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Namba-Hamano T, Hamano T, Doi Y, Hiraoka A, Yonishi H, Sakai S, Takahashi A, Mizui M, Nakazawa S, Yamanaka K, Kakuta Y, Imamura R, Nonomura N, Isaka Y. Clinical Impacts of Allograft Biopsy in Renal Transplant Recipients 10 Years or Longer After Transplantation. Transpl Int 2024; 37:13022. [PMID: 39091613 PMCID: PMC11292417 DOI: 10.3389/ti.2024.13022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/25/2024] [Indexed: 08/04/2024]
Abstract
We aimed to investigate the clinical value of allograft biopsy performed long after renal transplantation. We retrospectively evaluated 99 allograft biopsies in recipients with transplantation vintages of 10 years or longer. Mixed-effects model showed that 1-year estimated glomerular filtration rate (eGFR) slopes after biopsy were significantly greater than those before biopsy [-3.13, -4.42 mL/min/1.73 m2/year, p = 0.01]. Renal biopsy changed the treatment strategies in more than half of the patients. Improvement in eGFR slopes was pronounced in 51 patients with treatment modification based on the biopsy results [2.27 (95% confidence interval (CI): 0.66, 3.89) mL/min/1.73 m2/year], whereas no improvement was observed in those without [0.33 (95% CI: -1.05, 1.71) mL/min/1.73 m2/year, Pinteraction = 0.001]. Among the treatment modifications, enhancement of immunosuppression (IS) led to the most remarkable improvement in eGFR slope. Patients with g scores ≥2 were more likely to receive IS enhancement than those with g scores = 0 [odds ratio; 15.0 (95% CI: 1.65, 136)]. Patients with active glomerulitis (g ≥ 1) without chronicity (cg ≤ 1) showed the most significant improvement in eGFR slope. Given the prevalence of active glomerulitis (g ≥ 1, 21%), which is responsive to treatment even long after transplantation, and the observed magnitude of eGFR slope improvement, renal biopsy can indeed improve allograft prognosis.
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Affiliation(s)
- Tomoko Namba-Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takayuki Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsuko Hiraoka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroaki Yonishi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinsuke Sakai
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Takahashi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayuki Mizui
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shigeaki Nakazawa
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuaki Yamanaka
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoichi Kakuta
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryoichi Imamura
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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Hara S. The Chronology of Renal Allograft Dysfunction: The Pathological Perspectives. Nephron Clin Pract 2023; 147 Suppl 1:67-73. [PMID: 37573772 DOI: 10.1159/000531575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/22/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Antibody-mediated rejection (ABMR), T-cell-mediated rejection (TCMR), BK polyomavirus nephropathy, and calcineurin inhibitor (CNI) toxicity are all common causes of kidney allograft dysfunction that can affect long-term allograft function. SUMMARY The prevalence of various pathological diagnoses changes over time for both indication and protocol biopsies. Active ABMR and CNI toxic tubulopathy are the leading causes of kidney allograft dysfunction in the early posttransplant period. Active ABMR can also manifest as thrombotic microangiopathy. Acute TCMR, borderline for acute TCMR, and BK polyomavirus nephropathy will occur, then comes a causal peak of renal allograft dysfunction, followed by chronic active ABMR. Active ABMR in the late posttransplant period would progress to chronic active ABMR, indicating sequential evolution from the incipient to advanced phase of chronic active ABMR. CNI toxicity also manifests as chronic lesions of arteriolar hyalinosis. Interstitial fibrosis and tubular atrophy are the result of multiple insults and are linked to underlying diseases, particularly in the late posttransplant period. Even with established pathological criteria of the Banff scheme, it can be still challenging to clearly delineate the causes of the allograft dysfunction, especially in the complicated cases. Understanding the chronological causes of renal allograft dysfunctions improves comprehension of renal allograft pathology. KEY MESSAGES Identifying the time-dependent prevalence of renal allograft dysfunction can be a critical and effective approach to pathological diagnosis.
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Affiliation(s)
- Shigeo Hara
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Kobe, Japan
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
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3
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Puri P. Renal Dysfunction After Liver Transplant: Is CNI Nephrotoxicity Overrated. J Clin Exp Hepatol 2023; 13:556-558. [PMID: 37440945 PMCID: PMC10333944 DOI: 10.1016/j.jceh.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, Fortis Escorts Hospital, New Delhi, 110025, India
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4
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Time-Limited Therapy with Belatacept in Kidney Transplant Recipients. J Clin Med 2022; 11:jcm11113229. [PMID: 35683619 PMCID: PMC9181670 DOI: 10.3390/jcm11113229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: In kidney transplant recipients, belatacept is usually pursued indefinitely after it has been started. In the setting of the belatacept shortage and after having evaluated the benefit–risk ratio, we established a strategy consisting of time-limited belatacept therapy/transient calcineurin inhibitor withdrawal, whose results are analyzed in that study. Methods: We considered all the kidney transplant recipients that had been switched from conventional immunosuppressive therapy to belatacept and then for whom belatacept has been withdrawn intentionally. Furthermore, in the first 8 patients, we assessed changes in peripheral blood mononuclear cells (PBMC) transcriptome using RNAseq before and 3 months after belatacept withdrawal. Results: Over the study period, 28 out of 94 patients had belatacept intentionally withdrawn including 25 (89%) switched to low-dose CNI. One rejection due to poor compliance occurred. The eGFR after 12 months remained stable from 48 ± 19 mL.1.73 m−2 to 46 ± 17 mL.1.73 m−2 (p = 0.68). However, patients that resumed belatacept/withdrew CNIs (n = 10) had a trend towards a better eGFR comparing with the others (n = 15): 54 ± 20 mL.1.73 m−2 vs. eGFR 43 ± 16 mL.1.73 m−2, respectively (p = 0.15). The only factor associated with belatacept resumption was when the withdrawal took place during the COVID-19 outbreak. Transcriptome analysis of PBMCs, did not support rebound in alloimmune response. Conclusions: These findings underpin the use of belatacept as part of a time-limited therapy, in selected kidney transplant recipients, possibly as an approach to allow efficient vaccination against SARS-CoV-2.
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5
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Pallet N. Calcineurin inhibitors nephrotoxicity revisited. Am J Transplant 2021; 21:2929-2930. [PMID: 33797862 DOI: 10.1111/ajt.16590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/08/2021] [Accepted: 03/29/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Nicolas Pallet
- INSERM U1138, Centre de Recherche des Cordeliers, Université de Paris, Paris, France.,Service de Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France.,Service de Néphrologie, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
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6
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Miyaoka Y, Okada T, Tomiyama H, Morikawa A, Rinno S, Kato M, Tsujimoto R, Suzuki R, China R, Nagai M, Nagaoka Y, Nagao T, Kanno Y. Structural changes in renal arterioles are closely associated with central hemodynamic parameters in patients with renal disease. Hypertens Res 2021; 44:1113-1121. [PMID: 33859396 DOI: 10.1038/s41440-021-00656-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/10/2021] [Indexed: 02/06/2023]
Abstract
Although central hemodynamics are known to be closely associated with microvascular damage, their association with lesions in the small renal arteries has not yet been fully clarified. We focused on arterioles in renal biopsy specimens and analyzed whether their structural changes were associated with noninvasive vascular function parameters, including central blood pressure (BP) and brachial-ankle pulse wave velocity (baPWV). Forty-four nondiabetic patients (18-50 years of age) with preserved renal function underwent renal biopsy. Wall thickening of arterioles was analyzed based on the media/diameter ratio, and hyalinosis was analyzed by semiquantitative grading. Associations of these indexes (arteriolar wall remodeling grade index (RG index) and arteriolar hyalinosis index (Hyl index)) with clinical variables were analyzed. Multiple regression analyses demonstrated that the RG index was significantly associated with central systolic BP (β = 0.97, p = 0.009), serum cystatin C-based estimated glomerular filtration rate (β = -0.36, p = 0.04), and high-density lipoprotein cholesterol levels (β = -0.37, p = 0.02). The Hyl index was significantly associated with baPWV (β = 0.75, p = 0.01). Our results indicate that aortic stiffness and abnormal central hemodynamics are closely associated with renal microvascular damage in young to middle-aged, nondiabetic kidney disease patients with preserved renal function.
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Affiliation(s)
| | - Tomonari Okada
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | | | - Atsuko Morikawa
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Sho Rinno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Miho Kato
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Ryuji Tsujimoto
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Rie Suzuki
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Rieko China
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Miho Nagai
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Yume Nagaoka
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Toshitaka Nagao
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
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7
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Krejčí K, Tichý T, Bednaříková J, Bartková M, Žamboch K, Orság J, Zadražil J. Nephrotoxicity of calcineurin inhibitors as a risk factor for BK polyomavirus replication after kidney transplantation. J Med Virol 2021; 93:3871-3879. [PMID: 32940913 DOI: 10.1002/jmv.26520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
BK polyomavirus-associated nephropathy (PyVAN) is responsible for a significant percentage of transplanted kidneys prematurely terminating their function. Its occurrence is closely related to the intensity of immunosuppressive therapy. In a group of 161 newly transplanted patients, we prospectively evaluated 457 protocol renal biopsies performed within the first year after transplantation. Using the calcineurin inhibitors (CI) nephrotoxicity score, the incidence of nephrotoxicity was monitored as a manifestation of excessive immunosuppression. Findings were correlated with clinical evidence of active BK polyomavirus (BKPyV) replication and PyVAN. Compared to the normal histology, nephrotoxicity was associated with more frequent BKPyV viremia and viruria (p = .01 and p < .01, respectively) and more common occurrence of PyVAN. The persistence of toxicity in the subsequent biopsy proved to be a negative risk factor of viremia and viruria (p = .03 and p < .01, respectively), independently of the initial BKPyV status. Toxicity could also be used as a predictor of viremia and viruria (p = .04 and p < .01, respectively) even in the absence of viral replication at the time of initial biopsy. The early histological manifestation of CI nephrotoxicity was associated with significant BKPyV reactivation in the risky first posttransplant year.
