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Mour GK, Ninan J, Butterfield D, Zhang N, Nair SS, Smith M, Ryan M, Reddy K, Heilman RL. Outcomes of Early Thrombotic Microangiopathy in Renal Transplantation. Clin Transplant 2024; 38:e15373. [PMID: 39023085 DOI: 10.1111/ctr.15373] [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: 01/24/2024] [Revised: 05/02/2024] [Accepted: 05/23/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Alternate complement dysregulation postrenal transplantation can result in thrombotic microangiopathy (TMA). There is a scarcity of data regarding outcomes based on the timing of TMA post-transplant, coupled with a lack of follow-up biopsy findings post TMA diagnosis. This study aims to assess allograft and patient outcomes in individuals developing early TMA, defined within 4 months post-transplantation, and explore any differences in follow-up surveillance biopsies compared to a non-TMA group. DESIGN This is a single center retrospective study between January 1, 2002 and October 10, 2019. Patients who developed TMA within 4 months post-transplantation were compared to a propensity matched non-TMA group. RESULTS Thirty-one patients developed TMA within 4 months of renal transplantation. Index TMA biopsy featured noticeable glomerular, and vascular lesions along with acute tubular injury. Four-month surveillance biopsy showed significant glomerulitis, transplant glomerulopathy and chronic interstitial fibrosis as compared to non-TMA group. However, at 1 year, these differences were no longer significant. There was no significant difference in patient survival (TMA vs. non-TMA, p = 0.083); however, death censored graft survival was significantly lower in the TMA group (p < 0.001). TMA patients had a significantly lower estimated glomerular filtration rate at 4 months and at 1 year as compared to the non-TMA group. CONCLUSION Early onset TMA post renal transplant leads to decreased renal function and lower graft survival. Early recognition and prompt treatment may help in reducing the adverse outcomes.
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Affiliation(s)
- Girish K Mour
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Jacob Ninan
- Division of Nephrology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Duke Butterfield
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Sumi S Nair
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Maxwell Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Margaret Ryan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam Reddy
- Division Chair, Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Afrouzian M, Kozakowski N, Liapis H, Broecker V, Truong L, Avila-Casado C, Regele H, Seshan S, Ambruzs JM, Farris AB, Buob D, Chander PN, Cheraghvandi L, Clahsen-van Groningen MC, de Almeida Araujo S, Ertoy Baydar D, Formby M, Galesic Ljubanovic D, Herrera Hernandez L, Honsova E, Mohamed N, Ozluk Y, Rabant M, Royal V, Stevenson HL, Toniolo MF, Taheri D. Thrombotic Microangiopathy in the Renal Allograft: Results of the TMA Banff Working Group Consensus on Pathologic Diagnostic Criteria. Transpl Int 2023; 36:11590. [PMID: 37680648 PMCID: PMC10481335 DOI: 10.3389/ti.2023.11590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023]
Abstract
The Banff community summoned the TMA Banff Working Group to develop minimum diagnostic criteria (MDC) and recommendations for renal transplant TMA (Tx-TMA) diagnosis, which currently lacks standardized criteria. Using the Delphi method for consensus generation, 23 nephropathologists (panelists) with >3 years of diagnostic experience with Tx-TMA were asked to list light, immunofluorescence, and electron microscopic, clinical and laboratory criteria and differential diagnoses for Tx-TMA. Delphi was modified to include 2 validations rounds with histological evaluation of whole slide images of 37 transplant biopsies (28 TMA and 9 non-TMA). Starting with 338 criteria in R1, MDC were narrowed down to 24 in R8 generating 18 pathological, 2 clinical, 4 laboratory criteria, and 8 differential diagnoses. The panelists reached a good level of agreement (70%) on 76% of the validated cases. For the first time in Banff classification, Delphi was used to reach consensus on MDC for Tx-TMA. Phase I of the study (pathology phase) will be used as a model for Phase II (nephrology phase) for consensus regarding clinical and laboratory criteria. Eventually in Phase III (consensus of the consensus groups) and the final MDC for Tx-TMA will be reported to the transplantation community.
