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Masterson JM, Zhao H, Taich L, Naser‐Tavakolian A, Johnson H, Najjar R, Kim IK, Gupta A. Robotic bilateral nephrectomy for large polycystic kidney disease. BJUI COMPASS 2023; 4:701-708. [PMID: 37818019 PMCID: PMC10560624 DOI: 10.1002/bco2.263] [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: 02/02/2023] [Revised: 05/26/2023] [Accepted: 05/28/2023] [Indexed: 10/12/2023] Open
Abstract
Objective This study aims to describe our technique and review our experience with synchronous robotic bilateral nephrectomy for large kidneys in ADPKD with the da Vinci XI and da Vinci Single Port platforms (Intuitive Surgical, Sunnyvale, CA). Materials and Methods We performed a retrospective review of all robotic bilateral nephrectomy cases from January 2020 to present at a high-volume robotic single centre. Demographic data and perioperative details including preoperative CT scans, indication for nephrectomy and renal function were collected. We also collected post-op course data and final specimen data details. Results Fourteen cases were included. Patient demographics, indications for surgery and specimen data are outlined in Table 1. The largest kidney removed has a measurement of 32 cm in the largest dimension on preoperative imaging. Median operating time from incision to closure was 299 min (IQR 260, 339). Median estimated blood loss was 75 cc (IQR 50, 187.5). Two patients were transfused intraoperatively. Median pre- and post-operative Hgb was 11.0 and 9.6, respectively. Median length of stay was 3 days (IQR 2, 3.5). There were no intraoperative complications and no open conversions. Post-operative complications included one incisional hematoma and one superficial wound infection. One patient was admitted to the surgical ICU post operatively for ventilatory support. Two patients were readmitted within 30 days of surgery. Conclusion The robotic approach to bilateral native nephrectomy for ADPKD should be considered when native nephrectomies are indicated. The operative times and outcomes are favourable compared with prior series, and this technique works even for very large kidneys.
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Affiliation(s)
- John M. Masterson
- Division of UrologyCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Hanson Zhao
- Hoag UrologyHoag HospitalNewport BeachCaliforniaUSA
| | - Lior Taich
- Division of UrologyCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Hayley Johnson
- Division of UrologyCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Reiad Najjar
- Division of NephrologyCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Irene K. Kim
- Department of SurgeryCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Amit Gupta
- Division of UrologyCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
- Beverly Hills UrologyBeverly HillsCaliforniaUSA
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Wu K, Schmidt D, López del Moral C, Osmanodja B, Lachmann N, Halleck F, Choi M, Bachmann F, Ronicke S, Duettmann W, Naik M, Schrezenmeier E, Rudolph B, Budde K. Poor Outcomes in Patients With Transplant Glomerulopathy Independent of Banff Categorization or Therapeutic Interventions. Front Med (Lausanne) 2022; 9:889648. [PMID: 35646957 PMCID: PMC9133540 DOI: 10.3389/fmed.2022.889648] [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: 03/04/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTransplant glomerulopathy (TG) may indicate different disease entities including chronic AMR (antibody-mediated rejection). However, AMR criteria have been frequently changed, and long-term outcomes of allografts with AMR and TG according to Banff 2017 have rarely been investigated.Methods282 kidney allograft recipients with biopsy-proven TG were retrospectively investigated and diagnosed according to Banff'17 criteria: chronic AMR (cAMR, n = 72), chronic active AMR (cAAMR, n = 76) and isolated TG (iTG, n = 134). Of which 25/72 (34.7%) patients of cAMR group and 46/76 (60.5%) of cAAMR group were treated with antihumoral therapy (AHT).ResultsUp to 5 years after indication biopsy, no statistically significant differences were detected among iTG, cAMR and cAAMR groups in annual eGFR decline (−3.0 vs. −2.0 vs. −2.8 ml/min/1.73 m2 per year), 5-year median eGFR (21.5 vs. 16.0 vs. 20.0 ml/min/1.73 m2), 5-year graft survival rates (34.1 vs. 40.6 vs. 31.8%) as well as urinary protein excretion during follow-up. In addition, cAMR and cAAMR patients treated with AHT had similar graft and patient survival rates in comparison with those free of AHT, and similar comparing with iTG group. The TG scores were not associated with 5-year postbiopsy graft failure; whereas the patients with higher scores of chronic allograft scarring (by mm-, ci- and ct-lesions) had significantly lower graft survival rates than those with mild scores. The logistic-regression analysis demonstrated that Banff mm-, ah-, t-, ci-, ct-lesions and the eGFR level at biopsy were associated with 5-year graft failure.ConclusionsThe occurrence of TG is closely associated with graft failure independent of disease categories and TG score, and the long-term clinical outcomes were not influenced by AHT. The Banff lesions indicating progressive scarring might be better suited to predict an unfavorable outcome.
