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Xu N, Wang D, Hong Y, Huang P, Xu Q, Sun H, Cai L, Yin J, Zhang L, Yang B. A nomogram based on contrast-enhanced ultrasound for evaluating the glomerulosclerosis rate in transplanted kidneys. Quant Imaging Med Surg 2024; 14:3060-3074. [PMID: 38617161 PMCID: PMC11007528 DOI: 10.21037/qims-23-1514] [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: 10/26/2023] [Accepted: 02/27/2024] [Indexed: 04/16/2024]
Abstract
Background A high rate of glomerulosclerosis serves as an important signal of poor response to treatment and a high risk of disease progression or adverse prognosis in transplanted kidneys. We hypothesized that contrast-enhanced ultrasound (CEUS) could serve as a novel imaging biomarker in the early prediction of glomerulosclerosis rate by evaluating renal allograft microcirculation. Methods A retrospective analysis was performed on 143 transplanted kidney recipients with confirmed pathology, including 100 in the training group and 43 in the validation group. All patients underwent conventional ultrasound (CUS) and CEUS examinations. The patients were divided into two groups: those with >50% glomerulosclerosis and those with ≤50% glomerulosclerosis. The nomograms derived from independent predictors identified by multivariate logistic analysis were assessed using receiver operating characteristic (ROC) curve analysis, 1,000 bootstrap resamples, calibration curves, and decision curve analysis (DCA). Results The patients with >50% glomerulosclerosis and those with ≤50% glomerulosclerosis showed statistically significant differences in CEUS parameters, including in peak intensity (PI) (25 vs. 30; P<0.001), absolute time to peak (ATTP) (10 vs. 9; P=0.004), and time to peak (TTP) (22 vs. 19.5; P=0.026). Multivariate analysis revealed that PI [odds ratio (OR) =0.852; 95% confidence interval (CI): 0.737-0.986], peak systolic velocity (PSV) of the interlobar artery (OR =0.850; 95% CI: 0.758-0.954), cortical echogenicity (OR =38.429; 95% CI: 3.695-399.641), and time since transplantation (OR =1.017; 95% CI: 1.006-1.028) were independent predictors of whether the glomerulosclerosis rate was >50% and were incorporated into the construction of a nomogram. The area under the curve (AUC) of the nomogram in the training and validation groups was 0.914 (95% CI: 0.840-0.960) and 0.909 (95% CI: 0.781-0.975), respectively, with a bootstrap resampling AUC of 0.877. The calibration curve and DCA confirmed the diagnostic performance of the nomogram model. Conclusions The nomogram, which combined CUS, CEUS, and clinical indicators, exhibited notable predictive efficacy for the glomerulosclerosis rate in transplanted kidneys, thereby demonstrating the potential to improve clinical decision-making.
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Affiliation(s)
- Nan Xu
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dandan Wang
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Hong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Pengfei Huang
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qianjin Xu
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hui Sun
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Liping Cai
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jing Yin
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lijuan Zhang
- Department of Ultrasound Medicine, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bin Yang
- Department of Ultrasound, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Niemann M, Matern BM, Spierings E. Repeated local ellipsoid protrusion supplements HLA surface characterization. HLA 2024; 103:e15260. [PMID: 37853578 DOI: 10.1111/tan.15260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/11/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
Allorecognition of donor HLA is a major risk factor for long-term kidney graft survival. Although several molecular matching algorithms have been proposed that compare physiochemical and structural features of the donors' and recipients' HLA proteins in order to predict their compatibility, the exact underlying mechanisms are still not fully understood. We hypothesized that the ElliPro approach of single ellipsoid fitting and protrusion ranking lacks sensitivity for the characteristic shape of HLA molecules and developed a prediction pipeline named Snowball that is fitting smaller ellipsoids iteratively to substructures. Aggregated protrusion ranks of locally fitted ellipsoids were calculated for 712 publicly available HLA structures and 78 predicted structures using AlphaFold 2. Amino-acid sequence and protrusion ranks were used to train deep neural network predictors to infer protrusion ranks for all known HLA sequences. Snowball protrusion ranks appear to be more sensitive than ElliPro scores in fine parts of the HLA such as the helix structures forming the HLA binding groove in particular when the ellipsoids are fitted to substructures considering atoms within a 15 Å radius. A cloud-based web service was implemented based on amino-acid matching considering both protein- and position-specific surface area and protrusion ranks extending the previously presented Snowflake prediction pipeline.
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Affiliation(s)
| | - Benedict M Matern
- Research and Development, PIRCHE AG, Berlin, Germany
- Center for Translational Immunology, University Medical Center, Utrecht, Netherlands
| | - Eric Spierings
- Center for Translational Immunology, University Medical Center, Utrecht, Netherlands
- Central Diagnostic Laboratory, University Medical Center, Utrecht, Netherlands
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3
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Han HS, Lubetzky ML. Immune monitoring of allograft status in kidney transplant recipients. FRONTIERS IN NEPHROLOGY 2023; 3:1293907. [PMID: 38022723 PMCID: PMC10663942 DOI: 10.3389/fneph.2023.1293907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
Kidney transplant patients require careful management of immunosuppression to avoid rejection while minimizing the risk of infection and malignancy for the best long-term outcome. The gold standard for monitoring allograft status and immunosuppression adequacy is a kidney biopsy, but this is invasive and costly. Conventional methods of allograft monitoring, such as serum creatinine level, are non-specific. Although they alert physicians to the need to evaluate graft dysfunction, by the time there is a clinical abnormality, allograft damage may have already occurred. The development of novel and non-invasive methods of evaluating allograft status are important to improving graft outcomes. This review summarizes the available conventional and novel methods for monitoring allograft status after kidney transplant. Novel and less invasive methods include gene expression, cell-free DNA, urinary biomarkers, and the use of artificial intelligence. The optimal method to manage patients after kidney transplant is still being investigated. The development of less invasive methods to assess allograft function has the potential to improve patient outcomes and allow for a more personalized approach to immunosuppression management.
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Affiliation(s)
- Hwarang S. Han
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, United States
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Farkona S, Pastrello C, Konvalinka A. Proteomics: Its Promise and Pitfalls in Shaping Precision Medicine in Solid Organ Transplantation. Transplantation 2023; 107:2126-2142. [PMID: 36808112 DOI: 10.1097/tp.0000000000004539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Solid organ transplantation is an established treatment of choice for end-stage organ failure. However, all transplant patients are at risk of developing complications, including allograft rejection and death. Histological analysis of graft biopsy is still the gold standard for evaluation of allograft injury, but it is an invasive procedure and prone to sampling errors. The past decade has seen an increased number of efforts to develop minimally invasive procedures for monitoring allograft injury. Despite the recent progress, limitations such as the complexity of proteomics-based technology, the lack of standardization, and the heterogeneity of populations that have been included in different studies have hindered proteomic tools from reaching clinical transplantation. This review focuses on the role of proteomics-based platforms in biomarker discovery and validation in solid organ transplantation. We also emphasize the value of biomarkers that provide potential mechanistic insights into the pathophysiology of allograft injury, dysfunction, or rejection. Additionally, we forecast that the growth of publicly available data sets, combined with computational methods that effectively integrate them, will facilitate a generation of more informed hypotheses for potential subsequent evaluation in preclinical and clinical studies. Finally, we illustrate the value of combining data sets through the integration of 2 independent data sets that pinpointed hub proteins in antibody-mediated rejection.
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Affiliation(s)
- Sofia Farkona
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Soham and Shaila Ajmera Family Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Chiara Pastrello
- Osteoarthritis Research Program, Division of Orthopedic Surgery, Schroeder Arthritis Institute University Health Network, Toronto, ON, Canada
- Data Science Discovery Centre for Chronic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Ana Konvalinka
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Soham and Shaila Ajmera Family Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
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5
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Keijbeck A, Raaijmaakers A, Hillen L, Gelens M, van Kuijk S, Cleutjens JPM, Peutz-Kootstra C, Christiaans M. Visual interstitial fibrosis assessment as continuous variable in protocol renal transplant biopsies. Histopathology 2023; 82:713-721. [PMID: 36579371 DOI: 10.1111/his.14857] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022]
Abstract
AIMS In current renal transplant pathology practice, interstitial fibrosis is visually assessed in categories according to the Banff classification. As this has a moderate reproducibility, which is little ameliorated by morphometric analysis, we investigated whether visual renal fibrosis assessment is feasible on a continuous scale, i.e. as a percentage of affected area of the cortex. METHODS AND RESULTS Protocol renal biopsies taken at transplantation (n = 125), three (n = 73) and 12 months (n = 88) after transplantation were visually scored in categories (Banff) and percentages for interstitial fibrosis (ci). Interobserver variation (ICC and weighted κ) was assessed, and morphometric analysis on Sirius red-stained sections was performed. Correlations between the different methods and their association with donor age and eGFR 1 and 5 years post-transplant were analysed using Pearson's or Spearman's rho. Interobserver agreement was equivalent for Banff and %ci (κ = 0.713 versus ICC = 0.792), and for Banff IF/TA and %IF/TA (κ = 0.615 versus ICC = 0.743). Both Banff and %ci were associated with Sirius red morphometry in 3 and 12 months. With all three methods, a significant correlation was found between donor age and fibrosis in the implantation biopsy and between fibrosis in the 12 months' biopsy and eGFR at 1 and 5 years (eGFR at 1 year: Sirius red ρ = 0.487, %ci ρ = 0.393, Banff ρ = 0.413, all P < 0.01, eGFR at 5 years: Sirius red ρ = 0.392, %ci ρ = 0.333, Banff ρ = 0.435, all P < 0.01). CONCLUSION Interstitial fibrosis assessment on a continuous scale can be used next to scoring in categories according to the Banff classification in protocol renal transplant biopsies.
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Affiliation(s)
- Anke Keijbeck
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Anniek Raaijmaakers
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa Hillen
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marielle Gelens
- Department of Internal Medicine, Division of Nephrology, School of Nutrition and Translational Research in Metabolism University Maastricht (NUTRIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jack P M Cleutjens
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Carine Peutz-Kootstra
- Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Maarten Christiaans
- Department of Internal Medicine, Division of Nephrology, School of Nutrition and Translational Research in Metabolism University Maastricht (NUTRIM), Maastricht University Medical Centre, Maastricht, the Netherlands
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Chuang YW, Huang ST, Wang IK, Lo YC, Chang CT, Lin CL, Yu TM, Li CY. Risk of Severe Alphaherpesvirus Infection after Solid Organ Transplantation: A Nationwide Population-Based Cohort Study. Biomedicines 2023; 11:biomedicines11020637. [PMID: 36831173 PMCID: PMC9953582 DOI: 10.3390/biomedicines11020637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Patients after solid organ transplantation (SOT) are more susceptible to various viral infections, including alphaherpesviruses. Therefore, the aim of our study was to investigate the risk of alphaherpesvirus infections, including herpes simplex and herpes zoster, after solid organ transplantation. Inpatient records from the Taiwan National Health Insurance Research Database (NHIRD) defined solid organ recipients, including heart, liver, lung, and kidney, hospitalized for alphaherpesvirus infections as a severe case group of transplants and matched them with a nontransplant cohort. We enrolled 18,064 individuals, of whom 9032 were in each group. A higher risk of severe alphaherpesvirus infection was noted in solid organ recipients (aHR = 9.19; p < 0.001) than in the general population. In addition, solid organ transplant recipients had the highest risk of alphaherpesvirus infection within 1 year after transplantation (aHR = 25.18). The comparison found a higher risk of herpes zoster and herpes simplex infections in recipients of kidney (aHR = 9.13; aHR = 12.13), heart (aHR = 14.34; aHR = 18.54), and liver (aHR = 5.90; aHR = 8.28) transplants. Patients who underwent solid organ transplantation had a significantly higher risk of alphaherpesvirus infection than the general population.
