Historical perspectives in kidney transplantation: an updated review

Clinical Research in Renal Transplantation: A Bibliometric Perspective on a Half-century of Innovation and Progress

BACKGROUND

Groundbreaking biomedical research has transformed renal transplantation (RT) into a widespread clinical procedure that represents the mainstay of treatment for end-stage kidney failure today. Here, we aimed to provide a comprehensive bibliometric perspective on the last half-century of innovation in clinical RT.

METHODS

The Web of Science Core Collection was used for a comprehensive screening yielding 123 303 research items during a 50-y period (January 1973-October 2022). The final data set of the 200 most-cited articles was selected on the basis of a citation-based strategy aiming to minimize bias.

RESULTS

Studies on clinical and immunological outcomes (n = 63 and 48), registry-based epi research (n = 38), and randomized controlled trials (n = 35) dominated the data set. Lead US authors have signed 110 of 200 articles. The overall level of evidence was high, with 84% of level1 and -2 reports. Highest numbers of these articles were published in New England Journal of Medicine , Transplantation , and American Journal of Transplantation. Increasing trend was observed in the number of female authors in the postmillennial era (26% versus 7%).

CONCLUSIONS

This study highlights important trends in RT research of the past half-century. This bibliometric perspective identifies the most intensively researched areas and shift of research interests over time; however, it also describes important imbalances in distribution of academic prolificacy based on topic, geographical aspects, and gender.

Depression, Quantified Medication Adherence, and Quality of Life in Renal Transplant Candidates and Recipients

Like patients with many chronic illnesses, ESRD patients experience psychological challenges with greater incidence of depression and reduced quality of life (QoL). A series of 139 transplant candidates' depression and QoL, and a subset of 82 candidates' medication adherence were monitored, revealing heterogenous patterns of depression and adherence and reduced QoL. Twenty-eight patients who received kidney transplants were re-evaluated 6 months post-transplant revealing mixed patterns. Mean depression and quantitated adherence decreased and QoL increased. Some patients improved whereas others declined in depression and adherence. Pre-transplant depression was negatively correlated with post-transplant adherence but positively correlated with post-transplant depression. Nevertheless, the ability to predict individuals' post-transplant adherence and depression, principal objectives of pre-transplant psychological evaluations, is limited. Consequently, it is important to provide periodic screening of ESRD patients for depression and adherence pre- and post-transplant as they reflect changing states, rather than static traits, with variable patterns across patients.

Knowledge and Attitudes about Organ Donation among Patient Companion at a Tertiary Hopsital in Ethiopia

BACKGROUND

Worldwide, the supply of organs continues to be much less than the demand. Many studies identify poor knowledge and negative attitude about organ donation for this. The purpose of this study was to assess knowledge and attitude towards organ donation and associated factors among people who accompany patient during hospital visit at tertiary hospital in Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted from March 1st to May 31, 2019, at a tertiary hospital and the only transplant center in Ethiopia. The patient companions were interviewed with structured questionnaires. Descriptive statistics were presented and factors associated with good knowledge and favorable attitude were assessed using Binary logistic regression.

RESULTS

A total of 414 patient companion participated in the study. The mean age of the respondents was 35±13years, and 252(60.9%) were males. Forty-four (10.6%) of the study participants had good knowledge about organ donation. Male gender was significantly associated with improved knowledge (AOR=2.127 95% CI: 1.036, 4.368). A favorable attitude towards donation was found in 219(52.9%) of the study participants. Participants who had completed secondary education were more likely to have unfavorable attitude towards organ donation (AOR =0.498, 95% CI: 0.290, 0.857).

CONCLUSION

Knowledge about organ donation was found to be poor, and attitudes towards organ donation were found to be unfavorable among patient companions at a major medical center in Ethiopia. Strategies focused on education of the general public and broad dissemination of information on the benefits of organ donation will be critical for improving the organ donor pool.

Is There Decreasing Public Interest in Renal Transplantation? A Google TrendsTM Analysis

BACKGROUND AND OBJECTIVES

Renal transplantation is the preferred form of renal replacement therapy for the majority of patients with end stage renal disease (ESRD). The Internet is a key tool for people seeking healthcare-related information. This current work explored the interest in kidney transplantation based on Internet search queries using Google Trends^TM.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We performed a Google Trends^TM search with the search term "kidney transplantation" between 2004 (year of inception) and 2018. We retrieved and analyzed data on the worldwide trend as well as data from the United Network for Organ Sharing (UNOS), the Organización Nacional de Trasplantes (ONT), the Eurotransplant area, and the National Health Service (NHS) Transplant Register. Google Trends^TM indices were investigated and compared to the numbers of performed kidney transplants, which were extracted from the respective official websites of UNOS, ONT, Eurotransplant, and the NHS.

