1
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Ettenger RB, Seifert ME, Blydt-Hansen T, Briscoe DM, Holman J, Weng PL, Srivastava R, Fleming J, Malekzadeh M, Pearl M. Detection of Subclinical Rejection in Pediatric Kidney Transplantation: Current and Future Practices. Pediatr Transplant 2024; 28:e14836. [PMID: 39147695 DOI: 10.1111/petr.14836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION The successes in the field of pediatric kidney transplantation over the past 60 years have been extraordinary. Year over year, there have been significant improvements in short-term graft survival. However, improvements in longer-term outcomes have been much less apparent. One important contributor has been the phenomenon of low-level rejection in the absence of clinical manifestations-so-called subclinical rejection (SCR). METHODS Traditionally, rejection has been diagnosed by changes in clinical parameters, including but not limited to serum creatinine and proteinuria. This review examines the shortcomings of this approach, the effects of SCR on kidney allograft outcome, the benefits and drawbacks of surveillance biopsies to identify SCR, and new urine and blood biomarkers that define the presence or absence of SCR. RESULTS Serum creatinine is an unreliable index of SCR. Surveillance biopsies are the method most utilized to detect SCR. However, these have significant drawbacks. New biomarkers show promise. These biomarkers include blood gene expression profiles and donor derived-cell free DNA; urine gene expression profiles; urinary cytokines, chemokines, and metabolomics; and other promising blood and urine tests. CONCLUSION Specific emphasis is placed on studies carried out in pediatric kidney transplant recipients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03719339.
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Affiliation(s)
- Robert B Ettenger
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michael E Seifert
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom Blydt-Hansen
- Multi-Organ Transplant Program, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David M Briscoe
- Division of Nephrology, Department of Pediatrics Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Holman
- Transplant Genomics Inc., Framingham, Massachusetts, USA
| | - Patricia L Weng
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - James Fleming
- Transplant Genomics Inc., Framingham, Massachusetts, USA
| | - Mohammed Malekzadeh
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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2
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Landsberg A, Raza SS, Seifert ME, Blydt-Hansen TD. Follow-up biopsies identify high rates of persistent rejection in pediatric kidney transplant recipients after treatment of T cell-mediated rejection. Pediatr Transplant 2024; 28:e14617. [PMID: 37750353 PMCID: PMC10872996 DOI: 10.1111/petr.14617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Incomplete resolution of T cell-mediated rejection (TCMR) after treatment may not be detected with serum creatinine monitoring and is associated with donor-specific antibodies and chronic rejection. We evaluate the utility of follow-up biopsies (FUB) to identify and characterize rates of persistent TCMR after treatment in pediatric kidney transplant patients. METHODS Patients from two pediatric transplant centers performing standard of care FUB at 1.5-2 months after treatment for TCMR were included. FUB were evaluated for extent of rejection resolution (complete vs. incomplete) and grade. Clinical data at time of FUB and later were reported, where available. RESULTS Fifty-eight patients underwent FUB, at mean of 1.7 months (SD 0.7) post-index biopsy. Rejection grade on index biopsy was Banff borderline (≥i1t1 and CONCLUSIONS FUB were effective at detecting persistent rejection, which was common among pediatric transplant patients after standard TCMR treatment. Until more effective rejection treatments or sensitive biomarkers are available, FUB may be effectively utilized to identify patients with ongoing rejection who would benefit from further treatment.