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Affiliation(s)
- Ya-Wen Chuang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Shih-Ting Huang
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - I-Kuan Wang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, China Medical University Hospital, Taichung 404333, Taiwan
| | - Ying-Chih Lo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Chiz-Tzung Chang
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, China Medical University Hospital, Taichung 404333, Taiwan
| | - Cheng-Li Lin
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung 404333, Taiwan
| | - Tung-Min Yu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Correspondence: (T.-M.Y.); (C.-Y.L.); Tel.: +886-4-2205212 (C.-Y.L.)
| | - Chi-Yuan Li
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Department of Anesthesiology, China Medical University Hospital, Taichung 404333, Taiwan
- Correspondence: (T.-M.Y.); (C.-Y.L.); Tel.: +886-4-2205212 (C.-Y.L.)
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Lopez-Soler RI, Nikouee A, Kim M, Khan S, Sivaraman L, Ding X, Zang QS. Beclin-1 dependent autophagy improves renal outcomes following Unilateral Ureteral Obstruction (UUO) injury. Front Immunol 2023; 14:1104652. [PMID: 36875088 PMCID: PMC9978333 DOI: 10.3389/fimmu.2023.1104652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
Background Interstitial Fibrosis and Tubular Atrophy (IFTA) is the most common cause of long-term graft failure following renal transplant. One of the hallmarks of IFTA is the development of interstitial fibrosis and loss of normal renal architecture. In this study, we evaluated the role of autophagy initiation factor Beclin-1 in protecting against post-renal injury fibrosis. Methods Adult male wild type (WT) C57BL/6 mice were subjected to Unilateral Ureteral Obstruction (UUO), and kidney tissue samples were harvested at 72-hour, 1- and 3-week post-injury. The UUO-injured and uninjured kidney samples were examined histologically for fibrosis, autophagy flux, inflammation as well activation of the Integrated Stress Response (ISR). We compared WT mice with mice carrying a forced expression of constitutively active mutant form of Beclin-1, Becn1F121A/F121A . Results In all experiments, UUO injury induces a progressive development of fibrosis and inflammation. These pathological signs were diminished in Becn1F121A/F121A mice. In WT animals, UUO caused a strong blockage of autophagy flux, indicated by continuously increases in LC3II accompanied by an over 3-fold accumulation of p62 1-week post injury. However, increases in LC3II and unaffected p62 level by UUO were observed in Becn1F121A/F121A mice, suggesting an alleviation of disrupted autophagy. Beclin-1 F121A mutation causes a significant decrease in phosphorylation of inflammatory STING signal and limited production of IL6 and IFNγ, but had little effect on TNF-α, in response to UUO. Furthermore, activation of ISR signal cascade was detected in UUO-injured in kidneys, namely the phosphorylation signals of elF2S1 and PERK in addition to the stimulated expression of ISR effector ATF4. However, Becn1F121A/F121A mice did not reveal signs of elF2S1 and PERK activation under the same condition and had a dramatically reduced ATF level at 3-week post injury. Conclusions The results suggest that UUO causes a insufficient, maladaptive renal autophagy, which triggered downstream activation of inflammatory STING pathway, production of cytokines, and pathological activation of ISR, eventually leading to the development of fibrosis. Enhancing autophagy via Beclin-1 improved renal outcomes with diminished fibrosis, via underlying mechanisms of differential regulation of inflammatory mediators and control of maladaptive ISR.
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Affiliation(s)
- Reynold I. Lopez-Soler
- Section of Renal Transplantation, Edward Hines Jr. VA Hospital, Hines, IL, United States
- Department of Surgery, Division of Intra-Abdominal Transplantation, Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
| | - Azadeh Nikouee
- Department of Surgery, Burn & Shock Trauma Research Institute; Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
| | - Matthew Kim
- Department of Surgery, Burn & Shock Trauma Research Institute; Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
| | - Saman Khan
- Department of Surgery, Burn & Shock Trauma Research Institute; Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
| | - Lakshmi Sivaraman
- Department of Biology, Loyola University Chicago, Chicago, IL, United States
| | - Xiangzhong Ding
- Department of Pathology, Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
| | - Qun Sophia Zang
- Department of Surgery, Burn & Shock Trauma Research Institute; Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
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8
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Adam BA. Importance of Confounding Factors in the Evaluation of Surrogate Measures for Kidney Transplant Fibrosis. KIDNEY360 2022; 3:1829-1830. [PMID: 36514406 PMCID: PMC9717621 DOI: 10.34067/kid.0005852022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Benjamin A. Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
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9
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Archer KJ, Bardhi E, Maluf DG, McDaniels J, Rousselle T, King A, Eason JD, Gallon L, Akalin E, Mueller TF, Mas VR. Pretransplant kidney transcriptome captures intrinsic donor organ quality and predicts 24-month outcomes. Am J Transplant 2022; 22:2515-2528. [PMID: 35730259 PMCID: PMC9710201 DOI: 10.1111/ajt.17127] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/08/2022] [Accepted: 06/09/2022] [Indexed: 01/25/2023]
Abstract
With the development of novel prognostic tools derived from omics technologies, transplant medicine is entering the era of precision medicine. Currently, there are no established predictive biomarkers for posttransplant kidney function. A total of 270 deceased donor pretransplant kidney biopsies were collected and posttransplant function was prospectively monitored. This study first assessed the utility of pretransplant gene expression profiles in predicting 24-month outcomes in a training set (n = 174). Nearly 600 differentially expressed genes were associated with 24-month graft function. Grafts that progressed to low function at 24 months exhibited upregulated immune responses and downregulated metabolic processes at pretransplantation. Using penalized logistic regression modeling, a 55 gene model area under the receiver operating curve (AUROC) for 24-month graft function was 0.994. Gene expression for a subset of candidate genes was then measured in an independent set of pretransplant biopsies (n = 96) using quantitative polymerase chain reaction. The AUROC when using 13 genes with three donor characteristics (age, race, body mass index) was 0.821. Subsequently, a risk score was calculated using this combination for each patient in the validation cohort, demonstrating the translational feasibility of using gene markers as prognostic tools. These findings support the potential of pretransplant transcriptomic biomarkers as novel instruments for improving posttransplant outcome predictions and associated management.
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Affiliation(s)
- Kellie J Archer
- Division of Biostatistics, College of Public Health, The Ohio State University 1841 Neil Avenue, 240 Cunz Hall, Columbus, OH 43210
| | - Elissa Bardhi
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201
| | - Daniel G Maluf
- Division of Transplantation, Department of Surgery, School of Medicine, University of Maryland, 29S Greene St, Baltimore, MD 21201
- Program of Transplantation, School of Medicine, University of Maryland, 29S Greene St, Baltimore, MD 21201
| | - Jennifer McDaniels
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201
| | - Thomas Rousselle
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201
| | - Anne King
- Division of Nephrology, Internal Medicine. Virginia Commonwealth University, VA 1101 E. Marshall Street, Richmond, VA 23298-0662
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, University of Tennessee, Memphis, TN
| | - Lorenzo Gallon
- Department of Medicine-Nephrology, Northwestern University 676 N St Clair St # 100, Chicago, IL 60611
| | - Enver Akalin
- Kidney Transplant Program, Albert Einstein College of Medicine, Montefiore Medical Center, 11 E 210th St, Bronx, NY 10467
| | | | - Valeria R. Mas
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201
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10
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The Current State of Donor-Derived Cell-Free DNA Use in Allograft Monitoring in Kidney Transplantation. J Pers Med 2022; 12:jpm12101700. [PMID: 36294839 PMCID: PMC9605518 DOI: 10.3390/jpm12101700] [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: 09/01/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Renal transplantation is the definitive therapy for patients suffering from end-stage renal disease. Though there have been significant advances in immunosuppression in these patients, there is still up to 30% acute and subclinical rejection. Current standards employ lab markers of renal function and biopsy results for accurate diagnosis. However, donor derived cell-free DNA has been identified as a measurable lab test that may be able to adequately diagnose rejection at early stages, precluding the need for invasive procedures like biopsy. We obtained published data directly from companies that offer ddcfDNA assay tests and additionally conducted a literature review using databases like PUBMED and NIH U.S. National Library of Medicine. We comprehensively compare the most used ddcfDNA assays, delineate their respective limitations, and further explore future directions in the utility of ddcfDNA in renal transplant patients.
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11
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Liu SJ, Ma K, Liu LS, Wang K, Zhang YA, Bi ZR, Chen YX, Chen KZ, Wang CX, Qiao SL. Point-of-care non-invasive enzyme-cleavable nanosensors for acute transplant rejection detection. Biosens Bioelectron 2022; 215:114568. [PMID: 35850041 DOI: 10.1016/j.bios.2022.114568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/24/2022] [Accepted: 07/09/2022] [Indexed: 12/28/2022]
Abstract
Accurate and non-invasive monitoring of allograft posttransplant is essential for early detection of acute cellular rejection and determines the long-term survival of the graft. Clinically, tissue biopsy is the most effective approach for diagnosing transplant rejection. Nonetheless, the procedure is invasive and potentially triggers organ failure. This work aims to design and apply GzmB-responsive nanosensors (GBRNs) that can readily size-change in graft tissues. Subsequently, we investigate the activity of serine protease granzyme B by generating a direct colorimetric urinary readout for non-invasive detection of transplant rejection in under 1 h. In preclinical heart graft mice models of transplant rejection, GBRNs were cleaved by GzmB and excreted by the kidneys via accurate nanometre-size glomerular filtration. By exploiting the catalytic activity of ultrasmall gold nanoclusters, GBRNs urinalysis promotes ultrasensitive surveillance of rejection episodes with a receiver operator characteristic curve area under the curve of 0.896 as well as a 95% confidence interval of about 0.7701-1.000. Besides, the catalytic activity of gold nanoclusters in urine can be detected at point-of-care testing to predict the immunity responses in mice with insufficient immunosuppressive therapy. Therefore, this non-invasive, sensitive, and quantitative method is a robust and informative approach for rapid and routine monitoring of transplant allografts without invasive biopsy.
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Affiliation(s)
- Shi-Jie Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510020, PR China
| | - Ke Ma
- Lab of Functional and Biomedical Nanomaterials, College of Materials Science and Engineering, Qingdao University of Science and Technology (QUST), Qingdao, 266042, PR China
| | - Long-Shan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510020, PR China
| | - Ke Wang
- Lab of Functional and Biomedical Nanomaterials, College of Materials Science and Engineering, Qingdao University of Science and Technology (QUST), Qingdao, 266042, PR China
| | - Ying-Ao Zhang
- Lab of Functional and Biomedical Nanomaterials, College of Materials Science and Engineering, Qingdao University of Science and Technology (QUST), Qingdao, 266042, PR China
| | - Zi-Rong Bi
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510020, PR China
| | - Yan-Xu Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510020, PR China
| | - Ke-Zheng Chen
- Lab of Functional and Biomedical Nanomaterials, College of Materials Science and Engineering, Qingdao University of Science and Technology (QUST), Qingdao, 266042, PR China.
| | - Chang-Xi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510020, PR China.
| | - Sheng-Lin Qiao
- Lab of Functional and Biomedical Nanomaterials, College of Materials Science and Engineering, Qingdao University of Science and Technology (QUST), Qingdao, 266042, PR China.