RESULTS

During an investigational period of 15 years, there was a significant decrease of the worldwide Google Trends^TM index from 76.3 to 25.4, corresponding to an absolute reduction of -50.9% and a relative reduction by -66.7%. The trend was even more pronounced for the UNOS area (-75.2%), while in the same time period the number of transplanted kidneys in the UNOS area increased by 21.9%. Events of public interest had an impact on the search queries in the year of occurrence, as shown by an increase in the Google Trends^TM index by 39.2% in the year 2005 in Austria when a person of public interest received his second live donor kidney transplant.

CONCLUSIONS

This study indicates a decreased public interest in kidney transplantation. There is a clear need to raise public awareness, since transplantation represents the best form of renal replacement therapy for patients with ESRD. Information should be provided on social media, with a special focus on readability and equitable access, as well as on web pages.

Effect of Intravenous Total Anesthesia on Hemodynamic Changes in Renal Transplant

BACKGROUND

The objective of the transanesthetic management of renal transplant is to achieve graft function and improve its prognosis and quality of life of the patient; total intravenous anesthesia (TIVA) is an attractive alternative for the maintenance of hemodynamic stability, lower immunologic involvement, and prevention of reperfusion ischemia injury, which are fundamental in the success of the transplant. The objective of the study was to determine the effect of TIVA on hemodynamic changes in renal transplant.

METHODS

We performed a retrospective observational study of patients who received transplants under TIVA from March 1, 2014, to March 31, 2019. Baseline vital signs and their variability were analyzed in addition to the times and goals of surgery and anesthesia. The statistical analysis was descriptive and inferential and with χ² test, Student t test, and Fisher exact test.

RESULTS

A total of 30 patients were included, and P < .001 was determined in the variability of hemodynamics during the transanesthetic period and at the end of the surgery (χ² and Student t was applied). In addition, P < .001 was obtained with a mean difference of 6.12 and CI of 5.02 to 7.22 for creatinine at 24 hours post transplant, of 2.42 and CI of 1.89 to 2.95 and P < .001 for creatinine at 48 hours, and P < .001 at 72 hours. There was spontaneous uresis in 90%.

CONCLUSIONS

TIVA and the use of adjuvants could be the best option for the anesthetic management of renal transplant and offers greater benefits compared with traditional management.

Impact of Pre-Transplant Malignancy on Outcomes After Kidney Transplantation: United Network for Organ Sharing Database Analysis

BACKGROUND

Kidney transplant recipients with a history of a pre-transplant malignancy (pre-TM) have an increased risk of post-transplant malignancies (post-TM) and suspected inferior long-term outcomes. No large database studies have examined modern day trends and outcomes in this patient population compared with those without a pre-TM.

STUDY DESIGN

The United Network for Organ Sharing (UNOS) database was queried for primary adult kidney transplant recipients with pre-TM. Outcomes were compared in patients with and without pre-TM from 2004 to 2016 using multivariable Cox proportional hazard analyses (n = 170,684).

RESULTS

The rate of kidney transplants in patients with pre-TM increased from <1% of all kidney transplants in 1994 (n = 77) to 8.3% in 2016 (n = 1,329). Pre-TM was associated with development of post-TM (hazard ratio [HR] 1.77 CI 1.68, 1.86), all cause (HR 1.22 CI 1.18, 1.27), and death-censored graft failure (HR 1.08 CI 1.02, 1.15) between 2004 and 2016. The 5-year all cause graft failure rate was 28% for pre-TM patients and 22% for non-pre-TM patients. Pre-TM was associated with decreased patient survival (5-year 80% vs 88% and HR 1.23 CI 1.18, 1.28). Of the deceased, more pre-TM patients died of malignancy (19% vs 11%).

CONCLUSIONS

Increasing numbers of patients with pre-TM are undergoing kidney transplantation. This analysis indicates that patients with pre-TM are at increased risk of post-TM, graft loss, and decreased overall survival. The study's limitations highlight the need for collaborative database development between transplant and cancer registries to better define the inter-relationship between a pre-TM and cancer survivorship vs freedom from prolonged dialysis.