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Affiliation(s)
- Adina Landsberg
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - S. Sikandar Raza
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
| | - Michael E. Seifert
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
| | - Tom D. Blydt-Hansen
- BC Children’s Hospital, Division of Nephrology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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3
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Hoffmann AJ, Gibson IW, Ho J, Nickerson P, Rush D, Sharma A, Wishart D, Blydt-Hansen TD. Early surveillance biopsy utilization and management of pediatric renal allograft acute T cell-mediated rejection in Canadian centers: Observations from the PROBE multicenter cohort study. Pediatr Transplant 2021; 25:e13870. [PMID: 33026135 DOI: 10.1111/petr.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early TCMR surveillance with protocol kidney biopsy is used differentially among pediatric kidney transplant centers. Little has been reported about actual center-based differences, and this variability may influence TCMR ascertainment, treatment, and monitoring more broadly. METHODS Data from the PROBE multicenter study were used to identify patients from centers conducting ESB or LSIB. ESB was defined as >50% of patients having at least 1 surveillance biopsy in the first 9 months. Patients were compared for number of biopsies, rejection episodes, treatment, and follow-up monitoring. RESULTS A total of 261 biopsies were performed on 97 patients over 1-2 years of follow-up. A total of 228 (87%) of biopsies were performed in ESB centers. Compared to LSIB centers, ESB centers had 7-fold more episodes of TCMR diagnosed on any biopsy [0.8 ± 1.2 vs 0.1 ± 0.4; P < .001] and a 3-fold higher rate from indication biopsies [0.3 ± 0.9 vs 0.1 ± 0.3; P = .04]. The proportion of rejection treatment varied based on severity: Banff borderline i1t1 (40%);>i1t1 and < Banff 1A (86%); and ≥ Banff 1A (100%). Biopsies for follow-up were performed after treatment in 80% of cases (n = 28) of rejection almost exclusively at ESB centers, with 17 (61%) showing persistence of TCMR (≥i1t1). CONCLUSIONS Practice variation exists across Canadian pediatric renal transplant centers with ESB centers identifying more episodes of rejection. Additionally, treatment of Banff borderline is not universal and varies with severity regardless of center type. Lastly, follow-up biopsies are performed inconsistently and invariably show persistence of rejection.
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Affiliation(s)
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Shared Health Services Manitoba, Transplant/Immunology Lab, Winnipeg, MB, Canada
| | - David Rush
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - David Wishart
- The Metabolomics Innovation Centre, University of Alberta, Edmonton, AB, Canada
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4
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Landsberg A, Riazy M, Blydt-Hansen TD. Yield and utility of surveillance kidney biopsies in pediatric kidney transplant recipients at various time points post-transplant. Pediatr Transplant 2021; 25:e13869. [PMID: 33073499 DOI: 10.1111/petr.13869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/29/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Due to a lack of consensus on SB for pediatric kidney transplant recipients, we evaluated the yield and clinical utility of SB findings at various time points post-transplant. METHODS Patients transplanted at a single institution between 2014 and 2020 with at least one SB at 1.5, 3, 6, 12, and 24 months post-transplant were included. Additional biopsies were done for indication (IB). TCMR was classified by Banff criteria (score ≥i1t1). RESULTS Forty-seven patients had 142 biopsies (SB = 113, IB = 29); 19 (40.4%) of whom experienced at least one TCMR episode in the first-year post-transplant. The greatest SB yield of any pathologic abnormality was at 6 months (57.1%; P < .001). Six months also had the highest yield for TCMR (42.9%), compared with 3.3%, 20.8%, 15.0%, and 9.1% at 1.5, 3, 12 months, and 24 months, respectively (P = .003). SB instigated intensification of immunosuppression (28.3% cases), reduction of immunosuppression (2.7% cases), and other non-immunosuppressant changes (1.8% cases). The 6-month SB led to the greatest number of changes in management (53.6%), compared with 1.5, 3, 12, and 24 months (13.3, 20.8, 25.0, and 36.4%, respectively; P = .012). There were no major biopsy-related complications. CONCLUSIONS SBs identify an important burden of subclinical rejection and other pathology leading to changes in clinical management. The greatest yield was at 6 months, whereas the least utility was at the 1.5 months. Selection of SB timing may be tailored such that the optimal yield is balanced against the procedural risk.
