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Gutiérrez‐Govea A, Jalomo‐Martínez B, Evangelista‐Carrillo LA, Cerrillos‐Gutiérrez JI, Medina‐Pérez M. Thrombotic microangiopathy associated with calcineurin inhibitor induction doses in patients with a kidney transplant. Clin Case Rep 2024; 12:e9125. [PMID: 38947539 PMCID: PMC11213714 DOI: 10.1002/ccr3.9125] [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: 01/20/2024] [Revised: 04/16/2024] [Accepted: 06/12/2024] [Indexed: 07/02/2024] Open
Abstract
We present a case of a 23-year-old male who developed thrombotic microangiopathy associated with the induction dose of tacrolimus. Get an early diagnosis and give timely treatment of thrombotic microangiopathy is essential to improve the prognosis of the kidney transplant.
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Affiliation(s)
- Alfredo Gutiérrez‐Govea
- Department of Nephrology and Organ Transplant UnitSpecialties Hospital, National Western Medical Centre, Mexican Social Security InstituteGuadalajaraJaliscoMexico
- University Health Sciences CenterUniversity of GuadalajaraGuadalajaraJaliscoMexico
| | - Basilio Jalomo‐Martínez
- Department of Nephrology and Organ Transplant UnitSpecialties Hospital, National Western Medical Centre, Mexican Social Security InstituteGuadalajaraJaliscoMexico
| | - Luis Alberto Evangelista‐Carrillo
- Department of Nephrology and Organ Transplant UnitSpecialties Hospital, National Western Medical Centre, Mexican Social Security InstituteGuadalajaraJaliscoMexico
| | - José Ignacio Cerrillos‐Gutiérrez
- Department of Nephrology and Organ Transplant UnitSpecialties Hospital, National Western Medical Centre, Mexican Social Security InstituteGuadalajaraJaliscoMexico
| | - Miguel Medina‐Pérez
- Department of Nephrology and Organ Transplant UnitSpecialties Hospital, National Western Medical Centre, Mexican Social Security InstituteGuadalajaraJaliscoMexico
- University Health Sciences CenterUniversity of GuadalajaraGuadalajaraJaliscoMexico
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2
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Bouwmeester RN, Wetzels JF, van de Kar NC. Eculizumab in Posttransplant TMA: Unproven Benefit: A Response to Maritati et al.: "Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:1929. [PMID: 38899173 PMCID: PMC11184289 DOI: 10.1016/j.ekir.2024.02.1442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Romy N. Bouwmeester
- Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Nijmegen, The Netherlands
| | - Jack F.M. Wetzels
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Nicole C.A.J. van de Kar
- Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Nijmegen, The Netherlands
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Maritati F, La Manna G, Comai G. Response to Letter to the Editor From Bouwmeester RN et al.: "Eculizumab in Postransplant TMA: Unproven Benefit.". Kidney Int Rep 2024; 9:1930-1931. [PMID: 38899217 PMCID: PMC11184294 DOI: 10.1016/j.ekir.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Maritati F, Corradetti V, Bini C, Provenzano M, Cuna V, Busutti M, Tondolo F, Zappulo F, Vischini G, Iacovella F, Abenavoli C, Borelli G, Demetri M, Fabbrizio B, Radi G, Ravaioli M, Mele C, La Manna G, Comai G. "Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:982-993. [PMID: 38765562 PMCID: PMC11101752 DOI: 10.1016/j.ekir.2024.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Posttransplant thrombotic microangiopathy (PT-TMA) is an uncommon event that characterizes approximately 3% to 14% of kidney transplants (KTs), and that is associated with a higher risk of delayed graft function and graft loss. PT-TMA occurs more frequently within the first 3 months after transplant and can be a manifestation of de novo disease or the recurrence of previous atypical hemolytic uremic syndrome (aHUS). Abnormalities in complement regulation genes could explain the increased susceptibility of some patients to PT-TMA. Eculizumab is a humanized monoclonal antibody that inhibits the formation of the membrane attack complex C5b-9. The aim of this study is to evaluate the efficacy of eculizumab as treatment for PT-TMA. Methods We retrospectively analyzed clinical records of 45 KT patients who received eculizumab