Clinical Features of Kidney Transplant Recipients Admitted to the Intensive Care Unit

INTRODUCTION

There is a paucity of data regarding the complications in kidney transplant patients who may require intensive care unit (ICU) management, despite being the most common solid organ transplant worldwide.

OBJECTIVE

To identify the main reasons for ICU admission and to determine the factors associated with hospital mortality in kidney transplant recipients.

DESIGN

This single-center retrospective cohort study was conducted between September 2013 and June 2014, including all consecutive kidney transplant patients requiring ICU admission. We collected data on patient demographics, transplant characteristics, clinical data, and prognostic scores. The independent determinants of hospital mortality were identified by multiple logistic regression analysis. We also assessed the performance of Simplified Acute Physiology Score 3 (SAPS 3) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores.

RESULTS

We analyzed data from 413 patients, the majority of whom were admitted late after renal transplantation (1169 days; 63-3003 days). The main reason for admission was sepsis (33.2%), followed by cardiovascular disease (16%). Age (odds ratio [OR] 1.05, confidence interval [CI], 1.01-1.09), SAPS 3 score (OR 1.04, CI, 1.01-1.08), the need for mechanical ventilation (OR 26.47, CI, 10.30-68.08), and vasopressor use (OR 3.34, CI, 1.37-8.13) were independently associated with hospital mortality. The performance of SAPS 3 and APACHE II scores was poor in this population and overestimated the mortality rates.

CONCLUSION

Sepsis was the main reason for ICU admission in kidney transplant recipients, followed by cardiovascular disease. Age and disease severity were associated with hospital mortality.

Immunomodulatory effects of OX40Ig gene-modified adipose tissue-derived mesenchymal stem cells on rat kidney transplantation

Recent studies have suggested that adipose tissue-derived mesenchymal stem cell (ADSC) therapy and OX40 costimulation blockade are two immunomodulatory strategies used to suppress the immune response to alloantigens. However, relatively little has been reported regarding the immunomodulatory potential of the abilityof these two strategies to synergize. Thus, in the present study, we aimed to investigate OX40-Ig fusion protein (OX40Ig) expression in ADSCs and to validate their more potent immunosuppressive activity in preventing renal allograft rejection. For this purpose, ADSCs from Lewis rats were transfected with the recombinant plasmid, pcDNA3.1(-)OX40Ig, by nucleofection. The ADSCs transduced with the plasmid (termed ADSCsOX40Ig) or untransduced ADSCs (termed ADSCsnative) were added to allostimulated mixed lymphocyte reaction (MLR) in vitro. In vivo, ADSCsOX40Ig, ADSCsnative, or PBS were administered to an allogeneic renal transplantation model, and the therapeutic effects, as well as the underlying mechanisms were examined. The results revealed that both the ADSCsnative and ADSCsOX40Ig significantly suppressed T cell proliferation and increased the percentage of CD4+CD25+ regulatory T cells in allogeneic MLR assays, with the ADSCsOX40Ig being more effective. Furthermore, the results from our in vivo experiments revealed that compared with the ADSCsnative or PBS group, the administration of autologous ADSCsOX40Ig markedly prolonged the mean survival time of renal grafts, reduced allograft rejection, and significantly downregulated the mRNA expression of intragraft interferon-γ (IFN-γ) , and upregulated the mRNA expression of interleukin (IL)‑10, transforming growth factor-β (TGF-β) and forkhead box protein 3 (Foxp3). The findings of our study indicate that the use of ADSCsOX40Ig is a promising strategy for preventing renal allograft rejection. This strategy provides the synergistic benefits of ADSC immune modulation and OX40-OX40L pathway blockade, and may therefore have therapeutic potential in clinical renal transplantation.

