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Yaffe HC, von Ahrens D, Urioste A, Mas VR, Akalin E. Impact of Deceased-donor Acute Kidney Injury on Kidney Transplantation. Transplantation 2024; 108:1283-1295. [PMID: 37990359 DOI: 10.1097/tp.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Even as record numbers of deceased donors are undergoing organ recovery, the global transplant community continues to struggle with a shortage of donor organs and a high organ discard rate. Acute kidney injury (AKI) occurs in many hospitalized patients, including up to 25% of patients in critical condition. Registry studies have shown a significant increase in nonrecovery or organ discard rates in AKI donors, despite most studies reporting similar clinical outcomes compared with non-AKI donors. This review aims to capture the salient information learned from these studies and to summarize the efforts that have been made to gain a more granular understanding of how kidneys from donors with AKI behave posttransplant. In particular, we reviewed the studies that analyzed the clinical outcomes in different stages of AKI and AKI in marginal donors, such as kidney donor profile index of >85%, older donors, and donation after circulatory death donors. We summarized studies investigating molecular biomarkers, transcriptomics, and possible future therapeutic targets for postdonation AKI.
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Affiliation(s)
- Hillary C Yaffe
- Montefiore Einstein Center for Transplantation, Department of Surgery, Montefiore Medical Center, Bronx, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Dagny von Ahrens
- Montefiore Einstein Center for Transplantation, Department of Surgery, Montefiore Medical Center, Bronx, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Alejandra Urioste
- Surgical Sciences Division, University of Maryland School of Medicine, Baltimore, MD
| | - Valeria R Mas
- Surgical Sciences Division, University of Maryland School of Medicine, Baltimore, MD
| | - Enver Akalin
- Albert Einstein College of Medicine, Bronx, NY
- Montefiore Einstein Center for Transplantation, Department of Medicine, Montefiore Medical Center, Bronx, NY
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Parajuli S, Aziz F, Zhong W, Djamali A. BK polyomavirus infection: more than 50 years and still a threat to kidney transplant recipients. FRONTIERS IN TRANSPLANTATION 2024; 3:1309927. [PMID: 38993764 PMCID: PMC11235301 DOI: 10.3389/frtra.2024.1309927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/08/2024] [Indexed: 07/13/2024]
Abstract
BK polyomavirus (BKPyV) is a ubiquitous human polyomavirus and a major infection after kidney transplantation, primarily due to immunosuppression. BKPyV reactivation can manifest as viruria in 30%-40%, viremia in 10%-20%, and BK polyomavirus-associated nephropathy (BKPyVAN) in 1%-10% of recipients. BKPyVAN is an important cause of kidney graft failure. Although the first case of BKPyV was identified in 1971, progress in its management has been limited. Specifically, there is no safe and effective antiviral agent or vaccine to treat or prevent the infection. Even in the current era, the mainstay approach to BKPyV is a reduction in immunosuppression, which is also limited by safety (risk of de novo donor specific antibody and rejection) and efficacy (graft failure). However, recently BKPyV has been getting more attention in the field, and some new treatment strategies including the utilization of viral-specific T-cell therapy are emerging. Given all these challenges, the primary focus of this article is complications associated with BKPyV, as well as strategies to mitigate negative outcomes.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center Maine Health, Portland, ME, United States
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Reese PP, Doshi MD, Hall IE, Besharatian B, Bromberg JS, Thiessen-Philbrook H, Jia Y, Kamoun M, Mansour SG, Akalin E, Harhay MN, Mohan S, Muthukumar T, Schröppel B, Singh P, Weng FL, Parikh CR. Deceased-Donor Acute Kidney Injury and Acute Rejection in Kidney Transplant Recipients: A Multicenter Cohort. Am J Kidney Dis 2023; 81:222-231.e1. [PMID: 36191727 PMCID: PMC9868058 DOI: 10.1053/j.ajkd.2022.08.011] [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: 04/13/2022] [Accepted: 08/02/2022] [Indexed: 01/26/2023]
Abstract
RATIONALE & OBJECTIVE Donor acute kidney injury (AKI) activates innate immunity, enhances HLA expression in the kidney allograft, and provokes recipient alloimmune responses. We hypothesized that injury and inflammation that manifested in deceased-donor urine biomarkers would be associated with higher rates of biopsy-proven acute rejection (BPAR) and allograft failure after transplantation. STUDY DESIGN Prospective cohort. SETTING & PARTICIPANTS 862 deceased donors for 1,137 kidney recipients at 13 centers. EXPOSURES We measured concentrations of interleukin 18 (IL-18), kidney injury molecule 1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) in deceased donor urine. We also used the Acute Kidney Injury Network (AKIN) criteria to assess donor clinical AKI. OUTCOMES The primary outcome was a composite of BPAR and graft failure (not from death). A secondary outcome was the composite of BPAR, graft failure, and/or de novo donor-specific antibody (DSA). Outcomes were ascertained in the first posttransplant year. ANALYTICAL APPROACH Multivariable Fine-Gray models with death as a competing risk. RESULTS Mean recipient age was 54 ± 13 (SD) years, and 82% received antithymocyte globulin. We found no significant associations between donor urinary IL-18, KIM-1, and NGAL and the primary outcome (subdistribution hazard ratio [HR] for highest vs lowest tertile of 0.76 [95% CI, 0.45-1.28], 1.20 [95% CI, 0.69-2.07], and 1.14 [95% CI, 0.71-1.84], respectively). In secondary analyses, we detected no significant associations between clinically defined AKI and the primary outcome or between donor biomarkers and the composite outcome of BPAR, graft failure, and/or de novo DSA. LIMITATIONS BPAR was ascertained through for-cause biopsies, not surveillance biopsies. CONCLUSIONS In a large cohort of kidney recipients who almost all received induction with thymoglobulin, donor injury biomarkers were associated with neither graft failure and rejection nor a secondary outcome that included de novo DSA. These findings provide some reassurance that centers can successfully manage immunological complications using deceased-donor kidneys with AKI.
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Affiliation(s)
- Peter P Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mona D Doshi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Behdad Besharatian
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan S Bromberg
- Department of Surgery, Division of Transplantation and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | - Heather Thiessen-Philbrook
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yaqi Jia
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sherry G Mansour
- Program of Applied Translational Research and Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT
| | - Enver Akalin
- Kidney Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Meera N Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA; Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
| | - Sumit Mohan
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY; Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Thangamani Muthukumar
- Department of Medicine, Division of Nephrology and Hypertension and Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY
| | | | - Pooja Singh
- Department of Medicine, Division of Nephrology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Francis L Weng
- Renal and Pancreas Transplant Division at Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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