Acute Rejection Is a Strong Negative Predictor of Graft Survival in Living-Donor Pediatric Renal Transplant: 10-Year Follow-Up in a Single Mexican Center

Follow-up biopsies identify high rates of persistent rejection in pediatric kidney transplant recipients after treatment of T cell-mediated rejection

BACKGROUND

Incomplete resolution of T cell-mediated rejection (TCMR) after treatment may not be detected with serum creatinine monitoring and is associated with donor-specific antibodies and chronic rejection. We evaluate the utility of follow-up biopsies (FUB) to identify and characterize rates of persistent TCMR after treatment in pediatric kidney transplant patients.

METHODS

Patients from two pediatric transplant centers performing standard of care FUB at 1.5-2 months after treatment for TCMR were included. FUB were evaluated for extent of rejection resolution (complete vs. incomplete) and grade. Clinical data at time of FUB and later were reported, where available.

RESULTS

Fifty-eight patients underwent FUB, at mean of 1.7 months (SD 0.7) post-index biopsy. Rejection grade on index biopsy was Banff borderline (≥i1t1 and

CONCLUSIONS

FUB were effective at detecting persistent rejection, which was common among pediatric transplant patients after standard TCMR treatment. Until more effective rejection treatments or sensitive biomarkers are available, FUB may be effectively utilized to identify patients with ongoing rejection who would benefit from further treatment.

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Key Words

• biopsy
• pediatric
• rejection

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MESH Headings

• Humans
• Child
• Kidney Transplantation/adverse effects
• T-Lymphocytes
• Follow-Up Studies
• Biopsy
• Treatment Outcome
• Transplant Recipients
• Graft Rejection
• Kidney/pathology

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Grants

• R01 DK126807 NIDDK NIH HHS

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Affiliation(s)

Adina Landsberg Department of Medicine, University of Calgary, Calgary, AB, Canada
S. Sikandar Raza Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
Michael E. Seifert Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL, United States
Tom D. Blydt-Hansen BC Children’s Hospital, Division of Nephrology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

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Immunological Nuances and Complications of Pediatric Organ Transplant: A Narrative Review

Organ transplantation is considered an exaggerated immune state in which the body reacts in an elaborate cascade of reactions against the lifesaving graft transplanted. Unrepairable organ damage is the main indication for a pediatric patient to undergo a transplant. The host and the donor must fulfill the criteria for a successful transplant to have as few side effects as possible. There has been much-needed research in the domain of surgery of organ transplantation, thereby extending into the pediatric age group. This article elaborates on the post-transplant management, the immuno-biochemistry aspect, and its post-surgery treatment. The post-surgery period requires great emphasis as morbidity and mortality are highest. There is much to understand about managing transplant patients to avoid complications such as infections, hypertension, or side effects of immunosuppressive drugs. The treating clinician faces the challenges of managing the dose and frequency of immuno-suppressive medicines to prevent complications in the patients. If the dose is inadequate, there are chances of graft rejection. If the immuno-suppression is prolonged, there may be chances of infections in the patient. This article aims to summarize the mechanism of graft rejection and put forth the need for further research about creating a universal protocol for managing a patient's immune system post-transplant. The authors hope this protocol will help the clinician better understand the patient's current state and help in appropriately using immuno-suppressive drugs. It calls upon the need for a reliable and easily repeatable battery of investigations that will help solve this dilemma.

Changes in graft function after living donor kidney transplantation in children

BACKGROUND

This study aimed to evaluate the change in graft function in two groups stratified by the estimated glomerular filtration rate (eGFR) at 1 month after transplantation (eGFR-1 M) in pediatric living donor kidney transplant recipients.

METHODS

Forty-three pediatric recipients were classified as those with an eGFR-1 M ≥ 90 mL/min/1.73 m² (n = 19; high eGFR group) or those with an eGFR-1 M of 60-89 mL/min/1.73 m² (n = 24; middle eGFR group). In the two groups, changes in the eGFR were retrospectively evaluated for 5 years after kidney transplantation.

RESULTS

The mean recipient age at transplantation in the high/middle eGFR group was 6.1 ± 3.4/7.8 ± 4.0 years (P = 0.14). The mean eGFR-1, -12, and -60 M (mL/min/1.73 m²) in the high/middle eGFR group were 106.8 ± 2.99/78.5 ± 1.52 (P < 0.001), 79.3 ± 3.22/62.7 ± 2.38 (P < 0.001), and 73.1 ± 4.16/59.2 ± 2.79 (P = 0.006), respectively. The change in the mean eGFR remained mostly parallel in the two groups. In both groups, the eGFR significantly decreased only between 1 and 12 months after transplantation (P < 0.0001). Approximately 70% of the patients had an eGFR-60 M ≥ 60 mL/min/1.73 m².

CONCLUSIONS

The high and middle eGFR groups showed a rapid decline in the eGFR by 1 year after transplantation, but the change thereafter was gradual. In pediatric living donor kidney transplant recipients, the eGFR was relatively well maintained up to 5 years after transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.