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Affiliation(s)
- Kaiyin Wu
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
- *Correspondence: Kaiyin Wu
| | - Danilo Schmidt
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Covadonga López del Moral
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Lachmann
- HLA Laboratory, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, BIH, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Simon Ronicke
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Birgit Rudolph
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
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Wu K, Schmidt D, López del Moral C, Osmanodja B, Lachmann N, Zhang Q, Halleck F, Choi M, Bachmann F, Ronicke S, Duettmann W, Naik MG, Schrezenmeier E, Rudolph B, Budde K. Poor Long-Term Renal Allograft Survival in Patients with Chronic Antibody-Mediated Rejection, Irrespective of Treatment-A Single Center Retrospective Study. J Clin Med 2021; 11:jcm11010199. [PMID: 35011939 PMCID: PMC8745558 DOI: 10.3390/jcm11010199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/25/2021] [Accepted: 12/27/2021] [Indexed: 01/16/2023] Open
Abstract
The Banff 2017 report permits the diagnosis of pure chronic antibody-mediated rejection (cAMR) in absence of microcirculation inflammation. We retrospectively investigated renal allograft function and long-term outcomes of 67 patients with cAMR, and compared patients who received antihumoral therapy (cAMR-AHT, n = 21) with patients without treatment (cAMRwo, n = 46). At baseline, the cAMR-AHT group had more concomitant T-cell-mediated rejection (9/46 (19.2%) vs. 10/21 (47.6%); p = 0.04), a higher g-lesion score (0.4 ± 0.5 versus 0.1 ± 0.3; p = 0.01) and a higher median eGFR decline in the six months prior to biopsy (6.6 vs. 3.0 mL/min; p = 0.04). The median eGFR decline six months after biopsy was comparable (2.6 vs. 4.9 mL/min, p = 0.61) between both groups, and three-year graft survival after biopsy was statistically lower in the cAMR-AHT group (35.0% vs. 61.0%, p = 0.03). Patients who received AHT had more infections (0.38 vs. 0.20 infections/patient; p = 0.04). Currently, antihumoral therapy is more often administered to patients with cAMR and rapidly deteriorating renal function or concomitant TCMR. However, long-term graft outcomes remain poor, despite treatment.
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Affiliation(s)
- Kaiyin Wu
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Correspondence: ; Tel.: +49-30-450-514002; Fax: +49-30-450-514902
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Nils Lachmann
- Institute of Transfusion Medicine, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Qiang Zhang
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Simon Ronicke
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Birgit Rudolph
- Institute of Pathology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
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Robot-assisted Synchronous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease: A Stepwise Description of Technique. Urology 2020; 153:333-338. [PMID: 32562776 DOI: 10.1016/j.urology.2020.05.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe our technique of robot-assisted synchronous bilateral nephrectomy (RASBN) for autosomal dominant polycystic kidney disease (ADPKD). METHODS Given prior abdominal surgery/transplant in most patients, we prefer an open cut-down access to place a 12 mm port 10 cm infraumbilically. Four (8 mm) robotic ports are then placed under vision in a fan distribution along the umbilical level. The operating table is placed in reverse Trendelenburg and tilted opposite to the targeted side. Provided there are no concerns for malignancy, some cysts encountered in large kidneys (>2.5 L) may require puncture, to facilitate access and mobilization. The resected kidney is placed in a large bag and tucked in the pelvis. A similar procedure is carried out on the contralateral side after redocking the robot and tilting the table in the opposite direction. The specimen bags are extracted by elongating the lower midline 12 mm port site. RESULTS Seven cases of RASBN performed for ADPKD were identified (December 2015 to December 2018). Median (interquartile range, IQR) values for patient demographics were: Age = 59 years (47-63), body mass index = 29 (26-32), and American Society of Anaesthesiology grade = 3. Three patients had prior deceased- and 4 had prior living- donor transplants. Indication for nephrectomy were: pain (5), hemorrhage into cysts (3), and renal masses (2). Perioperative outcomes were: operating room time = 388 minutes, estimated blood loss = 200 mL, hemoglobin change = 1.3 g/dL, transfusion = 0, length of hospital stay = 3 days, Grade I Clavien-Dindo complications = 2 cases. All patients were alive at a median follow-up of 3.8 years. CONCLUSION RASBN is safe and effective in ADPKD even in the context of prior renal transplant patients with attendant comorbidities.