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Affiliation(s)
- Karel Krejčí
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Tomáš Tichý
- Department of Clinical and Molecular Pathology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jana Bednaříková
- Department of Clinical Biochemistry, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Margita Bartková
- Department of Microbiology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Kamil Žamboch
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Jiří Orság
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Josef Zadražil
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
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8
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An Integrated Transcriptomic Approach to Identify Molecular Markers of Calcineurin Inhibitor Nephrotoxicity in Pediatric Kidney Transplant Recipients. Int J Mol Sci 2021; 22:ijms22115414. [PMID: 34063776 PMCID: PMC8196602 DOI: 10.3390/ijms22115414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 01/29/2023] Open
Abstract
Calcineurin inhibitors are highly efficacious immunosuppressive agents used in pediatric kidney transplantation. However, calcineurin inhibitor nephrotoxicity (CNIT) has been associated with the development of chronic renal allograft dysfunction and decreased graft survival. This study evaluated 37 formalin-fixed paraffin-embedded biopsies from pediatric kidney transplant recipients using gene expression profiling. Normal allograft samples (n = 12) served as negative controls and were compared to biopsies exhibiting CNIT (n = 11). The remaining samples served as positive controls to validate CNIT marker specificity and were characterized by other common causes of graft failure such as acute rejection (n = 7) and interstitial fibrosis/tubular atrophy (n = 7). MiRNA profiles served as the platform for data integration. Oxidative phosphorylation and mitochondrial dysfunction were the top molecular pathways associated with overexpressed genes in CNIT samples. Decreased ATP synthesis was identified as a significant biological function in CNIT, while key toxicology pathways included NRF2-mediated oxidative stress response and increased permeability transition of mitochondria. An integrative analysis demonstrated a panel of 13 significant miRNAs and their 33 CNIT-specific gene targets involved with mitochondrial activity and function. We also identified a candidate panel of miRNAs/genes, which may serve as future molecular markers for CNIT diagnosis as well as potential therapeutic targets.
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9
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Clinical Relevance of Arteriolar C4d Staining in Patients With Chronic-active Antibody-mediated Rejection: A Pilot Study. Transplantation 2020; 104:1085-1094. [PMID: 31517782 DOI: 10.1097/tp.0000000000002957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND C4d staining in peritubular capillaries is a well-established feature of antibody-mediated rejection (AMR). The relevance of C4d staining outside peritubular capillaries is not well understood. We investigated the significance of arteriolar C4d staining in chronic-active AMR (c-aAMR). METHODS All for-cause renal allograft biopsies performed in 2007-2014 at the Erasmus MC and meeting the criteria for suspicious/diagnostic c-aAMR using the Banff Classification 2015 were included. For comparison, renal allograft biopsies from a matched control group and native renal biopsies were analyzed. Arteriolar C4d staining was semiquantitatively scored as negative (0), small deposits in 1 arteriole (1+), small/large deposits in >1 arterioles (2+), or at least extensive deposits in most arterioles (3+). RESULTS Thirty-four of 40 (85%) patients with c-aAMR showed arteriolar C4d staining. A significant difference in arteriolar C4d score was observed between cases and matched controls (P = 0.01) and a trend toward significance difference between cases and native renal biopsies (P = 0.05). In the cases, arteriolar C4d staining was significantly associated with severity of arteriolar hyalinosis (P = 0.004) and ≥2 arteriolar C4d staining was independently associated with better graft outcome in a multivariate Cox regression analysis (hazard ratio, 0.260; 95% CI, 0.104-0.650; P = 0.004). CONCLUSIONS This pilot study shows that arteriolar C4d staining is more common in biopsies with c-aAMR compared with those without and that it is associated with arteriolar hyalinosis and ≥2 arteriolar C4d staining is associated with superior graft outcome. However, larger studies are needed to examine these findings in more detail to asses if arteriolar C4d staining is truly related to antibody-mediated injury.
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10
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Gupta G, Raynaud M, Kumar D, Sanghi P, Chang J, Kimball P, Kang L, Levy M, Sharma A, Bhati CS, Kamal L, Yakubu I, Massey HD, Kidd C, King AL, Halloran PF. Impact of belatacept conversion on kidney transplant function, histology, and gene expression - a single-center study. Transpl Int 2020; 33:1458-1471. [PMID: 32790889 DOI: 10.1111/tri.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
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Affiliation(s)
- Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Dhiren Kumar
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Pooja Sanghi
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
| | - Pam Kimball
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Marlon Levy
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Amit Sharma
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Chandra S Bhati
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Idris Yakubu
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Hugh D Massey
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Chelsea Kidd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Anne L King
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
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11
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Bentata Y. Tacrolimus: 20 years of use in adult kidney transplantation. What we should know about its nephrotoxicity. Artif Organs 2019; 44:140-152. [PMID: 31386765 DOI: 10.1111/aor.13551] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/22/2019] [Accepted: 07/28/2019] [Indexed: 12/21/2022]
Abstract
Tacrolimus (or FK506), a calcineurin inhibitor (CNI) introduced in field of transplantation in the 1990s, is the cornerstone of most immunosuppressive regimens in solid organ transplantation. Its use has revolutionized the future of kidney transplantation (KT) and has been associated with better graft survival, a lower incidence of rejection, and improved drug tolerance with fewer side effects compared to cyclosporine. However, its monitoring remains complicated and underexposure increases the risk of rejection, whereas overexposure increases the risk of adverse effects, primarily nephrotoxicity, neurotoxicity, infections, malignancies, diabetes, and gastrointestinal complaints. Tacrolimus nephrotoxicity can be nonreversible and can lead to kidney graft loss, and its diagnosis is therefore best made with reference to the clinical context and after exclusion of other causes of graft dysfunction. Many factors contribute to its development including: systemic levels of tacrolimus; local renal exposure to tacrolimus; exposure to metabolites of tacrolimus; local susceptibility factors for CNI nephrotoxicity independent of systemic or local tacrolimus levels, such as the age of a kidney; local renal P-glycoprotein, local intestinal and hepatic cytochrome P450A3, and renin angiotensin system activation. The aim of this review is to describe the pharmacokinetics, pharmacodynamics, and mechanisms of acute and chronic tacrolimus nephrotoxicity in adult KT.
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Affiliation(s)
- Yassamine Bentata
- Nephrology and Kidney Transplantation Unit, University Hospital Mohammed VI, University Mohammed First, Oujda, Morocco.,Laboratory of Epidemiology, Clinical Research and Public Health, Medical School, University Mohammed First, Oujda, Morocco
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12
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Furuzawa‐Carballeda J, Uribe‐Uribe NO, Arreola‐Guerra JM, Reyes‐Acevedo R, Vilatobá M, López‐Toledo A, Mondragón‐Salgado G, Chávez‐Fernández R, López‐Verdugo F, Mondragón‐Ramírez G, Alberú J. Tissue talks: immunophenotype of cells infiltrating the graft explains histological findings and the benefits of belatacept at 10 years. Clin Exp Immunol 2019; 197:250-261. [PMID: 30916387 PMCID: PMC6642879 DOI: 10.1111/cei.13296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2019] [Indexed: 12/30/2022] Open
Abstract
Previously, we found a substantial number of regulatory T cells (Tregs ) and fewer senescent and T helper type 17 (Th17) and a decrease in interstitial fibrosis (IF) in 12-month graft biopsies in belatacept versus cyclosporin (CNI)-treated patients [Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial (BENEFIT) study]. Seven years after kidney transplantation (KT), mean estimated glomerular filtration rate (eGFR), patient and graft survival were significantly higher with belatacept versus CNI treatment. The aim of this study was to determine whether the immunophenotypes of inflammatory and regulatory cell subsets infiltrating the grafts contribute to the BENEFIT's clinical findings a decade after KT. Twenty-three adult patients with functionally stable KT treated with belatacept and 10 treated with CNI were enrolled. Biopsies were analyzed by histomorphometry and immunohistochemistry for proliferation, senescence, apoptosis, inflammatory and regulatory cell markers in a blinded manner. Significantly lower percentages of inflammatory/fibrogenic cells [interleukin (IL)-22+ /Th17/Th2/M1 macrophages] were observed in patients treated with belatacept than in patients treated with CNI. By contrast, remarkably higher percentages of regulatory cells [Tregs /Bregs / plasmacytoid dendritic regulatory cells (pDCregs )/M2] were found in belatacept-treated patients than in CNI-treated patients. Conspicuously lower percentages of apoptosis and senescence and higher proliferation markers were found in belatacept-treated patients than in CNI-treated patients. Consequently, there was significantly more inflammation in the microvascular compartments as well as increased tubular atrophy and IF in CNI-treated patients. These findings strongly suggest that regulatory mechanisms, along with the absence of deleterious effects of CNI, contribute to the long-term graft histology and function stability in patients treated with belatacept.