immediately after the clinical diagnosis of PT-TMA. Results Kidney biopsy was performed in 91.1% of patients, and complement genetic study was performed in 64.4%. Of the kidney biopsies, 85.4% showed signs of TMA; genetic analysis revealed 1 pathogenetic variant, 2 variants of uncertain significance, 1 likely benign variant, 8 risk polymorphisms, and 27 risk haplotypes. After 2 weeks from the treatment starting, hemoglobin and platelets significantly increased. A remarkable improvement in kidney function was also observed. After 6 months, 28.8% of patients had a complete renal recovery whereas 44.4% had a partial recovery. Conclusion This is, to our knowledge, the largest series of KT patients with PT-TMA treated with eculizumab. These data suggest that eculizumab is associated with a normalization of hemolysis indices and an important and progressive improvement of graft function.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Fulvia Zappulo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Gisella Vischini
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Iacovella
- Nephrology and Dialysis Unit, Azienda USL della Romagna, Infermi Hospital, Rimini, Italy
| | - Chiara Abenavoli
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Greta Borelli
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Demetri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Benedetta Fabbrizio
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Radi
- Hepato-biliary Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Hepato-biliary Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Mele
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò Ranica, Bergamo, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
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Mubarak M, Raza A, Rashid R, Sapna F, Shakeel S. Thrombotic microangiopathy after kidney transplantation: Expanding etiologic and pathogenetic spectra. World J Transplant 2024; 14:90277. [PMID: 38576763 PMCID: PMC10989473 DOI: 10.5500/wjt.v14.i1.90277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 03/15/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is an uncommon but serious complication that not only affects native kidneys but also transplanted kidneys. This review is specifically focused on post-transplant TMA (PT-TMA) involving kidney transplant recipients. Its reported prevalence in the latter population varies from 0.8% to 14% with adverse impacts on both graft and patient survival. It has many causes and associations, and the list of etiologic agents and associations is growing constantly. The pathogenesis is equally varied and a variety of patho genetic pathways lead to the development of microvascular injury as the final common pathway. PT-TMA is categorized in many ways in order to facilitate its management. Ironically, more than one causes are contributory in PT-TMA and it is often difficult to pinpoint one particular cause in an individual case. Pathologically, the hallmark lesions are endothelial cell injury and intravascular thrombi affecting the microvasculature. Early diagnosis and classification of PT-TMA are imperative for optimal outcomes but are challenging for both clinicians and pathologists. The Banff classification has addressed this issue and has developed minimum diagnostic criteria for pathologic diagnosis of PT-TMA in the first phase. Management of the condition is also challenging and still largely empirical. It varies from simple maneuvers, such as plasmapheresis, drug withdrawal or modification, or dose reduction, to lifelong complement blockade, which is very expensive. A thorough understanding of the condition is imperative for an early diagnosis and quick treatment when the treatment is potentially effective. This review aims to increase the awareness of relevant stakeholders regarding this important, potentially treatable but under-recognized cause of kidney allograft dysfunction.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Amber Raza
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Rahma Rashid
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Fnu Sapna
- Department of Pathology, Montefiore Medical Center, The University Hospital for Albert Einstein School of Medicine, Bronx, NY 10461, United States