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Sortica DA, Crispim D, Bauer AC, Nique PS, Nicoletto BB, Crestani RP, Staehler JT, Manfro RC, Canani LH. K121Q polymorphism in the Ectonucleotide Pyrophosphatase/Phosphodiesterase 1 gene is associated with acute kidney rejection. PLoS One 2019; 14:e0219062. [PMID: 31318911 PMCID: PMC6639061 DOI: 10.1371/journal.pone.0219062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/15/2019] [Indexed: 12/31/2022] Open
Abstract
The identification of risk factors for acute rejection (AR) may lead to strategies to improve success of kidney transplantation. Ectonucleotidases are ectoenzymes that hydrolyze extracellular nucleotides into nucleosides, modulating the purinergic signaling. Some members of the Ectonucleotidase family have been linked to transplant rejection processes. However, the association of Ectonucleotide Pyrophosphatase / Phosphodiesterase 1 (ENPP1) with AR has not yet been evaluated. The aim of this study was to evaluate the association between the K121Q polymorphism of ENPP1 gene and AR in kidney transplant patients. We analyzed 449 subjects without AR and 98 with AR from a retrospective cohort of kidney transplant patients from Southern Brazil. K121Q polymorphism was genotyped using allelic discrimination-real-time PCR. Cox regression analysis was used to evaluate freedom of AR in kidney transplant patients according to genotypes. Q allele frequency was 17.6% in recipients without AR and 21.9% in those with AR (P = 0.209). Genotype frequencies of the K121Q polymorphism were in Hardy-Weinberg equilibrium in non-AR patients (P = 0.70). The Q/Q genotype (recessive model) was associated with AR (HR = 2.83, 95% CI 1.08–7.45; P = 0.034) after adjusting for confounders factors. Our findings suggest a novel association between the ENPP1 121Q/Q genotype and AR in kidney transplant recipients.
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Affiliation(s)
- Denise A. Sortica
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daisy Crispim
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Andrea C. Bauer
- Postgraduate Program in Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Pamela S. Nique
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bruna B. Nicoletto
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Life Science Knowledge Area, Universidade de Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil, Nutrition Course, Área do Conhecimento de Ciências da Vida, Universidade de Caxias do Sul (UCS), Caxias do Sul, Brazil
| | - Ricieli P. Crestani
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jennifer T. Staehler
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Roberto C. Manfro
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luis H. Canani
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- * E-mail:
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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Wu K, Budde K, Schmidt D, Neumayer HH, Lehner L, Bamoulid J, Rudolph B. The inferior impact of antibody-mediated rejection on the clinical outcome of kidney allografts that develop de novo thrombotic microangiopathy. Clin Transplant 2016; 30:105-17. [PMID: 26448478 DOI: 10.1111/ctr.12645] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) can induce and develop thrombotic microangiopathy (TMA) in renal allografts. A definitive AMR (dAMR) co-presents three diagnostic features. A suspicious AMR (sAMR) is designated when one of the three features is missing. METHODS Thirty-two TMA cases overlapping with AMR (AMR+ TMA) were studied, which involved 14 cases of sAMR+ TMA and 18 cases of dAMR+ TMA. Thirty TMA cases free of AMR features (AMR- TMA) were enrolled as control group. RESULTS The ratio of complete response to treatment was similar between AMR- TMA and AMR+ TMA group (23.3% vs. 12.5%, p = 0.33), or between sAMR+ TMA and dAMR+ TMA group (14.3% vs. 11.1%, p = 0.79). At eight yr post-transplantation, the death-censored graft survival (DCGS) rate of AMR- TMA group was 62.8%, which was significantly higher than 28.0% of AMR+ TMA group (p = 0.01), but similar between sAMR+ TMA and dAMR+ TMA group (30.0% vs. 26.7%, p = 0.92). Overall, the intimal arteritis and the broad HLA (Human leukocyte antigens) mismatches were closely associated with over time renal allograft failure. CONCLUSION The AMR+ TMA has inferior long-term graft survival, but grafts with sAMR+ TMA or dAMR+ TMA have similar characteristics and clinical courses.