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Affiliation(s)
- J. Furuzawa‐Carballeda
- Department of Immunology and RheumatologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | - N. O. Uribe‐Uribe
- Department of Pathology and Anatomic PathologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | - J. M. Arreola‐Guerra
- Department of TransplantationCentenario Hospital Miguel HidalgoAguascalientesMexico
| | - R. Reyes‐Acevedo
- Department of TransplantationCentenario Hospital Miguel HidalgoAguascalientesMexico
| | - M. Vilatobá
- Department of TransplantationInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | | | | | - R. Chávez‐Fernández
- Department of Immunology and RheumatologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | - F. López‐Verdugo
- Department of Immunology and RheumatologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | | | - J. Alberú
- Department of TransplantationInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
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13
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Jouve T, Noble J, Rostaing L, Malvezzi P. An update on the safety of tacrolimus in kidney transplant recipients, with a focus on tacrolimus minimization. Expert Opin Drug Saf 2019; 18:285-294. [DOI: 10.1080/14740338.2019.1599858] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
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14
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Vasa recta hyalinosis reflects severe arteriolopathy in renal allografts. Clin Exp Nephrol 2019; 23:799-806. [PMID: 30734165 DOI: 10.1007/s10157-019-01709-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
AIM We examined the clinicopathologic significance of hyalinosis in the vasa recta in the medulla of allograft kidney biopsies. METHOD We analyzed biopsy specimens from January 2010 to December 2015, obtained from both the cortex and medulla (including the vasa recta) ≥ 1 year after living-donor kidney transplantation. We excluded biopsy specimens from recipients who had undergone transplantation due to diabetic nephropathy or who had diabetes mellitus after transplantation. We evaluated hyaline arteriolopathy in the cortex using the aah score determined by the Banff 2007 classification. RESULT Among 381 biopsy specimens obtained from 248 transplant recipients ≥ 1 year after transplantation, 36 specimens obtained from 34 recipients showed vasa recta hyalinosis (VRH) in the medulla. Among these 36 specimens, 17 had a score of aah3, 16 had a score of aah2, and 3 had a score of aah1. The incidence of VRH was 1.9% at ≥ 1 to < 4 years, 7.1% at ≥ 4 to < 8 years, and 50.0% at ≥ 8 years. The aah scores and the proportion of hyalinosis in the arteriolar media among all muscular arterioles in the cortex were significantly higher in the VRH group at ≥ 8 years in the late-phase biopsy (P < 0.01). The graft survival was worse in the VRH group (P = 0.024), although there was no significant difference in the graft survival between the ≥ aah2 and < aah2 groups at ≥ 8 years in the late-phase biopsy (P = 0.159). CONCLUSION VRH in renal allografts reflects severe arteriolopathy of the cortex. VRH in the late-phase biopsy may be a prognostic factor for graft survival.
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15
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Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
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16
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Yamakawa T, Kobayashi A, Yamamoto I, Kawaguchi T, Imasawa T, Aoyama H, Akutsu N, Maruyama M, Saigo K, Yokoo T, Kitamura H. Impact of primary diabetic nephropathy on arteriolar hyalinosis lesions in patients following kidney transplantation. Nephrology (Carlton) 2018; 23 Suppl 2:70-75. [PMID: 29968417 DOI: 10.1111/nep.13276] [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] [Accepted: 03/16/2018] [Indexed: 01/03/2023]
Abstract
AIM Arteriolar hyalinosis (AH) is a common lesion in allograft biopsies taken following kidney transplantation. Recent studies have shown that severe AH may predict transplant outcomes and provide information about previous exposure to certain drugs, such as calcineurin inhibitors (CNI). However, the incidence of AH as a direct result of diabetic nephropathy (DN) after kidney transplantation has not been fully evaluated. This study aimed to assess the impact of primary DN on the development of AH lesions in patients who underwent kidney transplantation. METHODS Eighty-three patients who underwent living-donor kidney transplantation between April 2005 and June 2015 were enrolled in this study. A total of 33 patients had DN prior to transplantation. Allograft biopsies were scored according to the Banff classification, and the relationship between the individual histological lesions and clinical baseline data was assessed. RESULTS At early biopsy (3-12 months), there were no differences in the rates of AH lesions between the DN group and the non-DN group (ah ≥ 1: 37% vs. 41.3%, P = 0.719; aah ≥ 1: 14.8% vs. 6.5%; P = 0.453). However, there were significant differences between the groups in biopsies taken more than 3 years after the transplant (ah ≥ 2: 83.3% vs. 36.8%, P = 0.013; aah ≥ 2: 66.7% vs. 21.1%, P = 0.011). Multivariable analysis showed that both the length of time after transplantation and the presence of DN were independent risk factors for ah ≥ 2 (odds ratio [OR]: 2.55, 95% confidence interval [CI]: 1.47-19.54, P = 0.011) and aah ≥ 2 (OR: 7.55, 95% CI: 1.49-38.33, P = 0.015). CONCLUSION This is the first report showing that the presence of primary DN disease contributes to the development of severe AH late in the course after kidney allografts.
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Affiliation(s)
- Takafumi Yamakawa
- Department of Pathology, Chiba-East Hospital, Chiba, Japan.,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
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | | | - Naotake Akutsu
- Department of Surgery, Chiba-East Hospital, Chiba, Japan
| | | | - Kenichi Saigo
- Department of Surgery, Chiba-East Hospital, Chiba, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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17
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Carmona-Escamilla MA, Queipo G, García-Mosqueda LA, García-Covarrubias L, Fonseca-Sánchez MA, Villanueva-Ortega E, Prieto P, Lascurain R. Peripheral Blood Regulatory T Cells Are Diminished in Kidney Transplant Patients With Chronic Allograft Nephropathy. Transplant Proc 2018; 50:444-448. [PMID: 29579824 DOI: 10.1016/j.transproceed.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our aim in this study was to assess peripheral blood CD4+CD25+FOXP3+ regulatory T cell (Treg) levels in patients with chronic allograft nephropathy (CAN) 1 year after kidney transplantation. METHODS Twelve renal transplant patients with an initial onset of CAN, 12 patients with chronic kidney disease (CKD) stage G5 on dialysis, and 13 healthy control individuals were evaluated regarding the proportion of Tregs in their peripheral blood via flow cytometry. RESULTS The renal transplant patients with CAN had a significantly lower proportion of Tregs than the hemodialysis CKD patients and healthy controls (P < .0001). In contrast, the hemodialysis CKD patients showed higher levels of Tregs than the renal transplant patients with CAN and the healthy controls (P < .0001). CONCLUSION The high level of peripheral blood Tregs in the hemodialysis CKD patients suggests a chronic inflammatory state. However, the low frequency of Tregs in the peripheral blood from the renal transplant patients with CAN suggests an unfavorable prognosis for allograft immune tolerance.
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Affiliation(s)
- M A Carmona-Escamilla
- Programa de posgrado en Ciencias Médicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - G Queipo
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México; Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México; Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, México City, México; Departamento de Bioquímica, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, México
| | - L A García-Mosqueda
- Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - L García-Covarrubias
- Programa de posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, México
| | - M A Fonseca-Sánchez
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - E Villanueva-Ortega
- Departamento de Genética Humana, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - P Prieto
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, México City, México
| | - R Lascurain
- Departamento de Bioquímica, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, México; Hospital Nacional Homeopático, Secretaría de Salud, Mexico City, Mexico.
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18
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Oguchi H, Sakai K, Yamaguchi Y, Mikami T, Nemoto T, Ohashi Y, Kawamura T, Muramatsu M, Itabashi Y, Shinoda K, Hyodo Y, Takahashi Y, Kawaguchi Y, Onishi H, Hamasaki Y, Shibuya K, Shishido S. Interlobular hyaline arteriopathy reflects severe arteriolopathy in renal allografts. Nephrology (Carlton) 2018; 23 Suppl 2:58-62. [PMID: 29968404 DOI: 10.1111/nep.13275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 11/30/2022]
Abstract
AIM The present study was performed to examine the clinicopathological significance of hyaline deposits in the smooth muscle of the interlobular artery (interlobular hyaline arteriopathy [IHA]) in renal allografts. METHODS Tissue specimens that included the interlobular artery from biopsies performed from January 2012 to December 2015, as well as specimens from biopsies performed ≥1 year after living kidney transplantation were analyzed. Biopsies of recipients with new-onset diabetes mellitus after transplantation were excluded, as well as those of recipients who had undergone transplantation because of diabetic nephropathy. Arteriolopathy was evaluated using the aah score determined by the Banff 2007 classification. RESULTS In total, 51 specimens with IHA lesions were identified among 381 biopsies obtained from 243 recipients performed ≥1 year after kidney transplantation. Among these 51 biopsies, 18 specimens had a score of aah3, 29 had a score of aah2, and four had a score of aah1. The incidence of IHA lesions was 3.6% at ≥1 to <4 years, 18.5% at ≥4 to <8 years, and 54.1% at ≥8 years. Older kidney grafts exhibited more IHA lesions. Among the biopsy specimens obtained ≥8 years after transplantation, no significant differences in the recipient or donor age, duration after transplantation, or prevalence of hypertension were observed between the IHA and non-IHA groups. The aah scores were significantly higher in the IHA group ≥8 years after transplantation as determined by the mean score test (P < 0.01). CONCLUSION IHA in renal allografts is associated with severe arteriolopathy.