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Affiliation(s)
- Adina Landsberg
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maziar Riazy
- Department of Pathology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Division of Nephrology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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5
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Puliyanda DP, Swinford R, Pizzo H, Garrison J, De Golovine AM, Jordan SC. Donor-derived cell-free DNA (dd-cfDNA) for detection of allograft rejection in pediatric kidney transplants. Pediatr Transplant 2021; 25:e13850. [PMID: 33217125 DOI: 10.1111/petr.13850] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/22/2020] [Accepted: 08/26/2020] [Indexed: 01/13/2023]
Abstract
In pediatric transplantation, acute rejection is a major contributor of graft failure. Current approaches include kidney biopsy in response to graft dysfunction and/or the emergence of donor-specific HLA antibodies (DSA). However, biopsy is associated with potential complications. Thus, there is a need for non-invasive diagnostics. Detection of donor-derived cell-free DNA (dd-cfDNA, AlloSure) > 1% is associated with rejection in adult kidney transplants. Here, we evaluate the utility of dd-cfDNA for identifying allograft rejection in pediatric patients. Between 10/2017 and 10/2019, 67 patients, who underwent initial testing with dd-cfDNA as part of routine monitoring or in response to clinical suspicion for rejection, were included. Biopsies were performed when dd-cfDNA > 1.0% or where clinical suspicion was high. Demographics, dd-cfDNA, antibody status, and biopsies were collected prospectively. Data were analyzed to determine predictive value of dd-cfDNA for identifying grafts at risk for rejection. 19 of 67 patients had dd-cfDNA testing as part of routine monitoring with a median dd-cfDNA score of 0.37 (IQR: 0.19-1.10). 48 of 67 patients who had clinical suspicion of rejection had median dd-cfDNA score of 0.47 (0.24-2.15). DSA-positive recipients had higher dd-cfDNA scores than those who were negative or had AT1R positivity alone (P = .003). There was no association between dd-cfDNA score and strength of DSA positivity. 7 of 48 recipients had a biopsy with a dd-cfDNA score <1%; two showed evidence of rejection. Neither DSA nor AT1R positivity was statistically associated with biopsy-proven rejection. However, dd-cfDNA >1% was diagnostic of rejection with sensitivity of 86% and specificity of 100% (AUC: 0.996, 0.98-1.00; P = .002). dd-cfDNA represents a non-invasive method for early detection of rejection in pediatric renal transplants. Our study shows dd-cfDNA to be highly predictive of histological rejection and superior to other indicators such as graft dysfunction or antibody positivity alone. Further studies are necessary to refine these initial observations.
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Affiliation(s)
- Dechu P Puliyanda
- Pediatric Nephrology Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rita Swinford
- Pediatric Nephrology, UTHealth, University of Texas at Houston, Houston, TX, USA
| | - Helen Pizzo
- Pediatric Nephrology Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Jonathan Garrison
- Pediatric Nephrology Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stanley C Jordan
- Pediatric Nephrology Cedars Sinai Medical Center, Los Angeles, CA, USA
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6
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Odum JD, Kats A, VanSickle JS, Chadha V, Brewer B, Staggs VS, Warady BA. Characterizing the frequency of modifiable histological changes observed on surveillance biopsies in pediatric kidney allograft recipients. Pediatr Nephrol 2020; 35:2173-2182. [PMID: 32556543 DOI: 10.1007/s00467-020-04624-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Rejection is responsible for just under 50% of graft loss in the pediatric kidney transplant population. Early identification and treatment of allograft injury, specifically modifiable pathologies such as subclinical rejection (SCR), calcineurin inhibitor toxicity, and BK virus nephropathy, may improve allograft survival. Protocol surveillance biopsy (SB) currently offers the earliest opportunity for targeted interventions. METHODS This is a single-center retrospective review of 215 kidney SBs obtained from 2008 to 2016 in 97 pediatric kidney transplant recipients. SBs were obtained at 6, 12, and 24 months post-transplantation. Frequency of abnormal histologic findings, estimated glomerular filtration rate at time of SB, and SB-related complications were recorded. Data were analyzed to investigate possible time trends and the presence of demographic or clinical associations with abnormal histologic findings. RESULTS Potentially modifiable histologic findings were seen in 38.1% of all SBs. SCR was found with increasing frequency across all time points with an estimated 49% increase in the odds of a SCR finding per additional 6 months post-transplantation (aOR 1.49, 95% CI 1.06-2.09, p = 0.022). Among follow-up biopsies in patients who underwent treatment for SCR, 50% had no SCR and 18.8% showed histologic improvement. The complication rate associated with SB was 1.9% (4/215 SBs) and consisted of only minor complications. CONCLUSIONS SBs are safe and offer the opportunity to identify and treat modifiable histologic changes in the pediatric kidney transplant population. The performance of SBs for up to 2 years after transplantation can have meaningful clinical impact.