| | - Shaheera Shakeel
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
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Kanbay M, Copur S, Yilmaz ZY, Baydar DE, Bilge I, Susal C, Kocak B, Ortiz A. The role of anticomplement therapy in the management of the kidney allograft. Clin Transplant 2024; 38:e15277. [PMID: 38485664 DOI: 10.1111/ctr.15277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
As the number of patients living with kidney failure grows, the need also grows for kidney transplantation, the gold standard kidney replacement therapy that provides a survival advantage. This may result in an increased rate of transplantation from HLA-mismatched donors that increases the rate of antibody-mediated rejection (AMR), which already is the leading cause of allograft failure. Plasmapheresis, intravenous immunoglobulin therapy, anti-CD20 therapies (i.e., rituximab), bortezomib and splenectomy have been used over the years to treat AMR as well as to prevent AMR in high-risk sensitized kidney transplant recipients. Eculizumab and ravulizumab are monoclonal antibodies targeting the C5 protein of the complement pathway and part of the expanding field of anticomplement therapies, which is not limited to kidney transplant recipients, and also includes complement-mediated microangiopathic hemolytic anemia, paroxysmal nocturnal hemoglobinuria, and ANCA-vasculitis. In this narrative review, we summarize the current knowledge concerning the pathophysiological background and use of anti-C5 strategies (eculizumab and ravulizumab) and C1-esterase inhibitor in AMR, either to prevent AMR in high-risk desensitized patients or to treat AMR as first-line or rescue therapy and also to treat de novo thrombotic microangiopathy in kidney transplant recipients.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dilek Ertoy Baydar
- Department of Pathology, Koc University School of Medicine, Istanbul, Turkey
| | - Ilmay Bilge
- Department of Pediatrics, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Susal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz, Madrid, Spain
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Song JY, Oh SH, Kim Y. Life-Threatening Diffuse Alveolar Hemorrhage and Graft Failure in Atypical Hemolytic Uremic Syndrome with C3 Gene Mutation following Kidney Transplant. Nephron Clin Pract 2023; 148:474-479. [PMID: 38008090 PMCID: PMC11216361 DOI: 10.1159/000535192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 11/01/2023] [Indexed: 11/28/2023] Open
Abstract
INTRODUCTION Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) disease entity primarily attributed to genetic or acquired abnormalities in the alternative complement pathway. TMA can manifest in kidney transplant (KT) recipients owing to various factors, resulting in diverse clinical presentations. Given its adverse effects on allograft function and patient prognosis, genetic diagnostic approaches for aHUS are essential. Although rarely associated with diffuse alveolar hemorrhage, only a few mild cases have been reported to date. In this report, we present a case of the patient who experienced recurrent and life-threatening diffuse alveolar hemorrhage shortly after KT accompanied by graft failure. CASE PRESENTATION An 18-year-old girl who underwent deceased donor KT developed recurrent diffuse alveolar hemorrhage with acute kidney injury, leading to graft failure. Microangiopathic hemolytic anemia, thrombocytopenia, and schistocytes in blood smears suggested the presence of TMA. The patient underwent therapeutic plasma exchange, and clinical condition improved during the procedure. Genetic testing confirmed a heterozygous c.1273C>T mutation in C3 gene, leading to the diagnosis of aHUS. However, after discontinuing the plasma exchange, the patient experienced seizures, recurrent pulmonary hemorrhage, and oliguria with recurring TMA features. The patient subsequently underwent eculizumab treatment, which resulted in complete remission, although hemodialysis was continued after graft nephrectomy. CONCLUSION In patients presenting with unexplained pulmonary hemorrhage and kidney injury following KT, genetic aHUS should be considered as a potential differential diagnosis for TMA.