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Affiliation(s)
- Marjan Afrouzian
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | | | - Helen Liapis
- Department of Pathology and Immunology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Nephrology, Ludwig Maximilian University, Munich, Germany
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Luon Truong
- Department of Pathology, The Houston Methodist Hospital, Houston, TX, United States
| | - Carmen Avila-Casado
- Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Surya Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - David Buob
- Department of Pathology, Université de Sorbonne, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | | | - Lukman Cheraghvandi
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Stanley de Almeida Araujo
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Dilek Ertoy Baydar
- Department of Pathology, School of Medicine, Koç University, Sarıyer, Türkiye
| | - Mark Formby
- Department of Anatomical Pathology, NSW Health Pathology, Callaghan, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | | | | | - Eva Honsova
- AeskuLab Pathology and Department of Pathology, Charles University, Prague, Czechia
| | - Nasreen Mohamed
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Virginie Royal
- Department of Pathology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada
| | - Heather L Stevenson
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Maria Fernanda Toniolo
- Kidney Pancreas Transplantation, Instituto de Nefrología-Nephrology, Buenos Aires, Argentina
| | - Diana Taheri
- Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Kim YJ. A new pathological perspective on thrombotic microangiopathy. Kidney Res Clin Pract 2022; 41:524-532. [PMID: 35791743 PMCID: PMC9576460 DOI: 10.23876/j.krcp.22.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Thrombotic microangiopathy (TMA) refers to a condition caused by microvascular injury that includes thrombosis, hemolytic anemia, and thrombocytopenia. There are two classic TMAs, hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura, as well as an atypical HUS (aHUS). aHUS includes a broad spectrum of disorders with diverse etiologies and shares clinical manifestations with classic TMA; however, it frequently lacks typical clinical and laboratory findings. These traits can confuse clinicians and pathologists in terms of renal pathologic diagnosis, especially in cases where TMA is associated with other glomerulopathies or hypertensive renal disease. In this review, new paradigms for classifying TMA and the diversity of histopathologic changes including associated renal diseases are discussed. Renal biopsy is an important and useful diagnostic tool for diagnosing TMA and identifying TMA changes in other renal diseases, including hypertension. Adopting the term “TMA features” for TMA-like changes in glomerulus or artery/arteriole in addition to the pathological diagnosis of glomerulopathy would be informative to clinicians for a prompt diagnosis and treatment of aHUS.
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Affiliation(s)
- Yong-Jin Kim
- Department of Pathology, Kyungpook National University Hospital, Daegu, Republic of Korea
- Correspondence: Yong-Jin Kim Department of Pathology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea. E-mail:
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Kovala M, Seppälä M, Kaartinen K, Meri S, Honkanen E, Räisänen-Sokolowski A. Vascular Occlusion in Kidney Biopsy Is Characteristic of Clinically Manifesting Thrombotic Microangiopathy. J Clin Med 2022; 11:jcm11113124. [PMID: 35683519 PMCID: PMC9181253 DOI: 10.3390/jcm11113124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) can sometimes manifest only histologically. Our aim was to retrospectively compare biopsy-proven adult TMA patients showing only histological (h-TMA) or both histological and clinical (c-TMA) TMA in 2006–2017. All native kidney biopsies with TMA were included. Biopsies were re-evaluated by light and electron microscopy, and immunofluorescence. Clinical characteristics, laboratory variables, and treatments were recorded from the electronic medical database. Patients were categorized into h-TMA and c-TMA and these groups were compared. In total, 30 biopsy-proven cases among 7943 kidney biopsies were identified and, of these, 15 had h-TMA and 15 c-TMA. Mean follow-up was 6.3 y, and 73.3% had secondary hemolytic uremic syndrome (HUS) and the rest were atypical HUS. Patient characteristics, treatments, and kidney, and patient survival in the groups were similar. Statistically significant differences were found in histological variables. Vascular myxoid swelling and vascular onion-skinning were almost exclusively detected in c-TMA and, thus, vascular occlusive changes indicate clinically apparent rather than merely histological TMA. In addition, regardless of clinical presentation, kidney and patient survival times were similar in the patient groups highlighting the importance of a kidney biopsy in the case of any kidney-related symptoms.