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Affiliation(s)
- James D Odum
- Division of Graduate Medical Education, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Alexander Kats
- Department of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Judith Sebestyen VanSickle
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brenda Brewer
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Vincent S Staggs
- Biostatistics & Epidemiology Core, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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7
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Fadel FI, Bazaraa HM, Badawy H, Morsi HA, Saadi G, Abdel Mawla MA, Salem AM, Abd Alazem EA, Helmy R, Fathallah MG, Ramadan Y, Fahmy YA, Sayed S, Eryan EF, Atia FM, ElGhonimy M, Shoukry AI, Shouman AM, Ghonima W, Salah Eldin M, Soaida SM, Ismail W, Salah DM. Pediatric kidney transplantation in Egypt: Results of 10-year single-center experience. Pediatr Transplant 2020; 24:e13724. [PMID: 32388917 DOI: 10.1111/petr.13724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/01/2020] [Accepted: 04/07/2020] [Indexed: 12/28/2022]
Abstract
Pediatric kidney transplantation is a multidisciplinary therapy that needs special consideration and experience. In this study, we aimed to present CUCH experience; over a 10-year period, as a specialized center of kidney transplantation in children. We studied 148 transplantations performed at a single center from 2009 to 2018. Pretransplant and follow-up data were collected and graft/patient survival rates were evaluated. A total of 48 patients developed at least one rejection episode during 688 patient-years of follow-up. Infections, recurrence of original disease, and malignancy were the most important encountered medical complications (20%, 2%, and 1.4%, respectively). One-year patient survival was 94.1%, while graft and patient survival was 91.9%. Graft/patient survival at 5, 7, and 9 years was 90%, 77%, and 58%, respectively. Infections were the main cause (69%) of mortality. Death with a functioning graft and CR were the main causes of graft loss (48% and 33%, respectively). Pediatric kidney transplantation in Egypt is still a challenging yet successful experience. Rejections and infections are the most frequent complications. Short-term outcomes surpass long-term ones and graft survival rates are similar to the international standard.
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Affiliation(s)
- Fatina I Fadel
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Hafez M Bazaraa
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Hesham Badawy
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hany A Morsi
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gamal Saadi
- Department of Internal Medicine, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Amr Mohamed Salem
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | | | - Rasha Helmy
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Mohamed Gamal Fathallah
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Yasmin Ramadan
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Yosra Aboelnaga Fahmy
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Shaimaa Sayed
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Eman Fathy Eryan
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Fatma Mohammad Atia
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
| | - Mohamed ElGhonimy
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed I Shoukry
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed M Shouman
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Waleed Ghonima
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Salah Eldin
- Department of Urology, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherif M Soaida
- Department of Anesthesia, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wesam Ismail
- Department of Pathology, Beni Suef University, Beni Suef, Egypt
| | - Doaa M Salah
- Department of Pediatrics, Kasr Al Aini Faculty of Medicine, Cairo University, Cairo, Egypt.,Pediatric Nephrology & Transplantation Units, Cairo University Children Hospital, Cairo, Egypt
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8