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Affiliation(s)
- Kaiyin Wu
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Klemens Budde
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Danilo Schmidt
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Hans-Hellmut Neumayer
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Lukas Lehner
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Jamal Bamoulid
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Birgit Rudolph
- Institut für Pathologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
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The Relationship of the Severity and Category of Acute Rejection With Intimal Arteritis Defined in Banff Classification to Clinical Outcomes. Transplantation 2015; 99:e105-14. [PMID: 25719260 DOI: 10.1097/tp.0000000000000640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear if the category of acute rejection with intimal arteritis (ARV) is relevant to short- and long-term clinical outcomes and if the graft outcomes are affected by the severity of intimal arteritis. METHODS One hundred forty-eight ARV episodes were reviewed and categorized according to the 2013 Banff criteria of AMR: T cell-mediated rejection with intimal arteritis (v) lesion (TCMRV; n = 78), total antibody-mediated rejection with v lesion (AMRV), which were further divided into suspicious AMRV (n = 37) and AMRV (n = 33). The Banff scores of intimal arteritis (v1, v2 and v3) represented low, moderate, and high ARV severity. RESULTS The grafts with TCMRV, suspicious AMRV (sAMRV), and AMRV showed similar responses to antirejection therapy, whereas the grafts with v2- or v3-ARV responded significantly poorer compared to those with v1-ARV. The 8-year death-censored graft survival (DCGS) rate was 56.8% of TCMRV versus 34.1% of total AMRV (Log rank, P = 0.03), but the 1- and 5-year DCGS rates were comparable between the 2 groups; moreover, the 1-, 5-, and 8-year DCGS rates of v1-ARV were evidently higher than v2- and v3-ARV (each pairwise comparison to v1-AVR yields P < 0.01); in contrast, the DCGS rates were similar between sAMRV and AMRV. The existing donor-specific antibodies or moderate microvascular inflammation or C4d-positive staining or intensive tubulointerstitial inflammation played a less significant role on the long-term graft survival. CONCLUSIONS Compared to the category, the ARV severity is more closely associated with the initial response to antirejection therapy and long-term graft failure. The sAMRV and AMRV might represent a spectrum of the same disorder.
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Translational research in kidney transplantation and the role of patient engagement. Can J Kidney Health Dis 2015; 2:42. [PMID: 26543564 PMCID: PMC4634742 DOI: 10.1186/s40697-015-0077-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 09/02/2015] [Indexed: 12/25/2022] Open
Abstract
Background Translational research is an evolving discipline that is intended to bridge the gaps between basic science research, clinical research, and implementation in clinical practice. It is a fluid, multidirectional process that requires strong interdisciplinary collaboration to produce research that is relevant to end-users. Purpose of this review This review summarizes current perspectives on translational research and outlines its relevance and importance to kidney transplantation research. Sources of information Sources of information used for this review include published reports, articles, and research funding websites. Findings Tissue typing is used as an in-depth example of how translational research has been applied in the field of kidney transplant medicine, and how it has resulted in successful implementation of diagnostic and management options for sensitized individuals undergoing kidney transplantation. The value of actively involving kidney transplant stakeholders (patients, caregivers, and clinicians) in setting research priorities and determining relevant outcomes for future investigation is also discussed. Limitations This is a narrative review of the literature which has been partly influenced by the perspectives and experiences of its authors. Implications Translational and patient-oriented research practices should be incorporated into future research endeavours in the field of kidney transplantation in order to create beneficial change in clinical practice and improve patient outcomes. What was known before Translational research which engages patients in the investigative process can enhance the likelihood that medical discoveries will have a meaningful impact at the bedside. What this adds This article applies current perspectives on translational research and patient engagement to the field of kidney transplantation, illustrating how these approaches have led to significant advancements in the field. It provides further justification for deliberate, targeted efforts to cross-collaborate and incorporate the patient voice into kidney transplant research.