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Affiliation(s)
- Hideyo Oguchi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Tetuo Mikami
- Department of Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Tetsuo Nemoto
- Department of Surgical Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yasushi Ohashi
- Department of Nephrology, Sakura Medical Center, Toho University, Chiba, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Sakura Medical Center, Toho University, Chiba, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kazunobu Shinoda
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yoji Hyodo
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Takahashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yuki Kawaguchi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Hiroka Onishi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kazutoshi Shibuya
- Department of Surgical Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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Yang L, de Winter BCM, van Schaik RHN, Xie RX, Li Y, Andrews LM, Shuker N, Bahmany S, Koch B, van Gelder T, Hesselink DA. CYP3A5 and ABCB1 polymorphisms in living donors do not impact clinical outcome after kidney transplantation. Pharmacogenomics 2018; 19:895-903. [PMID: 29991328 DOI: 10.2217/pgs-2018-0066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: To investigate the association between donor CYP3A5 and ABCB1 polymorphisms and tacrolimus (Tac)-induced nephrotoxicity and renal function in kidney transplant recipients. Methods: The CYP3A5 6986A>G and ABCB1 3435C>T polymorphisms were determined in 237 recipients and donors. Results: There was no significant association between Tac-related nephrotoxicity and donor CYP3A5 and ABCB1 genotype. The donor ABCB1 3435C>T polymorphism was associated with estimated glomerular filtration rate on day 7 and month 1. The combined donor–recipient ABCB1 genotype (3435C>T polymorphism) was significantly related with estimated glomerular filtration rate on day 3 and 7 in univariate analysis. However, these differences were no longer statistically significant in multivariate analysis. Conclusion: A genetic analysis of ABCB1 and CYP3A5 of kidney transplant donors is not helpful to improve renal transplant outcomes.
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Affiliation(s)
- Lin Yang
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, PR China
| | - Brenda CM de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron HN van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rui-Xiang Xie
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, PR China
| | - Yi Li
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, PR China
| | - Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nauras Shuker
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Soma Bahmany
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Nephrology & Transplantation, Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology & Transplantation, Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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20
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Krezdorn N, Tasigiorgos S, Wo L, Lopdrup R, Turk M, Kiwanuka H, Ahmed S, Petruzzo P, Bueno E, Pomahac B, Riella LV. Kidney Dysfunction After Vascularized Composite Allotransplantation. Transplant Direct 2018; 4:e362. [PMID: 30046652 PMCID: PMC6056276 DOI: 10.1097/txd.0000000000000795] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Kidney dysfunction is a major complication after nonrenal solid organ transplants. Transplantation of vascularized composite allografts (VCA) has yielded successful midterm outcomes despite high rates of acute rejection and greater requirements of immunosuppression. Whether this translates in higher risks of kidney complications is unknown. METHODS Ninety-nine recipients of facial or extremity transplants from the Brigham and Women's Hospital (BWH) and the International Registry on Hand and Composite Tissue Transplantation (IR) were reviewed. We assessed immunosuppression, markers of renal function over time, as well as pretransplant and posttransplant renal risk factors. RESULTS Data were obtained from 10 patients from BWH (age at transplant, 42.5 ± 13.8 years) and 89 patients (37.8 ± 11.5 years) from IR. A significant rise in creatinine levels (BWH, P = 0.0195; IR, P < 0.0001) and drop in estimated glomerular filtration rate (GFR) within the first year posttransplant was observed. The BWH and IR patients lost a mean of 22 mL/min GFR and 60 mL/min estimated GFR in the first year, respectively. This decrease occurred mostly in the first 6 months posttransplant (BWH). Pretransplant creatinine levels were not restored in either cohort. A mixed linear model identified multiple variables correlating with renal dysfunction, particularly tacrolimus trough levels. CONCLUSIONS Kidney dysfunction represents a major complication posttransplantation in VCA recipients early on. Strategies to mitigate this complication, such as reducing calcineurin inhibitor trough levels or using alternative immunosuppressive agents, may improve long-term patient outcomes. Standardizing laboratory and data collection of kidney parameters and risk factors in VCA patients will be critical for better understanding of this complication.
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Affiliation(s)
- Nicco Krezdorn
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rachel Lopdrup
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marvee Turk
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Salman Ahmed
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Palmina Petruzzo
- Department of Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Ericka Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonardo V. Riella
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
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21
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Jouve T, Noble J, Rostaing L, Malvezzi P. Tailoring tacrolimus therapy in kidney transplantation. Expert Rev Clin Pharmacol 2018; 11:581-588. [PMID: 29779413 DOI: 10.1080/17512433.2018.1479638] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The prevalence of end-stage renal disease is increasing worldwide. The best treatment is kidney transplantation, although life-long immunosuppressive therapy is then mandatory. Currently, the cornerstone immunosuppressive therapy relies on tacrolimus (Tac), a calcineurin inhibitor that is nephrotoxic but whose exposition can be minimized in a delicate balance. Area covered: We addressed whether, in the setting of kidney transplantation, Tac-based therapy can be tailored to medical needs: to achieve this, we searched for suitable articles in PubMed. Expert commentary: Too over-minimization of Tac, when associated with mycophenolic acid (MPA), may cause the development of de novo donor-specific alloantibodies (DSA). However, Tac minimization, in the context of everolimus-associated therapy instead of MPA, does not increase DSA formation as demonstrated in the TRANSFORM study and, in addition, can prevent cytomegalovirus (CMV) infection/reactivation. Nonetheless, Tac therapy, regardless of its formulation (immediate or extended release) compared to cyclosporine A, increases the risk of posttransplant diabetes mellitus; this increase is not affected by steroid therapy. Tac-based immunosuppression remains the best immunosuppressive therapy in kidney-transplant recipients and can be tailored according to patients' need.
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Affiliation(s)
- Thomas Jouve
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Johan Noble
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Lionel Rostaing
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France.,b Health Department , Grenoble Alpes University , Grenoble , France
| | - Paolo Malvezzi
- a Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation , Centre Hospitalier Universitaire (CHU) Grenoble-Alpes , Grenoble , France
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22
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Snanoudj R, Legendre C. Response to: "Renal allograft histology at 10 years after transplantation in the tacrolimus era: Evidence of pervasive chronic injury". Am J Transplant 2018; 18:1292. [PMID: 29194941 DOI: 10.1111/ajt.14612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Renaud Snanoudj
- Nephrology and Transplantation Department, Foch Hospital, Suresnes, France
| | - Christophe Legendre
- Nephrology and Transplantation Department, Necker Hospital, Paris, France.,University Sorbonne Paris Cité, Paris, France
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23
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Einecke G, Reeve J, Halloran PF. A molecular biopsy test based on arteriolar under-hyalinosis reflects increased probability of rejection related to under-immunosuppression. Am J Transplant 2018; 18:821-831. [PMID: 28985016 DOI: 10.1111/ajt.14532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/15/2017] [Accepted: 09/26/2017] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitor immunosuppressive drugs induce changes such as arteriolar hyalinosis (ah) in kidney transplants, raising the possibility that molecular changes in biopsies related to histologic ah can provide information about drug exposure. We hypothesized that molecular changes associated with less-than-expected hyalinosis might highlight a subpopulation of patients with under-immunosuppression/nonadherence at intermediate times of biopsy posttransplant (TxBx). Using gene expression data from 562 indication biopsies, we developed a molecular classifier for predicting the expected ah lesions (Mah ) at a particular TxBx. Mah -scores increased linearly with log(TxBx), but some biopsies had lower scores than expected for TxBx. The deviation of individual Mah -scores below the predicted regression line of Mah -scores vs TxBx is defined as "low hyalinosis index." Low hyalinosis indices were frequent in biopsies between 3 months and 3 years posttransplant, particularly among biopsies lacking histologic hyalinosis (ah0), and were associated with T cell-mediated rejection and a subset of recent-onset antibody-mediated rejection without glomerular double contours. In patients with medical records available for review, low hyalinosis indices were frequently associated with physician-recorded concerns about nonadherence (suspected or proven). We conclude that the Mah classifier and hyalinosis index identify indication biopsies with rejection for which the possibility of patient nonadherence should be considered.
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Affiliation(s)
- Gunilla Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre Edmonton, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre Edmonton, Edmonton, AB, Canada
- Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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24
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Leal R, Tsapepas D, Crew RJ, Dube GK, Ratner L, Batal I. Pathology of Calcineurin and Mammalian Target of Rapamycin Inhibitors in Kidney Transplantation. Kidney Int Rep 2018; 3:281-290. [PMID: 30276344 PMCID: PMC6161639 DOI: 10.1016/j.ekir.2017.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/15/2017] [Accepted: 10/23/2017] [Indexed: 12/26/2022] Open
Abstract
The recent evolution in immunosuppression therapy has led to significant improvement in short-term kidney allograft outcomes; however, this progress did not translate into similar improvement in long-term graft survival. The latter, at least in part, is likely to be attributed to immunosuppressant side effects. In this review, we focus on the histologic manifestations of calcineurin inhibitor and mammalian target of rapamycin inhibitor toxicity. We discuss the pathologic features attributed to such toxicity and allude to the lack of highly specific pathognomonic lesions. Finally, we highlight the importance of clinicopathologic correlation to achieve a meaningful pathologic interpretation.