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Moreno Gonzales M, Duran J, Ponce O, Navarro G, Benavides M, Cisneros M, Lipa R, Mayo N, Sumire J, Mendez C, Gonzalez M, Cruzado J, Sánchez A, Carrasco F. Pediatric Kidney Transplantation in Perú: A Single-Center Initial Experience. Transplant Proc 2020; 52:800-806. [PMID: 32115239 DOI: 10.1016/j.transproceed.2020.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pediatric kidney transplantation (PKTx) is the preferred therapy for children with end-stage renal disease (ESRD) worldwide. Regrettably, in Perú, access to PKTx is extremely difficult due to recipient/donor socio-economic status, health care structure and especially, scarcity of organs. Our center (the only pediatric institute in the country) has recently started a PKTx program with good midterm results. The aim of this study was to present our outcomes. METHODS Retrospective analysis of prospectively collected data between December 2017 and August 2019. Fourteen PKTx (< 18 years old) were achieved. As per our protocol: pre-implantation/protocol biopsies, antibody assessment (T/B cell flow cytometric plus HLA testing applying polymerase chain reaction-based technology), triple immunosuppression (tacrolimus, mycophenolate mofetil, steroids) and induction therapy was performed in every case. RESULTS The recipient's mean age at the time of PKTx was 14.14 ± 2.62, 8/14 (57.14%) were male, 50% developed ESRD due to undetermined etiology, 11/14 (78.57%) received a deceased donor allograft, and 9/14 (64.28%) required induction with thymoglobulin. Postoperative complications included: delayed graft function (1/14, 7.14%), 1 (7.14%) developed gross hematuria associated with allograft disfunction post-protocol allograft biopsy that was managed conservatively and 1 recipient (7.14%) developed grade II oligoastrocytoma, at 10 months post PKTx. CONCLUSIONS PKTx is the best therapeutic option for children with ESRD. Our group demonstrated that even in countries with limited resources like Perú, good midterm results can be achieved. Emphasis should be given to improve access to transplantation especially in the setting of pediatric recipients.
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Affiliation(s)
- Manuel Moreno Gonzales
- Department of Surgery, Clínica Anglo Americana, Lima, Peru; Organ Donation and Procurement Unit, Instituto Nacional de Salud del Niño San Borja, Lima, Peru.
| | - José Duran
- Organ Donation and Procurement Unit, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Omar Ponce
- Organ Donation and Procurement Unit, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Graciela Navarro
- Organ Donation and Procurement Unit, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Melva Benavides
- Organ Donation and Procurement Unit, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Marlene Cisneros
- Pediatric Nephrology, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Roxana Lipa
- Anatomic Pathology Laboratory, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Nancy Mayo
- Anatomic Pathology Laboratory, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Julia Sumire
- Department of Anatomic Pathology, Hospital Guillermo Almenara Yrigoyen, Lima, Peru
| | - Carla Mendez
- Clinical Pathology Laboratory, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Marco Gonzalez
- Pediatric Urology, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Juan Cruzado
- Pediatric Urology, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Antonio Sánchez
- Department of Urology, Hospital Guillermo Almenara Yrigoyen, Lima, Peru
| | - Félix Carrasco
- Liver Transplant Unit, Hospital Edgardo Rebagliati Martins, Lima, Peru
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9
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Gordillo R, Munshi R, Monroe EJ, Shivaram GM, Smith JM. Benefits and risks of protocol biopsies in pediatric renal transplantation. Pediatr Nephrol 2019; 34:593-598. [PMID: 29725772 DOI: 10.1007/s00467-018-3959-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/14/2018] [Accepted: 04/03/2018] [Indexed: 11/30/2022]
Abstract
Protocol biopsies are defined as sampling of allograft tissue at predetermined times regardless of function. This procedure can be justified due to the lack of non-invasive methods to reliably diagnose rejection (acute or subclinical). Changes in creatinine are not seen with subclinical rejection or early acute rejection and do not always correlate with efficacy of treatment. Parents and providers are still hesitant to pursue protocol biopsy due to the potential complications and lack of definitive evidence of a benefit from doing this procedure. Importantly, the rate of transplant renal biopsy complications requiring additional intervention is low. It is unclear if detection and treatment of subclinical rejection detected on protocol biopsy will lead to improved graft survival. Our goal is to review the literature on this topic and share some of the experience in our center. Definition, indications, and complications of diagnostic transplant renal biopsies are not included in this review.
