant associated with higher risk of CPR (relative risk, 2.68; 95% confidence interval, 1.26 to 5.71; P=0.01; area under the receiver operating characteristic curve, 0.62; 95% confidence interval, 0.51 to 0.74; P=0.05). Normalized Gd-IgA1-specific IgG autoantibody level remained an independent risk factor for CPR in multivariate analysis. Serum Gd-IgA1-specific IgA autoantibody level did not change between diagnosis and transplant or predict outcome. This study emphasizes post-transplant prognostic value of normalized serum IgG antiglycan autoantibody level in patients with IgAN.
Collapse
Affiliation(s)
- Francois Berthoux
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France;
| | - Hitoshi Suzuki
- Division of Nephrology, Department of Internal Medicine, Juntendo University, Tokyo, Japan
| | - Hesham Mohey
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France
| | - Nicolas Maillard
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Equipe d'Accueil 3064, Saint-Etienne, France; and Departments of
| | - Christophe Mariat
- Department of Nephrology, Dialysis, and Renal Transplantation, University North Hospital, Saint Etienne, France.,Microbiology and
| | | | - Bruce A Julian
- Microbiology and.,Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
44
|
Lionaki S, Panagiotellis K, Melexopoulou C, Boletis JN. The clinical course of IgA nephropathy after kidney transplantation and its management. Transplant Rev (Orlando) 2017; 31:106-114. [PMID: 28209246 DOI: 10.1016/j.trre.2017.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/07/2016] [Accepted: 01/26/2017] [Indexed: 01/06/2023]
Abstract
Immunoglobulin (Ig) A nephropathy is one of the most common primary glomerulonephritides worldwide causing end stage renal disease in up to 20-40% of affected patients, nearly two decades post diagnosis. Kidney transplantation is the treatment of choice for patients with renal failure, secondary to glomerular diseases. However, IgA nephropathy has a strong tendency to recur in the graft, and although initially thought to be a benign condition, several reports of graft loss, due to recurrent IgA nephropathy, there have been over the last three decades. Overall graft survival has been significantly improved in kidney transplantation, as a result of reduced incidence of acute rejection, as more potent and more specific immunosuppressive agents are now available in clinical practice. Thus, the rates of IgA nephropathy and other glomerulonephritides recurrence are expected to increase, since graft survival has been improved. However, the reported incidence of IgA nephropathy recurrence in the graft varies substantially across centers, as a consequence of different levels of interest, diverse biopsy policies and differing durations of follow up, of the published studies. Notably, recurrence rates of patients receiving graft biopsies by clinical indication only, ranges from 13% to 50% with graft loss being between 1.3% and 16%. The aim of this review is to underline important pathogenetic insights of IgA nephropathy, describe the clinical course of the disease after kidney transplantation, with emphasis on the incidence of recurrence and the associated risk factors, and finally provide all available options for its management in transplant recipients.
Collapse
Affiliation(s)
- Sophia Lionaki
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece.
| | - Konstantinos Panagiotellis
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Christine Melexopoulou
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - John N Boletis
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| |
Collapse
|
45
|
Avasare RS, Rosenstiel PE, Zaky ZS, Tsapepas DS, Appel GB, Markowitz GS, Bomback AS, Canetta PA. Predicting Post-Transplant Recurrence of IgA Nephropathy: The Importance of Crescents. Am J Nephrol 2017; 45:99-106. [PMID: 28056461 DOI: 10.1159/000453081] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/02/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Most studies that have assessed the predictors of recurrent IgA nephropathy (IgAN) in the renal allograft have focused on post-transplant features. Identifying high-risk pre-transplant features of IgAN is useful for counseling patients and may help in tailoring post-transplant immunosuppression. METHODS We investigated the pre-transplant clinical and biopsy features of 62 patients with IgAN who received transplants at Columbia University Medical Center from 2001 to 2012 and compared the characteristics and outcomes of patients with IgAN recurrence to those without recurrence. The primary outcome was time to recurrent IgAN. Secondary outcomes were a composite of doubling of creatinine or allograft failure, and recurrent IgAN as a cause of allograft dysfunction. RESULTS Of the 62 patients, 14 had recurrent IgAN in the allograft. Mean time to recurrence was 2.75 years. Those with recurrent disease were younger at the time of native kidney biopsy (29 vs. 41 years, p < 0.0009). Black race and Hispanic ethnicity composed a higher proportion of the recurrent disease group. On multivariable analysis, significant predictors of recurrent IgAN included age at diagnosis (hazards ratio (HR) 0.911, 95% CI 0.85-0.98), burden of crescents on native biopsy (HR 1.21 per 10% increase in crescents, 95% CI 1.00-1.47) and allograft rejection (HR 3.59, 95% CI 1.10-11.7). CONCLUSIONS Features of native IgAN can help predict the risk of recurrent disease in the renal allograft. In particular, immunologically active disease represented by earlier age of onset and greater burden of crescents on native biopsy is more likely to recur after transplant.