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Affiliation(s)
- Rita Leal
- Department of Nephrology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Department of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Demetra Tsapepas
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Russell J. Crew
- Department of Medicine, Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Geoffrey K. Dube
- Department of Medicine, Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Lloyd Ratner
- Department of Surgery, Division of Transplantation, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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25
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Tacrolimus-induced nephrotoxicity in mice is associated with microRNA deregulation. Arch Toxicol 2018; 92:1539-1550. [DOI: 10.1007/s00204-018-2158-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/17/2018] [Indexed: 01/16/2023]
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26
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Stegall MD, Cornell LD, Park WD, Smith BH, Cosio FG. Renal Allograft Histology at 10 Years After Transplantation in the Tacrolimus Era: Evidence of Pervasive Chronic Injury. Am J Transplant 2018; 18:180-188. [PMID: 28710896 DOI: 10.1111/ajt.14431] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 01/25/2023]
Abstract
Improving long-term renal allograft survival remains an important unmet need. To assess the extent of histologic injury at 10 years after transplantation in functioning grafts, we studied 575 consecutive adult solitary renal transplants performed between 2002 and 2005: 77% from living donors and 81% maintained on tacrolimus-based immunosuppression. Ten-year graft survival was 59% and death-censored graft survival was 74%. Surveillance allograft biopsies were assessed at implantation, 5 years, and 10 years from 145 patients who reached 10 years. At implantation, 5% of biopsies had major histologic abnormalities (chronic transplant glomerulopathy score > 0, other chronic Banff scores ≥ 2, global glomerulosclerosis > 20%, or mesangial sclerosis ≥ 2). This increased to 54% at 5 years and 82% at 10 years. Major lesions at 10 years included the following: arteriolar hyalinosis (66%), mesangial sclerosis (67%), and global glomerulosclerosis > 20% (43%), with 48% of grafts having more than one major lesion. Transplant glomerulopathy and moderate-to-severe interstitial fibrosis were uncommon (12% each). Major lesions were associated with increased proteinuria and decreased graft function. In patients with diabetes at baseline, 52% had diabetic nephropathy/mesangial sclerosis at 10 years. We conclude that almost all renal allografts sustain major histologic injury by 10 years after transplantation. Much damage appears nonimmunologic, suggesting that new approaches are needed to decrease late injury.
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Affiliation(s)
- M D Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - L D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - W D Park
- Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - B H Smith
- Department of Biostatics, Mayo Clinic, Rochester, MN
| | - F G Cosio
- Department of Medicine, Mayo Clinic, Rochester, MN
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27
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Liquete E, Williamson SR, Janakiraman N, Venkat KK. Renal Complications of Hematopoietic Stem Cell Transplantation: Report of a Case and Review of the Literature. Indian J Nephrol 2017; 27:468-471. [PMID: 29217887 PMCID: PMC5704415 DOI: 10.4103/ijn.ijn_230_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We report the development of minimal change disease superimposed on preexisting chronic kidney disease secondary to chronic calcineurin inhibitor nephrotoxicity in a hematopoietic stem cell transplantation (HSCT) recipient and review the renal complications of HSCT.
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Affiliation(s)
- E Liquete
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
| | - S R Williamson
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - N Janakiraman
- Division of Hematology/Oncology, Henry Ford Hospital, Detroit, MI, USA
| | - K K Venkat
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
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28
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Van Loon E, Lerut E, Naesens M. The time dependency of renal allograft histology. Transpl Int 2017; 30:1081-1091. [DOI: 10.1111/tri.13042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/05/2017] [Accepted: 08/21/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Elisabet Van Loon
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
| | - Evelyne Lerut
- Translational Cell and Tissue Research; Department of Imaging and Pathology; KU Leuven; Leuven Belgium
- Department of Morphology and Molecular Pathology; University Hospitals Leuven; Leuven Belgium
| | - Maarten Naesens
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
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29
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Pihlstrøm HK, Gatti F, Hammarström C, Eide IA, Kasprzycka M, Wang J, Haraldsen G, Svensson MHS, Midtvedt K, Mjøen G, Dahle DO, Hartmann A, Holdaas H. Early introduction of oral paricalcitol in renal transplant recipients. An open-label randomized study. Transpl Int 2017; 30:827-840. [PMID: 28436117 DOI: 10.1111/tri.12973] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/31/2016] [Accepted: 04/18/2017] [Indexed: 02/01/2023]
Abstract
In stable renal transplant recipients with hyperparathyroidism, previous studies have indicated that vitamin D agonist treatment might have anti-proteinuric effects. Animal studies indicate possible anti-fibrotic and anti-inflammatory effects. Early introduction of paricalcitol in de novo renal transplant recipients might reduce proteinuria and prevent progressive allograft fibrosis. We performed a single-center, prospective, randomized, open-label trial investigating effects of paricalcitol 2 μg/day added to standard care. Participants were included 8 weeks after engraftment and followed for 44 weeks. Primary end point was change in spot urine albumin/creatinine ratio. Exploratory microarray analyses of kidney biopsies at study end investigated potential effects on gene expression. Secondary end points included change in glomerular filtration rate (GFR), pulse wave velocity (PWV), and endothelial function measured by peripheral arterial tonometry as reactive hyperemia index (RHI). Seventy-seven de novo transplanted kidney allograft recipients were included, 37 receiving paricalcitol. Paricalcitol treatment lowered PTH levels (P = 0.01) but did not significantly reduce albuminuria (P = 0.76), change vascular parameters (PWV; P = 0.98, RHI; P = 0.33), or influence GFR (P = 0.57). Allograft gene expression was not influenced. To summarize, in newly transplanted renal allograft recipients, paricalcitol reduced PTH and was well tolerated without negatively affecting kidney function. Paricalcitol did not significantly reduce/prevent albuminuria, improve parameters of vascular health, or influence allograft gene expression.
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Affiliation(s)
- Hege Kampen Pihlstrøm
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Franscesca Gatti
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Clara Hammarström
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Ivar Anders Eide
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Monika Kasprzycka
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Junbai Wang
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Guttorm Haraldsen
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | | | - Karsten Midtvedt
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Geir Mjøen
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dag Olav Dahle
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Hartmann
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hallvard Holdaas
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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30
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Chow KV, Flint SM, Shen A, Landgren A, Finlay M, Murugasu A, Masterson R, Hughes P, Cohney SJ. Histological and Extended Clinical Outcomes After ABO-Incompatible Renal Transplantation Without Splenectomy or Rituximab. Transplantation 2017; 101:1433-1440. [DOI: 10.1097/tp.0000000000001415] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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31
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Jouve T, Rostaing L, Malvezzi P. New formulations of tacrolimus and prevention of acute and chronic rejections in adult kidney-transplant recipients. Expert Opin Drug Saf 2017; 16:845-855. [DOI: 10.1080/14740338.2017.1328051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Faculté de médecine, Université Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Faculté de médecine, Université Grenoble-Alpes, Grenoble, France
- INSERM U563, IFR–BMT, CHU Purpan, Toulouse, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
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32
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Calcineurin Inhibitor Nephrotoxicity Through the Lens of Longitudinal Histology: Comparison of Cyclosporine and Tacrolimus Eras. Transplantation 2017; 100:1723-31. [PMID: 27306529 DOI: 10.1097/tp.0000000000001243] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The contribution of calcineurin inhibitors (CNI) nephrotoxicity to progressive kidney transplant injury remains debated, with little long-term data from the modern tacrolimus (TAC) era using lower doses. METHODS This longitudinal cohort study evaluated histological evidence of CNI nephrotoxicity from normal donor kidneys of successful kidney-pancreas transplant recipients during cyclosporine (CSA) and TAC eras, analyzed by intention-to-treat. RESULTS From 200 patients, 1622 adequate prospective protocol (84.3%) and indication (15.7%) kidney biopsies yielded 8.1 ± 4.1 samples per patient, over 7.4 ± 4.4 years posttransplant. The TAC era demonstrated less rejection and reduced early immune-mediated tubular damage, compared with CSA (P < 0.001). The incidences of acute mild arteriolopathy, striped interstitial fibrosis, glomerular congestion, and tubular microcalcification were all greater with CSA (hazard ratios of 1.70, 9.35, and 3.78, respectively) and maximal within the first posttransplant year, compared with TAC-treated patients (P < 0.001). However, the 1-, 5-, and 10-year prevalence moderate arteriolar hyalinosis was similar: CSA was 5.4%, 38.4%, and 79.1%; and TAC was 4.3%, 33.6% and 77.2%, respectively (P = NS). Morphometric measurement demonstrated lumenal narrowing from inwards collapse of hyalinized arteriolar walls unable to maintain its structural integrity. Severe hyalinosis was calculated to reduce arteriolar blood flow to 20 ± 34% of normal. Severity of arteriolar hyalinosis correlated with contemporaneous glomerulosclerosis (r = 0.44, P < 0.001), and subsequent progression in 1356 sequential biopsy pairs, consistent with glomerular ischemia. CONCLUSIONS Tacrolimus-based therapy appeared superior to the CSA era, with less early CNI nephrotoxicity and fewer rejection episodes, but comparable chronic arteriolar toxicity. Calcineurin inhibitors are imperfect long-term maintenance immunosuppressive agents because of frequent and irreversible chronic toxicity.