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Chen J, Wang Q, Yin D, Vu V, Sciammas R, Chong AS. Cutting Edge: CTLA-4Ig Inhibits Memory B Cell Responses and Promotes Allograft Survival in Sensitized Recipients. THE JOURNAL OF IMMUNOLOGY 2015; 195:4069-73. [PMID: 26416270 DOI: 10.4049/jimmunol.1500940] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 09/04/2015] [Indexed: 12/28/2022]
Abstract
Sensitized recipients with pretransplant donor-specific Abs are at higher risk for Ab-mediated rejection than nonsensitized recipients, yet little is known about the properties of memory B cells that are central to the recall alloantibody responses. Using cell enrichment and MHC class I tetramers, C57BL/6 mice sensitized with BALB/c splenocytes were shown to harbor H-2K(d)-specific IgG(+) memory B cells with a post-germinal center phenotype (CD73(+)CD273(+)CD38(hi)CD138(-)GL7(-)). These memory B cells adoptively transferred into naive mice without memory T cells recapitulated class-switched recall alloantibody responses. During recall, memory H-2K(d)-specific B cells preferentially differentiated into Ab-secreting cells, whereas in the primary response, H-2K(d)-specific B cells differentiated into germinal center cells. Finally, our studies revealed that, despite fundamental differences in alloreactive B cell fates in sensitized versus naive recipients, CTLA-4Ig was unexpectedly effective at constraining B cell responses and heart allograft rejection in sensitized recipients.
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Affiliation(s)
- Jianjun Chen
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
| | - Qiang Wang
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
| | - Dengping Yin
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
| | - Vinh Vu
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
| | - Roger Sciammas
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
| | - Anita S Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637
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Abstract
PURPOSE OF REVIEW Scientific and technical developments in the field of lung transplantation have allowed it to become a successful treatment option for various end-stage lung diseases. As the demand for lung allografts increases and waitlists expand, it is vital that lung transplant centers optimize use of this limited resource by selecting recipients who have the best prospects of positive long-term outcomes. Recipient selection criteria vary across transplant selection committees. We review the most recent body of literature for recipient consideration and describe potential effects on morbidity and mortality posttransplantation. RECENT FINDINGS Although prior guidelines for contraindications to lung transplantation have been described, the benchmarks for recipient selection are constantly being challenged. Age, weight, and psychologic condition of recipients pretransplant have more recently been shown to have significant influence on posttransplant outcomes. Advancements in human leukocyte antigen antibody testing and use of extracorporeal membrane oxygenation as a bridge to lung transplantation have additionally impacted recipient selection standards. SUMMARY Recipient selection criteria continue to evolve because of advances in mechanical bridging to transplant and postoperative management. This review will cover some of the new concepts in lung transplant recipient selection and their potential effect on posttransplant outcomes.
