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Roufosse C, Naesens M, Haas M, Lefaucheur C, Mannon RB, Afrouzian M, Alachkar N, Aubert O, Bagnasco SM, Batal I, Bellamy COC, Broecker V, Budde K, Clahsen-Van Groningen M, Coley SM, Cornell LD, Dadhania D, Demetris AJ, Einecke G, Farris AB, Fogo AB, Friedewald J, Gibson IW, Horsfield C, Huang E, Husain SA, Jackson AM, Kers J, Kikić Ž, Klein A, Kozakowski N, Liapis H, Mangiola M, Montgomery RA, Nankinvell B, Neil DAH, Nickerson P, Rabant M, Randhawa P, Riella LV, Rosales I, Royal V, Sapir-Pichhadze R, Sarder P, Sarwal M, Schinstock C, Stegall M, Solez K, van der Laak J, Wiebe C, Colvin RB, Loupy A, Mengel M. The Banff 2022 Kidney Meeting Work Plan: Data-driven refinement of the Banff Classification for renal allografts. Am J Transplant 2024; 24:350-361. [PMID: 37931753 DOI: 10.1016/j.ajt.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
The XVIth Banff Meeting for Allograft Pathology was held in Banff, Alberta, Canada, from September 19 to 23, 2022, as a joint meeting with the Canadian Society of Transplantation. In addition to a key focus on the impact of microvascular inflammation and biopsy-based transcript analysis on the Banff Classification, further sessions were devoted to other aspects of kidney transplant pathology, in particular T cell-mediated rejection, activity and chronicity indices, digital pathology, xenotransplantation, clinical trials, and surrogate endpoints. Although the output of these sessions has not led to any changes in the classification, the key role of Banff Working Groups in phrasing unanswered questions, and coordinating and disseminating results of investigations addressing these unanswered questions was emphasized. This paper summarizes the key Banff Meeting 2022 sessions not covered in the Banff Kidney Meeting 2022 Report paper and also provides an update on other Banff Working Group activities relevant to kidney allografts.
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Affiliation(s)
- Candice Roufosse
- Department of Immunology and Inflammation, Faculty Medicine, Imperial College London, London, UK.
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Nephrology and Transplantation, Saint-Louis Hospital, Paris, France
| | - Roslyn B Mannon
- Department of Internal Medicine, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marjan Afrouzian
- Department of Pathology, University of Texas Medical Branch at Galveston, Texas, USA
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivier Aubert
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ibrahim Batal
- Pathology & Cell Biology, Columbia University Irving Medical Center, New York, USA
| | | | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
| | - Marian Clahsen-Van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus University Center Rotterdam, Rotterdam, Netherlands; Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Shana M Coley
- Transplant Translational Research, Arkana Laboratories, Arkansas, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Darshana Dadhania
- Department Medicine, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Anthony J Demetris
- UPMC Hepatic and Transplantation Pathology, Pittsburg, Pennsylvania, USA
| | - Gunilla Einecke
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Germany
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University, USA
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
| | | | - Edmund Huang
- Department of Medicine, Division of Nephrology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Syed A Husain
- Division of Nephrology, Columbia University, New York, New York, USA
| | | | - Jesper Kers
- Department of Pathology, Leiden University Medical Center, Netherlands; Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | | | | | - Helen Liapis
- Ludwig Maximillian University Munich, Nephrology Center, Germany
| | | | | | - Brian Nankinvell
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Desley A H Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Peter Nickerson
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Marion Rabant
- Pathology department, Necker-Enfants Malades Hospital, Paris, France
| | - Parmjeet Randhawa
- Pathology, Thomas E. Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leonardo V Riella
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Immunopathology Research Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginie Royal
- Maisonneuve-Rosemont Hospital, University of Montreal, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology & Multiorgan Transplant Program, McGill University, Montreal, Quebec, Canada
| | - Pinaki Sarder
- Department of Medicine-Quantitative Health, University of Florida College of Medicine, Florida, USA
| | - Minnie Sarwal
- Division of MultiOrgan Transplantation, UCSF, San Francisco, California, USA
| | - Carrie Schinstock
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Stegall
- Department Transplantation Surgery, Mayo Clinic, Rochester, Massachusetts, USA
| | - Kim Solez
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | | | - Chris Wiebe
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandre Loupy
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
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Alachkar N, Delsante M, Greenberg RS, Koirala A, Alhamad T, Abdalla B, Anand M, Boonpheng B, Blosser C, Maggiore U, Bagnasco SM. Evaluation of the Modified Oxford Score in Recurrent IgA Nephropathy in North American Kidney Transplant Recipients: The Banff Recurrent Glomerulonephritis Working Group Report. Transplantation 2023; 107:2055-2063. [PMID: 37202854 DOI: 10.1097/tp.0000000000004640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND The modified Oxford classification mesangial and endocapillary hypercellularity, segmental sclerosis, interstitial fibrosis/tubular atrophy, and the presence of crescents (MEST-C) of immunoglobulin A nephropathy (IgAN) was recently shown to be a predictor of graft failure in Asians with recurrent IgAN. We aimed to validate these findings in a cohort from North American centers participating in the Banff Recurrent Glomerulopathies Working Group. METHODS We examined 171 transplant recipients with end-stage kidney disease because of IgAN; 100 of them with biopsy-proven recurrent IgAN (57 of them had complete MEST-C scores) and 71 with no recurrence. RESULTS IgAN recurrence, which was associated with younger age at transplantation ( P = 0.012), strongly increased the risk of death-censored graft failure (adjusted hazard ratio, 5.10 [95% confidence interval (CI), 2.26-11.51]; P < 0.001). Higher MEST-C score sum was associated with death-censored graft failure (adjusted hazard ratio, 8.57 [95% CI, 1.23-59.85; P = 0.03] and 61.32 [95% CI, 4.82-779.89; P = 0.002] for score sums 2-3 and 4-5 versus 0, respectively), and so were the single components endocapillary hypercellularity, interstitial fibrosis/tubular atrophy, and crescents ( P < 0.05 each). Overall, most of the pooled adjusted hazard ratio estimates associated with each MEST-C component were consistent with those from the Asian cohort (heterogeneity I2 close to 0%, and P > 0.05). CONCLUSIONS Our findings may validate the prognostic usefulness of the Oxford classification for recurrent IgAN and support the inclusion of the MEST-C score in allograft biopsies diagnostic reports.
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Affiliation(s)
- Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marco Delsante
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ross S Greenberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abbal Koirala
- Department of Medicine, University of Washington, Seattle, WA
| | - Tarek Alhamad
- Department of Medicine, Washington University, St Louis, MO
| | - Basmah Abdalla
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Manish Anand
- Department of Medicine, Division of Nephrology, University of Cincinnati, Cincinnati, OH
| | - Ben Boonpheng
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Serena M Bagnasco
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD
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Alachkar N, Alachkar N. Automating kidney transplant diagnostics. Nat Med 2023; 29:1066-1067. [PMID: 37142761 DOI: 10.1038/s41591-023-02300-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Nissrin Alachkar
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- School of Mathematics, Faculty of Science and Engineering, University of Manchester, Manchester, UK
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Reynolds ML, Oliverio AL, Zee J, Hendren EM, O’Shaughnessy MM, Ayoub I, Almaani S, Vasylyeva TL, Twombley KE, Wadhwani S, Steinke JM, Rizk DV, Waldman M, Helmuth ME, Avila-Casado C, Alachkar N, Nester CM, Derebail VK, Hladunewich MA, Mariani LH. Pregnancy History and Kidney Disease Progression Among Women Enrolled in Cure Glomerulonephropathy. Kidney Int Rep 2023; 8:805-817. [PMID: 37069979 PMCID: PMC10105239 DOI: 10.1016/j.ekir.2023.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 02/04/2023] Open
Abstract
Introduction Preeclampsia increases the risk for future chronic kidney disease (CKD). Among those diagnosed with CKD, it is unclear whether a prior history of preeclampsia, or other complications in pregnancy, negatively impact kidney disease progression. In this longitudinal analysis, we assessed kidney disease progression among women with glomerular disease with and without a history of a complicated pregnancy. Methods Adult women enrolled in the Cure Glomerulonephropathy study (CureGN) were classified based on a history of a complicated pregnancy (defined by presence of worsening kidney function, proteinuria, or blood pressure; or a diagnosis of preeclampsia, eclampsia, or hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome), pregnancy without these complications, or no pregnancy history at CureGN enrollment. Linear mixed models were used to assess estimated glomerular filtration rate (eGFR) trajectories and urine protein-to-creatinine ratios (UPCRs) from enrollment. Results Over a median follow-up period of 36 months, the adjusted decline in eGFR was greater in women with a history of a complicated pregnancy compared to those with uncomplicated or no pregnancies (-1.96 [-2.67, -1.26] vs. -0.80 [-1.19, -0.42] and -0.64 [-1.17, -0.11] ml/min per 1.73 m2 per year, P = 0.007). Proteinuria did not differ significantly over time. Among those with a complicated pregnancy history, eGFR slope did not differ by timing of first complicated pregnancy relative to glomerular disease diagnosis. Conclusions A history of complicated pregnancy was associated with greater eGFR decline in the years following glomerulonephropathy (GN) diagnosis. A detailed obstetric history may inform counseling regarding disease progression in women with glomerular disease. Continued research is necessary to better understand pathophysiologic mechanisms by which complicated pregnancies contribute to glomerular disease progression.
