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Donor-derived Cell-free DNA Complements De Novo Class II DSA in Detecting Late Alloimmune Injury Post Kidney Transplantation. Transplant Direct 2022; 8:e1285. [PMID: 35187211 PMCID: PMC8806361 DOI: 10.1097/txd.0000000000001285] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 01/09/2023] Open
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Stites E, Kumar D, Olaitan O, John Swanson S, Leca N, Weir M, Bromberg J, Melancon J, Agha I, Fattah H, Alhamad T, Qazi Y, Wiseman A, Gupta G. High levels of dd-cfDNA identify patients with TCMR 1A and borderline allograft rejection at elevated risk of graft injury. Am J Transplant 2020; 20:2491-2498. [PMID: 32056331 PMCID: PMC7496411 DOI: 10.1111/ajt.15822] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 01/25/2023]
Abstract
The clinical importance of subclinical, early T cell-mediated rejection (Banff TCMR 1A and borderline lesions) remains unclear, due, in part to the fact that histologic lesions used to characterize early TCMR can be nonspecific. Donor-derived cell-free DNA (dd-cfDNA) is an important molecular marker of active graft injury. Over a study period from June 2017 to May 2019, we assessed clinical outcomes in 79 patients diagnosed with TCMR 1A/borderline rejection across 11 US centers with a simultaneous measurement of dd-cfDNA. Forty-two patients had elevated dd-cfDNA (≥0.5%) and 37 patients had low levels (<0.5%). Elevated levels of dd-cfDNA predicted adverse clinical outcomes: among patients with elevated cfDNA, estimated glomerular filtration rate declined by 8.5% (interquartile rate [IQR] -16.22% to -1.39%) (-3.50 mL/min/1.73 m2 IQR -8.00 to -1.00) vs 0% (-4.92%, 4.76%) in low dd-cfDNA patients (P = .004), de novo donor-specific antibody formation was seen in 40% (17/42) vs 2.7% (P < .0001), and future or persistent rejection occurred in 9 of 42 patients (21.4%) vs 0% (P = .003). The use of dd-cfDNA may complement the Banff classification and to risk stratify patients with borderline/TCMR 1A identified on biopsy.
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Affiliation(s)
| | - Dhiren Kumar
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | | | | | - Nicolae Leca
- Division of NephrologyDepartment of MedicineUniversity of Washington Medical CenterSeattleWashingtonUSA
| | - Matthew Weir
- Division of NephrologyUniversity of MarylandBaltimoreMarylandUSA
| | | | - Joseph Melancon
- SurgeryGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Irfan Agha
- Medical City Dallas HospitalDallasTexasUSA
| | - Hasan Fattah
- University of Kentucky Medical CenterLexingtonKentuckyUSA
| | - Tarek Alhamad
- Washington University in Saint LouisSaint LouisMissouriUSA
| | - Yasir Qazi
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Internal MedicineDivision of NephrologyLos AngelesCaliforniaUSA
| | | | - Gaurav Gupta
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
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Pathak V, Madhavan D, Narayanasamy K, Kumar S, Ramalingam V, Sengodagounder B, Bodonyi-Kovacs G. Low-dose Rituximab and Thymoglobulin Induction With Steroid-free Maintenance Immunosuppression and Protocol Biopsies Improves Long-term Patient and Graft Survival After Kidney Transplantation: Survival and Safety Outcomes in More Than 1100 Patients From a Single Center. Transplant Direct 2019; 5:e475. [PMID: 31576371 PMCID: PMC6708634 DOI: 10.1097/txd.0000000000000923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Steroid-free maintenance immunosuppression after kidney transplantation provides acceptable patient and graft survival and minimizes steroid-associated side effects among recipients with a low immunological risk. However, the long-term outcomes of such protocols, incorporating low-dose rituximab and thymoglobulin induction along with protocol biopsies, in non-European populations remains underreported. METHODS We retrospectively analyzed 1142 consecutive kidney transplantations conducted at our center from July 2005 to October 2017. Immunosuppression protocol included induction with thymoglobulin and low-dose preoperative rituximab. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil; prednisolone was discontinued on postoperative day 5. Protocol biopsies were carried out at 3 months and at 1, 5, and 10 years after transplantation-in addition to the indicated biopsies. The 12-year patient and graft survival and posttransplantation complications were studied. RESULTS The analysis of outcomes was conducted for 1111 transplant recipients. Patients (70.59%) remained steroid-free at 12 years after transplantation. The patient survival rates at 1, 5, and 12 years were 97.7%, 94.8%, and 92.4%, respectively. The corresponding graft survival rates were 97.2%, 90.9%, and 86.1%, respectively. Biopsy-proven acute rejection occurred in 12.7% of recipients, including 3.5% subclinical rejections. The cumulative incidence of graft loss was 6.56% at 12.3 years. The overall incidence of death was 5.3%. CONCLUSIONS Steroid-free maintenance immunosuppression was associated with excellent long-term patient and graft survival rates and reduced incidence of prednisolone-related side effects, despite acceptable rejection rates. Low-dose rituximab with thymoglobulin induction with immediate steroid withdrawal and surveillance biopsies resulted in excellent long-term outcomes in our single-center experience.