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Huber L, Lachmann N, Niemann M, Naik M, Liefeldt L, Glander P, Schmidt D, Halleck F, Waiser J, Brakemeier S, Neumayer HH, Schönemann C, Budde K. Pretransplant virtual PRA and long-term outcomes of kidney transplant recipients. Transpl Int 2015; 28:710-9. [DOI: 10.1111/tri.12533] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/22/2014] [Accepted: 01/26/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Lu Huber
- Section of Nephrology; Department of Medicine; Georgia Regents University Medical Centre; Augusta GA USA
| | - Nils Lachmann
- Center for Transfusion Medicine and Cell Therapy; Regional Tissue Typing Laboratory; Campus Virchow Klinikum; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Matthias Niemann
- Center for Transfusion Medicine and Cell Therapy; Regional Tissue Typing Laboratory; Campus Virchow Klinikum; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Marcel Naik
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Lutz Liefeldt
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Petra Glander
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Danilo Schmidt
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Fabian Halleck
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Johannes Waiser
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Susanne Brakemeier
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Hans H. Neumayer
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Constanze Schönemann
- Center for Transfusion Medicine and Cell Therapy; Regional Tissue Typing Laboratory; Campus Virchow Klinikum; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Klemens Budde
- Department of Nephrology; Charité Campus Mitte; Charité Universitätsmedizin Berlin; Berlin Germany
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14
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Budde K, Lehner LJ. Bortezomib-based antibody reduction therapy: the first step to “true” desensitization? Am J Transplant 2015; 15:10-12. [PMID: 25534967 DOI: 10.1111/ajt.13048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 09/24/2014] [Accepted: 09/28/2014] [Indexed: 01/25/2023]
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15
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Human Leukocyte Antigen–Incompatible Kidney Transplantation After “Desensitization”—Hope and Reality. Transplantation 2014; 98:819-20. [DOI: 10.1097/tp.0000000000000296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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. EXP CLIN TRANSPLANT 2014; 12. [DOI: 10.6002/ect.2014.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hebral AL, Cointault O, Connan L, Congy-Jolivet N, Esposito L, Cardeau-Desangles I, Del Bello A, Lavayssière L, Nogier MB, Ribes D, Guitard J, Sallusto F, Gamé X, Parant O, Berrebi A, Rostaing L, Kamar N. Pregnancy after kidney transplantation: outcome and anti-human leucocyte antigen alloimmunization risk. Nephrol Dial Transplant 2014; 29:1786-1793. [DOI: 10.1093/ndt/gfu208] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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The severity of acute cellular rejection defined by Banff classification is associated with kidney allograft outcomes. Transplantation 2014; 97:1146-54. [PMID: 24892962 DOI: 10.1097/01.tp.0000441094.32217.05] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear if the severity or the timing of acute cellular rejection (ACR) defined by Banff classification 2009 is associated with graft survival. METHODS Borderline changes, TCMR I (interstitial rejection), and TCMR II/III (vascular rejection) were defined as low, moderate, and high ACR severity, respectively. Approximately 270 patients who had at least one episode of ACR were enrolled, 270 biopsies were chosen which showed the highest ACR severity of each patient and were negative for donor-specific antibodies (DSA), C4d, and microcirculation changes (MC). Six months were used as the cutoff to define early and late ACR; 370 patients without biopsy posttransplantation were recruited in the control group. RESULTS Up to 8-year posttransplantation, death-censored graft survival (DCGS) rates of control, borderline, TCMR I, and TCMR II/III groups were 97.6%, 93.3%, 79.6%, and 73.6% (log rank test, P<0.001); the control group had significantly higher DCGS rate than the three ACR groups (each pairwise comparison yields P<0.05). The DCGS rate of late ACR was significantly lower compared with early ACR (63.6% vs. 87.4%, P<0.001). Intimal arteritis (Banff v-lesion) was an independent histologic risk factor correlated with long-term graft loss regardless of the timing of ACR. The v-lesions with minimal or high-grade tubulitis displayed similar graft survival (72.7% vs. 72.9%, P=0.96). CONCLUSION All types of ACR affect long-term graft survival. Vascular or late ACR predict poorer graft survival; the extent of tubulointerstitial inflammation (TI) is of no prognostic significance for vascular rejection.