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33
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Einecke G, Reeve J, Halloran PF. Hyalinosis Lesions in Renal Transplant Biopsies: Time-Dependent Complexity of Interpretation. Am J Transplant 2017; 17:1346-1357. [PMID: 27873464 DOI: 10.1111/ajt.14136] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/28/2016] [Indexed: 01/25/2023]
Abstract
Because calcineurin inhibitor (CNI) immunosuppressive drugs induce arteriolar hyalinosis (ah) in kidney transplants, ah lesions can potentially provide information about drug exposure. We studied the relationship of ah lesions to findings and outcomes in 562 indication biopsies taken 3 days to 35 years after transplant. Prevalence of ah lesions increased with time of biopsy after transplant (TxBx). The ah scores correlated with arterial intimal thickening and atrophy-fibrosis but, unlike atrophy-fibrosis, did not increase until after 500 days because of a background of ah1 lesions in early biopsies reflecting donor aging. Correlation of ah scores with other features varied with TxBx-in early biopsies, donor age and related changes, and in very late biopsies, chronic antibody-mediated rejection and glomerulonephritis and associated lesions. After correction for TxBx, ah0 in intermediate time periods was associated with increased risk of T cell-mediated rejection and graft loss, probably because of underimmunosuppression and nonadherence. Thus, ah lesions in indication biopsies have multiple associations: donor age (early, usually ah1), chronic glomerular diseases (late, often ah2/3), and adequate exposure to CNIs at intermediate times. This threefold TxBx-dependent complexity must be considered when interpreting indication biopsies: ah lesions often indicate adequate CNI exposure, not toxicity, and unexpected ah0 should increase vigilance for nonadherence and underimmunosuppression.
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Affiliation(s)
- G Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - J Reeve
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - P F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.,Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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34
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Bemelman FJ, de Fijter JW, Kers J, Meyer C, Peters-Sengers H, de Maar EF, van der Pant KAMI, de Vries APJ, Sanders JS, Zwinderman A, Idu MM, Berger S, Reinders MEJ, Krikke C, Bajema IM, van Dijk MC, Ten Berge IJM, Ringers J, Lardy J, Roelen D, Moes DJ, Florquin S, Homan van der Heide JJ. Early Conversion to Prednisolone/Everolimus as an Alternative Weaning Regimen Associates With Beneficial Renal Transplant Histology and Function: The Randomized-Controlled MECANO Trial. Am J Transplant 2017; 17:1020-1030. [PMID: 27639190 DOI: 10.1111/ajt.14048] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/20/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
In renal transplantation, use of calcineurin inhibitors (CNIs) is associated with nephrotoxicity and immunosuppression with malignancies and infections. This trial aimed to minimize CNI exposure and total immunosuppression while maintaining efficacy. We performed a randomized controlled, open-label multicenter trial with early cyclosporine A (CsA) elimination. Patients started with basiliximab, prednisolone (P), mycophenolate sodium (MPS), and CsA. At 6 months, immunosuppression was tapered to P/CsA, P/MPS, or P/everolimus (EVL). Primary outcomes were renal fibrosis and inflammation. Secondary outcomes were estimated glomerular filtration rate (eGFR) and incidence of rejection at 24 months. The P/MPS arm was prematurely halted. The trial continued with P/CsA (N = 89) and P/EVL (N = 96). Interstitial fibrosis and inflammation were significantly decreased and the eGFR was significantly higher in the P/EVL arm. Cumulative rejection rates were 13% (P/EVL) and 19% (P/CsA), (p = 0.08). A post hoc analysis of HLA and donor-specific antibodies at 1 year after transplantation revealed no differences. An individualized immunosuppressive strategy of early CNI elimination to dual therapy with everolimus was associated with decreased allograft fibrosis, preserved allograft function, and good efficacy, but also with more serious adverse events and discontinuation. This can be a valuable alternative regimen in patients suffering from CNI toxicity.
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Affiliation(s)
- F J Bemelman
- Renal Transplant Unit, Amsterdam, the Netherlands
| | - J W de Fijter
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Kers
- Department of Pathology, Academic Medical Centre, Amsterdam, the Netherlands
| | - C Meyer
- University of Amsterdam, Amsterdam, the Netherlands
| | | | - E F de Maar
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | | | - A P J de Vries
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J-S Sanders
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | - A Zwinderman
- Department of Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, the Netherlands
| | - M M Idu
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | - S Berger
- Department of Nephrology, Groningen University Hospital, Groningen, the Netherlands
| | - M E J Reinders
- Renal Transplant Unit, Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Krikke
- Department of Surgery, Groningen University Hospital, Groningen, the Netherlands
| | - I M Bajema
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M C van Dijk
- Department of Pathology, Groningen University Hospital, Groningen, the Netherlands
| | | | - J Ringers
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Lardy
- Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - D Roelen
- Department of Immunogenetics and Transplantation Immunology, Leiden University Medical Centre, Leiden, the Netherlands
| | - D-J Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
| | - S Florquin
- Department of Pathology, Academic Medical Centre, Amsterdam, the Netherlands
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35
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Current status of pediatric renal transplant pathology. Pediatr Nephrol 2017; 32:425-437. [PMID: 27221522 DOI: 10.1007/s00467-016-3381-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 03/07/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
Histopathology is still an indispensable tool for the diagnosis of kidney transplant dysfunction in adult and pediatric patients. This review presents consolidated knowledge, recent developments and future prospects on the biopsy procedure, the diagnostic work-up, classification schemes, the histopathology of rejection, including antibody-mediated forms, ABO-incompatible transplants, protocol biopsies, recurrent and de novo disease, post-transplant lymphoproliferative disorder, infectious complications and drug-induced toxicity. It is acknowledged that frequently the correct diagnosis can only be reached in consensus with clinical, serological, immunogenetical, bacteriological and virological findings. This review shall enhance the understanding of the pediatric nephrologist for the thought processes of nephropathologists with the aim to facilitate teamwork between these specialist groups for the benefit of the patient.
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36
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Riella LV, Djamali A, Pascual J. Chronic allograft injury: Mechanisms and potential treatment targets. Transplant Rev (Orlando) 2017; 31:1-9. [DOI: 10.1016/j.trre.2016.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/05/2023]
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37
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Norero B, Serrano CA, Sanchez-Fueyo A, Duarte I, Torres J, Ocquetau M, Barrera F, Arrese M, Soza A, Benítez C. Conversion to mycophenolate mofetil monotherapy in liver recipients: Calcineurin inhibitor levels are key. Ann Hepatol 2017; 16:94-106. [PMID: 28051798 DOI: 10.5604/16652681.1226820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to mycophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow-up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112.
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Affiliation(s)
- Blanca Norero
- Departamentos de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Carolina A Serrano
- Departamentos de Gastroenterología y Nutrición Pediátrica, Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, MRC Centre for Transplantation, King's College London, London SE5 9RS, United Kingdom
| | - Ignacio Duarte
- Patología y Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Javiera Torres
- Patología y Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Mauricio Ocquetau
- Hemato-Oncología, Escuela de Medicina, Pontificia Universidad Católica de Chile
| | | | - Marco Arrese
- Departamentos de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Alejandro Soza
- Departamentos de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile
| | - Carlos Benítez
- Departamentos de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile
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38
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Flahault A, Anglicheau D, Loriot MA, Thervet E, Pallet N. Clinical impact of the CYP3A5 6986A>G allelic variant on kidney transplantation outcomes. Pharmacogenomics 2016; 18:165-173. [PMID: 27977332 DOI: 10.2217/pgs-2016-0146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM Meta-analyses and large cohort studies provide confusing results on the association of the CYP3A5 6986A>G allelic variant and adverse outcomes in kidney transplant recipients under tacrolimus-based immunosuppressive regimen. A residual effect of CYP3A5 recipient genotype is unexpected if kidney transplant recipients have similar exposure of tacrolimus. PATIENTS & METHODS We have undertaken a population-based, observational study, to investigate all the consecutive patients who received a kidney transplant at the Necker hospital between 2005 and 2015, who were treated with tacrolimus and for whom the CYP3A5 genotype was available. RESULTS & CONCLUSION We analyzed 577 patients followed for up to 5 years. We found a significant association of CYP3A5 genotypes with tacrolimus daily dose as well as with tacrolimus dose-adjusted concentrations. We however found no association of CYP3A5 genotypes with histology scores on biopsies, measured renal function, biopsy-proven acute rejection episodes and graft survival.
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Affiliation(s)
- Adrien Flahault
- College de France, Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis & Cardiovascular Functions, CIRB, INSERM U1050, Paris, France
| | - Dany Anglicheau
- Paris Descartes University, Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France.,Department of Nephrology & Kidney Transplantation, Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Marie-Anne Loriot
- Paris Descartes University, Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France.,Clinical Chemistry Department, Hôpital Européen Georges Pompidou Assistance Publique Hôpitaux de Paris, Paris, France
| | - Eric Thervet
- Paris Descartes University, Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France.,Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Nicolas Pallet
- Paris Descartes University, Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France.,Clinical Chemistry Department, Hôpital Européen Georges Pompidou Assistance Publique Hôpitaux de Paris, Paris, France
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39
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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]
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40
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Steubl D, Block M, Herbst V, Schlumberger W, Nockher A, Angermann S, Schmaderer C, Heemann U, Renders L, Scherberich J. Serum uromodulin predicts graft failure in renal transplant recipients. Biomarkers 2016; 22:171-177. [PMID: 27790922 DOI: 10.1080/1354750x.2016.1252957] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE AND METHODS Test the ability of serum uromodulin concentrations 1-3 months after renal transplantation to predict all-cause mortality (ACM) and graft loss (GL) in 91 patients. RESULTS uromodulin predicted GL equivalently to the other markers studied: the risk for GL was reduced by 0.21 per one standard deviation (SD) increase (cystatin C: hazard ratio [HR] 4.57, creatinine: HR 4.53, blood-urea-nitrogen [BUN]: HR 2.50, estimated glomerular filtration rate [eGFR]: HR 0.10). In receiver-operating-characteristic (ROC) analysis, uromodulin predicted GL with an area-under-the curve of 0.782 at an optimal cut-off (OCO) of 24.0 ng/ml with a sensitivity of 90.0% and a specificity of 70.2%. CONCLUSION Serum uromodulin predicted GL equivalently compared to conventional biomarkers of glomerular filtration.