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12
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Magnetic Resonance Elastography-derived Stiffness Predicts Renal Function Loss and Is Associated With Microvascular Inflammation in Kidney Transplant Recipients. Transplant Direct 2022; 8:e1334. [PMID: 35721457 PMCID: PMC9197345 DOI: 10.1097/txd.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022] Open
Abstract
Background. Organ stiffening can be caused by inflammation and fibrosis, processes that are common causes of transplant kidney dysfunction. Magnetic resonance elastography (MRE) is a contrast-free, noninvasive imaging modality that measures kidney stiffness. The objective of this study was to assess the ability of MRE to serve as a prognostic factor for renal outcomes. Methods. Patients were recruited from the St Michael’s Hospital Kidney Transplant Clinic. Relevant baseline demographic, clinical, and Banff histologic information, along with follow-up estimated glomerular filtration rate (eGFR) data, were recorded. Two-dimensional gradient-echo MRE imaging was performed to obtain kidney “stiffness” maps. Binary logistic regression analyses were performed to examine for relationships between stiffness and microvascular inflammation score. Linear mixed-effects modeling was used to assess the relationship between stiffness and eGFR change over time controlling for other baseline variables. A G2-likelihood ratio Chi-squared test was performed to compare between the baseline models with and without “stiffness.” Results. Sixty-eight transplant kidneys were scanned in 66 patients (mean age 56 ± 12 y, 24 females), with 38 allografts undergoing a contemporaneous biopsy. Mean transplant vintage was 7.0 ± 6.8 y. In biopsied allografts, MRE-derived allograft stiffness was associated only with microvascular inflammation (Banff g + ptc score, Spearman ρ = 0.43, P = 0.01), but no other histologic parameters. Stiffness was negatively associated with eGFR change over time (Stiffness × Time interaction β = –0.80, P < 0.0001), a finding that remained significant even when adjusted for biopsy status and baseline variables (Stiffness × Time interaction β = –0.46, P = 0.04). Conversely, the clinical models including “stiffness” showed significantly better fit (P = 0.04) compared with the baseline clinical models without “stiffness.” Conclusions. MRE-derived renal stiffness provides important prognostic information regarding renal function loss for patients with allograft dysfunction, over and above what is provided by current clinical variables.
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13
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Sazpinar O, Gaspert A, Sidler D, Rechsteiner M, Mueller TF. Histologic and Molecular Patterns in Responders and Non-responders With Chronic-Active Antibody-Mediated Rejection in Kidney Transplants. Front Med (Lausanne) 2022; 9:820085. [PMID: 35573002 PMCID: PMC9099145 DOI: 10.3389/fmed.2022.820085] [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: 11/22/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThere is no proven therapy for chronic-active antibody-mediated rejection (caABMR), the major cause of late kidney allograft failure. Histological and molecular patterns associated with possible therapy responsiveness are not known.MethodsBased on rigorous selection criteria this single center, retrospective study identified 16 out of 1027 consecutive kidney transplant biopsies taken between 2008 and 2016 with pure, unquestionable caABMR, without other pathologic features. The change in estimated GFR pre- and post-biopsy/treatment were utilized to differentiate subjects into responders and non-responders. Gene sets reflecting active immune processes of caABMR were defined a priori, including endothelial, inflammatory, cellular, interferon gamma (IFNg) and calcineurin inhibitor (CNI) related-genes based on the literature. Transcript measurements were performed in RNA extracted from stored, formalin-fixed, paraffin-embedded (FFPE) samples using NanoString™ technology. Histology and gene expression patterns of responders and non-responders were compared.ResultsA reductionist approach applying very tight criteria to identify caABMR and treatment response excluded the vast majority of clinical ABMR cases. Only 16 out of 139 cases with a written diagnosis of chronic rejection fulfilled the caABMR criteria. Histological associations with therapy response included a lower peritubular capillaritis score (p = 0.028) along with less glomerulitis. In contrast, no single gene discriminated responders from non-responders. Activated genes associated with NK cells and endothelial cells suggested lack of treatment response.ConclusionIn caABMR active microvascular injury, in particular peritubular capillaritis, differentiates treatment responders from non-responders. Transcriptome changes in NK cell and endothelial cell associated genes may further help to identify treatment response. Future prospective studies will be needed which include more subjects, who receive standardized treatment protocols to identify biomarkers for treatment response.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT03430414].
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Affiliation(s)
- Onur Sazpinar
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, University Hospital Bern, Bern, Switzerland
| | - Markus Rechsteiner
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Thomas F. Mueller
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
- *Correspondence: Thomas F. Mueller,
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14
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Nasic S, Mölne J, Stegmayr B, Peters B. Histological diagnosis from kidney transplant biopsy can contribute to prediction of graft survival. Nephrology (Carlton) 2022; 27:528-536. [PMID: 35150598 PMCID: PMC9302625 DOI: 10.1111/nep.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/29/2022]
Abstract
Aim The primary aim of this study was to in depth examine if the histological findings in a transplanted kidney biopsy can predict the prognosis for the graft and the patient. The secondary aim was to extend knowledge of the impact of time elapsed on biopsy findings. Methods Data from 1462 patients were merged from a kidney transplantation registry and a biopsy registry during 1 January 2007 and 30 September 2017. Kaplan–Meier analysis and multivariate Cox‐regression analysis were performed and hazard ratios (HR) with 95% confidence intervals (CI) were presented. Results Compared to normal biopsy findings, graft survival after biopsy (gsaBiopsy) was shorter for patients with glomerular diseases (HR 8.2, CI:3.2–21.1), rejections (HR 4.2, CI:1.7–10.3), chronic changes including IFTA (HR 3.2, CI:1.3–8.0), acute tubular injuries (HR 3.0, CI:1.2–7.8), and borderline changes (HR 2.9, CI:1.1–7.6). Sub‐analysis of rejections showed shorter gsaBiopsy for chronic TCMR (HR 4.7, CI:1.9–11.3), active ABMR (HR 3.6, CI:1.7–7.7) and chronic ABMR (HR 3.5, CI:2.0–6.0). Patients with TCMR Banff grade II (HR 0.35, CI:0.20–0.63) and grade I (HR 0.52, CI:0.29–0.93) had a better gsaBiopsy compared to all other types of rejections. Conclusion Shorter gsaBiopsy was noted in kidneys with glomerular diseases, rejections, acute tubular injuries and borderline changes. TCMR Banff rejections grade I and II were associated with a better prognosis. This Swedish single centre study showed that the impact on allograft survival is dependent on the nature of the biopsy findings, with histological findings of glomerular disease, severe rejections and chronic changes being associated with more rapid allograft loss.
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Affiliation(s)
- Salmir Nasic
- Research and Development Centre at Skaraborg Hospital, Skövde, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Institute of Biomedicine, Laboratory Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Björn Peters
- Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Nephrology, Skaraborg Hospital, Skövde, Sweden
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15
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Sarwal RD, Yazar W, Titzler N, Wong J, Lai CH, Chin C, Krieger D, Stoll J, Dias Lourenco F, Sarwal MM, Ghosh S. Through the Looking Glass: Unraveling the Stage-Shift of Acute Rejection in Renal Allografts. J Clin Med 2022; 11:jcm11040910. [PMID: 35207183 PMCID: PMC8879913 DOI: 10.3390/jcm11040910] [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: 11/24/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 02/05/2023] Open
Abstract
Sub-optimal sensitivity and specificity in current allograft monitoring methodologies underscore the need for more accurate and reflexive immunosurveillance to uncover the flux in alloimmunity between allograft health and the onset and progression of rejection. QSant—a urine based multi-analyte diagnostic test—was developed to profile renal transplant health and prognosticate injury, risk of evolution, and resolution of acute rejection. Q-Score—the composite score, across measurements of DNA, protein and metabolic biomarkers in the QSant assay—enables this risk prognostication. The domain of immune quiescence—below a Q-Score threshold of 32—is well established, based on published AUC of 98% for QSant. However, the trajectory of rejection is variable, given that causality is multi-factorial. Injury and subtypes of rejection are captured by the progression of Q-Score. This publication explores the clinical utility of QSant across the alloimmunity gradient of 32–100 for the early diagnosis of allograft injury and rejection.
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Affiliation(s)
- Reuben D. Sarwal
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Wanzin Yazar
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Nicholas Titzler
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Jeremy Wong
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Chih-hung Lai
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Christopher Chin
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Danielle Krieger
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Jeff Stoll
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Francisco Dias Lourenco
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
| | - Minnie M. Sarwal
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
- Department of Surgery, University of California, 400 Parnassus Ave, San Francisco, CA 94143, USA
- Correspondence: (M.M.S.); (S.G.)
| | - Srinka Ghosh
- NephroSant Inc., 1900 Alameda de las Pulgas, San Mateo, CA 94403, USA; (R.D.S.); (W.Y.); (N.T.); (J.W.); (C.-h.L.); (C.C.); (D.K.); (J.S.); (F.D.L.)
- Correspondence: (M.M.S.); (S.G.)
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16
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Yu S, Lu J. Macrophages in transplant rejection. Transpl Immunol 2022; 71:101536. [PMID: 35017096 DOI: 10.1016/j.trim.2022.101536] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/17/2022]
Abstract
Transplant rejection is one of the primary factors leading to loss of allograft function, and macrophages are involved in allograft rejection. Macrophages polarize into different phenotypes according to stimulation by different external factors. Different types of macrophages play distinct roles in inflammation, tumors, and autoimmune diseases and are involved in transplant rejection. In this review, we introduce the origin and migration of macrophages, outline the classification of macrophages and their polarization mechanisms, and review the currently understood mechanisms of their involvement in transplant rejection. Finally, we discuss the regulation of macrophage polarization and miRNA expression with respect to transplant rejection, which is important for the development of new anti-rejection therapies.
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Affiliation(s)
- Shaochen Yu
- Department of Emergency and Critical Care Medicine, Guangdong Second Provincial General Hospital, No. 466, Xingang Middle Road, Haizhu District, Guangzhou, Guangdong 510317, China.
| | - Jian Lu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei, Anhui 230022, China.
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17
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Qazi Y, Patel A, Fajardo M, McCormick S, Fehringer G, Ahmed E, Malhotra M, Demko ZP, Billings PR, Tabriziani H, Gauthier P. Incorporation of Donor-derived Cell-free DNA Into Clinical Practice for Renal Allograft Management. Transplant Proc 2021; 53:2866-2872. [PMID: 34774309 DOI: 10.1016/j.transproceed.2021.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Donor-derived cell-free DNA (dd-cfDNA) in plasma is an established noninvasive biomarker for allograft injury and rejection. A single-nucleotide polymorphism (SNP)-based massively multiplexed polymerase chain reaction methodology can be used to quantify dd-cfDNA in kidney transplant recipients. In this study we describe our clinical experience in using a SNP-based dd-cfDNA assay for the management of active rejection in renal transplant recipients. METHODS To assess the clinical utility of a clinically available SNP-based massively multiplexed polymerase chain reaction dd-cfDNA assay, we analyzed biopsy data contemporaneous to dd-cfDNA results at 33 participating clinics and calculated the rate of rejection in dd-cfDNA-matched biopsy results. RESULTS A total of 1347 dd-cfDNA test samples from 879 patients were accessioned from October 3, 2019, to November 2, 2020. The dd-cfDNA testing classified 25.2% (340/1347) of samples as high-risk (dd-cfDNA fraction ≥ 1%). Clinical follow-up was available for 32.1% (109/340) of the high-risk results, which included samples from 28 patients with definitive biopsy results within 2 weeks of dd-cfDNA testing. Pathology reports indicated a 64% (18/28) rate of active rejection in biopsy result-matched samples. Total cfDNA measurements indicated a skewed distribution and a correlation with dd-cfDNA-derived patient risk classification. CONCLUSIONS This is the first report showing the impact of dd-cfDNA on patient management in a multicenter real-world clinical cohort. The data indicate that incorporating dd-cfDNA testing into practice may improve physician decision making regarding renal allograft recipients.
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Affiliation(s)
- Yasir Qazi
- Department of Medicine, University of Southern California, Los Angeles, California
| | - Anup Patel
- Saint Barnabas Medical Center, Livingston, New Jersey
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18
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Abstract
With the incremental improvements in long-term kidney transplant survival, there is renewed focus on what causes failure of the transplanted allograft. Over the past decade, our understanding of the injuries that lead to loss of graft function over time has evolved. Chronic allograft injury includes both immune-mediated and nonimmune-mediated injuries, which may involve the organ donor, the recipient, or both. The targets of injury include the kidney tubular epithelium, the endothelium, and the glomerulus. As a response to injury, there are the expected tissue remodeling and repair processes. However, if inflammation persists, which is not uncommon in the transplant setting, the resulting maladaptive response is matrix deposition and/or fibrosis. This ultimately leads to declining graft function and, finally, failure. With our advancing knowledge of the multiple etiologies and mechanisms, enhanced by more recent cohort studies in humans, there is an opportunity to identify those at greater risk to initiate new strategies to ameliorate the process. Although the most recent studies focus on immune-mediated injuries, there is a critical need to identify both markers of injury and mechanisms of injury. In this review, we highlight the findings of recent studies, highlight the potential therapeutic targets, and identify the continued unmet need for understanding the mechanisms of late graft failure.