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Affiliation(s)
- Ji Yeon Song
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seung Hwan Oh
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Younga Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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Kitamura M, Doraiswamy M, Parkinson B, Yenebre P, Ibrahim D, Dasgupta A, Tyagi A, Nori U, Nadasdy T, Rajab A, Brodsky SV, Satoskar AA. Isolated arterial mucoid intimal thickening lesion in early post-transplant kidney allograft biopsies. Clin Transplant 2023; 37:e15007. [PMID: 37170811 DOI: 10.1111/ctr.15007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/03/2023] [Accepted: 04/19/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Thrombotic microangiopathy (TMA) on kidney biopsy shows a variable combination of features: arterial mucoid intimal thickening, acellular closure of glomerular capillary loops, fragmented red blood cells, fibrin thrombi, and arterial fibrinoid necrosis. However, some early post-transplant kidney biopsies show only arterial mucoid intimal thickening. We aimed to elucidate the importance of this finding. METHODS We identified 19 biopsies showing isolated arterial mucoid intimal thickening and compared them with 22 bona fide TMA biopsies identified based on the pathological findings (excluding rejection) (2011-2020). Additionally, delayed graft function (DGF) (n = 237), and no DGF (control, n = 1314) groups were included for survival analysis. RESULTS Seven of 19 cases with isolated arterial mucoid intimal thickening showed peripheral blood schistocytes but no other systemic features of TMA. Eight patients underwent adjustments in maintenance immunosuppression (mainly calcineurin inhibitors). None of the cases progressed to full-blown TMA on consecutive biopsies. The overall and death-censored graft survival rates in this group were comparable to the DGF group, but significantly better than the TMA group (P = .005 and .04, respectively). CONCLUSIONS Isolated arterial mucoid intimal thickening in early post-transplant biopsies may be an early/mild form of TMA, probably requiring adjustment in immunosuppressive regimen. Careful exclusion of known causes of TMA, and donor-derived arterial injury are important.
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Affiliation(s)
- Mineaki Kitamura
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mohan Doraiswamy
- Department of Medicine, Mercy Hospital, Fort Smith, Arkansas, US
| | - Bryce Parkinson
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Priya Yenebre
- Department of Transplant, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Dalia Ibrahim
- Department of Pathology, University of Toledo Medical Center, Toledo, Ohio, US
| | - Alana Dasgupta
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Alka Tyagi
- Department of Critical Care Medicine, Mercy Hospital, St Luis, Missouri, US
| | - Uday Nori
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Tibor Nadasdy
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Amer Rajab
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
- Department of Surgery, Division of Transplant Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Sergey V Brodsky
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
| | - Anjali A Satoskar
- Department of Pathology, Division of Renal and Transplant Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, US
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Douté M, Sannier A, Even G, Tran TT, Gaston AT, Delbosc S, Loyau S, Bruneval P, Witko-Sarsat V, Mouthon L, Nicoletti A, Caligiuri G, Clement M. Thrombopoietin-Dependent Myelo-Megakaryopoiesis Fuels Thromboinflammation and Worsens Antibody-Mediated Chronic Renal Microvascular Injury. J Am Soc Nephrol 2023; 34:1207-1221. [PMID: 37022108 PMCID: PMC10356147 DOI: 10.1681/asn.0000000000000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 03/07/2023] [Indexed: 04/07/2023] Open
Abstract
SIGNIFICANCE STATEMENT Kidney-derived thrombopoietin (TPO) increases myeloid cell and platelet production during antibody-mediated chronic kidney disease (AMCKD) in a mouse model, exacerbating chronic thromobinflammation in microvessels. The effect is mirrored in patients with extracapillary glomerulonephritis associated with thromboinflammation, TGF β -dependent glomerulosclerosis, and increased bioavailability of TPO. Neutralization of TPO in mice normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. The findings suggest that TPO is a relevant biomarker and a promising therapeutic target for patients with CKD and other chronic thromboinflammatory diseases.Neutralization of TPO in mice normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. The findings suggest that TPO is a relevant biomarker and a promising therapeutic target for patients with CKD and other chronic thromboinflammatory diseases. BACKGROUND Chronic thromboinflammation provokes microvascular alterations and rarefaction, promoting organ dysfunction in individuals with various life-threatening diseases. Hematopoietic growth factors (HGFs) released by the affected organ may sustain emergency hematopoiesis and fuel the thromboinflammatory process. METHODS Using a murine model of antibody-mediated chronic kidney disease (AMCKD) and pharmacological interventions, we comprehensively monitored the response to injury in the circulating blood, urine, bone marrow, and kidney. RESULTS Experimental AMCKD was associated with chronic thromboinflammation and the production of HGFs, especially thrombopoietin (TPO), by the injured kidney, which stimulated and skewed hematopoiesis toward myelo-megakaryopoiesis. AMCKD was characterized by vascular and kidney dysfunction, TGF β -dependent glomerulosclerosis, and microvascular rarefaction. In humans, extracapillary glomerulonephritis is associated with thromboinflammation, TGF β -dependent glomerulosclerosis, and increased bioavailability of TPO. Analysis of albumin, HGF, and inflammatory cytokine levels in sera from patients with extracapillary glomerulonephritis allowed us to identify treatment responders. Strikingly, TPO neutralization in the experimental AMCKD model normalized hematopoiesis, reduced chronic thromboinflammation, and ameliorated renal disease. CONCLUSION TPO-skewed hematopoiesis exacerbates chronic thromboinflammation in microvessels and worsens AMCKD. TPO is both a relevant biomarker and a promising therapeutic target in humans with CKD and other chronic thromboinflammatory diseases.