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Affiliation(s)
- Dominik Steubl
- a Department of Nephrology, Klinikum rechts der Isar , Technische Universität , München , Germany
| | - Matthias Block
- b Research&Development Department, Euroimmun Medizinische Labordiagnostika AG , Lübeck , Germany
| | - Victor Herbst
- b Research&Development Department, Euroimmun Medizinische Labordiagnostika AG , Lübeck , Germany
| | - Wolfgang Schlumberger
- b Research&Development Department, Euroimmun Medizinische Labordiagnostika AG , Lübeck , Germany
| | - Andreas Nockher
- c Institute of Laboratory Medicine and Pathobiochemistry , Universitätsklinikum Marburg, Philipps-Universität Marburg , Marburg , Germany
| | - Susanne Angermann
- a Department of Nephrology, Klinikum rechts der Isar , Technische Universität , München , Germany
| | - Christoph Schmaderer
- a Department of Nephrology, Klinikum rechts der Isar , Technische Universität , München , Germany
| | - Uwe Heemann
- a Department of Nephrology, Klinikum rechts der Isar , Technische Universität , München , Germany
| | - Lutz Renders
- a Department of Nephrology, Klinikum rechts der Isar , Technische Universität , München , Germany
| | - Jürgen Scherberich
- d Department of Nephrology and Clinical Immunology, Klinikum München-Harlaching , Teaching Hospital of the Ludwig-Maximilian-Universität , München , Germany
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Early Kidney Allograft Dysfunction (Threatened Allograft): Comparative Effectiveness of Continuing Versus Discontinuation of Tacrolimus and Use of Sirolimus to Prevent Graft Failure: A Retrospective Patient-Centered Outcome Study. Transplant Direct 2016; 2:e98. [PMID: 27795990 PMCID: PMC5068206 DOI: 10.1097/txd.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 12/02/2022] Open
Abstract
Supplemental digital content is available in the text. Background Due to lack of treatment options for early acute allograft dysfunction in the presence of tubular-interstitial injury without histological features of rejection, kidney transplant recipients are often treated with sirolimus-based therapy to prevent cumulative calcineurin inhibitor exposure and to prevent premature graft failure. Methods We analyzed transplant recipients treated with sirolimus-based (n = 220) compared with continued tacrolimus-based (n = 276) immunosuppression in recipients of early-onset graft dysfunction (threatened allograft) with the use of propensity score-based inverse probability treatment weighted models to balance for potential confounding by indication between 2 nonrandomized groups. Results Weighted odds for death-censored graft failure (odds ratio [OR], 1.20; 95% confidence interval [95% CI], 0.66-2.19, P = 0.555) was similar in the 2 groups, but a trend for increased risk of greater than 50% loss in estimated glomerular filtration rate from baseline in sirolimus group (OR, 1.90; 95% CI, 0.96-3.76; P = 0.067) compared with tacrolimus group. Sirloimus group compared with tacrolimus group had increased risk for death with functioning graft (OR, 2.01; 95% CI, 1.29-3.14; P = 0.002) as well as increased risk of late death (death after graft failure while on dialysis) (OR, 2.39; 95% CI, 1.59-3.59; P < 0.001). Analysis of subgroups based on the absence or presence of T cell–mediated rejection or tubulointerstitial inflammation in the index biopsy, or the use of different types of induction agents, and all subgroups had increased risk of death with functioning graft and late death if exposed to sirolimus-based therapy. Conclusions Use of sirolimus compared with tacrolimus in recipients with early allograft dysfunction during the first year of transplant may not prevent worsening of allograft function and could potentially lead to poor survival along with increased risk of late death.
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Žilinská Z, Dedinská I, Breza J, Laca L. Impact of Trough Levels of Tacrolimus on Kidney Function and Graft Survival in Short and Longer Periods After Renal Transplantation. Transplant Proc 2016; 48:2637-2643. [PMID: 27788794 DOI: 10.1016/j.transproceed.2016.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/22/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Optimizing immunosuppressive treatment in the early posttransplant period is important for achieving long-term graft function and survival. MATERIAL AND METHODS There were 205 renal transplant recipients involved in this study. Patients were divided into groups according to the induction therapy (no induction vs basiliximab/daclizumab vs rabbit antithymocyte globulin), maintenance therapy at the time of transplantation (tacrolimus [TAC] vs cyclosporine), the average trough TAC levels in months 4 to 6 after TO and serum creatinine 5 years after renal transplantation. RESULTS The incidence of acute rejection was significantly higher in cyclosporine than in TAC group of patients (P = .0364). The average TAC levels on elapsed time after transplantation significantly decreased (P < .0001). Five years after renal transplantation, there were higher TAC levels (5.6 ± 0.7 ng/mL) in the group with "zero" low levels than in the group with "zero" high levels (4.6 ± 1.1 ng/mL), which was statistically significant (P < .0001). We did not find any difference in graft and patient survival in posttransplant years 2 to 5 according to TAC levels or the induction treatment. CONCLUSIONS In our study, we have confirmed that better graft function 5 years after transplantation was connected with higher trough tacrolimus levels on elapsed time after renal transplantation.
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Affiliation(s)
- Z Žilinská
- Department of Urology with Kidney Transplant Center, University Hospital Bratislava, Bratislava, Slovak Republic
| | - I Dedinská
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine, Martin, Slovak Republic.
| | - J Breza
- Department of Urology with Kidney Transplant Center, University Hospital Bratislava, Bratislava, Slovak Republic
| | - L Laca
- Surgery Clinic and Transplant Center, University Hospital Martin and Jessenius Faculty of Medicine, Martin, Slovak Republic
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Rose EM, Kennedy SE, Mackie FE. Surveillance biopsies after paediatric kidney transplantation: A review. Pediatr Transplant 2016; 20:748-55. [PMID: 27306873 DOI: 10.1111/petr.12733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 11/28/2022]
Abstract
Kidney transplantation is the most effective means of treating children with end-stage kidney disease, and yet, there continues to be a limited "life span" of transplanted kidneys in paediatric recipients. Early graft monitoring, using the surveillance biopsy, has the potential to extend renal allograft survival in paediatric recipients. The surveillance biopsy provides important and timely information about acute and chronic graft pathology, particularly SCR and calcineurin inhibitor-induced nephrotoxicity, which can subsequently guide management decisions and improve long-term graft survival. The ostensible value of the surveillance biopsy is furthered by the limitations of conventional renal functional studies. However, there is still much debate surrounding the surveillance biopsy in paediatric recipients, particularly in regard to its overall utility, safety and timing. This review discusses the current literature regarding the utility, safety, and potential predictive value of surveillance biopsies for guiding post-transplant management in paediatric renal allograft recipients, as well as the viability of other potentially newer non-invasive strategies for renal allograft monitoring.
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Affiliation(s)
- Edward M Rose
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sean E Kennedy
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Fiona E Mackie
- School of Women's & Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia.,Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
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Vázquez LC, González AP, Juega J, Hernández-Gallego A, López D, Cañas L, Bancu I, Bonet J, Lauzurica R. Nodular Arteriolar Hyalinosis as Histopathologic Hallmark of Calcineurin Inhibitor Nephrotoxicity: Does It Always Have the Same Meaning? Transplant Proc 2016; 47:2357-60. [PMID: 26518926 DOI: 10.1016/j.transproceed.2015.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Nodular arteriolar hyalinosis (NAH) is a typical, although not specific, histological finding of calcineurin inhibitor toxicity (CNIT). The objective of our study was to assess the reason why some patients showing strong NAH in renal graft biopsies who underwent calcineurin inhibitor (CNI) withdrawal presented very poor outcome whereas others improved graft function. MATERIAL AND METHODS We performed 207 renal graft biopsies between January 2011 and May 2014 due to clinical criteria. In 13 patients CNI withdrawal was performed, and the major histopathological finding was severe NAH. The results after this action were analyzed. RESULTS We selected 2 groups: good outcome and poor outcome. Eight patients showed good results including stabilization or improvement of graft function. Five patients presented poor results requiring chronic hemodialysis. C4d staining was negative in all biopsy specimens, and peritubular capillaritis was not observed. To identify potential prognostic markers we retrospectively reviewed biopsy samples looking for minor or nonspecific features, especially inflammation scores both global and on fibrotic areas as per Banff classification. Mean serum creatinine level at time of biopsy and mean arteriolar hyalinosis score did not show significant differences between both groups. In contrast, the poor results group presented a higher mean global inflammation score compared with the good results patients. CONCLUSIONS NAH is not a risk factor for poor renal graft outcome by itself. Other histopathologic findings, usually considered as secondary markers, like the inflammation score, should be considered before deciding CNI withdrawal.