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Karaba AH, Zhou W, Hsieh LL, Figueroa A, Massaccesi G, Rothman RE, Fenstermacher KZJ, Sauer L, Shaw-Saliba K, Blair PW, Robinson ML, Leung S, Wesson R, Alachkar N, El-Diwany R, Ji H, Cox AL. Differential Cytokine Signatures of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Influenza Infection Highlight Key Differences in Pathobiology. Clin Infect Dis 2022; 74:254-262. [PMID: 34013339 PMCID: PMC8243556 DOI: 10.1093/cid/ciab376] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Several inflammatory cytokines are upregulated in severe coronavirus disease 2019 (COVID-19). We compared cytokines in COVID-19 versus influenza to define differentiating features of the inflammatory response to these pathogens and their association with severe disease. Because elevated body mass index (BMI) is a known risk factor for severe COVID-19, we examined the relationship of BMI to cytokines associated with severe disease. METHODS Thirty-seven cytokines and chemokines were measured in plasma from 135 patients with COVID-19, 57 patients with influenza, and 30 healthy controls. Controlling for BMI, age, and sex, differences in cytokines between groups were determined by linear regression and random forest prediction was used to determine the cytokines most important in distinguishing severe COVID-19 and influenza. Mediation analysis was used to identify cytokines that mediate the effect of BMI and age on disease severity. RESULTS Interleukin-18 (IL-18), IL-1β, IL-6, and tumor necrosis factor-α (TNF-α) were significantly increased in COVID-19 versus influenza patients, whereas granulocyte macrophage colony-stimulating factor, interferon-γ (IFN-γ), IFN-λ1, IL-10, IL-15, and monocyte chemoattractant protein 2 were significantly elevated in the influenza group. In subgroup analysis based on disease severity, IL-18, IL-6, and TNF-α were elevated in severe COVID-19, but not in severe influenza. Random forest analysis identified high IL-6 and low IFN-λ1 levels as the most distinct between severe COVID-19 and severe influenza. Finally, IL-1RA was identified as a potential mediator of the effects of BMI on COVID-19 severity. CONCLUSIONS These findings point to activation of fundamentally different innate immune pathways in severe acute respiratory syndrome coronavirus 2 and influenza infection, and emphasize drivers of severe COVID-19 to focus both mechanistic and therapeutic investigations.
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Affiliation(s)
- Andrew H Karaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Weiqiang Zhou
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leon L Hsieh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexis Figueroa
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Guido Massaccesi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Lauren Sauer
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Shaw-Saliba
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul W Blair
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Robinson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sherry Leung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Russell Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nada Alachkar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ramy El-Diwany
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hongkai Ji
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrea L Cox
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Avery RK, Motter JD, Jackson KR, Montgomery RA, Massie AB, Kraus ES, Marr KA, Lonze BE, Alachkar N, Holechek MJ, Ostrander D, Desai N, Waldram MM, Shoham S, Steinke SM, Subramanian A, Hiller JM, Langlee J, Young S, Segev DL, Garonzik Wang JM. Quantifying infection risks in incompatible living donor kidney transplant recipients. Am J Transplant 2021; 21:1564-1575. [PMID: 32949093 PMCID: PMC7972996 DOI: 10.1111/ajt.16316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
Desensitization has enabled incompatible living donor kidney transplantation (ILDKT) across HLA/ABO barriers, but added immunomodulation might put patients at increased risk of infections. We studied 475 recipients from our center from 2010 to 2015, categorized by desensitization intensity: none/compatible (n = 260), low (0-4 plasmaphereses, n = 47), moderate (5-9, n = 74), and high (≥10, n = 94). The 1-year cumulative incidence of infection was 50.1%, 49.8%, 66.0%, and 73.5% for recipients who received none, low, moderate, and high-intensity desensitization (P < .001). The most common infections were UTI (33.5% of ILDKT vs. 21.5% compatible), opportunistic (21.9% vs. 10.8%), and bloodstream (19.1% vs. 5.4%) (P < .001). In weighted models, a trend toward increased risk was seen in low (wIRR = 0.77 1.402.56 ,P = .3) and moderately (wIRR = 0.88 1.352.06 ,P = .2) desensitized recipients, with a statistically significant 2.22-fold (wIRR = 1.33 2.223.72 ,P = .002) increased risk in highly desensitized recipients. Recipients with ≥4 infections were at higher risk of prolonged hospitalization (wIRR = 2.62 3.574.88 , P < .001) and death-censored graft loss (wHR = 1.15 4.0113.95 ,P = .03). Post-KT infections are more common in desensitized ILDKT recipients. A subset of highly desensitized patients is at ultra-high risk for infections. Strategies should be designed to protect patients from the morbidity of recurrent infections, and to extend the survival benefit of ILDKT across the spectrum of recipients.
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Affiliation(s)
- Robin K. Avery
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Jennifer D. Motter
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Kyle R. Jackson
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Robert A. Montgomery
- The NYU Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Allan B. Massie
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland,Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMaryland
| | - Edward S. Kraus
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Kieren A. Marr
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Bonnie E. Lonze
- The NYU Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Nada Alachkar
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary J. Holechek
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Darin Ostrander
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Niraj Desai
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Madeleine M. Waldram
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Shmuel Shoham
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Seema Mehta Steinke
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | | | - Janet M. Hiller
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Julie Langlee
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Sheila Young
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland,Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMaryland,Scientific Registry of Transplant RecipientsMinneapolisMinnesotaUSA
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Abuzeineh M, Kyeso Y, Philogene MC, Alachkar N, Alasfar S. Presentation and Outcomes of Antibody-Mediated Rejection Associated With Angiotensin II Receptor 1 Antibodies Among Kidney Transplant Recipients. Transplant Proc 2021; 53:1501-1508. [PMID: 33573814 DOI: 10.1016/j.transproceed.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/30/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND It remains challenging to manage antibody-mediated rejection (ABMR) associated with angiotensin II type 1 receptor antibodies (AT1R-Abs) in kidney transplant recipients and the outcomes are not well defined. We describe the presentation, clinical course, and outcomes of this condition. METHODS This retrospective study included kidney transplant recipients with AT1R-Ab levels ≥10 units/mL and biopsy-proven ABMR in the absence of significant HLA-donor-specific antibodies at the time of rejection. RESULTS We identified 13 recipients. Median creatinine (Cr) at rejection was significantly higher (2.05 mg/dL) compared with baseline (1.2 mg/dL), P = .006. After ABMR management, the difference in median Cr was not significant (1.5 mg/dL), P = .152. Median AT1R-Ab level was higher in the pretransplant sample (34.5 units/mL) compared with the level at rejection (19 units/mL) and after rejection treatment (13 units/mL); however, these differences were not significant, P = .129. Eight of the 13 recipients received antibody reduction therapy with plasmapheresis and intravenous immunoglobulin, and 5 of the 13 recipients had other therapies. After rejection management, 6 of the 13 recipients had improvement in Cr to baseline and 7 of the 13 recipients had > 50% reduction in proteinuria. CONCLUSIONS AT1R-Ab-associated ABMR management and outcomes depend on the clinical presentation and may include antibody-reducing therapies among other therapies. Further prospective cohorts will improve recognizing and managing this condition.