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Affiliation(s)
- Mélodie Douté
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Aurélie Sannier
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Université de Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Anatomie et Cytologie Pathologiques, Hôpital Bichat, Paris, France
| | - Guillaume Even
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Thi-Thu Tran
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Ahn-Tu Gaston
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Sandrine Delbosc
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Stéphane Loyau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
| | - Patrick Bruneval
- Departments of Nephrology Pathology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Witko-Sarsat
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Université de Paris, INSERM U1016, CNRS UMR 8104, Institut Cochin, Paris, France
| | - Luc Mouthon
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Université de Paris, INSERM U1016, CNRS UMR 8104, Institut Cochin, Paris, France
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares d'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP)-CUP-CUP, Hôpital Cochin, Université Paris Cité, Paris, France
| | - Antonino Nicoletti
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
| | - Giuseppina Caligiuri
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Nord Val-de-Seine, Site Bichat, Paris, France
| | - Marc Clement
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM U1148, Laboratory for vascular science (LVTS), Paris, France
- Laboratoire d'Excellence INFLAMEX, Paris, France
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11
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Fiorentino M, Bagagli F, Deleonardis A, Stasi A, Franzin R, Conserva F, Infante B, Stallone G, Pontrelli P, Gesualdo L. Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management. Biomedicines 2023; 11:biomedicines11051474. [PMID: 37239144 DOI: 10.3390/biomedicines11051474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Kidney transplantation is the first-choice treatment for end-stage renal disease (ESRD). Kidney transplant recipients (KTRs) are at higher risk of experiencing a life-threatening event requiring intensive care unit (ICU) admission, mainly in the late post-transplant period (more than 6 months after transplantation). Urosepsis and bloodstream infections account for almost half of ICU admissions in this population; in addition, potential side effects related to immunosuppressive treatment should be accounted for cytotoxic and ischemic changes induced by calcineurin inhibitor (CNI), sirolimus/CNI-induced thrombotic microangiopathy and posterior reversible encephalopathy syndrome. Throughout the ICU stay, Acute Kidney Injury (AKI) incidence is common and ranges from 10% to 80%, and up to 40% will require renal replacement therapy. In-hospital mortality can reach 30% and correlates with acute illness severity and admission diagnosis. Graft survival is subordinated to baseline estimated glomerular filtration rate (eGFR), clinical presentation, disease severity and potential drug nephrotoxicity. The present review aims to define the impact of AKI events on short- and long-term outcomes in KTRs, focusing on the epidemiologic data regarding AKI incidence in this subpopulation; the pathophysiological mechanisms underlying AKI development and potential AKI biomarkers in kidney transplantation, graft and patients' outcomes; the current diagnostic work up and management of AKI; and the modulation of immunosuppression in ICU-admitted KTRs.