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Affiliation(s)
- Marja Kovala
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
- Correspondence:
| | - Minna Seppälä
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Kati Kaartinen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Seppo Meri
- Department of Bacteriology and Immunology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
| | - Eero Honkanen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Anne Räisänen-Sokolowski
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
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5
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Aleš Rigler A, Večerić-Haler Ž, Arnol M, Perše M, Boštjančič E, Pleško J, Simčič S, Kojc N. Exploring the role of the complement system, endothelial injury, and microRNAs in thrombotic microangiopathy after kidney transplantation. J Int Med Res 2021; 48:300060520980530. [PMID: 33372813 PMCID: PMC7783899 DOI: 10.1177/0300060520980530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective We investigated whether the recipient’s complement system function, kidney
graft endothelial ultrastructural injury, and microRNA (miRNA) expression
before transplantation may be associated with the risk of posttransplant
de novo thrombotic microangiopathy (TMA). Methods Complement system function assessment, histological and ultrastructural
examination of preimplantation and kidney graft biopsies, and microRNA
assessment were performed on kidney transplant recipients (KTRs) with
de novo TMA. Results On the basis of the clinical course, histological findings, and miRNA
patterns, the following two de novo TMA phenotypes were
observed: a self-limiting disease that was localized to the kidney graft and
a systemic disease that progressed to graft failure without timely
treatment. Decreased alternative complement pathway activity and
ultrastructural endothelial injury before transplantation were confirmed in
all five KTRs and four of five KTRs, respectively, but they did not
correlate with de novo TMA severity. Conclusions Alternative complement pathway abnormalities in KTRs and endothelial
ultrastructural injury on preimplantation biopsy might be associated with
de novo posttransplant TMA, although they did not
predict posttransplant TMA severity (localized vs.
systemic). The specific miRNA expression patterns in preimplantation kidney
graft biopsies demonstrated a borderline statistically significant
difference and might provide more accurate information on posttransplant TMA
severity.
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Affiliation(s)
| | - Željka Večerić-Haler
- Department of Nephrology, University Medical Centre Ljubljana, Slovenia.,Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Slovenia.,Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Martina Perše
- Medical Experimental Centre, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Emanuela Boštjančič
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Jerica Pleško
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Saša Simčič
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Nika Kojc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Slovenia
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Teixeira CM, Tedesco Silva Junior H, de Moura LAR, Proença HMDS, de Marco R, Gerbase de Lima M, Cristelli MP, Viana LA, Felipe CR, Medina Pestana JO. Clinical and pathological features of thrombotic microangiopathy influencing long-term kidney transplant outcomes. PLoS One 2020; 15:e0227445. [PMID: 31923282 PMCID: PMC6953866 DOI: 10.1371/journal.pone.0227445] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/18/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Thrombotic microangiopathy (TMA) in post-transplant setting has heterogeneous clinical manifestations. METHODS We retrospectively studied data of 89 patients with post-transplant TMA, which was characterized by thrombi in at least one glomerulus and/or arteriole. Systemic TMA was defined by thrombocytopenia and microangiopathic anemia and early onset TMA, when occurred less than 90 days post transplant. RESULTS The cumulative incidence was 0.93%. The majority of the recipients were young (mean age 39 years), female (52%) and Caucasian (48%) with primary kidney disease of unknown etiology (37%). Early TMA occurred in 51% of the patients and systemic TMA, in 25%. Underlying precipitating factors were: infection (54%), acute rejection (34%), calcineurin inhibitor toxicity (13%) and pregnancy (3%). 18% of the patients had several triggers. Glomerular TMA was observed in 50% of the biopsies and endothelial cell activation, in 61%. The 1-year patient survival was 97% and corresponding graft survival, 66%. Allograft survival was inferior when acute antibody mediated rejection (ABMR) occurred (with 41%; without 70%, p = 0.01), however no differences were determined by hemolysis, time of onset, thrombi location or endothelial cell activation. CONCLUSIONS Our results suggest that post-transplant TMA is a rare but severe condition, regardless of its clinical and histological presentation, mainly when associated to ABMR.