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Affiliation(s)
- Mohammad Abuzeineh
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yousuf Kyeso
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Nada Alachkar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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8
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Jackson KR, Chen J, Kraus E, Desai N, Segev DL, Alachkar N. Outcomes of cPRA 100% deceased donor kidney transplant recipients under the new Kidney Allocation System: A single-center cohort study. Am J Transplant 2020; 20:2890-2898. [PMID: 32342630 DOI: 10.1111/ajt.15956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 03/15/2020] [Accepted: 04/19/2020] [Indexed: 01/25/2023]
Abstract
In light of changes in donor/recipient case-mix and increased cold ischemia times under the Kidney Allocation System (KAS), there is some concern that cPRA 100% recipients might be doing poorly under KAS. We used granular, single-center data on 109 cPRA 100% deceased donor kidney transplant (DDKT) recipients to study post-KAS posttransplant outcomes not readily available in national registry data. We found that 3-year patient (96.4%) and death-censored graft survival (96.8%) was excellent. We also found that cPRA 100% recipients had a relatively low incidence of T cell-mediated rejection (9.2%) and antibody-mediated rejection (AMR) (13.8%). T cell-mediated rejection episodes tended to be relatively mild-50% (5 episodes) were grade 1, 50% (5 episodes) were grade 2, and none were grade 3. Only 1 episode was associated with graft loss, but this was in the context of a mixed rejection. Although only 15 recipients (13.8%) developed an AMR episode, 2 of these were associated with a graft loss. Despite the rejection episodes, the vast majority of recipients had excellent graft function 3 years posttransplant (median serum creatinine 1.5 mg/dL). In conclusion, cPRA 100% DDKT recipients are doing well under KAS, although every effort should be made to prevent AMR to ensure long-term outcomes remain excellent.
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Affiliation(s)
- Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward Kraus
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Loupy A, Haas M, Roufosse C, Naesens M, Adam B, Afrouzian M, Akalin E, Alachkar N, Bagnasco S, Becker JU, Cornell LD, Clahsen‐van Groningen MC, Demetris AJ, Dragun D, Duong van Huyen J, Farris AB, Fogo AB, Gibson IW, Glotz D, Gueguen J, Kikic Z, Kozakowski N, Kraus E, Lefaucheur C, Liapis H, Mannon RB, Montgomery RA, Nankivell BJ, Nickeleit V, Nickerson P, Rabant M, Racusen L, Randhawa P, Robin B, Rosales IA, Sapir‐Pichhadze R, Schinstock CA, Seron D, Singh HK, Smith RN, Stegall MD, Zeevi A, Solez K, Colvin RB, Mengel M. The Banff 2019 Kidney Meeting Report (I): Updates on and clarification of criteria for T cell- and antibody-mediated rejection. Am J Transplant 2020; 20:2318-2331. [PMID: 32463180 PMCID: PMC7496245 DOI: 10.1111/ajt.15898] [Citation(s) in RCA: 410] [Impact Index Per Article: 102.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 01/25/2023]
Abstract
The XV. Banff conference for allograft pathology was held in conjunction with the annual meeting of the American Society for Histocompatibility and Immunogenetics in Pittsburgh, PA (USA) and focused on refining recent updates to the classification, advances from the Banff working groups, and standardization of molecular diagnostics. This report on kidney transplant pathology details clarifications and refinements to the criteria for chronic active (CA) T cell-mediated rejection (TCMR), borderline, and antibody-mediated rejection (ABMR). The main focus of kidney sessions was on how to address biopsies meeting criteria for CA TCMR plus borderline or acute TCMR. Recent studies on the clinical impact of borderline infiltrates were also presented to clarify whether the threshold for interstitial inflammation in diagnosis of borderline should be i0 or i1. Sessions on ABMR focused on biopsies showing microvascular inflammation in the absence of C4d staining or detectable donor-specific antibodies; the potential value of molecular diagnostics in such cases and recommendations for use of the latter in the setting of solid organ transplantation are presented in the accompanying meeting report. Finally, several speakers discussed the capabilities of artificial intelligence and the potential for use of machine learning algorithms in diagnosis and personalized therapeutics in solid organ transplantation.
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Abuzeineh M, Aala A, Alasfar S, Alachkar N. Angiotensin II receptor 1 antibodies associate with post-transplant focal segmental glomerulosclerosis and proteinuria. BMC Nephrol 2020; 21:253. [PMID: 32615995 PMCID: PMC7331243 DOI: 10.1186/s12882-020-01910-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/25/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Angiotensin II type 1 receptors (AT1Rs) are expressed on podocytes, endothelial and other cells, and play an essential role in the maintenance of podocyte function and vascular homeostasis. The presence of AT1R antibodies (AT1R-Abs) leads to activation of these receptors resulting in podocyte injury and endothelial cell dysfunction. We assessed the correlation between AT1R-Abs and the risk of post-transplant FSGS. METHODS This is a retrospective study, which included all kidney transplant recipients with positive AT1R-Abs (≥ 9 units/ml), who were transplanted and followed at our center between 2006 and 2016. We assessed the development of biopsy proven FSGS and proteinuria by urine protein to creatinine ratio of ≥1 g/g and reviewed short and long term outcomes. RESULTS We identified 100 patients with positive AT1R-Abs at the time of kidney transplant biopsy or proteinuria. 49% recipients (FSGS group) had biopsy-proven FSGS and/or proteinuria and 51% did not (non-FSGS group). Pre-transplant hypertension was present in 89% of the FSGS group compared to 72% in the non-FSGS group, p = 0.027. Of the FSGS group, 43% were on angiotensin converting enzyme inhibitors or angiotensin receptor blockers prior to transplantation, compared to 25.5% in the non-FSGS group, p = 0.06. Primary idiopathic FSGS was the cause of ESRD in 20% of the FSGS group, compared to 6% in the non-FSGS group, p = 0.03. The allograft loss was significantly higher in the FSGS group 63% compared to 39% in non-FSGS. Odds ratio and 95% confidence interval were 2.66 (1.18-5.99), p = 0.017. CONCLUSIONS Our data suggest a potential association between AT1R-Abs and post-transplant FSGS leading to worse allograft outcome. Therefore, AT1R-Abs may be considered biomarkers for post-transplant FSGS.
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Affiliation(s)
- Mohammad Abuzeineh
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA
| | - Amtul Aala
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, MD, 21287, USA.
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11
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Kant S, Bhalla A, Alasfar S, Alachkar N. Ten-year outcome of Eculizumab in kidney transplant recipients with atypical hemolytic uremic syndrome- a single center experience. BMC Nephrol 2020; 21:189. [PMID: 32434487 PMCID: PMC7238522 DOI: 10.1186/s12882-020-01847-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) can result in severe kidney dysfunction, secondary to thrombotic microangiopathy. Eculizumab has been used to treat this disorder, and has resulted in favourable outcomes in both, native and transplanted kidneys. There is limited long term follow up data in kidney transplant recipients (KTRs) who received prevention and treatment with Eculizumab. We report our long term follow up data from our center to address safety and efficacy of this therapy in KTRs. Methods We performed a retrospective analysis of KTRs between January 2009 and December 2018. Clinical diagnosis of aHUS established with presence of thrombotic microangiopathy, acute kidney injury, absence of alternate identifiable etiology. We reviewed clinical data, including genetic testing for complement factor mutations, post-transplant course, and response to therapy including therapeutic and prophylactic use of eculizumab. Results Nineteen patients with aHUS received a total of 36 kidney transplants; 10 of them had 2 or more prior kidney transplants. Median age at time of last transplant was 37 years (range 27–59), 72% were female (n = 14), 78% Caucasian (n = 15), with 61% had live donor transplant (n = 12) as the last transplant. Eculizumab prophylaxis was given to 10/19 (56%) at the time of transplantation, with no aHUS recurrence during the follow up. Median duration of follow up was 46 (range 6–237) months. Mean estimated glomerular filtration rate (eGFR) at the time of last follow up was 59.5 ml/min/m2. No infections secondary to encapsulated organisms or other major infectious complications occurred during the follow up. Conclusions Eculizumab prophylaxis is safe and effective in KTRs with aHUS. Long term follow up demonstrates that it may be possible to discontinue prophylaxis carefully in selected patients with no evidence of complement mutations.
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Affiliation(s)
- Sam Kant
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, Maryland, 21287, USA
| | - Anshul Bhalla
- Department of Surgery, Division of Transplant Surgery, James D. Eason Transplant Institute, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, Maryland, 21287, USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Carnegie 344B, Baltimore, Maryland, 21287, USA.