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Affiliation(s)
- Vivek Pathak
- Consultant Nephrologist, Kovai Medical Center, Coimbatore, India
| | - Devdas Madhavan
- Consultant Urologist, Kovai Medical Center, Coimbatore, India
| | | | - Sampath Kumar
- Consultant Urologist, Kovai Medical Center, Coimbatore, India
| | | | | | - Gabor Bodonyi-Kovacs
- Assistant Professor, Division of Nephrology, MFA, George Washington University, Washington, DC
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Couvrat-Desvergnes G, Foucher Y, Le Borgne F, Dion A, Mourad G, Garrigue V, Legendre C, Rostaing L, Kamar N, Kessler M, Ladrière M, Morelon E, Buron F, Giral M, Dantan E. Comparison of graft and patient survival according to the transplantation centre policy for 1-year screening biopsy among stable kidney recipients: a propensity score-based study. Nephrol Dial Transplant 2018; 34:703-711. [DOI: 10.1093/ndt/gfy221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Grégoire Couvrat-Desvergnes
- Department of Nephrology, Dialysis and Transplantation, Departmental Hospital of Vendée, La Roche-sur-Yon, France
- Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS “Centaure”, Nantes, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Florent Le Borgne
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- IDBC/A2com, Pacé, France
| | - Angelina Dion
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Georges Mourad
- Department of Nephrology, Dialysis and Transplantation, Lapeyronie University Hospital, Montpellier, France
| | - Valérie Garrigue
- Department of Nephrology, Dialysis and Transplantation, Lapeyronie University Hospital, Montpellier, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS “Centaure”, Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Lionel Rostaing
- Department of Nephrology, Dialysis, and Organ Transplantation, Rangueil University Hospital and University Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis, and Organ Transplantation, Rangueil University Hospital and University Paul Sabatier, Toulouse, France
| | - Michèle Kessler
- Department of Renal Transplantation, Brabois University Hospital, Nancy, France
| | - Marc Ladrière
- Department of Renal Transplantation, Brabois University Hospital, Nancy, France
| | - Emmanuel Morelon
- Department of Nephrology, Transplantation and Clinic Immunology, RTRS “Centaure”, Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Fanny Buron
- Department of Nephrology, Transplantation and Clinic Immunology, RTRS “Centaure”, Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Magali Giral
- Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS “Centaure”, Nantes, France
- Centre d’Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
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Giral M, Renaudin K, Naesens M, Luning R, Anglicheau D, Morelon E, Huneau A, Paul C, Brouard S, Couvrat-Desvergnes G, Foucher Y, Dantan E. The 1-year Renal Biopsy Index: a scoring system to drive biopsy indication at 1-year post-kidney transplantation. Transpl Int 2018; 31:947-955. [PMID: 29893433 DOI: 10.1111/tri.13290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/26/2018] [Accepted: 06/07/2018] [Indexed: 11/27/2022]
Abstract
Surveillance biopsies after renal transplantation remain debatable. To drive the decision of such intervention, we propose a predictive score of abnormal histology at 1-year post-transplantation, named 1-year Renal Biopsy Index (1-RBI). We studied 466 kidney recipients from the DIVAT cohort alive with a functioning graft and a surveillance biopsy at 1-year post-transplantation. Patients displaying abnormal histology (49%) (borderline, acute rejection, interstitial fibrosis and tubular atrophy [IFTA] grade 2 or 3, glomerulonephritis) were compared to the normal or subnormal (IFTA grade 1) histology group. Obtained from a lasso penalized logistic regression, the 1-RBI was composed of recipient gender, serum creatinine at 3, 6, and 12 month post-transplantation and anticlass II immunization at transplantation (internal validation: AUC = 0.71, 95% CI [0.53-0.83]; external validation: AUC = 0.62, 95% CI [0.58-0.66]). While we could not determinate a threshold able to identify patients at high chance of normal or subnormal histology, we estimated and validated a discriminating threshold capable of identifying a subgroup of 15% of the patients with a risk of abnormal histology higher than 80%. The 1-RBI is computable online at www.divat.fr. The 1-RBI could be a useful tool to standardize 1-year biopsy proposal and may for instance help to indicate one in case of high risk of abnormal histology.
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Affiliation(s)
- Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Karine Renaudin
- Pathological Anatomy and Cytology, CHU Hôtel-Dieu, Nantes, France
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Redmer Luning
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dany Anglicheau
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS "Centaure", Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinic Immunology Department, RTRS "Centaure", Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Alexandre Huneau
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Chloé Paul
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Sophie Brouard
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France
| | - Grégoire Couvrat-Desvergnes
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France
- Department of Nephrology, Dialysis and Transplantation, Departmental Hospital of Vendée, La Roche-sur-Yon, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
- CHU NANTES, Nantes, France
| | - Etienne Dantan
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
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Broecker V, Mengel M. The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 2014; 28:136-43. [PMID: 25205033 DOI: 10.1111/tri.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 01/20/2023]
Abstract
In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
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Affiliation(s)
- Verena Broecker
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Regulatory T cells in the immunodiagnosis and outcome of kidney allograft rejection. Clin Dev Immunol 2013; 2013:852395. [PMID: 23843861 PMCID: PMC3697130 DOI: 10.1155/2013/852395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 05/02/2013] [Accepted: 06/02/2013] [Indexed: 12/27/2022]
Abstract
Acute rejection (AR) is responsible for up to 12% of graft loss with the highest risk generally occurring during the first six months after transplantation. AR may be broadly classified into humoral as well as cellular rejection. Cellular rejection develops when donor alloantigens, presented by antigen-presenting cells (APCs) through class I or class II HLA molecules, activate the immune response against the allograft, resulting in activation of naive T cells that differentiate into subsets including cytotoxic CD8+ and helper CD4+ T cells type 1 (TH1) and TH2 cells or into cytoprotective immunoregulatory T cells (Tregs). The immune reaction directed against a renal allograft has been suggested to be characterized by two major components: a destructive one, mediated by CD4+ helper and CD8+ cytotoxic T cells, and a protective response, mediated by Tregs. The balance between these two opposite immune responses can significantly affect the graft survival. Many studies have been performed in order to define the role of Tregs either in the immunodiagnosis of transplant rejection or as predictor of the clinical outcome. However, information available from the literature shows a contradictory picture that deserves further investigation.
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