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Swanson KJ, Zhong W, Mandelbrot DA, Parajuli S. Histopathological Features and Role of Allograft Kidney Biopsy Among Recipients With Prolonged Delayed Graft Function: A Review. Transplantation 2024; 108:1911-1921. [PMID: 38383958 DOI: 10.1097/tp.0000000000004928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Delayed graft function (DGF) is an early posttransplant complication predictive of adverse outcomes. This "acute kidney injury of transplantation" is often defined as allograft dysfunction requiring renal replacement within 7 d posttransplantation. DGF is an important area of study because it is emerging with efforts to expand the donor pool and address the supply-demand gap in kidney transplantation. DGF is often caused by severe kidney injury mechanisms because of multiple donors, recipients, and immunologic factors. The role of kidney biopsy, particularly in prolonged DGF, is an ongoing area of research and inquiry for clinicians and researchers alike to better define, manage, and predict outcomes of this early posttransplant event. This review aims to provide an in-depth, comprehensive summary of the literature to date on the histopathology of DGF and the role of kidney transplant biopsies in prolonged DGF.
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Affiliation(s)
- Kurtis J Swanson
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Weixiong Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Castro Filho JBSD, Pompeo JDC, Machado RB, Gonçalves LFS, Bauer AC, Manfro RC. Delayed Graft Function Under the Microscope: Surveillance Biopsies in Kidney Transplantation. Transpl Int 2022; 35:10344. [PMID: 35401043 PMCID: PMC8988887 DOI: 10.3389/ti.2022.10344] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022]
Abstract
Delayed graft function (DGF) is a common complication of kidney transplantation and frequently leads to the necessity of surveillance biopsies. The purpose of this study is to describe the histological findings in surveillance biopsies of deceased donor kidney transplant recipients and evaluate the risk factors for graft outcomes. This is a monocentric, retrospective study including kidney transplant recipients that underwent a graft biopsy during the DGF period between January 2006 and July 2019. 356 biopsies were performed in 335 deceased donor transplant recipients. Biopsies were analyzed according to the Banff classification. The main histological findings were: acute tubular necrosis in 150 biopsies (42.1%), acute rejection in 96 biopsies (26.9%), and borderline findings in 91 biopsies (25.5%). In the multivariate analysis, recipient age (p = 0.028) and DGF duration (p = 0.005) were associated with rejection, antibody-induction with anti-thymocyte globulin (ATG) was protective (p = 0.001). The occurrence of rejection was associated with lower death-censored graft survival (log-rank; p = 0.009). Surveillance biopsies of kidney grafts experiencing DGF remain an essential tool for the care of kidney transplant recipients. The recipient’s age and duration of DGF are independent risk factors for acute rejection, while antibody-induction therapy with ATG is associated with protection from its occurrence.
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Affiliation(s)
| | | | - Rafael Berlezi Machado
- UFRGS Medical School, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luiz Felipe Santos Gonçalves
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,UFRGS Medical School, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,UFRGS Medical School, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Roberto Ceratti Manfro
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,UFRGS Medical School, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Division of Transplantation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Outcomes of Delayed Graft Function in Kidney Transplant Recipients Stratified by Histologic Biopsy Findings. Transplant Proc 2021; 53:1462-1469. [PMID: 33579551 DOI: 10.1016/j.transproceed.2021.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/08/2021] [Indexed: 01/06/2023]
Abstract
Delayed graft function (DGF) after kidney transplantation is associated with an increased risk of graft failure. We studied the histologic findings among adult kidney transplant recipients transplanted between January 2000 and June 2015 who had DGF and had a kidney biopsy within 14 days of transplant. Death censored graft failure (DCGF) and death at 1 and 3 years after transplant were examined. A total of 269 transplant recipients fulfilled our selection criteria, of which 152 (56.51%) had acute tubular necrosis (ATN), 44 (16.4%) had acute rejection (AR), mainly T-cell mediated rejection (n = 31), 35 (13%) had ATN with AR (mainly T-cell mediated rejection, n = 26), and 38 (14.1%) had other pathology. Compared with those with ATN alone, kidney transplant recipients with AR alone had a significantly higher risk of DCGF at 1 year post transplant (adjusted hazard ratio = 3.70; 95% confidence interval 1.5-9.5; P = .006). Those with AR alone had an increased risk of DCGF at 3 years post transplant (hazard ratio = 3.10; 95% confidence interval 1.3-8.5; P = .01) in crude analyses. There was no association between DGF etiology and mortality. Early renal biopsy can be used to distinguish AR, which has protocolized treatments, from other etiologies. This could potentially alter allograft survival within 1 year of transplant complicated by DGF.