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Affiliation(s)
- Eric Langewisch
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska,Medical Service, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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19
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Snopkowski C, Salinas T, Li C, Stryjniak G, Ding R, Sharma V, Suthanthiran M. Urinary cell mRNA profiling of kidney allograft recipients: A systematic investigation of a filtration based protocol for the simplification of urine processing. J Immunol Methods 2021; 498:113132. [PMID: 34464607 PMCID: PMC8487946 DOI: 10.1016/j.jim.2021.113132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/27/2021] [Accepted: 08/24/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Kidney transplantation is a life-restorative therapy, but immune rejection undermines allograft survival. Urinary cell mRNA profiles offer a noninvasive means of diagnosing kidney allograft rejection, but urine processing protocols have logistical constraints. We aimed to determine whether the centrifugation-based method for urinary cell mRNA profiling could be replaced with a simpler filtration-based method without undermining quality. METHODS We isolated RNA from urine collected from kidney allograft recipients using the Cornell centrifugation-based protocol (CCBP) or the Zymo filter-based protocol (ZFBP) and compared RNA purity and yield using a spectrophotometer or a fluorometer and measured absolute copy number of transcripts using customized real-time quantitative PCR assays. We investigated the performance characteristics of RNA isolated using ZFBP and stored either at -80 °C or at ambient temperature for 2 to 4 days and also when shipped to our Gene Expression Monitoring (GEM) Core at ambient temperature. We examined the feasibility of initial processing of urine samples by kidney allograft recipients trained by the GEM Core staff and the diagnostic utility for acute rejection, of urine processed using the ZFBP. RESULTS RNA purity (P = 0.0007, Wilcoxon matched paired signed-ranks test) and yield (P < 0.0001) were higher with ZFBP vs. CCBP, and absolute copy number of 18S rRNA was similar (P = 0.79) following normalization of RNA yield by reverse transcribing a constant amount of RNA isolated using either protocol. RNA purity, yield, and absolute copy numbers of 18S rRNA, TGF-β1 mRNA and microRNA-26a were not different (P > 0.05) in the filtrates containing RNA stored either at -80 °C or at ambient temperature for 2 to 4 days or shipped overnight at ambient temperature. RNA purity, yield, and absolute copy numbers of 18S rRNA and TGF-β1 mRNA were also not different (P > 0.05) between home processed and laboratory processed urine filtrates. Urinary cell levels of mRNA for granzyme B (P = 0.01) and perforin (P = 0.0002) in the filtrates were diagnostic of acute rejection in human kidney allografts. CONCLUSIONS Urinary cell mRNA profiling was simplified using the ZFBP without undermining RNA quality or diagnostic utility. Home processing by the kidney allograft recipients, the stability of RNA containing filtrates at ambient temperature, and the elimination of the need for centrifuges and freezers represent some of the advantages of ZFBP over the CCBP for urinary cell mRNA profiling.
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Affiliation(s)
- Catherine Snopkowski
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Carol Li
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Gabriel Stryjniak
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Vijay Sharma
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, NewYork-Presbyterian-Weill Cornell Medicine, New York, NY, USA; Department of Transplantation Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA.
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20
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Lubetzky ML, Salinas T, Schwartz JE, Suthanthiran M. Urinary Cell mRNA Profiles Predictive of Human Kidney Allograft Status. Clin J Am Soc Nephrol 2021; 16:1565-1577. [PMID: 33906907 PMCID: PMC8499006 DOI: 10.2215/cjn.14010820] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Immune monitoring of kidney allograft recipients and personalized therapeutics may help reach the aspirational goal of "one transplant for life." The invasive kidney biopsy procedure, the diagnostic tool of choice, has become safer and the biopsy classification more refined. Nevertheless, biopsy-associated complications, interobserver variability in biopsy specimen scoring, and costs continue to be significant concerns. The dynamics of the immune repertoire make frequent assessments of allograft status necessary, but repeat biopsies of the kidney are neither practical nor safe. To address the existing challenges, we developed urinary cell mRNA profiling and investigated the diagnostic, prognostic, and predictive accuracy of absolute levels of a hypothesis-based panel of mRNAs encoding immunoregulatory proteins. Enabled by our refinements of the PCR assay and by investigating mechanistic hypotheses, our single-center studies identified urinary cell mRNAs associated with T cell-mediated rejection, antibody-mediated rejection, interstitial fibrosis and tubular atrophy, and BK virus nephropathy. In the multicenter National Institutes of Health Clinical Trials in Organ Transplantation-04, we discovered and validated a urinary cell three-gene signature of T-cell CD3 ε chain mRNA, interferon gamma inducible protein 10 (IP-10) mRNA, and 18s ribosomal RNA that is diagnostic of subclinical acute cellular rejection and acute cellular rejection and prognostic of acute cellular rejection and graft function. The trajectory of the signature score remained flat and below the diagnostic threshold for acute cellular rejection in the patients with no rejection biopsy specimens, whereas a sharp rise was observed during the weeks before the biopsy specimen that showed acute cellular rejection. Our RNA sequencing and bioinformatics identified kidney allograft biopsy specimen gene signatures of acute rejection to be enriched in urinary cells matched to acute rejection biopsy specimens. The urinary cellular landscape was more diverse and more enriched for immune cell types compared with kidney allograft biopsy specimens. Urinary cell mRNA profile-guided clinical trials are needed to evaluate their value compared with current standard of care.
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Affiliation(s)
- Michelle L. Lubetzky
- Division of Nephrology and Hypertension, Weill Cornell Department of Medicine, New York, New York,Department of Transplantation Medicine, New York–Presbyterian Hospital, New York, New York
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Weill Cornell Department of Medicine, New York, New York,Department of Transplantation Medicine, New York–Presbyterian Hospital, New York, New York
| | - Joseph E. Schwartz
- Division of Nephrology and Hypertension, Weill Cornell Department of Medicine, New York, New York,Department of Transplantation Medicine, New York–Presbyterian Hospital, New York, New York,Department of Psychiatry and Behavioral Sciences, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Weill Cornell Department of Medicine, New York, New York,Department of Transplantation Medicine, New York–Presbyterian Hospital, New York, New York
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21
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Change in Estimated GFR and Risk of Allograft Failure in Patients Diagnosed With Late Active Antibody-mediated Rejection Following Kidney Transplantation. Transplantation 2021; 105:648-659. [PMID: 33617203 DOI: 10.1097/tp.0000000000003274] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are challenges in designing adequate, well-controlled studies of patients with active antibody-mediated rejection (AMR) after kidney transplantation (KTx). METHODS We assessed the functional relationship between change in estimated glomerular filtration rate (eGFR) following the diagnosis of AMR and the risk of subsequent death-censored graft failure using the joint modeling framework. We included recipients of solitary KTx between 1995 and 2013 at 4 transplant centers diagnosed with biopsy-proven active AMR at least 1 year post-KTx, who had a minimum of 3-year follow-up. RESULTS A total of 91 patients across participating centers were included in the analysis. Of the 91 patients, n = 54 patients (59%) met the death-censored graft failure endpoint and n = 62 patients (68%) met the all-cause graft failure composite endpoint. Kaplan-Meier death-censored graft survival rates at 12, 36, and 60 months postdiagnosis of AMR pooled across centers were 88.9%, 58.9%, and 36.4%, respectively. Spaghetti plots indicated a linear trend in the change in eGFR, especially in the first 12 months postdiagnosis of active AMR. A significant change in eGFR was observed within the first 12 months postdiagnosis of active AMR, getting worse by a factor of -0.757 mL/min/1.73 m2 per month during the 12-month analysis period (a delta of -9.084 mL/min/1.73 m2 at 1 y). Notably, an extrapolated 30% improvement in the slope of eGFR in the first 12 months was associated with a 10% improvement in death-censored graft failure at 5 years. CONCLUSIONS If prospectively validated, this study may inform the design of pivotal clinical trials for therapies for late AMR.
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22
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Lai X, Zheng X, Mathew JM, Gallon L, Leventhal JR, Zhang ZJ. Tackling Chronic Kidney Transplant Rejection: Challenges and Promises. Front Immunol 2021; 12:661643. [PMID: 34093552 PMCID: PMC8173220 DOI: 10.3389/fimmu.2021.661643] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/27/2021] [Indexed: 01/09/2023] Open
Abstract
Despite advances in post-transplant management, the long-term survival rate of kidney grafts and patients has not improved as approximately forty percent of transplants fails within ten years after transplantation. Both immunologic and non-immunologic factors contribute to late allograft loss. Chronic kidney transplant rejection (CKTR) is often clinically silent yet progressive allogeneic immune process that leads to cumulative graft injury, deterioration of graft function. Chronic active T cell mediated rejection (TCMR) and chronic active antibody-mediated rejection (ABMR) are classified as two principal subtypes of CKTR. While significant improvements have been made towards a better understanding of cellular and molecular mechanisms and diagnostic classifications of CKTR, lack of early detection, differential diagnosis and effective therapies continue to pose major challenges for long-term management. Recent development of high throughput cellular and molecular biotechnologies has allowed rapid development of new biomarkers associated with chronic renal injury, which not only provide insight into pathogenesis of chronic rejection but also allow for early detection. In parallel, several novel therapeutic strategies have emerged which may hold great promise for improvement of long-term graft and patient survival. With a brief overview of current understanding of pathogenesis, standard diagnosis and challenges in the context of CKTR, this mini-review aims to provide updates and insights into the latest development of promising novel biomarkers for diagnosis and novel therapeutic interventions to prevent and treat CKTR.
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Affiliation(s)
- Xingqiang Lai
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xin Zheng
- Department of Urology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - James M Mathew
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Medicine, Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph R Leventhal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Zheng Jenny Zhang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Abstract
Tacrolimus was discovered in 1984 and entered clinical use shortly thereafter, contributing to successful solid organ transplantation across the globe. In this review, we cover development of tacrolimus, its evolving clinical utility, and issues affecting its current usage. Since earliest use of this class of immunosuppressant, concerns for calcineurin-inhibitor toxicity have led to efforts to minimize or eliminate these agents in clinical regimens but with limited success. Current understanding of the role of tacrolimus focuses more on its efficacy in preventing graft rejection and graft loss. As we enter the fourth decade of tacrolimus use, newer studies utilizing novel combinations (as with the mammalian target of rapamycin inhibitor, everolimus, and T-cell costimulation blockade with belatacept) offer potential for enhanced benefits.
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Affiliation(s)
- Song C Ong
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert S Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
- CTI Clinical Trial and Consulting, Inc., Covington, KT
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24
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Duflot T, Laurent C, Soudey A, Fonrose X, Hamzaoui M, Iacob M, Bertrand D, Favre J, Etienne I, Roche C, Coquerel D, Le Besnerais M, Louhichi S, Tarlet T, Li D, Brunel V, Morisseau C, Richard V, Joannidès R, Stanke-Labesque F, Lamoureux F, Guerrot D, Bellien J. Preservation of epoxyeicosatrienoic acid bioavailability prevents renal allograft dysfunction and cardiovascular alterations in kidney transplant recipients. Sci Rep 2021; 11:3739. [PMID: 33580125 PMCID: PMC7881112 DOI: 10.1038/s41598-021-83274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/27/2021] [Indexed: 12/25/2022] Open
Abstract
This study addressed the hypothesis that epoxyeicosatrienoic acids (EETs) synthesized by CYP450 and catabolized by soluble epoxide hydrolase (sEH) are involved in the maintenance of renal allograft function, either directly or through modulation of cardiovascular function. The impact of single nucleotide polymorphisms (SNPs) in the sEH gene EPHX2 and CYP450 on renal and vascular function, plasma levels of EETs and peripheral blood monuclear cell sEH activity was assessed in 79 kidney transplant recipients explored at least one year after transplantation. Additional experiments in a mouse model mimicking the ischemia–reperfusion (I/R) injury suffered by the transplanted kidney evaluated the cardiovascular and renal effects of the sEH inhibitor t-AUCB administered in drinking water (10 mg/l) during 28 days after surgery. There was a long-term protective effect of the sEH SNP rs6558004, which increased EET plasma levels, on renal allograft function and a deleterious effect of K55R, which increased sEH activity. Surprisingly, the loss-of-function CYP2C9*3 was associated with a better renal function without affecting EET levels. R287Q SNP, which decreased sEH activity, was protective against vascular dysfunction while CYP2C8*3 and 2C9*2 loss-of-function SNP, altered endothelial function by reducing flow-induced EET release. In I/R mice, sEH inhibition reduced kidney lesions, prevented cardiac fibrosis and dysfunction as well as preserved endothelial function. The preservation of EET bioavailability may prevent allograft dysfunction and improve cardiovascular disease in kidney transplant recipients. Inhibition of sEH appears thus as a novel therapeutic option but its impact on other epoxyfatty acids should be carefully evaluated.