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Affiliation(s)
- Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Francesca Bagagli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Annamaria Deleonardis
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Alessandra Stasi
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Rossana Franzin
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Francesca Conserva
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Paola Pontrelli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70121 Bari, Italy
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12
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Atlas-Lazar A, Levy-Erez D. Approach to acute kidney injury following paediatric kidney transplant. Curr Opin Pediatr 2023; 35:268-274. [PMID: 36591982 DOI: 10.1097/mop.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW In a child with evidence of acute kidney injury (AKI) following renal transplantation, it is important to quickly and accurately diagnose the cause to enable timely initiation of therapeutic interventions. The following article will discuss the differential diagnosis of acute graft dysfunction in paediatric kidney transplant recipients. This review will systematically guide the clinician through the common and less common causes and provide updates on current treatments. RECENT FINDINGS In patients with signs of graft dysfunction, rejection is an important cause to consider. Diagnosis of rejection relies on biopsy findings, an invasive and costly technique. Over the past 5 years, there has been a focus on noninvasive methods of diagnosing rejection, including serum and urinary biomarkers. SUMMARY This review discusses the differential diagnosis of acute graft dysfunction following transplant, with a focus on acute rejection, urinary tract infections and common viral causes, prerenal and postrenal causes, nephrotoxic medications, specifically calcineurin inhibitor toxicity, thrombotic microangiopathy and recurrence of the underlying disease. Each condition is discussed in detail, with a focus on clinical clues to the cause, incidence in the paediatric population, workup and treatment.
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Affiliation(s)
| | - Daniella Levy-Erez
- Schneider Children's Medical Center in Israel, Petah Tikva
- Tel Aviv, University School of Medicine, Tel Aviv, Israel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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13
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Norville K, Stephen J, Mead-Harvey C, Corey R, Votruba C. Evaluation of Eculizumab Use in Renal Transplant Recipients. Prog Transplant 2023; 33:162-167. [PMID: 36940100 DOI: 10.1177/15269248231164163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Introduction: Eculizumab is a monoclonal antibody that binds to complement protein C5, inhibiting complement-mediated thrombotic microangiopathy. It is approved for several indications including atypical hemolytic uremic syndrome. Additionally, eculizumab is used off-label for antibody-mediated rejection and C3 glomerulopathy in renal transplant recipients. Due to limited data available, the purpose of this study was to describe the use of eculizumab treatment in renal transplant recipients. Design: This retrospective single-center study evaluated the safety and efficacy of eculizumab for on- and off-label indications in renal transplant recipients. Adult renal transplant recipients receiving at least 1 dose of eculizumab posttransplant between October 2018 and September 2021 were included. The primary outcome evaluated was graft failure in patients treated with eculizumab. Results: Forty-seven patients were included in analysis. The median age at eculizumab initiation was 51 years [IQR 38-60], with 55% being female. Indications for eculizumab included atypical hemolytic uremic syndrome/thrombotic microangiopathy (63.8%), antibody-mediated rejection (27.7%), C3 glomerulopathy (4.3%), and other (4.3%). Graft failure occurred in 10 patients (21.3%) with a median of 2.4 weeks [IQR 0.5-23.3] from transplant to graft failure. At last follow-up (median 56.1 weeks), 44 (93.6%) patients were alive. After eculizumab initiation, renal function improved at 1 week, 1 month, and last follow-up. Conclusion: Eculizumab treatment demonstrated a benefit on graft and patient survival compared to reported incidence in thrombotic microangiopathy and antibody-mediated rejection. Due to the small sample size and retrospective design, further research is warranted to confirm these results.
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Affiliation(s)
- Kathryn Norville
- Department of Pharmacy, 23386Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Jenise Stephen
- Department of Pharmacy, 23386Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Carolyn Mead-Harvey
- Department of Research Biostatistics, 384840Mayo Clinic, Scottsdale, AZ, USA
| | - Rebecca Corey
- Department of Pharmacy, 23386Mayo Clinic Hospital, Phoenix, AZ, USA
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Anwar IJ, DeLaura I, Ladowski J, Gao Q, Knechtle SJ, Kwun J. Complement-targeted therapies in kidney transplantation-insights from preclinical studies. Front Immunol 2022; 13:984090. [PMID: 36311730 PMCID: PMC9606228 DOI: 10.3389/fimmu.2022.984090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/28/2022] [Indexed: 01/21/2023] Open
Abstract
Aberrant activation of the complement system contributes to solid-organ graft dysfunction and failure. In kidney transplantation, the complement system is implicated in the pathogenesis of antibody- and cell-mediated rejection, ischemia-reperfusion injury, and vascular injury. This has led to the evaluation of select complement inhibitors (e.g., C1 and C5 inhibitors) in clinical trials with mixed results. However, the complement system is highly complex: it is composed of more than 50 fluid-phase and surface-bound elements, including several complement-activated receptors-all potential therapeutic targets in kidney transplantation. Generation of targeted pharmaceuticals and use of gene editing tools have led to an improved understanding of the intricacies of the complement system in allo- and xeno-transplantation. This review summarizes our current knowledge of the role of the complement system as it relates to rejection in kidney transplantation, specifically reviewing evidence gained from pre-clinical models (rodent and nonhuman primate) that may potentially be translated to clinical trials.