Collapse
Affiliation(s)
- Rupali S Avasare
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, N.Y., USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
47
|
Cosio FG, Cattran DC. Recent advances in our understanding of recurrent primary glomerulonephritis after kidney transplantation. Kidney Int 2016; 91:304-314. [PMID: 27837947 DOI: 10.1016/j.kint.2016.08.030] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023]
Abstract
Recurrent glomerulonephritis (GN) is an important cause of kidney allograft failure, particularly in younger recipients. Approximately 15% of death-censored graft failures are due to recurrent GN, but this incidence is likely an underestimation of the magnitude of the problem. Overall, 18% to 22% of kidney allografts are lost due to GN, either recurrent or presumed de novo. The impact of recurrent GN on allograft survival was recognized from the earliest times in kidney transplantation. However, progress in this area has been slow, and our understanding of GN recurrence remains limited, in large part due to incomplete understanding of the pathogenesis of these diseases. This review focuses on recent advances in our general understanding of the pathophysiology of primary GN, the risk of recurrence in the allograft, and the consequences for kidney graft survival. We focus specifically on the most common forms of primary GN, including focal segmental glomerulosclerosis, membranous nephropathy, membranoproliferative glomerulonephritis, and IgA nephropathy. New understanding of the pathogenesis of these diseases has had direct clinical implications for transplantation, allowing better identification of candidates at high risk of recurrence and earlier diagnoses, and it is expected to lead to significance improvements in the therapy and perhaps even prevention of GN recurrence. More than ever, it is essential to fully characterize GN before transplantation as this information will direct our management posttransplantation. Further, the relative rarity of recurrent GN dictates the need for multicenter studies in order to evaluate, test, and validate recent advances and therapies.
Collapse
Affiliation(s)
- Fernando G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, William von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic, Rochester, Minnesota, USA.
| | - Daniel C Cattran
- Department of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Gopalakrishnan N, Murugananth S, Dineshkumar T, Dhanapriya J, Sakthirajan R, Balasubramaniyan T. Two consecutive recurrences of crescentic immunoglobulin A nephropathy in a renal transplant recipient. Indian J Nephrol 2016; 26:376-378. [PMID: 27795636 PMCID: PMC5015520 DOI: 10.4103/0971-4065.169565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report a 21-year-old male who developed end-stage renal disease, probably due to immunoglobulin A nephropathy (IgAN), received a renal transplant from his mother, which was lost due to crescentic IgAN after 18 months. Two years later, he received a second transplant from a deceased donor. He developed rapidly progressive graft dysfunction 3 years later. Allograft biopsy revealed crescentic IgAN, which was successfully treated with intravenous steroids and cyclophosphamide. Recurrence of IgAN in two successive allografts in one patient has not been reported previously.
Collapse
Affiliation(s)
- N Gopalakrishnan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - S Murugananth
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - T Dineshkumar
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - J Dhanapriya
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - R Sakthirajan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - T Balasubramaniyan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| |
Collapse
|
49
|
|
50
|
Naesens M, Berger S, Biancone L, Crespo M, Djamali A, Hertig A, Öllinger R, Portolés J, Zuckermann A, Pascual J. Lymphocyte-depleting induction and steroid minimization after kidney transplantation: A review. Nefrologia 2016; 36:469-480. [DOI: 10.1016/j.nefro.2016.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/12/2016] [Accepted: 03/28/2016] [Indexed: 12/28/2022] Open
|