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Affiliation(s)
- Thomas Duflot
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France.,Laboratory of Pharmacokinetics, Toxicology and Pharmacogenetics, Rouen University Hospital, 76000, Rouen, France
| | - Charlotte Laurent
- Department of Nephrology, Rouen University Hospital, 76000, Rouen, France
| | - Anne Soudey
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Xavier Fonrose
- Department of Pharmacology, Grenoble Alpes University Hospital, HP2, INSERM U1042, University of Grenoble Alpes, 38000, Grenoble, France
| | - Mouad Hamzaoui
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France.,Department of Nephrology, Rouen University Hospital, 76000, Rouen, France
| | - Michèle Iacob
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France
| | - Dominique Bertrand
- Department of Nephrology, Rouen University Hospital, 76000, Rouen, France
| | - Julie Favre
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Isabelle Etienne
- Department of Nephrology, Rouen University Hospital, 76000, Rouen, France
| | - Clothilde Roche
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - David Coquerel
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Maëlle Le Besnerais
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Safa Louhichi
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Tracy Tarlet
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Dongyang Li
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, Davis, CA, 95616, USA
| | - Valéry Brunel
- Department of General Biochemistry, Rouen University Hospital, 76000, Rouen, France
| | - Christophe Morisseau
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, Davis, CA, 95616, USA
| | - Vincent Richard
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France
| | - Robinson Joannidès
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France.,Centre d'Investigation Clinique (CIC)-INSERM 1404, Rouen University Hospital, 76000, Rouen, France
| | - Françoise Stanke-Labesque
- Department of Pharmacology, Grenoble Alpes University Hospital, HP2, INSERM U1042, University of Grenoble Alpes, 38000, Grenoble, France
| | - Fabien Lamoureux
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France.,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France.,Laboratory of Pharmacokinetics, Toxicology and Pharmacogenetics, Rouen University Hospital, 76000, Rouen, France
| | - Dominique Guerrot
- UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France.,Department of Nephrology, Rouen University Hospital, 76000, Rouen, France
| | - Jérémy Bellien
- Department of Pharmacology, Rouen University Hospital, 76000, Rouen, France. .,UNIROUEN, INSERM U1096, FHU CARNAVAL, Normandie University, 76000, Rouen, France. .,Centre d'Investigation Clinique (CIC)-INSERM 1404, Rouen University Hospital, 76000, Rouen, France. .,Department of Pharmacology, Rouen University Hospital, 76031, Rouen Cedex, France.
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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [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: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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26
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Hickson LJ, Herrmann SM, McNicholas BA, Griffin MD. Progress toward the Clinical Application of Mesenchymal Stromal Cells and Other Disease-Modulating Regenerative Therapies: Examples from the Field of Nephrology. KIDNEY360 2021; 2:542-557. [PMID: 34316720 PMCID: PMC8312727 DOI: 10.34067/kid.0005692020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drawing from basic knowledge of stem-cell biology, embryonic development, wound healing, and aging, regenerative medicine seeks to develop therapeutic strategies that complement or replace conventional treatments by actively repairing diseased tissue or generating new organs and tissues. Among the various clinical-translational strategies within the field of regenerative medicine, several can be broadly described as promoting disease resolution indirectly through local or systemic interactions with a patient's cells, without permanently integrating or directly forming new primary tissue. In this review, we focus on such therapies, which we term disease-modulating regenerative therapies (DMRT), and on the extent to which they have been translated into the clinical arena in four distinct areas of nephrology: renovascular disease (RVD), sepsis-associated AKI (SA-AKI), diabetic kidney disease (DKD), and kidney transplantation (KTx). As we describe, the DMRT that has most consistently progressed to human clinical trials for these indications is mesenchymal stem/stromal cells (MSCs), which potently modulate ischemic, inflammatory, profibrotic, and immune-mediated tissue injury through diverse paracrine mechanisms. In KTx, several early-phase clinical trials have also tested the potential for ex vivo-expanded regulatory immune cell therapies to promote donor-specific tolerance and prevent or resolve allograft injury. Other promising DMRT, including adult stem/progenitor cells, stem cell-derived extracellular vesicles, and implantable hydrogels/biomaterials remain at varying preclinical stages of translation for these renal conditions. To date (2021), no DMRT has gained market approval for use in patients with RVD, SA-AKI, DKD, or KTx, and clinical trials demonstrating definitive, cost-effective patient benefits are needed. Nonetheless, exciting progress in understanding the disease-specific mechanisms of action of MSCs and other DMRT, coupled with increasing knowledge of the pathophysiologic basis for renal-tissue injury and the experience gained from pioneering early-phase clinical trials provide optimism that influential, regenerative treatments for diverse kidney diseases will emerge in the years ahead.
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Affiliation(s)
- LaTonya J. Hickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Sandra M. Herrmann
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bairbre A. McNicholas
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, School of Medicine, National University of Ireland Galway, Ireland,Nephrology Services, Galway University Hospitals, Saolta University Healthcare System, Galway, Ireland,Critical Care Services, Galway University Hospitals, Saolta University Healthcare System, Galway, Ireland
| | - Matthew D. Griffin
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, School of Medicine, National University of Ireland Galway, Ireland,Nephrology Services, Galway University Hospitals, Saolta University Healthcare System, Galway, Ireland
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27
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Chronic Histologic Changes Are Present Regardless of HLA Mismatches: Evidence from HLA Identical Living Donor Kidney Transplants. Transplantation 2020; 105:e244-e256. [PMID: 33315759 DOI: 10.1097/tp.0000000000003579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND At 5 and 10 years after kidney transplantation, chronic histologic changes such as arteriolar hyalinosis and mesangial expansion are common, however, determining etiology is difficult. We compared surveillance biopsies in living donor kidney transplants (LDKTx) from HLA matched siblings (termed HLA-identical (HLA-ID)) to HLA non-ID to investigate which histologic changes were likely due to alloimmune injury and which were due to non-alloimmune injury. METHODS We performed a retrospective, cohort study comparing HLA-ID sibling LDKTx (n=175) to HLA non-ID LDKTx (n=175; matched for age, sex and year of transplant +/- 2 years) performed at a single institution from 03/1999 to 11/2018. RESULTS Baseline characteristics and maintenance immunosuppression were similar. Mortality rates were similar, but in the HLA-ID group, 10-year death-censored graft survival was higher (93.8% vs 80.9% HLA non-ID LDKTx, p<0.001), rejection rates were lower (after 1 year 9.6% vs 27.1%; p<0.001) and Banff inflammation scores including glomerulitis and peritubular capillaritis were lower on surveillance biopsies at 1, 5 and 10 years. In contrast, chronic Banff scores (interstitial fibrosis, arteriolar hyalinosis, mesangial expansion, etc.) were similar in prevalence and severity on surveillance biopsies at 1, 5 and 10 years. CONCLUSIONS HLA-ID LDKTx have less inflammation and less transplant glomerulopathy, but most chronic histologic changes were similar to less-well matched LDKTx. We conclude that these types of chronic changes are not associated with HLA mismatches and may be due to non-immunologic causes (hypertension, obesity, etc.) suggesting that new management approaches to prevent these lesions may be needed.
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Bhutani G, Astor BC, Mandelbrot DA, Mankowski-Gettle L, Ziemlewicz T, Wells SA, Frater-Rubsam L, Horner V, Boyer C, Laffin J, Djamali A. Long-Term Outcomes and Prognostic Factors in Kidney Transplant Recipients with Polycystic Kidney Disease. KIDNEY360 2020; 2:312-324. [PMID: 35373032 PMCID: PMC8740986 DOI: 10.34067/kid.0001182019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/03/2020] [Indexed: 02/04/2023]
Abstract
Background Polycystic kidney disease (PKD) accounts for approximately 15% of kidney transplants, but long-term outcomes in patients with PKD who have received a kidney transplant are not well understood. Methods In primary recipients of kidney transplants at our center (1994-2014), we compared outcomes of underlying PKD (N=619) with other native diseases (non-PKD, N=4312). Potential factors influencing outcomes in PKD were evaluated using Cox proportional-hazards regression and a rigorous multivariable model. Results Patients with PKD were older and were less likely to be sensitized or to experience delayed graft function (DGF). Over a median follow-up of 5.6 years, 1256 of all recipients experienced death-censored graft failure (DCGF; 115 patients with PKD) and 1617 died (154 patients with PKD). After adjustment for demographic, dialysis, comorbid disease, surgical, and immunologic variables, patients with PKD had a lower risk of DCGF (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.57 to 0.93; P=0.01) and death (aHR, 0.62; 95% CI, 0.51 to 0.75; P<0.001). In our multiadjusted model, calcineurin-inhibitor (CNI) use was associated with lower risk of DCGF (aHR, 0.45; 95% CI, 0.26 to 0.76; P=0.003), whereas HLA mismatch of five to six antigens (aHR, 2.1; 95% CI, 1.2 to 3.64; P=0.009) was associated with higher likelihood of DCGF. Notably, both pretransplant coronary artery disease (CAD) and higher BMI were associated with increased risk of death (CAD, aHR, 2.5; 95% CI, 1.69 to 3.71; P<0.001; per 1 kg/m2 higher BMI, aHR, 1.07; 95% CI, 1.04 to 1.11; P<0.001), DCGF, and acute rejection. Nephrectomy at time of transplant and polycystic liver disease were not associated with DCGF/death. Incidence of post-transplant diabetes mellitus was similar between PKD and non-PKD cohorts. Conclusions Recipients with PKD have better long-term graft and patient survival than those with non-PKD. Standard practices of CNI use and promoting HLA match are beneficial in PKD and should continue to be promoted. Further prospective studies investigating the potential benefits of CNI use and medical/surgical interventions to address CAD and the immunologic challenges of obesity are needed. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/K360/2021_02_25_KID0001182019.mp3.
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Affiliation(s)
- Gauri Bhutani
- Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Brad C. Astor
- Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin,Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Didier A. Mandelbrot
- Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lori Mankowski-Gettle
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Timothy Ziemlewicz
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shane A. Wells
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Leah Frater-Rubsam
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin
| | - Vanessa Horner
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin,Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, Wisconsin
| | - Courtney Boyer
- Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Jennifer Laffin
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin
| | - Arjang Djamali
- Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin,Division of Transplant Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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29
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Ordikhani F, Pothula V, Sanchez-Tarjuelo R, Jordan S, Ochando J. Macrophages in Organ Transplantation. Front Immunol 2020; 11:582939. [PMID: 33329555 PMCID: PMC7734247 DOI: 10.3389/fimmu.2020.582939] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/20/2020] [Indexed: 12/13/2022] Open
Abstract
Current immunosuppressive therapy has led to excellent short-term survival rates in organ transplantation. However, long-term graft survival rates are suboptimal, and a vast number of allografts are gradually lost in the clinic. An increasing number of animal and clinical studies have demonstrated that monocytes and macrophages play a pivotal role in graft rejection, as these mononuclear phagocytic cells recognize alloantigens and trigger an inflammatory cascade that activate the adaptive immune response. Moreover, recent studies suggest that monocytes acquire a feature of memory recall response that is associated with a potent immune response. This form of memory is called “trained immunity,” and it is retained by mechanisms of epigenetic and metabolic changes in innate immune cells after exposure to particular ligands, which have a direct impact in allograft rejection. In this review article, we highlight the role of monocytes and macrophages in organ transplantation and summarize therapeutic approaches to promote tolerance through manipulation of monocytes and macrophages. These strategies may open new therapeutic opportunities to increase long-term transplant survival rates in the clinic.