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12
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Bhalla A, Alachkar N, Alasfar S. Complement-Based Therapy in the Management of Antibody-Mediated Rejection. Adv Chronic Kidney Dis 2020; 27:138-148. [PMID: 32553246 DOI: 10.1053/j.ackd.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
Antibody-mediated rejection (AMR) is one of the leading causes of kidney allograft failure and is usually mediated by anti-human leukocyte antigen donor-specific antibodies (DSAs). Activation of classical pathway of the complement system is responsible for downstream effects of DSA and account for significant manifestations of AMR. Currently, the treatment of AMR is based on strategies to remove preformed antibodies or to prevent their production; however, these strategies are often unsuccessful. It is theoretically possible to inhibit complement activity to prevent the effect of DSA on kidney allograft function. Complement inhibitors such as eculizumab, a complement 5 monoclonal antibody, and complement 1 esterase inhibitors (C1 INHs) have been used in prevention and treatment of AMR with variable success. Eculizumab and C1 INH seem to reduce the incidence of early AMR and allow transplantation in highly sensitized kidney transplant recipients, but data on their long-term effect on kidney allograft function are limited. Several case reports described the successful use of eculizumab in the treatment of AMR, but there are no randomized controlled studies that showed efficacy. Treatment of AMR with C1 INH, in addition to standard of care, did not change short-term outcome but long-term studies are underway.
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13
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Alachkar N, Li J, Matar D, Vujjini V, Alasfar S, Tracy M, Reiser J, Wei C. Monitoring suPAR levels in post-kidney transplant focal segmental glomerulosclerosis treated with therapeutic plasma exchange and rituximab. BMC Nephrol 2018; 19:361. [PMID: 30558559 PMCID: PMC6296111 DOI: 10.1186/s12882-018-1177-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is an important therapy for recurrent focal segmental glomerulosclerosis (rFSGS) post kidney transplant. suPAR has been causally implicated in rFSGS, and shown to be a unique biomarker for the occurrence and progression of chronic kidney disease. This study was targeted to evaluate the application of monitoring suPAR in TPE treated rFSGS. METHODS A retrospective (n = 19) and a prospective (n = 15) cohort of post transplant FSGS patients treated with TPE and rituximab were enrolled. We measured serum suPAR levels before and after the combined therapies, and assessed the role of suPAR changes on proteinuria reduction and podocyte β3- integrin activity. RESULTS Treatment with TPE and rituximab resulted in significant decrease in proteinuria and suPAR levels. Among the variables including baseline suPAR, serum creatinine, proteinuria, eGFR, age at diagnosis, age at transplantation, transplantation numbers, time to recurrence, and TPE course numbers, only the reduction in suPAR levels and baseline proteinuria significantly correlated with the changes in proteinuria after treatment, with the former performed better in predicting proteinuria alteration. Additionally, the mean podocyte β3 integrin activity significantly decreased after TPE and rituximab treatment (1.10 ± 0.08) as compared to before treatment (1.34 ± 0.08), p < 0.05. Only the reduction in suPAR predicted the response to therapies with an odds ratio of 1.43, 95% CI (1.02, 2.00), p < 0.05. CONCLUSIONS Serum suPAR levels reduced significantly after TPE and rituximab treatment in post transplant FSGS patients. The reduction in suPAR levels may be utilized to assess the changes in proteinuria and monitor the response to the therapies. Larger, multi-centered prospective studies monitoring serum suPAR levels in TPE managed post transplant FSGS are warranted.
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Affiliation(s)
- Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, Baltimore, USA
- Division of Nephrology, Johns Hopkins Hospital, 600 Wolfe St. Carnegie 344B, Baltimore, MD 21287 USA
| | - Jing Li
- Department of Medicine, Rush University Medical Center, 1735 W Harrison ST, Cohn Bldg, 7th Floor, Suite 716, Chicago, IL 60612 USA
| | - Dany Matar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Vikas Vujjini
- Department of Medicine, Sinai Hospital, Baltimore, USA
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Melissa Tracy
- Department of Medicine, Rush University Medical Center, 1735 W Harrison ST, Cohn Bldg, 7th Floor, Suite 716, Chicago, IL 60612 USA
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, 1735 W Harrison ST, Cohn Bldg, 7th Floor, Suite 716, Chicago, IL 60612 USA
| | - Changli Wei
- Department of Medicine, Rush University Medical Center, 1735 W Harrison ST, Cohn Bldg, 7th Floor, Suite 716, Chicago, IL 60612 USA
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14
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Oliverio AL, Zee J, Mariani LH, Reynolds ML, O'Shaughnessy M, Hendren EM, Alachkar N, Herreshoff E, Rizk DV, Nester CM, Steinke J, Twombley KE, Hladunewich MA. Renal Complications in Pregnancy Preceding Glomerulonephropathy Diagnosis. Kidney Int Rep 2018; 4:159-162. [PMID: 30596179 PMCID: PMC6308828 DOI: 10.1016/j.ekir.2018.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/20/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Andrea L Oliverio
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Monica L Reynolds
- Division of Nephrology, Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michelle O'Shaughnessy
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Elizabeth M Hendren
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nada Alachkar
- Division of Nephrology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily Herreshoff
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carla M Nester
- Division of Nephrology, Departments of Internal Medicine and Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Julia Steinke
- Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Katherine E Twombley
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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15
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Houp JA, Desai NM, Kraus ES, Alachkar N, Jackson AM. P141Kas three years later: life after the bolus effect. Hum Immunol 2018. [DOI: 10.1016/j.humimm.2018.07.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, Nankivell BJ, Halloran PF, Colvin RB, Akalin E, Alachkar N, Bagnasco S, Bouatou Y, Becker JU, Cornell LD, van Huyen JPD, Gibson IW, Kraus ES, Mannon RB, Naesens M, Nickeleit V, Nickerson P, Segev DL, Singh HK, Stegall M, Randhawa P, Racusen L, Solez K, Mengel M. The Banff 2017 Kidney Meeting Report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018; 18:293-307. [PMID: 29243394 PMCID: PMC5817248 DOI: 10.1111/ajt.14625] [Citation(s) in RCA: 712] [Impact Index Per Article: 118.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 01/25/2023]
Abstract
The kidney sessions of the 2017 Banff Conference focused on 2 areas: clinical implications of inflammation in areas of interstitial fibrosis and tubular atrophy (i-IFTA) and its relationship to T cell-mediated rejection (TCMR), and the continued evolution of molecular diagnostics, particularly in the diagnosis of antibody-mediated rejection (ABMR). In confirmation of previous studies, it was independently demonstrated by 2 groups that i-IFTA is associated with reduced graft survival. Furthermore, these groups presented that i-IFTA, particularly when involving >25% of sclerotic cortex in association with tubulitis, is often a sequela of acute TCMR in association with underimmunosuppression. The classification was thus revised to include moderate i-IFTA plus moderate or severe tubulitis as diagnostic of chronic active TCMR. Other studies demonstrated that certain molecular classifiers improve diagnosis of ABMR beyond what is possible with histology, C4d, and detection of donor-specific antibodies (DSAs) and that both C4d and validated molecular assays can serve as potential alternatives and/or complements to DSAs in the diagnosis of ABMR. The Banff ABMR criteria are thus updated to include these alternatives. Finally, the present report paves the way for the Banff scheme to be part of an integrative approach for defining surrogate endpoints in next-generation clinical trials.