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Affiliation(s)
- L C Vázquez
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain; Nephrology Department of the "Hospital de Clínicas," San Lorenzo, Paraguay
| | - A P González
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain
| | - J Juega
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain
| | - A Hernández-Gallego
- Department of Pathological Anatomy of the University Hospital "Germans Trias I Pujol", Badalona, Spain
| | - D López
- Department of Pathological Anatomy of the University Hospital "Germans Trias I Pujol", Badalona, Spain
| | - L Cañas
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain; REDinREN, Spain
| | - I Bancu
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain
| | - J Bonet
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain; REDinREN, Spain
| | - R Lauzurica
- Nephrology Department of the University Hospital "Germans Trias I Pujol", Badalona, Spain; REDinREN, Spain.
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Tang JT, Andrews LM, van Gelder T, Shi YY, van Schaik RHN, Wang LL, Hesselink DA. Pharmacogenetic aspects of the use of tacrolimus in renal transplantation: recent developments and ethnic considerations. Expert Opin Drug Metab Toxicol 2016; 12:555-65. [PMID: 27010623 DOI: 10.1517/17425255.2016.1170808] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Tacrolimus (Tac) is effective in preventing acute rejection but has considerable toxicity and inter-individual variability in pharmacokinetics and pharmacodynamics. Part of this is explained by polymorphisms in genes encoding Tac-metabolizing enzymes and transporters. A better understanding of Tac pharmacokinetics and pharmacodynamics may help to minimize different outcomes amongst transplant recipients by personalizing immunosuppression. AREAS COVERED The pharmacogenetic contribution of Tac metabolism will be examined, with a focus on recent discoveries, new developments and ethnic considerations. EXPERT OPINION The strongest and most consistent association in pharmacogenetics is between the CYP3A5 genotype and Tac dose requirement, with CYP3A5 expressers having a ~ 40-50% higher dose requirement compared to non-expressers. Two recent randomized-controlled clinical trials using CYP3A5 genotype, however, did not show a decrease in acute rejections nor reduced toxicity. CYP3A4*22, CYP3A4*26, and POR*28 are also associated with Tac dose requirements and may be included to provide the expected improvement of Tac therapy. Studies focusing on the intracellular drug concentrations and on calcineurin inhibitor-induced nephrotoxicity also seem promising. For all studies, however, the ethnic prevalence of genotypes should be taken into account, as this may significantly impact the effect of pre-emptive genotyping.
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Affiliation(s)
- J T Tang
- a Department of Laboratory Medicine , West China Hospital of Sichuan University , Chengdu , China.,b Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - L M Andrews
- b Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - T van Gelder
- b Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.,c Department of Internal Medicine, Division of Nephrology and Renal Transplantation , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Y Y Shi
- d Department of Nephrology , West China Hospital of Sichuan University , Chengdu , China
| | - R H N van Schaik
- e Department of Clinical Chemistry , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - L L Wang
- a Department of Laboratory Medicine , West China Hospital of Sichuan University , Chengdu , China
| | - D A Hesselink
- c Department of Internal Medicine, Division of Nephrology and Renal Transplantation , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
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Yagisawa T, Omoto K, Shimizu T, Ishida H, Tanabe K. Arteriosclerosis in zero-time biopsy is a risk factor for tacrolimus-induced chronic nephrotoxicity. Nephrology (Carlton) 2016; 20 Suppl 2:51-7. [PMID: 26031587 DOI: 10.1111/nep.12461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 01/17/2023]
Abstract
AIM Calcineurin inhibitors reduce the acute rejection rate and greatly improve renal allograft survival. However, they are associated with some adverse events, including nephrotoxicity, a risk factor for allograft failure. Chronic calcineurin inhibitor-induced nephrotoxicity causes irreversible damage to renal components, such as arteriolar hyaline thickening. The aim of this study is to investigate the risk factors for tacrolimus-induced chronic nephrotoxicity using zero-time biopsy specimens. METHODS Between January 2001 and December 2010, 483 patients who underwent living-related kidney transplantation and had also been placed on a tacrolimus-based regimen were enrolled in this study. There were 1859 specimens evaluated comprising 483 zero-time biopsy specimens and 1376 protocol and for-cause biopsy specimens. De novo arteriolar hyaline thickening due to tacrolimus-induced chronic nephrotoxicity was scored according to the Banff classification aah score. In this study, tacrolimus-induced nephrotoxicity was defined as a positive aah score. RESULTS Of the 483 patients, 108 patients (22.4%) had biopsy-proven tacrolimus-induced chronic nephrotoxicity. Multivariate analysis showed that interlobular arteriosclerosis proven by zero-time biopsy (OR: 2.23, 95%CI: 1.38-3.58, P < 0.01) and acute rejection episodes (OR: 1.58, 95%CI: 1.00-2.47, P = 0.04) were independent risk factors for tacrolimus-induced chronic nephrotoxicity. However, tacrolimus-induced chronic nephrotoxicity did not affect long-term graft survival. CONCLUSION This is the first report showing that arteriosclerosis in zero-time biopsy specimens is a risk factor for histological tacrolimus-induced chronic nephrotoxicity.
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Affiliation(s)
- Takafumi Yagisawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomokazu Shimizu
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.2015.0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Very low early rejection rates and excellent short-term kidney allograft outcomes have been the mainstay of forwarding the field of Kidney Transplantation in the last few decades. This progress is mainly achieved by using the current armamentarium of maintenance immunosuppression in different combinations and dosages of calcineurin inhibitors (CNI), corticosteroids and antiproliferative drugs. Metabolic risks and nephrotoxicity of CNIs has led to a search for strategies to minimize their use. Similarly, metabolic risks, mood abnormalities and Cushing-like side effects of steroids have forced physicians and patients alike to try to minimize their use in transplantation. Here, we review the most recent randomized controlled trials of minimization of CNI/steroids in a manner (with incident immunologic risks, state of net immunosuppression and side- effects) that may be helpful to choose the best strategy for the individual patient. New trials testing minimization strategies should include in their design, an assessment of the impact of minimization on development of donor specific antibodies and antibody-mediated rejection as well as long-term outcomes.
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Affiliation(s)
- Jyoti Eknoor Brar
- Division of Transplantation, Department of Surgery, University of Wisconsin at Madison , Madison, WI , USA and
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49
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Abstract
Tacrolimus (FK506) is one of the principal immunosuppressive agents used after solid organ transplantations to prevent allograft rejection. Chronic renal injury induced by tacrolimus is characterized by linear fibrosis in the medullary rays; however, the early morphologic findings of acute tacrolimus nephrotoxicity are not well characterized. Kidney injury molecule-1 (KIM-1) is a specific injury biomarker that has been proven to be useful in the diagnosis of mild to severe acute tubular injury on renal biopsies. This study was motivated by a patient with acute kidney injury associated with elevated serum tacrolimus levels in whom KIM-1 staining was present only in proximal tubules located in the medullary rays in the setting of otherwise normal light, immunofluorescent, and electron microscopy. We subsequently evaluated KIM-1 expression in 45 protocol and 39 indicated renal transplant biopsies to determine whether higher serum levels of tacrolimus were associated with acute segment specific injury to the proximal tubule, as reflected by KIM-1 staining in the proximal tubules of the cortical medullary rays. The data suggest that tacrolimus toxicity preferentially affects proximal tubules in medullary rays and that this targeted injury is a precursor lesion for the linear fibrosis seen in chronic tacrolimus toxicity.
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Rego F, Alçântara P, Buinho F, Gomes da Costa A, Rodrigues Pena J. Long-term survival (>25 years) of deceased donor kidney transplant recipients: a single-center experience. Transplant Proc 2015; 47:967-70. [PMID: 26036496 DOI: 10.1016/j.transproceed.2015.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The aim of this preliminary work is to analyze the clinical features of 52 patients with a functional transplanted kidney for >25 years (all first transplant and all deceased donor recipients) and to compare with a similar though more complete study from Hôpital Necker-Paris 2012. METHODS The mean graft survival at 25 years is 12.7% and at 30 years is 10%. The actual mean serum creatinine concentration is 1.3 mg/L. We analyzed recipient age (mean, 35.9 years) and gender (29 men and 23 women). Donor age was 26.7 ± 10.3 years. Seven patients (13.4%) were transplanted with 1 HLA mismatch, 42.3% with 2 mismatches, and 44.2% with 3 mismatches. Mean cold ischemia time was 15.45 ± 7.7 hours. Of the recipients, 76% had immediate graft function; 38% experienced 1 acute rejection episode and 4 patients had 2 rejection crises. The initial immunosuppressive regimen was azathioprine (AZA) + prednisolone (Pred) in 14 patients, cyclosporin (CSA) + Pred in 13 patients, and CSA + AZA + Pred in 25 patients. Of these patients, 19% maintained their initial regimen, and 54% (28 patients) were very stable on a mixed CSA regimen for >25 years. RESULTS We present the major complications (diabetes, neoplasia, and hepatitis C virus positivity). CONCLUSION Our results in deceased donor kidney recipients for >25 years are similar to the mixed population (deceased donors and living donors) presented by the Necker group, although 54% of our patients remain on CSA immunosuppression, contradicting the idea that its use is not compatible with good long-term kidney function in transplant recipients.
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Affiliation(s)
- F Rego
- Renal Transplantation Unit, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal.
| | - P Alçântara
- Renal Transplantation Unit, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - F Buinho
- Renal Transplantation Unit, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - A Gomes da Costa
- Renal Transplantation Unit, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal; Nephrology Department, Hospital Santa Maria, Lisbon, Portugal
| | - J Rodrigues Pena
- Renal Transplantation Unit, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal; Surgery Department, Hospital Curry Cabral, Lisbon, Portugal
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