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Affiliation(s)
- Farideh Ordikhani
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Venu Pothula
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rodrigo Sanchez-Tarjuelo
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stefan Jordan
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jordi Ochando
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Immunología de Trasplantes, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
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30
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Alquadan KF, Santos AH, Leghrouz M, Ozrazgat-Baslanti T, Bozorgmehri S, Gupta G, Womer KL. A pilot study of immunosuppression resumption following BK viremia resolution. Transpl Infect Dis 2020; 23:e13508. [PMID: 33176016 DOI: 10.1111/tid.13508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/23/2020] [Accepted: 10/25/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppression reduction for BK viremia is associated with de novo humoral responses, which are a risk factor for rejection and graft loss. In this pilot project, we tested a protocol of immunosuppression resumption to standard dose after viral clearance for optimal protection against humoral immunity in patients undergoing treatment for BK viremia. METHODS Thirty-six consecutive kidney transplant recipients who developed BK viremia from 7/1/2014 to 11/18/2016 underwent immunosuppression reduction. After 4 weeks of absent viremia, mycophenolate mofetil (MMF) was increased by 500mg/day every 2 weeks up to standard dosage, followed by increase of tacrolimus trough levels to 5-7 ng/mL. If viremia recurred during the increase, immunosuppression was reduced in this same stepwise fashion, with stepwise increase again after 2 months of negative viremia. RESULTS Mean tacrolimus trough level (ng/mL) was 8.3 ± 2.7 at viremia onset, 5.3 ± 3.6 at resolution, and 5.6 ± 2.0 at study end date. Mean daily dose (mg) of MMF was 1574 ± 355 at onset, 910 ± 230 at resolution, and 1377 ± 451 at study end date. Only one patient developed low level viremia recurrence (peak 2875 copies/mL) during the period of immunosuppression resumption that ultimately resolved. CONCLUSIONS The results of our pilot project indicate that following BK viremia resolution, resumption of standard immunosuppression can be achieved safely without BK viremia recurrence. Larger trials with long-term follow up are required to determine whether such an approach improves long-term graft survival.
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Affiliation(s)
| | - Alfonso H Santos
- Medicine- Nephrology, University of Florida, Gainesville, FL, USA
| | | | | | | | - Gaurav Gupta
- Medicine-Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Karl L Womer
- Medicine- Nephrology, University of Florida, Gainesville, FL, USA
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31
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von Moos S, Cippà PE, van Breemen R, Mueller TF. HLA antibodies are associated with deterioration of kidney allograft function irrespective of donor specificity. Hum Immunol 2020; 82:19-24. [PMID: 33162184 DOI: 10.1016/j.humimm.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Donor-specific antibodies are associated with high immunological risk and poor allograft outcome. Risk and clinical relevance of non-donor-specific HLA antibodies is less clear. METHODS A retrospective single-center study was conducted in all patients receiving a first kidney transplant at the University hospital of Zürich between 01/2006 and 02/2015. Patients were stratified into 3 groups having either no HLA antibodies at all (NoAB), HLA antibodies with donor specificity (DSA) and HLA antibodies without donor specificity (NonDSA). Allograft outcome was assessed using the slope of the estimated glomerular filtration rate (eGFR slope) starting at 12 months after transplantation. RESULTS During a median follow-up of 1808 days HLA antibodies were detected in 106 of 238 eligible patients (44%). Out of these, 73 patients (69%) had DSA and 33 patients (31%) had NonDSA only. Medium-term allograft function, as determined by eGFR slope over three years, improved in patients with NoAB (months 12-48: +0.7 ml/min/1.73 m2) but deteriorated significantly in patients with both DSA (months 12-48: -1.5 ml/min per1.73 m2/year, p = 0.015) and NonDSA (months 12-48: -1.8 ml/min per1.73 m2/year, p = 0.03) as compared to the group with NoAB. CONCLUSION Both, donor-specific and non-donor-specific HLA antibodies are associated with medium-term kidney allograft dysfunction as compared to patients with no HLA antibodies.
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Affiliation(s)
- Seraina von Moos
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland.
| | - Pietro E Cippà
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Rob van Breemen
- Division of Informatics, University Hospital Zürich, Zürich, Switzerland.
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland.
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Torabi J, Melvin J, Rechnitzer A, Rocca JP, Ajaimy M, Lirano-Ward L, Azzi Y, Pynadath C, Alani O, Akalin E, Graham JA. High terminal creatinine donors should not preclude simultaneous kidney and pancreas transplantation. Am J Surg 2020; 221:677-680. [PMID: 33012501 DOI: 10.1016/j.amjsurg.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/10/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Simultaneous pancreas and kidney transplantation (SPK) in the setting of end-stage renal disease offers unmatched outcomes in insulin dependent diabetic patients. Donor pool expansion through the transplantation of kidneys with acute kidney injury (AKI) is controversial. METHODS 59 SPK transplants were classified by presence of donor AKI, defined as donor terminal creatinine ≥ 1.5x the initial creatinine or donor terminal creatinine > 4.0 mg/dL. Endpoints included graft and patient survival, delayed graft function (DGF), serum creatinine, glomerular filtration rate (GFR), Hemoglobin A1c (HbA1c) and acute rejection. RESULTS The donor AKI group (n = 35) had significantly higher rates of DGF (38 v. 9%, p = 0.01). There was no difference in creatinine or GFR at 1, 3, 6 and 12 months. HbA1c was comparable at 3, 6 and 12 months. There was no significant difference in the percentage of patients that required anti-diabetic agents after transplant (14 v. 4%, p = 0.56). CONCLUSIONS We observed increased rates of DGF in SPK recipients with donor AKI. However, equivalent outcomes of pancreas and kidney function in both groups were observed.
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Affiliation(s)
- Julia Torabi
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - Juan P Rocca
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Maria Ajaimy
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Luz Lirano-Ward
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Yorg Azzi
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Cindy Pynadath
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Omar Alani
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Enver Akalin
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Jay A Graham
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA.
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Abstract
Kidney diseases secondary to several pathogeneses affect millions of people worldwide and have become increasingly recognized as a global public health problem. Recent evidence suggests that cellular senescence plays an important role in the pathogenesis of different forms of renal damage, including acute and chronic kidney disease, and renal transplantation. Renal senescence involves cell cycle arrest and affects several cellular pathways, manifesting in downregulation of klotho, elevated expression of cyclin-dependent kinase inhibitors, cellular telomere shortening, and oxidative stress. Furthermore, senescent cells might induce kidney injury by paracrine release of inflammatory factors. Yet, cellular senescence may be renoprotective during development and in some models of renal diseases, reflecting the yin/yang duality of cellular senescence. This review provides an overview of the role of this emerging player in renal injury, with emphasis on new findings of cellular senescence.
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Affiliation(s)
- Yongxin Li
- From the Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (Y.L., L.O.L.).,Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, PR China (Y.L.)
| | - Lilach O Lerman
- From the Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN (Y.L., L.O.L.)
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34
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Niu Q, Mendoza Rojas A, Dieterich M, Roelen DL, Clahsen-van Groningen MC, Wang L, van Gelder T, Hesselink DA, van Besouw NM, Baan CC. Immunosuppression Has Long-Lasting Effects on Circulating Follicular Regulatory T Cells in Kidney Transplant Recipients. Front Immunol 2020; 11:1972. [PMID: 32983131 PMCID: PMC7483930 DOI: 10.3389/fimmu.2020.01972] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/21/2020] [Indexed: 02/05/2023] Open
Abstract
Background: FoxP3+ follicular regulatory T cells (Tfr) have been identified as the cell population controlling T follicular helper (Tfh) cells and B cells which, are both involved in effector immune responses against transplanted tissue. Methods: To understand the biology of Tfr cells in kidney transplant patients treated with tacrolimus and mycophenolate mofetil (MMF) combination immunosuppression, we measured circulating (c)Tfh and cTfr cells in peripheral blood by flow cytometry in n = 211 kidney transplant recipients. At the time of measurement patients were 5–7 years after transplantation. Of this cohort of patients, 23.2% (49/211) had been previously treated for rejection. Median time after anti-rejection therapy was 4.9 years (range 0.4–7 years). Age and gender matched healthy individuals served as controls. Results: While the absolute numbers of cTfh cells were comparable between kidney transplant recipients and healthy controls, the numbers of cTfr cells were 46% lower in immunosuppressed recipients (p < 0.001). More importantly, in transplanted patients, the ratio of cTfr to cTfh was decreased (median; 0.10 vs. 0.06), indicating a disruption of the balance between cTfr and cTfh cells. This shifted balance was observed for both non-rejectors and rejectors. Previous pulse methylprednisolone or combined pulse methylprednisolone + intravenous immunoglobulin anti-rejection therapy led to a non-significant 30.6% (median) and 51.2% (median) drop in cTfr cells, respectively when compared to cTfr cell numbers in transplant patients who did not receive anti-rejection therapy. A history of alemtuzumab therapy did lead to a significant decrease in cTfr cells of 85.8% (median) compared with patients not treated with anti-rejection therapy (p < 0.0001). No association with tacrolimus or MMF pre-dose concentrations was found. Conclusion: This cross-sectional study reveals that anti-rejection therapy with alemtuzumab significantly lowers the number of cTfr cells in kidney transplant recipients. The observed profound effects by these agents might dysregulate cTfr functions.
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Affiliation(s)
- Qian Niu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China.,The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Aleixandra Mendoza Rojas
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,The Rotterdam Transplant Group, Department of Clinical Pharmacology, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marjolein Dieterich
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dave L Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Marian C Clahsen-van Groningen
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,The Rotterdam Transplant Group, Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lanlan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Teun van Gelder
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,The Rotterdam Transplant Group, Department of Clinical Pharmacology, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dennis A Hesselink
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nicole M van Besouw
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Carla C Baan
- The Rotterdam Transplant Group, Department of Internal Medicine-Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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35
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Madubueze AG. Early Sonographic Evaluation of Intrarenal Arterial Resistive Index and Long-term Renal Function in Renal Transplant Recipients in South Western Nigeria. J Med Ultrasound 2020; 28:156-161. [PMID: 33282659 PMCID: PMC7709538 DOI: 10.4103/jmu.jmu_82_19] [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: 08/20/2019] [Revised: 10/17/2019] [Accepted: 12/13/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Color Doppler ultrasonography of intrarenal arterial Resistive Index (RI), performed early after kidney transplant, has proven to reliably predict short-term allograft function. The aim of this study was to assess whether early Doppler assessment could correlate with long-term renal function. METHODS This was a retrospective study of intrarenal RI using ultrasound in 41 stable kidney transplant patients who underwent RI assessment within 1 month after the transplant. Color Doppler ultrasonography was done to calculate the intrarenal RI within the first 4 weeks after transplant. The mean values of the intrarenal RI of the interlobar arteries of the allograft kidneys were measured and recorded. The data were analyzed with the aid of computer-based SPSS 20.0 software for windows (IBM, International Business Machines Corporation, Company, Armonk, New York, USA). RESULTS Older recipient age, active smoking, and proteinuria were associated with a higher intrarenal RI. Multivariate analyses showed that renal RI and donor age were independent predictors of allograft outcome. Kaplan-Meier estimates of cumulative graft survival were significantly worse in patients who had the values of the RI of 0.7 or more than they were in patients who had the values of the RI of <0.7. CONCLUSION This study reveals that renal RI determined within the 1st month after renal transplant correlates with long-term allograft function in kidney transplant recipients.