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Affiliation(s)
- M. Haas
- Department of Pathology and Laboratory MedicineCedars‐Sinai Medical CenterLos AngelesCAUSA
| | - A. Loupy
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance
| | - C. Lefaucheur
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and TransplantationHopital Saint LouisUniversité Paris VII and INSERM U 1160ParisFrance
| | - C. Roufosse
- Department of MedicineImperial College London and North West London PathologyLondonUK
| | - D. Glotz
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and TransplantationHopital Saint LouisUniversité Paris VII and INSERM U 1160ParisFrance
| | - D. Seron
- Nephrology DepartmentHospital Vall d'HebronAutonomous University of BarcelonaBarcelonaSpain
| | - B. J. Nankivell
- Department of Renal MedicineWestmead HospitalSydneyAustralia
| | - P. F. Halloran
- Alberta Transplant Applied Genomics CentreUniversity of AlbertaEdmontonAlbertaCanada
| | - R. B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Enver Akalin
- Montefiore‐Einstein Center for TransplantationMontefiore Medical CenterBronxNYUSA
| | - N. Alachkar
- Department of MedicineSection of NephrologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - S. Bagnasco
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Y. Bouatou
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance,Division of NephrologyDepartment of Medical SpecialitiesGeneva University HospitalsGenevaSwitzerland
| | - J. U. Becker
- Institute of PathologyUniversity Hospital of CologneCologneGermany
| | - L. D. Cornell
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMNUSA
| | - J. P. Duong van Huyen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance
| | - I. W. Gibson
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | - Edward S. Kraus
- Division of NephrologyDepartment of MedicineJohns Hopkins UniversityBaltimoreMDUSA
| | - R. B. Mannon
- Division of NephrologyDepartment of MedicineUniversity of Alabama School of MedicineBirminghamALUSA
| | - M. Naesens
- Department of Microbiology and ImmunologyUniversity of Leuven & Department of NephrologyUniversity Hospitals LeuvenLeuvenBelgium
| | - V. Nickeleit
- Division of NephropathologyDepartment of Pathology and Laboratory MedicineThe University of North Carolina School of MedicineChapel HillNCUSA
| | - P. Nickerson
- Department of Internal Medicine and ImmunologyUniversity of ManitobaWinnipegCanada
| | - D. L. Segev
- Department of SurgeryJohns Hopkins Medical InstitutionsBaltimoreMDUSA
| | - H. K. Singh
- Division of NephropathologyDepartment of Pathology and Laboratory MedicineThe University of North Carolina School of MedicineChapel HillNCUSA
| | - M. Stegall
- Departments of Surgery and ImmunologyMayo ClinicRochesterMNUSA
| | - P. Randhawa
- Division of Transplantation PathologyThomas E. Starzl Transplantation InstituteUniversity of PittsburghPittsburghPAUSA
| | - L. Racusen
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - K. Solez
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - M. Mengel
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
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17
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Lonze BE, Dagher NN, Alachkar N, Jackson AM, Montgomery RA. Nontraditional sites for vascular anastomoses to enable kidney transplantation in patients with major systemic venous thromboses. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Bonnie E. Lonze
- Transplant Institute; Department of Surgery; NYU Langone Medical Center; New York NY USA
| | - Nabil N. Dagher
- Transplant Institute; Department of Surgery; NYU Langone Medical Center; New York NY USA
| | - Nada Alachkar
- Division of Nephrology; Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Annette M. Jackson
- Immunogenetics Laboratory; Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Robert A. Montgomery
- Transplant Institute; Department of Surgery; NYU Langone Medical Center; New York NY USA
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18
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Lonze BE, Bae S, Kraus ES, Holechek MJ, King KE, Alachkar N, Naqvi FF, Dagher NN, Sharif A, Desai NM, Segev DL, Montgomery RA. Outcomes and risk stratification for late antibody-mediated rejection in recipients of ABO-incompatible kidney transplants: a retrospective study. Transpl Int 2017; 30:874-883. [DOI: 10.1111/tri.12969] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/20/2016] [Accepted: 03/27/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Bonnie E. Lonze
- Transplant Institute; NYU Langone Medical Center; New York NY USA
| | - Sunjae Bae
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Edward S. Kraus
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Mary J. Holechek
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Karen E. King
- Department of Pathology; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Nada Alachkar
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Fizza F. Naqvi
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Nabil N. Dagher
- Transplant Institute; NYU Langone Medical Center; New York NY USA
| | - Adnan Sharif
- Department of Nephrology and Transplantation; Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - Niraj M. Desai
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Dorry L. Segev
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
- Department of Epidemiology; The Johns Hopkins University School of Public Health; Baltimore MD USA
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19
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Loupy A, Haas M, Solez K, Racusen L, Glotz D, Seron D, Nankivell BJ, Colvin RB, Afrouzian M, Akalin E, Alachkar N, Bagnasco S, Becker JU, Cornell L, Drachenberg C, Dragun D, de Kort H, Gibson IW, Kraus ES, Lefaucheur C, Legendre C, Liapis H, Muthukumar T, Nickeleit V, Orandi B, Park W, Rabant M, Randhawa P, Reed EF, Roufosse C, Seshan SV, Sis B, Singh HK, Schinstock C, Tambur A, Zeevi A, Mengel M. The Banff 2015 Kidney Meeting Report: Current Challenges in Rejection Classification and Prospects for Adopting Molecular Pathology. Am J Transplant 2017; 17:28-41. [PMID: 27862883 PMCID: PMC5363228 DOI: 10.1111/ajt.14107] [Citation(s) in RCA: 482] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 01/25/2023]
Abstract
The XIII Banff meeting, held in conjunction the Canadian Society of Transplantation in Vancouver, Canada, reviewed the clinical impact of updates of C4d-negative antibody-mediated rejection (ABMR) from the 2013 meeting, reports from active Banff Working Groups, the relationships of donor-specific antibody tests (anti-HLA and non-HLA) with transplant histopathology, and questions of molecular transplant diagnostics. The use of transcriptome gene sets, their resultant diagnostic classifiers, or common key genes to supplement the diagnosis and classification of rejection requires further consensus agreement and validation in biopsies. Newly introduced concepts include the i-IFTA score, comprising inflammation within areas of fibrosis and atrophy and acceptance of transplant arteriolopathy within the descriptions of chronic active T cell-mediated rejection (TCMR) or chronic ABMR. The pattern of mixed TCMR and ABMR was increasingly recognized. This report also includes improved definitions of TCMR and ABMR in pancreas transplants with specification of vascular lesions and prospects for defining a vascularized composite allograft rejection classification. The goal of the Banff process is ongoing integration of advances in histologic, serologic, and molecular diagnostic techniques to produce a consensus-based reporting system that offers precise composite scores, accurate routine diagnostics, and applicability to next-generation clinical trials.
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20
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Alachkar H, Mutonga M, Kato T, Kalluri S, Kakuta Y, Uemura M, Imamura R, Nonomura N, Vujjini V, Alasfar S, Rabb H, Nakamura Y, Alachkar N. Quantitative characterization of T-cell repertoire and biomarkers in kidney transplant rejection. BMC Nephrol 2016; 17:181. [PMID: 27871261 PMCID: PMC5117555 DOI: 10.1186/s12882-016-0395-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 11/09/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND T-cell-mediated rejection (TCMR) remains a major cause of kidney allograft failure. The characterization of T-cell repertoire in different immunological disorders has emerged recently as a novel tool with significant implications. We herein sought to characterize T-cell repertoire using next generation sequencing to diagnose TCMR. METHODS In this prospective study, we analyzed samples from 50 kidney transplant recipients. We collected blood and kidney transplant biopsy samples at sequential time points before and post transplant. We used next generation sequencing to characterize T-cell receptor (TCR) repertoire by using illumina miSeq on cDNA synthesized from RNA extracted from six patients' samples. We also measured RNA expression levels of FOXP3, CD8, CD4, granzyme and perforin in blood samples from all 50 patients. RESULTS Seven patients developed TCMR during the first three months of the study. Out of six patients who had complete sets of blood and biopsy samples two had TCMR. We found an expansion of the TCR repertoire in blood at time of rejection when compared to that at pre-transplant or one-month post transplant. Patients with TCMR (n = 7) had significantly higher RNA expression levels of FOXP3, Perforin, Granzyme, CD4 and CD8 in blood samples than those with no TCMR (n = 43) (P = 0.02, P = 0.003, P = 0.002, P = 0.017, and P = 0.01, respectively). CONCLUSIONS Our study provides a potential utilization of TCR clone kinetics analysis in the diagnosis of TCMR. This approach may allow for the identification of the expanded T-cell clones associated with the rejection and lead to potential noninvasive diagnosis and targeted therapies of TCMR.
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Affiliation(s)
- Houda Alachkar
- School of Pharmacy, University of Southern California, Los Angeles, CA, 90089, USA.
| | - Martin Mutonga
- Department of Medicine, University of Chicago, Chicago, IL, 60637, USA
| | - Taigo Kato
- Department of Medicine, University of Chicago, Chicago, IL, 60637, USA
| | - Sowjanya Kalluri
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Kendall regional medical center, Miami, FL, 33175, USA
| | - Yoichi Kakuta
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryoichi Imamura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Vikas Vujjini
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Hamid Rabb
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Yusuke Nakamura
- Department of Medicine, University of Chicago, Chicago, IL, 60637, USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Hospital, Baltimore, MD, 21287, USA
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21
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Orandi BJ, Lonze BE, Jackson A, Terezakis S, Kraus ES, Alachkar N, Bagnasco SM, Segev DL, Orens JB, Montgomery RA. Splenic Irradiation for the Treatment of Severe Antibody-Mediated Rejection. Am J Transplant 2016; 16:3041-3045. [PMID: 27214874 DOI: 10.1111/ajt.13882] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 05/06/2016] [Accepted: 05/17/2016] [Indexed: 01/25/2023]
Abstract
Patients requiring desensitization prior to renal transplantation are at risk for developing severe antibody-mediated rejection (AMR) refractory to treatment with plasmapheresis and intravenous immunoglobulin (PP/IVIg). We have previously reported success at graft salvage, long-term graft survival and protection against transplant glomerulopathy with the use of eculizumab and splenectomy in addition to PP/IVIg. Splenectomy may be an important component of this combination therapy and is itself associated with a marked reduction in donor-specific antibody (DSA) production. However, splenectomy represents a major operation, and some patients with severe AMR have comorbid conditions that substantially increase their risk of complications during and after surgery. In an effort to spare recipients the morbidity of a second operation, we used splenic irradiation in lieu of splenectomy in two incompatible live donor kidney transplant recipients with severe AMR in addition to PP/IVIg, rituximab and eculizumab. This novel approach to the treatment of severe AMR was associated with allograft salvage, excellent graft function and no short- or medium-term adverse effects of the radiation therapy. One-year surveillance biopsies did not show transplant glomerulopathy (tg) on light microscopy, but microcirculation inflammation and tg were present on electron microscopy.