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Favi E, James A, Puliatti C, Whatling P, Ferraresso M, Rui C, Cacciola R. Utility and safety of early allograft biopsy in adult deceased donor kidney transplant recipients. Clin Exp Nephrol 2019; 24:356-368. [PMID: 31768863 DOI: 10.1007/s10157-019-01821-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Delayed graft function (DGF) is considered a risk factor for rejection after kidney transplantation (KTx). Clinical guidelines recommend weekly allograft biopsy until DGF resolves. However, who may benefit the most from such an aggressive policy and when histology should be evaluated remain debated. METHODS We analyzed 223 biopsies in 145 deceased donor KTx treated with basiliximab or anti-thymocyte globulin (rATG) and calcineurin inhibitor-based maintenance. The aim of the study was to assess the utility and safety of biopsies performed within 28 days of transplant. Relationships between transplant characteristics, indication, timing, and biopsy-related outcomes were evaluated. RESULTS Main indication for biopsy was DGF (87.8%) followed by lack of improvement in graft function (9.2%), and worsening graft function (3.1%). Acute tubular necrosis was the leading diagnosis (89.8%) whereas rejection was detected in 8.2% specimens. Rejection was more frequent in patients biopsied due to worsening graft function or lack of improvement in graft function than DGF (66.7% vs. 3.5%; P = 0.0075 and 33.3% vs. 3.5%; P = 0.0104, respectively) and in biopsies performed between day 15 and 28 than from day 0 to 14 (31.2% vs. 3.7%; P = 0.0002). Complication rate was 4.1%. Management was affected by the information gained with histology in 12.2% cases (7% considering DGF). CONCLUSIONS In low-immunological risk recipients treated with induction and calcineurin inhibitors maintenance, protocol biopsies obtained within 2 weeks of surgery to rule out rejection during DGF do not necessarily offer a favourable balance between risks and benefits. In these patients, a tailored approach may minimize complications thus optimizing results.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy.
| | - Ajith James
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Carmelo Puliatti
- Organ Transplantation, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Phil Whatling
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Chiara Rui
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
| | - Roberto Cacciola
- HPB and Transplant Unit, Department of Surgery, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy
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Nankivell BJ, Agrawal N, Sharma A, Taverniti A, P'Ng CH, Shingde M, Wong G, Chapman JR. The clinical and pathological significance of borderline T cell-mediated rejection. Am J Transplant 2019; 19:1452-1463. [PMID: 30501008 DOI: 10.1111/ajt.15197] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/28/2018] [Accepted: 11/15/2018] [Indexed: 01/25/2023]
Abstract
The pathological diagnosis of borderline rejection (BL-R) denotes possible T cell-mediated rejection (TCMR), but its clinical significance is uncertain. This single-center, cross-sectional cohort study compared the functional and histological outcomes of consecutive BL-R diagnoses (n = 146) against normal controls (n = 826) and acute TCMR (n = 55) from 551 renal transplant recipients. BL-R was associated with the following: contemporaneous renal dysfunction, acute tubular necrosis, and chronic tubular atrophy (P < .001); progressive tubular injury with fibrosis by longitudinal sequential histology (45.3% at 1 year); increased subsequent acute rejection (39.4%), allograft failure (P < .001), and patient mortality (P = .007). BL-R detected by biopsy indicated for impaired function was followed by suboptimal functional recovery (46.3%), persistent inflammation (27.2%), and acute rejection episodes (50.0%) despite antirejection treatment in 83.3%. By 1 year after BL-R, the incidence of new-onset microvascular inflammation (9.3%), C4d staining (22.3%), transplant glomerulopathy (13.3%), and de novo donor-specific antibodies (31.5%) exceeded normal controls (P < .05-.001). BL-R inflammation in protocol biopsy persisted in 28.0% and progressed to acute rejection in 32.6%; however, it resolved in 61.6% of the untreated cases. In summary, BL-R is a heterogeneous diagnostic grouping, ranging from mild inconsequential inflammation to clinically significant TCMR, which is capable of immune-mediated tubular injury resulting in inferior functional, immunological, and histological consequences.
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Affiliation(s)
| | - Nidhi Agrawal
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - Ankit Sharma
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Anne Taverniti
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Chow H P'Ng
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Meena Shingde
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Germaine Wong
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
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