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Affiliation(s)
- Roberto Gordillo
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
| | - Raj Munshi
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Eric J Monroe
- Division of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Giridhar M Shivaram
- Division of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Jodi M Smith
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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10
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Zotta F, Guzzo I, Morolli F, Diomedi-Camassei F, Dello Strologo L. Protocol biopsies in pediatric renal transplantation: a precious tool for clinical management. Pediatr Nephrol 2018; 33:2167-2175. [PMID: 29980849 DOI: 10.1007/s00467-018-4007-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Kidney transplantation is the best treatment for children with end-stage kidney disease. Early results have improved, but late graft loss is still a major problem. Non-invasive, fully reliable early biomarkers of acute rejection are currently missing. METHODS Our aim was to evaluate the efficacy of protocol biopsies (PBXs) in a pediatric population. During 11 years, 209 renal transplantations were performed in 204 pediatric patients. Biopsies were performed 3-6 months, 1 year, and 5 years after transplantation. Procedure-related complications were systematically looked for by means of ultrasound scans. RESULTS Unexpected findings (mainly subclinical rejections) requiring therapeutic intervention were found in 19.3% biopsies performed at 3-6 months, in 18.4% in 12-month biopsies and in none of those performed after 5 years. The 13.6% patients at 12-month biopsies and 23.6% at 5-year biopsies showed calcineurin inhibitor (CNI) toxicity. Interstitial fibrosis and tubular atrophy (IF/TA) was found in 17.6 and 83.6% of patients at 12-month and 5-year biopsies, respectively. Complications of the PBX were infrequent. Five-year estimated glomerular filtration rate (GFR) was not significantly different in patients who received treatment for any cause and patients with normal histology. CONCLUSIONS Although we do not have a control group, we may speculate that patients who received treatment returned to a "standard" condition possibly improving final outcome. Protocol biopsies are a powerful diagnostic tool for the management of pediatric renal transplant recipients. In view of the lack of evidence that biopsies taken 5 years after transplantation lead to any therapeutic change, their use should be reconsidered.
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Affiliation(s)
- Federica Zotta
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Federica Morolli
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | | | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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11
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Yang CH, Chen XX, Chen L, Zheng DH, Liu QS, Xie WF, Zhou TB, Drummen GPC. Relationship between cytotoxic T-lymphocyte antigen 4 -318C/T (rs5742909) gene polymorphism and the risk of acute rejection in renal transplantation. Pediatr Transplant 2017; 21. [PMID: 28449371 DOI: 10.1111/petr.12920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 01/17/2023]
Abstract
Results on the relationship between CTLA4 -318C/T (rs5742909) gene polymorphism and risk of acute rejection in renal transplantation are still conflicting. This meta-analysis was performed to update the association between CTLA4 -318C/T and risk of acute rejection in renal transplantation. The association investigations were identified from PubMed and Cochrane Library, and eligible studies were included and synthesized using meta-analysis method. Twelve reports were included in this meta-analysis for the association of CTLA4 -318C/T gene polymorphism with acute rejection risk in renal transplantation, consisting of 728 acute rejection patients and 1628 non-acute rejection controls. The association between CTLA4 -318C/T gene polymorphism and acute rejection risk in renal transplantation for overall populations was not found in this meta-analysis (T allele: OR=0.96, 95% CI: 0.60-1.54, P=.88; TT genotype: OR=0.90, 95% CI: 0.47-1.71, P=.74; CC genotype: OR=1.00, 95% CI: 0.62-1.59, P=.98). Interestingly, T allele was associated with the risk of acute rejection in renal transplantation in African population. In conclusion, CTLA4 -318C/T gene polymorphism is not associated with the risk of acute rejection in renal transplantation in overall populations.
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Affiliation(s)
- Chun-Hua Yang
- Department of Emergency, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xue-Xia Chen
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Chen
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dong-Hua Zheng
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiong-Shan Liu
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wen-Feng Xie
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tian-Biao Zhou
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gregor P C Drummen
- Cellular Stress and Ageing Program, Bionanoscience and Bio-Imaging Program, Bio&Nano-Solutions, Düsseldorf, Germany
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