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Affiliation(s)
- B J Orandi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B E Lonze
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Jackson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Terezakis
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E S Kraus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N Alachkar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S M Bagnasco
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J B Orens
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R A Montgomery
- New York University (NYU) Langone Transplant Institute, New York, NY
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22
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Nijim S, Vujjini V, Alasfar S, Luo X, Orandi B, Delp C, Desai N, Montgomery R, Lonze B, Alachkar N. Recurrent IgA Nephropathy After Kidney Transplantation. Transplant Proc 2016; 48:2689-2694. [DOI: 10.1016/j.transproceed.2016.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 08/03/2016] [Indexed: 10/20/2022]
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23
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Niranjan-Azadi AM, Araz F, Patel YA, Alachkar N, Alqahtani S, Cameron AM, Stevens RD, Gurakar A. Ammonia Level and Mortality in Acute Liver Failure: A Single-Center Experience. Ann Transplant 2016; 21:479-83. [PMID: 27480786 DOI: 10.12659/aot.898901] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Acute liver failure (ALF) is an emergent condition that requires intensive care and manifests in particular by significant elevation in serum ammonia level. Patients with ALF with concomitant renal failure experience a further rise in ammonia levels due to decreased kidney excretion. The aim of this study was to evaluate the relationship between elevated ammonia levels and mortality and to characterize the subgroup of ALF patients who develop acute kidney injury (AKI) and require renal replacement therapy. MATERIAL AND METHODS This was a retrospective study of 36 consecutive patients admitted to Johns Hopkins Hospital's intensive care units from December 2008 to May 2013 who presented with grade III and IV hepatic encephalopathy (HE). Patients who developed AKI and required hemodialysis (HD) were compared to those without AKI. Patients with chronic kidney disease were excluded. RESULTS Sixteen patients developed AKI and underwent HD (HD group). Median ammonia levels in the HD and non-HD groups were not significantly different (p=0.95). In the HD group, 4 patients underwent liver transplantation (LT) and 3 of them survived the hospitalization. Among the 12 HD patients who did not receive LT, 6 (50%) survived. Out of 20 non-HD patients, 3 were transplanted, all of whom survived the hospitalization. Among the 17 non-HD patients who did not receive LT, 14 (82%) survived. Admission ammonia level (>120 µmol/L) was associated with higher mortality rate (OR=7.188 [95% CI 1.3326-38.952], p=0.026) in all patients. CONCLUSIONS Admission ammonia level is predictive of mortality in ALF patients with grade 3-4 HE.
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Affiliation(s)
- Ashwini M Niranjan-Azadi
- Department of Gastroenterology, Osler Internal Medicine Residency Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Filiz Araz
- Visiting Research Fellow, Transplant Hepatology, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yuval A Patel
- Department of Gastroenterology, Osler Internal Medicine Residency Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nada Alachkar
- Transplant Nephrology, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Saleh Alqahtani
- Transplant Hepatology, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew M Cameron
- Department of Transplant Surgery, Division of Liver Transplantation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert D Stevens
- Division of Neuroscience Critical Care, Departments of Anesthesiology and Critical Care Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Transplant Hepatology, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Alasfar S, Carter-Monroe N, Rosenberg AZ, Montgomery RA, Alachkar N. Membranoproliferative glomerulonephritis recurrence after kidney transplantation: using the new classification. BMC Nephrol 2016; 17:7. [PMID: 26754737 PMCID: PMC4709883 DOI: 10.1186/s12882-015-0219-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/28/2015] [Indexed: 02/06/2023] Open
Abstract
Background Membranoproliferative glomerulonephritis (MPGN) is an uncommon glomerular disorder that may lead to end stage renal disease (ESRD). With new understanding of the disease pathogenesis, the classical classification as MPGN types I, II, III has changed. Data on post-transplant MPGN, in particular with the newly refined classification, is limited. We present our center’s experience of MPGN after kidney transplantation using the new classification. Methods This is a retrospective study of 34 patients with ESRD due to MPGN who received 40 kidney transplants between 1994 and 2014. We reviewed the available biopsies’ data using the new classification. We assessed post transplantation recurrence rate, risk factors of recurrence, the response to therapy and allografts’ survival. Results Median time of follow up was 5.3 years (range 0.5–14 years). Using the new classification, we found that pre-transplant MPGN disease was due to immune complex-mediated glomerulonephritis (ICGN) in 89 % of cases and complement-mediated glomerulonephritis (CGN) in 11 %. Recurrence was detected in 18 transplants (45 %). Living related allografts (P = 0.045), preemptive transplantations (P = 0.018), low complement level (P = 0.006), and the presence of monoclonal gammopathy (P = 0.010) were associated with higher recurrence rate in ICGN cases. Half of the patients with recurrence lost their allografts. The use of ACEi/ARB was associated with a trend toward less allograft loss. Conclusions MPGN recurs at a high rate after kidney transplantation. The risk of MPGN recurrence increases with preemptive transplantation, living related donation, low complement level, and the presence of monoclonal gammopathy. Recurrence of MPGN leads to allograft failure in half of the cases.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, The Johns Hopkins University School of Medicine, 600 Wolfe Street. Brady 502, 21287, Baltimore, MD, USA.
| | - Naima Carter-Monroe
- Department of Pathology, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Avi Z Rosenberg
- Department of Pathology, Children's National Medical Center, 111 Michigan Ave. NW, Washington, DC, 20010, USA.
| | - Robert A Montgomery
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, 600 Wolfe Street. Brady 502, 21287, Baltimore, MD, USA.
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25
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Orandi BJ, Alachkar N, Kraus ES, Naqvi F, Lonze BE, Lees L, Van Arendonk KJ, Wickliffe C, Bagnasco SM, Zachary A, Segev DL, Montgomery RA. Presentation and Outcomes of C4d-Negative Antibody-Mediated Rejection After Kidney Transplantation. Am J Transplant 2016; 16:213-20. [PMID: 26317487 PMCID: PMC6114097 DOI: 10.1111/ajt.13434] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 06/02/2015] [Accepted: 06/14/2015] [Indexed: 01/25/2023]
Abstract
The updated Banff classification allows for the diagnosis of antibody-mediated rejection (AMR) in the absence of peritubular capillary C4d staining. Our objective was to quantify allograft loss risk in patients with consistently C4d-negative AMR (n = 51) compared with C4d-positive AMR patients (n = 156) and matched control subjects without AMR. All first-year posttransplant biopsy results from January 2004 through June 2014 were reviewed and correlated with the presence of donor-specific antibody (DSA). C4d-negative AMR patients were not different from C4d-positive AMR patients on any baseline characteristics, including immunologic risk factors (panel reactive antibody, prior transplant, HLA mismatch, donor type, DSA class, and anti-HLA/ABO-incompatibility). C4d-positive AMR patients were significantly more likely to have a clinical presentation (85.3% vs. 54.9%, p < 0.001), and those patients presented substantially earlier posttransplantation (median 14 [interquartile range 8-32] days vs. 46 [interquartile range 20-191], p < 0.001) and were three times more common (7.8% vs 2.5%). One- and 2-year post-AMR-defining biopsy graft survival in C4d-negative AMR patients was 93.4% and 90.2% versus 86.8% and 82.6% in C4d-positive AMR patients, respectively (p = 0.4). C4d-negative AMR was associated with a 2.56-fold (95% confidence interval, 1.08-6.05, p = 0.033) increased risk of graft loss compared with AMR-free matched controls. No clinical characteristics were identified that reliably distinguished C4d-negative from C4d-positive AMR. However, both phenotypes are associated with increased graft loss and thus warrant consideration for intervention.