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7
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Grodsky JD, Craver RD, Ashoor IF. Early identification of transplant glomerulopathy in pediatric kidney transplant biopsies: A single-center experience with electron microscopy analysis. Pediatr Transplant 2019; 23:e13459. [PMID: 31062922 DOI: 10.1111/petr.13459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 02/09/2019] [Accepted: 04/03/2019] [Indexed: 01/06/2023]
Abstract
Banff 2013 criteria recommend performing ultrastructural studies with electron microscopy (EM) in kidney transplant biopsies if the technology is available. We sought to determine the impact of EM on enhancing diagnostic findings in pediatric kidney transplant biopsies and the prognostic information gained from the additional findings. All kidney transplant biopsies since routine EM use started on June 1, 2014, until October 31, 2016, were reviewed. Primary outcome measures included the positive yield frequency of EM use defined as an upgraded diagnosis based on EM findings relative to light microscopy, and 12-month kidney allograft outcome of progression to ESRD or doubling of serum creatinine stratified by transplant glomerulopathy (TG) status on EM. Eighty unique kidney transplant biopsies were reviewed. EM studies were completed for 61 biopsies (76%). Complication rate was low (3.7%). In 61 biopsies where EM was completed, EM findings included foot process fusion (62%), endothelial cell swelling (38%), subendothelial lucencies (31%), and glomerular basement membrane duplication (41%). EM confirmed FSGS recurrence in three cases. In the remaining 58 cases, there was a positive yield of 31% where 18 biopsies were upgraded to a worse category after TG identification on EM. Kidney allograft outcome was poor regardless whether TG was detected early on EM or advanced on LM. Routine EM use in analyzing pediatric kidney transplant biopsies proved safe and provided valuable additional diagnostic information in almost one-third of cases. Additional studies are needed to determine if clinical interventions for early TG identified on EM can improve long-term outcomes.
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Affiliation(s)
- Jacob D Grodsky
- Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Randall D Craver
- Pathology, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
| | - Isa F Ashoor
- Pediatrics, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana
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8
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Honma F, Fujigaki Y, Nemoto Y, Kikuchi H, Nagura M, Arai S, Ishizawa K, Yamazaki O, Tamura Y, Kondo F, Ohashi R, Uchida S, Shibata S. A Case of Rheumatoid Arthritis Presenting with Renal Thrombotic Microangiopathy Probably due to a Combination of Chronic Tacrolimus Arteriolopathy and Severe Hypertension. Case Rep Nephrol 2019; 2019:3923190. [PMID: 30963011 PMCID: PMC6431373 DOI: 10.1155/2019/3923190] [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: 12/22/2018] [Accepted: 02/18/2019] [Indexed: 11/24/2022] Open
Abstract
A 51-year-old woman with rheumatoid arthritis presented with mild hypertension 20 months after tacrolimus treatment and developing proteinuria 24 months after the treatment. Tacrolimus was discontinued 27 months after the treatment, followed by heavy proteinuria, accelerated hypertension, and deteriorating renal function without ocular fundus lesions as a clinical sign of malignant hypertension. Renal biopsy revealed malignant nephrosclerosis characterized by subacute and chronic thrombotic microangiopathy (TMA), involving small arteries, arterioles, and glomeruli. Focal segmental glomerulosclerosis, probably secondary to chronic TMA, was identified as a cause of heavy proteinuria. The zonal tubulointerstitial injury caused by subacute TMA may have mainly contributed to deteriorating renal function. The presence of nodular hyalinosis in arteriolar walls was indicative of tacrolimus-associated nephrotoxicity. Together with other antihypertensive drugs, administration of aliskiren stabilized renal function with reducing proteinuria. Owing to the preexisting proteinuria prior to severe hypertension and the complex renal histopathology, we postulated that chronic TMA, which was initially triggered by tacrolimus, was aggravated by severe hypertension, resulting in overt renal TMA.