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Affiliation(s)
| | | | | | | | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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15
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Wu Q, Tian X, Gong N, Zheng J, Liang D, Li X, Lu X, Xue W, Tian P, Wen J. Early graft loss due to acute thrombotic microangiopathy accompanied by complement gene variants in living-related kidney transplantation: case series report. BMC Nephrol 2022; 23:249. [PMID: 35836191 PMCID: PMC9284761 DOI: 10.1186/s12882-022-02868-7] [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: 01/27/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recently, early graft loss has become very rare in living-related kidney transplantation (LKT) as a result of decreased risk of hyperacute rejection and improvements in immunosuppressive regimens. Post-transplant acute thrombotic microangiopathy (TMA) is a rare, multi-factorial disease that often occurs shortly after kidney transplantation and is usually resistant to treatment with dismal renal outcomes. The complement genetic variants may accelerate the development of TMA. However, the complement genetic test was seldom performed in unknown native kidney disease recipients scheduled for LKT. Case presentation We reported three cases of unknown native kidney diseases who had fulminant TMA in the allograft shortly after LKT. Both the donors and the recipients were noted to carry complement genetic variants, which were identified by genetic testing after transplantation. However, all recipients were refractory to treatment and had allograft loss within 3 months after LKT. Conclusion This case series highlights the suggestion to screen complement gene variants in both the donors and the recipients with unknown native kidney diseases scheduled for LKT. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02868-7.
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Affiliation(s)
- Qianqian Wu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiaohui Tian
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Nianqiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jin Zheng
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xue Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xia Lu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wujun Xue
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Puxun Tian
- Department of Kidney Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China.
| | - Jiqiu Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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16
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Ganchiku Y, Riella LV. Pig-to-human kidney transplantation using brain-dead donors as recipients: One giant leap, or only one small step for transplantkind? Xenotransplantation 2022; 29:e12748. [PMID: 35616243 DOI: 10.1111/xen.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/11/2022]
Abstract
Pig kidney xenotransplantation is increasingly regarded as a realistic solution to the current shortage of human organ donors for patients with end-stage organ failure. Recently, the news of three pig-to-human transplantation cases has awakened public interest. Notably, the case by the Alabama team reported detailed and important findings for the xenotransplantation field. Using a genetically modified pig, two porcine kidneys were transplanted into a brain-dead recipient. They applied several approaches established in the preclinical NHP study, including gene-edited pig kidney graft and preoperative laboratory inspection such as crossmatching and infection screening. The pig-to-human kidney xenotransplantation had no unexpected events during surgery or evidence of hyperacute rejection. Unfortunately, the grafts did not work appropriately, and the study had to be terminated due to the decompensation of the recipient. While this study demonstrated the outstanding achievement in this research area, it also revealed remaining gaps to move xenotransplantation to the clinic. While brain-dead human recipients could reinforce the compatibility achievements of gene-edited pigs in NHP, their pro-inflammatory and pro-coagulant environment, in combination with short-duration of experiments will limit the assessment of kidney function, infection and rejection risk post-transplant, in particular antibody-mediated rejection. The use of successful immunosuppressive protocols of non-human primates xenotransplant experiments including anti-CD154 antibody will be critical to maximize the success in the first in-human trials.
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Affiliation(s)
- Yoshikazu Ganchiku
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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