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Affiliation(s)
- Babak J. Orandi
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Nada Alachkar
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Edward S. Kraus
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Fizza Naqvi
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Bonnie E. Lonze
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Laura Lees
- Johns Hopkins University School of Medicine, Department of Pharmacy, Baltimore, MD
| | - Kyle J. Van Arendonk
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Corey Wickliffe
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Serena M. Bagnasco
- Johns Hopkins University School of Medicine, Department of Pharmacy, Baltimore, MD
| | - Andrea Zachary
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Robert A. Montgomery
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
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26
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Kachurina N, Chung CF, Benderoff E, Babayeva S, Bitzan M, Goodyer P, Kitzler T, Matar D, Cybulsky AV, Alachkar N, Torban E. Novel unbiased assay for circulating podocyte-toxic factors associated with recurrent focal segmental glomerulosclerosis. Am J Physiol Renal Physiol 2015; 310:F1148-56. [PMID: 26719363 DOI: 10.1152/ajprenal.00349.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/28/2015] [Indexed: 01/28/2023] Open
Abstract
Focal segmental glomerular sclerosis (FSGS) is an irreversible renal pathology characterized by podocyte detachment from the glomerular basement membrane, hyalinosis, and sclerosis. Clinically, it manifests with proteinuria and progressive loss of glomerular filtration. Primary idiopathic FSGS can occur in isolation and frequently progresses to end-stage renal disease, requiring dialysis or kidney transplantation. In 30-50% of these patients, proteinuria and FSGS recur in the renal allograft, suggesting the presence of a podocyte-toxic factor(s) in the recipient's serum. Currently, there is no reliable way to quantify the serum activity or predict the subset of FSGS patients at risk for recurrence after transplantation. We describe a novel in vitro method that measures the podocyte-toxic activity of sera from FSGS patients using cultured human podocytes; we compare this with the effect of compounds such as adriamycin. Using immunofluorescence microscopy followed by computerized image-processing analysis, we show that incubation of human podocytes with adriamycin leads to a dose-dependent disassembly of focal adhesion complexes (FACs). We then demonstrate that sera from patients with posttransplant recurrent or idiopathic FSGS cause a similar FAC disturbance. In contrast, sera from nonrecurrent FSGS patients do not affect FACs. In some FSGS patients, toxic effects of serum can be prevented by blockade of the tumor necrosis factor-α pathway. We propose that this method may be useful as a diagnostic tool to identify FSGS patients with serum podocyte-toxic activity that presumably places them at increased risk for recurrence in the renal allograft.
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Affiliation(s)
- Nadezda Kachurina
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada
| | - Chen-Fang Chung
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada
| | - Erin Benderoff
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada
| | - Sima Babayeva
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada
| | - Martin Bitzan
- The Montreal Children's Hospital, Department of Paediatric Nephrology, McGill University Health Center, Montreal, Quebec, Canada
| | - Paul Goodyer
- The Montreal Children's Hospital, Department of Paediatric Nephrology, McGill University Health Center, Montreal, Quebec, Canada; Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Thomas Kitzler
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Dany Matar
- McKinsey & Company, Washington, District of Columbia; and
| | - Andrey V Cybulsky
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada
| | - Nada Alachkar
- Division of Nephrology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elena Torban
- Department of Medicine, McGill University and McGill University Health Center, Montreal, Quebec, Canada;
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27
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Delville M, Sigdel TK, Wei C, Li J, Hsieh SC, Fornoni A, Burke GW, Bruneval P, Naesens M, Jackson A, Alachkar N, Canaud G, Legendre C, Anglicheau D, Reiser J, Sarwal MM. A circulating antibody panel for pretransplant prediction of FSGS recurrence after kidney transplantation. Sci Transl Med 2015; 6:256ra136. [PMID: 25273097 DOI: 10.1126/scitranslmed.3008538] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recurrence of focal segmental glomerulosclerosis (rFSGS) after kidney transplantation is a cause of accelerated graft loss. To evaluate pathogenic antibodies (Abs) in rFSGS, we processed 141 serum samples from 64 patients with and without primary rFSGS and 34 non-FSGS control patients transplanted at four hospitals. We screened about 9000 antigens in pretransplant sera and selected 10 Abs targeting glomerular antigens for enzyme-linked immunosorbent assay (ELISA) validation. A panel of seven Abs (CD40, PTPRO, CGB5, FAS, P2RY11, SNRPB2, and APOL2) could predict posttransplant FSGS recurrence with 92% accuracy. Pretransplant elevation of anti-CD40 Ab alone had the best correlation (78% accuracy) with rFSGS risk after transplantation. Epitope mapping of CD40 with customized peptide arrays and rFSGS sera demonstrated altered immunogenicity of the extracellular CD40 domain in rFSGS. Immunohistochemistry of CD40 demonstrated a differential expression in FSGS compared to non-FSGS controls. Anti-CD40 Abs purified from rFSGS patients were particularly pathogenic in human podocyte cultures. Injection of anti-CD40/rFSGS Ab enhanced suPAR (soluble urokinase receptor)-mediated proteinuria in wild-type mice, yet no sensitizing effect was noted in mice deficient in CD40 or in wild-type mice that received blocking Ab to CD40. In conclusion, a panel of seven Abs can help identify primary FSGS patients at high risk of recurrence before transplantation. Intrarenal CD40 (and possibly other specific glomerular antigens) is an important contributor to FSGS disease pathogenesis. Human trials of anti-CD40 therapies are warranted to evaluate their efficacy for preventing rFSGS and improving graft survival.
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Affiliation(s)
- Marianne Delville
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, INSERM U1171, Réseau Thématique de Recherche et de Soins Centaure, Labex Transplantex, 75015 Paris, France
| | - Tara K Sigdel
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Changli Wei
- Department of Medicine, Rush University Medical Center, Chicago, IL 60612, USA
| | - Jing Li
- Department of Medicine, Rush University Medical Center, Chicago, IL 60612, USA
| | - Szu-Chuan Hsieh
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Alessia Fornoni
- Peggy and Harold Katz Family Drug Discovery Center, Division of Nephrology and Hypertension, University of Miami School of Medicine, Miami, FL 33146, USA
| | - George W Burke
- Division of Transplant Surgery, University of Miami School of Medicine, Miami, FL 33146, USA
| | - Patrick Bruneval
- Department of Pathology, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Maarten Naesens
- Nephrology and Renal Transplantation, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Annette Jackson
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Guillaume Canaud
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, INSERM U1171, Réseau Thématique de Recherche et de Soins Centaure, Labex Transplantex, 75015 Paris, France
| | - Christophe Legendre
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, INSERM U1171, Réseau Thématique de Recherche et de Soins Centaure, Labex Transplantex, 75015 Paris, France
| | - Dany Anglicheau
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, INSERM U1171, Réseau Thématique de Recherche et de Soins Centaure, Labex Transplantex, 75015 Paris, France
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, IL 60612, USA.
| | - Minnie M Sarwal
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA 94143, USA.
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28
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Garin EH, Reiser J, Cara-Fuentes G, Wei C, Matar D, Wang H, Alachkar N, Johnson RJ. Case series: CTLA4-IgG1 therapy in minimal change disease and focal segmental glomerulosclerosis. Pediatr Nephrol 2015; 30:469-77. [PMID: 25239302 PMCID: PMC4869736 DOI: 10.1007/s00467-014-2957-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/13/2014] [Accepted: 09/03/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimal Change Disease (MCD) in relapse is associated with increased podocyte CD80 expression and elevated urinary CD80 excretion, whereas focal segmental glomerulosclerosis (FSGS) has mild or absent CD80 podocyte expression and normal urinary CD80 excretion. METHODS One patient with MCD, one patient with primary FSGS and three patients with recurrent FSGS after transplantation received CD80 blocking antibodies (abatacept or belatacept). Urinary CD80 and CTLA-4 levels were measured by ELISA. Glomeruli were stained for CD80. RESULTS After abatacept therapy, urinary CD80 became undetectable with a concomitant transient resolution of proteinuria in the MCD patient. In contrast, proteinuria remained unchanged after abatacept or belatacept therapy in the one patient with primary FSGS and in two of the three patients with recurrent FSGS despite the presence of mild CD80 glomerular expression but normal urinary CD80 excretion. The third patient with recurrent FSGS after transplantation had elevated urinary CD80 excretion immediately after surgery which fell spontaneously before the initiation of abatacept therapy; after abatacept therapy, his proteinuria remained unchanged for 5 days despite normal urinary CD80 excretion. CONCLUSION These observations are consistent with a role of podocyte CD80 in the development of proteinuria in MCD. In contrast, CD80 may not play a role in recurrent FSGS since the urinary CD80 of our three patients with recurrent FSGS was only increased transiently after surgery and normalization of urinary CD80 did not result in resolution of proteinuria.