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36
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Sussell J, Silverstein AR, Goutam P, Incerti D, Kee R, Chen CX, Batty DS, Jansen JP, Kasiske BL. The economic burden of kidney graft failure in the United States. Am J Transplant 2020; 20:1323-1333. [PMID: 32020739 DOI: 10.1111/ajt.15750] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 01/25/2023]
Abstract
Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.
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Affiliation(s)
| | | | | | | | - Rebecca Kee
- Precision Health Economics, Los Angeles, California
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37
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Wan SS, Chadban SJ, Watson N, Wyburn K. Development and outcomes of de novo donor-specific antibodies in low, moderate, and high immunological risk kidney transplant recipients. Am J Transplant 2020; 20:1351-1364. [PMID: 31867849 DOI: 10.1111/ajt.15754] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 11/24/2019] [Accepted: 12/01/2019] [Indexed: 01/25/2023]
Abstract
De novo donor-specific antibodies (dnDSA) play an important role in antibody-mediated rejection (ABMR) and graft failure, yet their development in kidney transplant recipients (KTx) of higher immunological risk has not been characterized. We prospectively determined the incidence of dnDSA at 3 and 12 months posttransplant and assessed their associations with outcomes in recipients stratified by low, moderate, and high immunological risk. Adult KTx were screened for DSA pretransplant, months 3 and 12 posttransplant, and when clinically indicated. Outcomes included incidence of dnDSA, death-censored graft survival (DCGS), and ABMR. Of 371 recipients, 154 (42%) were transplanted across a pretransplant DSA that became undetectable by 12 months posttransplant in 78% of cases. dnDSA were detected in 16% (95% confidence interval [CI]: 12-20%) by 3 months and 23% (95% CI: 18-29%) by 12 months posttransplant. Incidence at 12 months was higher in the moderate (30%) and high-risk groups (29%) compared to the low-risk group (16%). dnDSA were associated with an increased risk of ABMR (hazard ratio [HR] 2.2; 95% CI: 1.1-4.4; P = .04) but were not an independent risk factor for DCGS. In conclusion, dnDSA were more frequent in transplant recipients of higher immune risk and associated with an increased risk of ABMR.
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Affiliation(s)
- Susan S Wan
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Charles Perkins Centre Kidney Node, The University of Sydney, Sydney, NSW, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Charles Perkins Centre Kidney Node, The University of Sydney, Sydney, NSW, Australia
| | - Narelle Watson
- New South Wales Transplantation and Immunogenetics Laboratory, Australian Red Cross Blood Services, Sydney, NSW, Australia
| | - Kate Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Charles Perkins Centre Kidney Node, The University of Sydney, Sydney, NSW, Australia
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38
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Kovács G, Devercelli G, Zelei T, Hirji I, Vokó Z, Keown PA. Association between transplant glomerulopathy and graft outcomes following kidney transplantation: A meta-analysis. PLoS One 2020; 15:e0231646. [PMID: 32343692 PMCID: PMC7188300 DOI: 10.1371/journal.pone.0231646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 03/28/2020] [Indexed: 02/07/2023] Open
Abstract
Transplant glomerulopathy (TG), a morphological lesion associated with confluent mechanisms of endothelial injury of renal allografts, may provide a viable predictor of graft failure. This systematic literature review and meta-analysis were performed according to the PRISMA statement to examine evidence describing the association between TG and graft loss or failure and time to these events. The literature review was conducted using the Scopus, EBSCO, and Cochrane Library search engines. Hazard ratios, median survival times, and 95% confidence intervals (CIs) were estimated to evaluate graft survival in the total population and prespecified subgroups. Meta-regression analysis assessed heterogeneity. Twenty-one publications comprising 6,783 patients were eligible for data extraction and inclusion in the meta-analysis. Studies were highly heterogeneous (I2 = 67.3%). The combined hazard ratio of graft loss or failure from random-effects meta-analysis was 3.11 (95% CI 2.44–3.96) in patients with TG compared with those without. Median graft survival in patients with TG was 3.25 (95% CI 0.94–11.21) years—15 years shorter than in those without TG (18.82 [95% CI 10.03–35.32] years). The effect of time from transplantation to biopsy on graft outcomes did not reach statistical significance (p = 0.116). TG was associated with a threefold increase in the risk of graft loss or failure and a 15-year loss in graft survival, indicating viability as a surrogate measure for both clinical practice and studies designed to prevent or reverse antibody-mediated rejection.
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Affiliation(s)
| | | | - Tamás Zelei
- Syreon Research Institute, Budapest, Hungary
| | - Ishan Hirji
- Shire, a Takeda company, Lexington, Massachusetts, United States of America
| | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Paul A. Keown
- Syreon Corporation, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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39
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Lee EJ, Jeon J, Lee KW, Yoo H, Jang HR, Park JB, Lee JE, Kim K, Huh W. The combination of area under the curve and percentage change in estimated glomerular filtration rate predicts long-term outcome of kidney transplants. Am J Transplant 2020; 20:1056-1062. [PMID: 31733034 DOI: 10.1111/ajt.15711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 11/10/2019] [Indexed: 01/25/2023]
Abstract
The development of surrogate markers for long-term outcomes of kidney transplant (KT) is a focus of attention. We examined the possibility of using a combination of the area under the curve of estimated glomerular filtration rate (eGFR) for 2 years (AUCeGFR2yrs ) and percent change in eGFR between 1 and 2 years after KT (% changeeGFR1/2yr ) as a surrogate marker. We compared the predictive power of death-censored graft failure with various combinations. The combination of >2% vs ≤2% for % changeeGFR1/2yr and >1300 vs ≤1300 mL/min/month for AUCeGFR2yr had the highest Harrell C-index (0.647; 95% confidence interval [95% CI], 0.604-0.690). The death-censored graft survival rate of the group with ≤2% changeeGFR1/2yr and ≤1300 mL/min/month AUCeGFR2yr was significantly lower than those of other groups. The AUC/% change eGFR had comparable predictive power to the previously identified marker ≥30% decline in eGFR between years 1 and 3 after KT (≤-30% changeeGFR1/3yr ) (Harrell's C-index = 0.645 [95% CI 0.628-0.662] for ≤-30% changeeGFR1/3yr ). The proposed combination might be useful as a surrogate marker in KT trials because it requires a shorter surveillance period than the established marker while having comparable predictive power.
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Affiliation(s)
- Eun Jeong Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junseok Jeon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Korea
| | - Hye Ryoun Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Korea
| | - Wooseong Huh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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40
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Ni X, Wang W, Li X, Li Y, Chen J, Shi D, Wen J. Utility of Diffusion-Weighted Imaging for Guiding Clinical Management of Patients With Kidney Transplant: A Prospective Study. J Magn Reson Imaging 2020; 52:565-574. [PMID: 32030832 DOI: 10.1002/jmri.27071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although biopsy is essential for the diagnosis and management of kidney transplant recipients, it is invasive. Intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) is a noninvasive technique that can assess both capillary perfusion and tissue diffusion. PURPOSE To evaluate the capability of IVIM-DWI as a differentiation of kidney transplant patients who need clinical intervention from those who need not. STUDY TYPE Prospective. SUBJECTS In all, 33 kidney transplant patients who needed clinical intervention and 19 who need not. FIELD STRENGTH/SEQUENCE 3.0T; IVIM-DWI with a single-shot echo planar imaging sequence. ASSESSMENT All patients underwent kidney transplant biopsy and IVIM-DWI scans. Patients were dichotomized into those who needed clinical intervention (CHANGE group) and those who need not (Non-CHANGE group) based on biopsy results. The values of total apparent diffusion coefficient (ADCT ), diffusion coefficient (D), and perfusion fraction (f) were acquired from renal cortex and medulla, respectively. The area under the curve (AUC) was calculated and compared. STATISTICAL TESTS Independent Student's t-test, receiver-operating characteristic curve, and Spearman correlation analysis. RESULTS All the cortical and medullary DWI parameters in the CHANGE group were significantly lower than those in the Non-CHANGE group (all P ≤ 0.012). Except for medullary fp, all DWI parameters in both the cortex and the medulla were inversely correlated with both the chronic (ρ ranging from -0.33 to -0.54, all P ≤ 0.02) and acute (ρ ranging from -0.35 to -0.60, all P ≤ 0.01) composite scores. Cortical ADCT and D had the largest AUC and specificity of 0.84 and 75.8%, respectively. Combined use of cortical D and medullary fp at each optimal cutoff point yielded a specificity of 90.9%. DATA CONCLUSION DWI demonstrated potential as a noninvasive biomarker to allow the stratification of patients into categories in which kidney allograft biopsy results are or are not likely to change clinical management. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 5 J. Magn. Reson. Imaging 2020;52:565-574.
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Affiliation(s)
- Xuefeng Ni
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wei Wang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue Li
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yanjun Li
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jinsong Chen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Donghong Shi
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiqiu Wen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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41
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The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article. Transplantation 2020; 104:e46-e56. [DOI: 10.1097/tp.0000000000003012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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42
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The Use of GLP1R Agonists for the Treatment of Type 2 Diabetes in Kidney Transplant Recipients. Transplant Direct 2020; 6:e524. [PMID: 32095510 PMCID: PMC7004635 DOI: 10.1097/txd.0000000000000971] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022] Open
Abstract
Glucagon-like peptide-1 receptor agonists (GLP1RA) have been shown to improve glucose control and diabetes-related comorbidities in patients without solid organ transplants. The effectiveness, safety, and tolerability of GLP1RA after kidney transplantation have not been adequately studied.
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43
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A Novel, Dose-Adjusted Tacrolimus Trough-Concentration Model for Predicting and Estimating Variance After Kidney Transplantation. Drugs R D 2019; 19:201-212. [PMID: 31073875 PMCID: PMC6544741 DOI: 10.1007/s40268-019-0271-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and Objective Given that a high intrapatient variability (IPV) of tacrolimus whole blood concentration increases the risk for a poor kidney transplant outcome, some experts advocate routine IPV monitoring for detection of high-risk patients. However, attempts to estimate the variance of tacrolimus trough concentrations (TTC) are limited by the need for patients to receive a fixed dose over time and/or the use of linear statistical models. A goal of this study is to overcome the current limitations through the novel application of statistical methodology generalizing the relationship between TTC and dose through the use of nonparametric functional regression modeling. Methods With TTC as a response and dose as a covariate, the model employs an unknown bivariate function, allowing for the potentially complex, nonlinear relationship between the two parameters. A dose-adjusted variance of TTC is then derived based on standard functional principal component analysis (FPCA). To assess the model, it was compared against an FPCA-based model and linear mixed-effects models using prediction error, bias, and coverage probabilities for simulated data as well as phase III data from the Astellas new drug application studies for extended-release tacrolimus. Results Our numerical investigation indicates that the new model better predicts dose-adjusted TTCs compared with the prediction of linear mixed effects models. Estimated coverage probabilities also indicate that the new model accurately accounts for the variance of TTC during the periods of large fluctuation in dose, whereas the linear mixed effects model consistently underestimates the coverage probabilities because of the inaccurate characterization of TTC fluctuation. Conclusion This is the first known application of a functional regression model to assess complex relationships between TTC and dose in a real clinical setting. This new method has applicability in future clinical trials including real-world data sets due to flexibility of the nonparametric modeling approach. Electronic supplementary material The online version of this article (10.1007/s40268-019-0271-2) contains supplementary material, which is available to authorized users.