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Maggiore U, Oberbauer R, Pascual J, Viklicky O, Dudley C, Budde K, Sorensen SS, Hazzan M, Klinger M, Abramowicz D. Strategies to increase the donor pool and access to kidney transplantation: an international perspective. Nephrol Dial Transplant 2014; 30:217-22. [PMID: 24907023 PMCID: PMC4309190 DOI: 10.1093/ndt/gfu212] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
In this position article, DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) board members describe the current strategies aimed at expanding living and deceased donor kidney pools. The article focuses on the recent progress in desensitization and kidney paired exchange programmes and on the expanded criteria for the use of donor kidneys and organs from donors after circulatory death. It also highlights differences in policies and practices across different regions with special regard to European Union countries. Living donor kidney paired exchange, the deceased donor Acceptable Mismatch Programme and kidneys from donors after circulatory death are probably the most promising innovations for expanding kidney transplantation in Europe over the coming decade. To maximize success, an effort is needed to standardize transplant strategies, policies and legislation across European countries.
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Affiliation(s)
- Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Rainer Oberbauer
- KH Elisabethinen Linz and Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Klemens Budde
- Department of Nephrology, Charité Medical University Berlin, Berlin, Germany
| | | | - Marc Hazzan
- Service de Néphrologie, Univ Lille Nord de France, Lille, France
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
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Chen J, Yin H, Xu J, Wang Q, Edelblum KL, Sciammas R, Chong AS. Reversing endogenous alloreactive B cell GC responses with anti-CD154 or CTLA-4Ig. Am J Transplant 2013; 13:2280-92. [PMID: 23855587 PMCID: PMC3797532 DOI: 10.1111/ajt.12350] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/07/2013] [Accepted: 05/27/2013] [Indexed: 01/25/2023]
Abstract
Alloantibodies mediate acute antibody-mediated rejection as well as chronic allograft rejection in clinical transplantation. To better understand the cellular dynamics driving antibody production, we focused on the activation and differentiation of alloreactive B cells in the draining lymph nodes and spleen following sensitization to allogeneic cells or hearts. We used a modified staining approach with a single MHC Class I tetramer (K(d)) bound to two different fluorochromes to discriminate between the Class I-binding and fluorochrome-streptavidin-binding B cells with a high degree of specificity and binding efficiency. By Day 7-8 postsensitization, there was a 1.5- to 3.2-fold increase in the total numbers of K(d) -binding B cells. Within this K(d) -binding B cell population, approximately half were IgD(low) , MHC Class II(high) and CD86(+), 30-45% expressed a germinal center (Fas(+) GL7(+)) phenotype and 3-12% were IRF4(hi) plasma cells. Remarkably, blockade with anti-CD40 or CTLA-4Ig, starting on Day 7 postimmunization for 1 or 4 weeks, completely dissolved established GCs and halted further development of the alloantibody response. Thus MHC Class I tetramers can specifically track the in vivo fate of endogenous, Class I-specific B cells and was used to demonstrate the ability of delayed treatment with anti-CD154 or CTLA-4Ig to halt established allo-B cell responses.
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Affiliation(s)
- J Chen
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
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Süsal C, Roelen DL, Fischer G, Campos EF, Gerbase-DeLima M, Hönger G, Schaub S, Lachmann N, Martorell J, Claas F. Algorithms for the determination of unacceptable HLA antigen mismatches in kidney transplant recipients. ACTA ACUST UNITED AC 2013; 82:83-92. [PMID: 23718733 DOI: 10.1111/tan.12137] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
One of the major tasks of human leukocyte antigen (HLA) laboratories is the pretransplant determination of unacceptable HLA antigen mismatches (UAM) in organ transplant recipients. HLA antigen specificities are determined against which the patient has circulating alloantibodies that are expected to harm the transplanted organ. Using the information on UAM, negative crossmatch (XM) prediction or 'virtual XM' is possible when a potential donor's complete HLA typing is available. Before the introduction of solid-phase antibody detection assays, UAM were determined using the complement-dependent cytotoxicity methodology. After the introduction of the single antigen bead technique, however, various UAM determination algorithms have emerged. In this report, six different laboratories worldwide present how they determine UAM in their collective of kidney transplant recipients in the pretransplant phase and proceed thereafter to transplantation.
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Affiliation(s)
- C Süsal
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Heidelberg, Germany.
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