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Affiliation(s)
- Fumika Honma
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yoshikazu Nemoto
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hirotoshi Kikuchi
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Kenichi Ishizawa
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Fukuo Kondo
- Department of Pathology, Teikyo University Hospital, Itabashi-ku, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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Özdemir BH, Ok Atılgan A, Yılmaz Akçay E, Özdemir G, Ayvazoğlu Soy E, Akdur A, Haberal M. De Novo Thrombotic Microangiopathy in Renal Transplant Patients. EXP CLIN TRANSPLANT 2018. [PMID: 29528010 DOI: 10.6002/ect.tond-tdtd2017.p27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Thrombotic microangiopathy is a form of renal capillary injury possibly associated with calcineurin inhibitor toxicity, acute humoral rejection, infections, and recurrent diseases. Here, we examined its incidence in patients diagnosed with acute and chronic active humoral rejection, polyomavirus nephropathy, acute cellular rejection, and immunoglobulin A recurrence. MATERIALS AND METHODS In total, 272 renal allograft recipients who met the inclusion criteria were reevaluated for presence of renal thrombotic microangiopathy. Thrombotic microangiopathy diagnosis was established by clinical, laboratory, and histologic features. C4d expression in peritubular capillaries was determined. Clinical data were collected from medical records. RESULTS Of 272 patients (mean age of 42.8 ± 12.7 years), only 74 patients (27.2%) had de novo thrombotic microangiopathy, which was found in 30/90 patients (33.3%) with acute humoral rejection, 9/51 (17.6%) with acute cellular rejection, 22/53 (41.5%) with chronic active humoral rejection, 10/55 (18.2%) with polyomavirus nephropathy, and 3/23 (13%) with immunoglobulin A nephropathy. Significant differences were shown between therapy type and thrombotic microangiopathy development (P = .02). Patients who received cyclosporine (38.5%) tended to show higher incidence of thrombotic microangiopathy than patients who received tacrolimus (20.7%) or sirolimus (7.7%). Patients with C4d-positive acute humoral (97.6% vs 2.4%) and chronic active humoral rejection (68.2% vs 31.8%) had greater incidence of thrombotic microangiopathy versus those who were C4d-negative. Graft loss was significantly higher in C4d-positive than in C4d-negative thrombotic microangiopathy groups (P < .001). Overall 1-, 3-, and 5-year graft survival was 94%, 85%, and 85% versus 83%, 51%, and 51% in thrombotic microangiopathy-negative versus thrombotic microangiopathy-positive patients (P < .001). CONCLUSIONS Acute humoral rejection and chronic active humoral rejection were the most common and therefore most important causes of de novo thrombotic microangiopathy in renal transplant patients. Its presence in the renal allograft biopsy should arouse suspicion for underlying acute or chronic active humoral rejection.
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Affiliation(s)
- B Handan Özdemir
- From the Department of Pathology, Başkent University Faculty of Medicine, Ankara, Turkey
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10
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[Thrombotic microangiopathy/haemolytic uraemic syndrome. Histopathology update]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:170-177. [PMID: 30012310 DOI: 10.1016/j.patol.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/24/2022]
Abstract
Thrombotic microangiopathy (TMA) encompasses different entities known as haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). The histopathological characteristics have remained constant since the initial description and consist in glomerular-type affectation with the presence of double contours, mesangiolysis and microthrombi. It is generally accepted that the vascular damage is related to the prognosis. Ultrastructure, together with conventional histology, shows notable changes in both capillaries and endothelial cells. A comprehensive histopathological study of the renal biopsy, using electronmicroscopy, is useful in the confirmation of a clinical suspicion and demonstrates the pathogenetic mechanisms in the microcirculatory damage. The close resemblance between the ultrastructural appearance and that seen with the light microscope of TMA and transplant glomerulopathy (TG) is precisely what suggests that both entities are subject to the same etiopathogenetic mechanism in which the endothelial cell is targeted. Recent advances in the pathology of atypical HUS, its relation with complement system and the discovery of specific therapeutic targets, has rekindled an interest in the study of TMA and the importance of renal biopsy.