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Altuğ Y, Liang N, Ram R, Ravi H, Ahmed E, Brevnov M, Swenerton RK, Zimmermann B, Malhotra M, Demko ZP, Billings PR, Ryan A. Analytical Validation of a Single-nucleotide Polymorphism-based Donor-derived Cell-free DNA Assay for Detecting Rejection in Kidney Transplant Patients. Transplantation 2019; 103:2657-2665. [PMID: 30801536 PMCID: PMC6867667 DOI: 10.1097/tp.0000000000002665] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/23/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early detection of rejection in kidney transplant recipients holds the promise to improve clinical outcomes. Development and implementation of more accurate, noninvasive methods to detect allograft rejection remain an ongoing challenge. The limitations of existing allograft surveillance methods present an opportunity for donor-derived cell-free DNA (dd-cfDNA), which can accurately and rapidly differentiate patients with allograft rejection from patients with stable organ function. METHODS This study evaluated the analytical performance of a massively multiplexed polymerase chain reaction assay that targets 13 962 single-nucleotide polymorphisms, characterized and validated using 66 unique samples with 1064 replicates, including cell line-derived reference samples, plasma-derived mixtures, and transplant patient samples. The dd-cfDNA fraction was quantified in both related and unrelated donor-recipient pairs. RESULTS The dd-cfDNA assay showed a limit of blank of 0.11%, a limit of detection and limit of quantitation of 0.15% for unrelated donors, and limit of blank of 0.23%, a limit of detection and limit of quantitation of 0.29% for related donors. All other metrics (linearity, accuracy, and precision) were observed to be equivalent between unrelated and related donors. The measurement precision of coefficient of variation was 1.8% (repeatability, 0.6% dd-cfDNA) and was <5% for all the different reproducibility measures. CONCLUSIONS This study validates the performance of a single-nucleotide polymorphism-based massively multiplexed polymerase chain reaction assay to detect the dd-cfDNA fraction with improved precision over currently available tests, regardless of donor-recipient relationships.
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Lee YH, Lee JJ, Lee SY, Jung SW, Kim YG, Moon JY, Kim JS, Hwang HS, Jeong KH, Chung BH, Kim CD, Park JB, Kim YH, Yang DH, Lee SH. Long-term Trends in the Clinicopathologic Features of Kidney Transplant Recipients With Graft Dysfunction. Transplant Proc 2019; 51:3297-3303. [PMID: 31732215 DOI: 10.1016/j.transproceed.2019.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/02/2019] [Accepted: 07/28/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Graft biopsy is the gold standard for the differential diagnosis of graft dysfunction. The time interval between transplant surgery and biopsy often provides clinicians with diagnostic clues. However, the clinicopathologic features of late graft biopsy, especially those obtained at more than 5 years after kidney transplant, are not well understood. MATERIALS AND METHODS We retrospectively collected graft biopsy tissues obtained from kidney transplant recipients who underwent indication biopsy between February 2012 and March 2017. Patients were divided according to their post-transplant period, and their clinical characteristics, pathologic diagnosis, and Banff scores were compared across groups. RESULTS A total of 410 indication biopsy specimens obtained from 321 kidney transplant recipients were analyzed in this study. Overall, the incidence of T cell-mediated rejection, borderline rejection, and BK virus-associated nephropathy decreased while that of antibody-mediated rejection, nonspecific interstitial fibrosis and tubular atrophy, and glomerulonephritis increased over time. Most samples obtained over 5 years after kidney transplant exhibited chronic glomerular and tubulointerstitial injuries irrespective of their pathologic diagnosis. In patients whose post-transplant period was less than 5 years, urine protein-to-creatinine ratio was significantly elevated in the glomerulonephritis and chronic active antibody-mediated rejection groups only. In contrast, patients who underwent graft biopsy more than 5 years after kidney transplant showed significantly high levels of proteinuria irrespective of the pathologic diagnosis, and there was no statistical difference between groups. CONCLUSION We demonstrated that the etiology of graft dysfunction is largely influenced by the biopsy time point.
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Affiliation(s)
- Yu Ho Lee
- Division of Nephrology, Department of Internal Medicine
| | - Jung Jun Lee
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - So-Young Lee
- Division of Nephrology, Department of Internal Medicine
| | - Su Woong Jung
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Yang-Gyun Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Ju-Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Jin Sug Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Kyung-Hwan Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Byung Ha Chung
- Transplant Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Seoul, Korea
| | - Yeong Hoon Kim
- Division of Nephrology, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Dong Ho Yang
- Division of Nephrology, Department of Internal Medicine
| | - Sang-Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea.
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Parajuli S, Aziz F, Garg N, Panzer SE, Joachim E, Muth B, Mohamed M, Blazel J, Zhong W, Astor BC, Mandelbrot DA, Djamali A. Histopathological characteristics and causes of kidney graft failure in the current era of immunosuppression. World J Transplant 2019; 9:123-133. [PMID: 31750089 PMCID: PMC6851501 DOI: 10.5500/wjt.v9.i6.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The histopathological findings on the failing kidney allograft in the modern era is not well studied. In this study, we present our experience working with kidney transplant recipients with graft failure within one year of the biopsy. AIM To report the histopathological characteristics of failed kidney allografts in the current era of immunosuppression based on the time after transplant, cause of the end-stage renal disease and induction immunosuppressive medications. METHODS In a single-center observational study, we characterized the histopathological findings of allograft biopsies in kidney transplant recipients with graft failure within one year after the biopsy. RESULTS We identified 329 patients with graft failure that met the selection criteria between January 1, 2006 and December 31, 2016. The three most common biopsy findings were interstitial fibrosis and tubular atrophy (IFTA, 53%), acute rejection (AR, 43%) and transplant glomerulopathy (TG, 33%). Similarly, the three most common causes of graft failure based on the primary diagnosis were AR (40%), TG (17%), and IFTA (13%). Most grafts failed within two years of post-transplant (36%). Subsequently, approximately 10%-15% of grafts failed every two years: > 2-4 years (16%), > 4-6 years (13%), > 6-8 years (11%), > 8-10 years (9%) and > 10 years (16%). AR was the most common cause of graft failure in the first six years (48%), whereas TG was the most prevalent cause of graft failure after 6 years (32%) of transplant. CONCLUSION In the current era of immunosuppression, AR is still the most common cause of early graft failure, while TG is the most prevalent cause of late graft failure.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Sarah E Panzer
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Emily Joachim
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Brenda Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Justin Blazel
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI 53705, United States
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Department of Population Health Sciences, University of Wisconsin, Madison, WI 53705, United States
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI 53705, United States
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Denic A, Morales MC, Park WD, Smith BH, Kremers WK, Alexander MP, Cosio FG, Rule AD, Stegall MD. Using computer-assisted morphometrics of 5-year biopsies to identify biomarkers of late renal allograft loss. Am J Transplant 2019; 19:2846-2854. [PMID: 30947386 PMCID: PMC8214914 DOI: 10.1111/ajt.15380] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 01/25/2023]
Abstract
The current Banff scoring system was not developed to predict graft loss and may not be ideal for use in clinical trials aimed at improving allograft survival. We hypothesized that scoring histologic features of digitized renal allograft biopsies using a continuous, more objective, computer-assisted morphometric (CAM) system might be more predictive of graft loss. We performed a nested case-control study in kidney transplant recipients with a surveillance biopsy obtained 5 years after transplantation. Patients that developed death-censored graft loss (n = 67) were 2:1 matched on age, gender, and follow-up time to controls with surviving grafts (n = 134). The risk of graft loss was compared between CAM-based models vs a model based on Banff scores. Both Banff and CAM identified chronic lesions associated with graft loss (chronic glomerulopathy, arteriolar hyalinosis, and mesangial expansion). However, the CAM-based models predicted graft loss better than the Banff-based model, both overall (c-statistic 0.754 vs 0.705, P < .001), and in biopsies without chronic glomerulopathy (c-statistic 0.738 vs 0.661, P < .001) where it identified more features predictive of graft loss (% luminal stenosis and % mesangial expansion). Using 5-year renal allograft surveillance biopsies, CAM-based models predict graft loss better than Banff models and might be developed into biomarkers for future clinical trials.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martha C. Morales
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Walter D. Park
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Byron H. Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter K. Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Fernando G. Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Mark D. Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
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Sexton DJ, O'Kelly P, Williams Y, Plant WD, Keogan M, Khalib K, Doyle B, Dorman A, Süsal C, Unterrainer C, Forde J, Power R, Smith G, Mohan P, Denton M, Magee C, de Freitas DG, Little D, O'Seaghdha CM, Conlon PJ. Progressive improvement in short‐, medium‐ and long‐term graft survival in kidney transplantation patients in Ireland – a retrospective study. Transpl Int 2019; 32:974-984. [DOI: 10.1111/tri.13470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 11/23/2018] [Accepted: 06/12/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Donal J. Sexton
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Patrick O'Kelly
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Yvonne Williams
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - William D. Plant
- The National Renal Office Health Service Executive of Ireland Cork University Hospital University College Cork Cork Ireland
| | - Marie Keogan
- Department of Immunology Beaumont Hospital Dublin Ireland
| | - Khairin Khalib
- Department of Immunology Beaumont Hospital Dublin Ireland
| | - Brendan Doyle
- Department of Pathology Beaumont Hospital Dublin Ireland
| | - Anthony Dorman
- Department of Pathology Beaumont Hospital Dublin Ireland
| | - Caner Süsal
- Collaborative Transplant Study Institute of Immunology Heidelberg University Heidelberg Germany
| | - Christian Unterrainer
- Collaborative Transplant Study Institute of Immunology Heidelberg University Heidelberg Germany
| | - James Forde
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Richard Power
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Gordon Smith
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Ponnusamy Mohan
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Mark Denton
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Colm Magee
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Declan G. de Freitas
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Dilly Little
- Department of Transplant Urology Beaumont Hospital Dublin Ireland
| | - Conall M. O'Seaghdha
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
| | - Peter J. Conlon
- National Kidney Transplant Service Department of Nephrology and Kidney Transplantation Beaumont Hospital Dublin Ireland
- Royal College of Surgeons in Ireland Dublin Ireland
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Suppressive Effect of Everolimus on IL-2, IL-10, IL-21, and IFNγ Levels: Implications for the Successful Minimization of Calcineurin Inhibitor Use in Transplantation. Ther Drug Monit 2019; 41:371-375. [DOI: 10.1097/ftd.0000000000000630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Matas AJ, Fieberg A, Mannon RB, Leduc R, Grande J, Kasiske BL, Cecka M, Gaston R, Hunsicker L, Connett J, Cosio F, Gourishankar S, Rush D. Long-term follow-up of the DeKAF cross-sectional cohort study. Am J Transplant 2019; 19:1432-1443. [PMID: 30506642 PMCID: PMC7653899 DOI: 10.1111/ajt.15204] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/24/2018] [Accepted: 11/19/2018] [Indexed: 01/25/2023]
Abstract
The DeKAF study was developed to better understand the causes of late allograft loss. Preliminary findings from the DeKAF cross-sectional cohort (with follow-up < 20 months) have been published. Herein, we present long-term outcomes in those recipients (mean follow-up ± SD, 6.6 ± 0.7 years). Eligibility included being transplanted prior to October 1, 2005; serum creatinine ≤ 2.0 mg/dL on January 1, 2006; and subsequently developing new-onset graft dysfunction leading to a biopsy. Mean time from transplant to biopsy was 7.5 ± 6.1 years. Histologic findings and DSA were studied in relation to postbiopsy outcomes. Long-term follow-up confirms and expands the preliminary results of each of 3 studies: (1) increasing inflammation in area of atrophy (irrespective of inflammation in nonscarred areas [Banff i]) was associated with increasingly worse postbiopsy death-censored graft survival; (2) hierarchical analysis based on Banff scores defined clusters (entities) that differed in long-term death-censored graft survival; and (3) C4d-/DSA- recipients had significantly better (and C4d+/DSA+ worse) death-censored graft survival than other groups. C4d+/DSA- and C4d-/DSA+ had similar intermediate death-censored graft survival. Clinical and histologic findings at the time of new-onset graft dysfunction define high- vs low-risk groups for long-term death-censored graft survival, even years posttransplant. These findings can help differentiate groups for potential intervention studies.
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Affiliation(s)
- Arthur J. Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann Fieberg
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Roslyn B. Mannon
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | - Robert Leduc
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Joe Grande
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Bertram L. Kasiske
- Chronic Disease and Research Group, Hennepin Healthcare, Minneapolis, Minnesota
| | - Michael Cecka
- Ronald Reagan UCLA Medicine Center, University of California, Los Angeles, California
| | - Robert Gaston
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | | | - John Connett
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Fernando Cosio
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Sita Gourishankar
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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