Renal transplant immunology in the last 20 years: A revolution towards graft and patient survival improvement

To deride the hope of progress is the ultimate fatuity, the last word in poverty of spirit and meanness of mind. There is no need to be dismayed by the fact that we cannot yet envisage a definitive solution of our problems, a resting-place beyond which we need not try to go. -P.B. Medawar, 1969 * Thomas E. Starlz, also known as the Father of Clinical Transplantation, once said that organ transplantation was the supreme exception to the rule that most major advances in medicine spring from discoveries in basic science [Starzl T. The mystique of organ transplantation. J Am Coll Surg 2005 Aug;201(2):160-170]. In fact, the first successful identical-twin kidney transplantation performed by Murray's team in December 1954 (Murray J et al. Renal homotransplantations in identical twins. Surg Forum 1955;6:432-436) was the example of an upside down translation medicine: Human clinical transplantation began and researchers tried to understand the underlying immune response and how to control the powerful rejection pathways through experimental models. In the last 20 years, we have witnessed an amazing progress in the knowledge of immunological mechanisms regarding alloimmune response and an outstanding evolution on the identification and characterization of major and minor histocompatibility antigens. This review presents an historical and clinical perspective of those important advances in kidney transplantation immunology in the last 20 years, which contributed to the improvement in patients' quality of life and the survival of end-stage renal patients. In spite of these significant progresses, some areas still need substantial progress, such as the definition of non-invasive biomarkers for acute rejection; the continuous reduction of immunosuppression; the extension of graft survival, and finally the achievement of real graft tolerance extended to HLA mismatch donor: recipient pairs.

Immunosuppression Minimization and Avoidance Protocols: When Less Is Not More

Kidney transplantation is well established as the best treatment option for end-stage kidney disease. It confers not only a better quality of life but also a significant survival advantage compared to dialysis. However, despite significant improvement in short-term kidney transplant graft survival over the past three decades, long-term graft survival remains suboptimal. Concerns about the possible contribution of chronic calcineurin inhibitor (CNI) nephrotoxicity to late allograft failure and other serious adverse effects of currently used immunosuppressive agents (especially corticosteroids) have led to increasing interest in developing regimens which may better preserve kidney allograft function and minimize other immunosuppression-related problems without increasing the risk of rejection. The availability of newer immunosuppressive agents has provided the opportunity to formulate such regimens. Approaches to this end include minimization, withdrawal, or avoidance of corticosteroids and CNIs. Currently, replacement of a CNI with a mammalian target of rapamycin inhibitor while continuing mycophenolate and discontinuation of corticosteroids within the first post-transplant week is being increasingly utilized. Belatacept-based, CNI-free immunosuppression is an emerging alternative approach to avoiding CNI-mediated nephrotoxicity. We also discuss the evolution, results, and pros and cons of corticosteroid- and CNI minimization protocols. Recent studies suggest that chronic alloimmune damage rather than chronic CNI nephrotoxicity is the major contributor to late kidney allograft failure. The implications of this finding for the use of CNI minimization protocols are also discussed.

Analysis of 4000 kidney transplantations in a single center: Across immunological barriers

Kidney transplant (KT) is the optimal renal replacement therapy for patients with end-stage renal disease (ESRD). The demand for kidneys, however, continues to exceed the supply. To overcome this problem, efforts to extend the donor pool by including human leukocyte antigen (HLA)- and ABO-incompatible (ABOi) KTs are increasing. The aim of this article was to retrospectively review data on recipients, donor profiles, and clinical outcomes in 4000 cases of KT. In addition, we analyzed clinical outcomes in ABOi and flow-cytometric crossmatch (FCXM) positive KT in a subgroup analysis.This was a retrospective, observational study using data extracted from medical records. A total of 4000 consecutive patients who underwent KT at our institution from January 1990 to February 2015 were included in this study. KTs across immunological barriers such as ABO incompatible (276 cases, 6.9%), FCXM positive (97 cases, 2.4%), and positive complement-dependent cytotoxicity (CDC) XM KT (16 cases, 0.4%) were included.From a Kaplan-Meier analysis, overall patient survival (PS) rates after KT at 1, 5, 10, and 20 years were 96.9%, 95.1%, 92.0%, and 88.9%, respectively. The overall graft survival (GS) rates after KT at 1, 5, 10, and 20 years were 96.3%, 88.9%, 81.2%, and 67.4%, respectively. Our subgroup analysis suggested that overall PS, GS, death-censored GS, and rejection-free GS in ABOi KT showed no significant differences in comparison with ABO-compatible KT if adequate immunosuppressive treatment was performed. The overall PS rate in patients who underwent FCXM positive KT did not differ significantly from that of the control group during the 3-year follow-up (P = 0.34). The overall GS, death-censored GS, and rejection-free GS also did not differ significantly between the FCXM KT and control groups (P = 0.99, 0.42, and 88).The outcomes of KTs continually improved during the study period, while the annual number of KTs increased. ABO or FCXM positive KTs can be performed safely with successful graft outcomes.