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11
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Paraffin Immunofluorescence: A Valuable Ancillary Technique in Renal Pathology. Kidney Int Rep 2018; 3:1260-1266. [PMID: 30450452 PMCID: PMC6224795 DOI: 10.1016/j.ekir.2018.07.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/28/2018] [Accepted: 07/02/2018] [Indexed: 01/10/2023] Open
Abstract
Immunofluorescence on frozen tissue is the gold standard immunohistochemical technique for evaluation of immune deposits in the kidney. When frozen tissue is not available or lacks glomeruli, immunofluorescence can be performed on paraffin tissue after antigen retrieval (paraffin immunofluorescence). Excellent results can be obtained by paraffin immunofluorescence in most immune complex-mediated glomerulonephritides and dysproteinemia-associated kidney lesions, and thus this technique has become a valuable salvage technique in renal pathology. Furthermore, new data have emerged suggesting that paraffin immunofluorescence can be used as an unmasking technique, as it is more sensitive than frozen tissue immunofluorescence in some kidney lesions, such as crystalline light chain proximal tubulopathy and is needed to establish the diagnosis of certain unique lesions, such as membranous-like glomerulopathy with masked IgG kappa deposits and membranoproliferative glomerulonephritis with masked monotypic Ig deposits. However, it is important to recognize and be aware of the limitations and pitfalls associated with paraffin immunofluorescence. These include poor sensitivity for detection of C3 deposits and for the diagnosis of primary membranous nephropathy. Here, we summarize the available techniques of paraffin immunofluorescence, review its role and performance as a salvage and unmasking technique in renal pathology, address its limitations and pitfalls, and highlight unusual forms of glomerulopathy that require paraffin immunofluorescence for diagnosis.
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Vazquez Martul E. [The pathology of renal transplants]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:110-123. [PMID: 29602372 DOI: 10.1016/j.patol.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 11/15/2022]
Abstract
In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.
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Affiliation(s)
- Eduardo Vazquez Martul
- Ex Jefe de Servicio de Anatomía Patológica, Hospital Universitario A Coruña (retirado), A Coruña, España; Ex profesor asociado de la Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Miembro del Club de Nefropatología (Sociedad Española de Nefrología), España.
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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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Manook M, Kwun J, Burghuber C, Samy K, Mulvihill M, Yoon J, Xu H, MacDonald AL, Freischlag K, Curfman V, Branum E, Howell D, Farris AB, Smith RA, Sacks S, Dorling A, Mamode N, Knechtle S. Thrombalexin: Use of a Cytotopic Anticoagulant to Reduce Thrombotic Microangiopathy in a Highly Sensitized Model of Kidney Transplantation. Am J Transplant 2017; 17:2055-2064. [PMID: 28226413 PMCID: PMC5519442 DOI: 10.1111/ajt.14234] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 01/04/2017] [Accepted: 01/26/2017] [Indexed: 01/25/2023]
Abstract
Early activation of coagulation is an important factor in the initiation of innate immunity, as characterized by thrombotic microangiopathy (TMA). In transplantation, systemic anticoagulation is difficult due to bleeding. A novel "cytotopic" agent, thrombalexin (TLN), combines a cell-membrane-bound (myristoyl tail) anti-thrombin (hirudin-like peptide [HLL]), which can be perfused directly to the donor organ or cells. Thromboelastography was used to measure time to clot formation (r-time) in both rhesus and human blood, comparing TLN versus HLL (without cytotopic tail) versus negative control. Both TLN- and HLL-treated rhesus or human whole blood result in significantly prolonged r-time compared to kaolin controls. Only TLN-treated human endothelial cells and neonatal porcine islets prolonged time to clot formation. Detection of membrane-bound TLN was confirmed by immunohistochemistry and fluorescence activated cell sorter. In vivo, perfusion of a nonhuman primate kidney TLN-supplemented preservation solution in a sensitized model of transplantation demonstrated no evidence of TLN systemically. Histologically, TLN was shown to be present up to 4 days after transplantation. There was no platelet deposition, and TMA severity, as well as microvascular injury scores (glomerulitis + peritubular capillaritis), were less in the TLN-treated animals. Despite promising evidence of localized efficacy, no survival benefit was demonstrated.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710,Renal and Transplant Department, Guy’s and St Thomas’ NHS Foundation Trust
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Christian Burghuber
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Kannan Samy
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Michael Mulvihill
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - He Xu
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Andrea L. MacDonald
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Kyle Freischlag
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Verna Curfman
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Evelyn Branum
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - David Howell
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Alton Brad Farris
- Department of Pathology, Emory University Hospital, Atlanta GA 30322
| | | | - Stephen Sacks
- MRC Centre for Transplantation, King’s College, London, UK
| | | | - Nizam Mamode
- Renal and Transplant Department, Guy’s and St Thomas’ NHS Foundation Trust
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710,Corresponding author: Stuart J Knechtle, MD, 330 Trent Drive, DUMC Box 3512, Durham, NC 27710, U.S.A., Phone: 919-613-9687; Fax: 919-684-8716;
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