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Affiliation(s)
- Eduardo H. Garin
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Jochen Reiser
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gabriel Cara-Fuentes
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Changli Wei
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dany Matar
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Heiman Wang
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Nada Alachkar
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Richard J. Johnson
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado, Denver, CO, USA
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Latt NL, Araz F, Alachkar N, Durand CM, Gurakar A. Management of hepatitis C infection among patients with renal failure. MINERVA GASTROENTERO 2015; 61:39-49. [PMID: 25390288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Hepatitis C virus (HCV) infection is a rising global public health burden with an estimated 130-150 million infected people worldwide and 350,000 to 500,000 HCV-related deaths each year. Chronic kidney disease (CKD) is also a highly prevalent public health issue as the escalating numbers of patients worldwide are developing type 2 diabetes mellitus and hypertension due to high fat diets and a growing obesity epidemic. The high incidence and prevalence of HCV infection leads to substantial morbidity and mortality among renal dialysis patients. Recommendations are to screen for HCV infection among all patients with renal failure especially prior to initiation of hemodialysis and renal transplant evaluation. HCV-antibody enzyme immunoassay (EIA) followed by confirmation with HCV RNA nucleic acid test (NAT) is recommended for low prevalence regions, but in dialysis centers with a high prevalence of HCV, initial testing with NAT is recommended due to higher false positive EIA rates. Liver biopsy is used to assess of liver disease severity. Transjugular liver biopsy, as an effective and safe technique in patients with ESRD can be considered instead of percutaneous approach. Non-invasive approaches to staging fibrosis, including liver stiffness measurement by transient elastography and panels of serum fibrosis biomarkers, are also widely used. Although difficult to manage, combined pegylated- interferon (PEG IFN) and ribavirin therapy was the only treatment modality available for HCV-positive patients until the recently introduced new direct-acting antiviral agents. However, except boceprevir, there are no currently available data to suggest that these new anti-viral drugs are safe and effective among end-stage renal failure patients. IFN-containing regimens were also associated with high rates of renal graft loss in post-renal transplant patients. Therefore, management of HCV infection in renal failure patients is unique and should be tailored individually with calculated risk/benefit ratio. New studies are immediately warranted to determine the safety profile and efficacy of newer anti-HCV drugs not only in patients with end-stage renal failure prior to kidney transplantation but also among kidney transplant recipients.
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Affiliation(s)
- N L Latt
- Department of Gastroenterology and Hepatology Kaiser Permanente Los Angeles Medical Center Los Angeles, CA, USA -
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Orandi BJ, Chow EHK, Hsu A, Gupta N, Van Arendonk KJ, Garonzik-Wang JM, Montgomery JR, Wickliffe C, Lonze BE, Bagnasco SM, Alachkar N, Kraus ES, Jackson AM, Montgomery RA, Segev DL. Quantifying renal allograft loss following early antibody-mediated rejection. Am J Transplant 2015; 15:489-98. [PMID: 25611786 PMCID: PMC4304875 DOI: 10.1111/ajt.12982] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/24/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
Unlike antibody-mediated rejection (AMR) with clinical features, it remains unclear whether subclinical AMR should be treated, as its effect on allograft loss is unknown. It is also uncertain if AMR's effect is homogeneous across donor (deceased/live) and (HLA/ABO) antibody types. We compared 219 patients with AMR (77 subclinical, 142 clinical) to controls matched on HLA/ABO-compatibility, donor type, prior transplant, panel reactive antibody (PRA), age and year. One and 5-year graft survival in subclinical AMR was 95.9% and 75.7%, compared to 96.8% and 88.4% in matched controls (p = 0.0097). Subclinical AMR was independently associated with a 2.15-fold increased risk of graft loss (95% CI: 1.19-3.91; p = 0.012) compared to matched controls, but not different from clinical AMR (p = 0.13). Fifty three point two percent of subclinical AMR patients were treated with plasmapheresis within 3 days of their AMR-defining biopsy. Treated subclinical AMR patients had no difference in graft loss compared to matched controls (HR 1.73; 95% CI: 0.73-4.05; p = 0.21), but untreated subclinical AMR patients did (HR 3.34; 95% CI: 1.37-8.11; p = 0.008). AMR's effect on graft loss was heterogeneous when stratified by compatible deceased donor (HR = 4.73; 95% CI: 1.57-14.26; p = 0.006), HLA-incompatible deceased donor (HR = 2.39; 95% CI: 1.10-5.19; p = 0.028), compatible live donor (no AMR patients experienced graft loss), ABO-incompatible live donor (HR = 6.13; 95% CI: 0.55-67.70; p = 0.14) and HLA-incompatible live donor (HR = 6.29; 95% CI: 3.81-10.39; p < 0.001) transplant. Subclinical AMR substantially increases graft loss, and treatment seems warranted.
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Affiliation(s)
- Babak J. Orandi
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Eric H. K. Chow
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Annie Hsu
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Natasha Gupta
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Kyle J. Van Arendonk
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | | | - John R. Montgomery
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Corey Wickliffe
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Bonnie E. Lonze
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Serena M. Bagnasco
- Johns Hopkins University School of Medicine, Department of Pathology, Baltimore, MD
| | - Nada Alachkar
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Edward S. Kraus
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Annette M. Jackson
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | - Robert A. Montgomery
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
| | - Dorry L. Segev
- Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, MD
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McAdams-DeMarco MA, Law A, King E, Orandi B, Salter M, Gupta N, Chow E, Alachkar N, Desai N, Varadhan R, Walston J, Segev DL. Frailty and mortality in kidney transplant recipients. Am J Transplant 2015; 15:149-54. [PMID: 25359393 PMCID: PMC4332809 DOI: 10.1111/ajt.12992] [Citation(s) in RCA: 235] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/22/2014] [Accepted: 08/23/2014] [Indexed: 01/25/2023]
Abstract
We have previously described strong associations between frailty, a measure of physiologic reserve initially described and validated in geriatrics, and early hospital readmission as well as delayed graft function. The goal of this study was to estimate its association with postkidney transplantation (post-KT) mortality. Frailty was prospectively measured in 537 KT recipients at the time of transplantation between November 2008 and August 2013. Cox proportional hazards models were adjusted for confounders using a novel approach to substantially improve model efficiency and generalizability in single-center studies. We precisely estimated the confounder coefficients using the large sample size of the Scientific Registry of Transplantation Recipients (n = 37 858) and introduced these into the single-center model, which then estimated the adjusted frailty coefficient. At 5 years, the survivals were 91.5%, 86.0% and 77.5% for nonfrail, intermediately frail and frail KT recipients, respectively. Frailty was independently associated with a 2.17-fold (95% CI: 1.01-4.65, p = 0.047) higher risk of death. In conclusion, regardless of age, frailty is a strong, independent risk factor for post-KT mortality, even after carefully adjusting for many confounders using a novel, efficient statistical approach.
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Affiliation(s)
- M. A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,Corresponding authors: Dorry L. Segev, and Mara A. McAdams-DeMarco,
| | - A. Law
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - B. Orandi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - M. Salter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - N. Gupta
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E. Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N. Alachkar
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N. Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - R. Varadhan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J. Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D. L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,Corresponding authors: Dorry L. Segev, and Mara A. McAdams-DeMarco,
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Alasfar S, Alachkar N. Atypical hemolytic uremic syndrome post-kidney transplantation: two case reports and review of the literature. Front Med (Lausanne) 2014; 1:52. [PMID: 25593925 PMCID: PMC4292050 DOI: 10.3389/fmed.2014.00052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 11/29/2014] [Indexed: 01/09/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by over-activation and dysregulation of the alternative complement pathway. Its estimated prevalence is 1–2 per million. The disease is characterized by thrombotic microangiopathy, which causes anemia, thrombocytopenia, and acute renal failure. aHUS has more severe course compared to typical (infection-induced) HUS and is frequently characterized by relapses that leads to end stage renal disease. For a long time, kidney transplantation for these patients was contraindicated because of high rate of recurrence and subsequent renal graft loss. The post-kidney transplantation recurrence rate largely depends on the pathogenetic mechanisms involved. However, over the past several years, advancements in the understanding and therapeutics of aHUS have allowed successful kidney transplantation in these patients. Eculizumab, which is a complement C5 antibody that inhibits complement factor 5a and subsequent formation of the membrane-attack complex, has been used in prevention and treatment of post-transplant aHUS recurrence. In this paper, we present two new cases of aHUS patients who underwent successful kidney transplantation in our center with the use of prophylactic and maintenance eculizumab therapy that have not been published before. The purpose of reporting these two cases is to emphasize the importance of using eculizumab as a prophylactic therapy to prevent aHUS recurrence post-transplant in high-risk patients. We will also review the current understanding of the genetics of aHUS, the pathogenesis of its recurrence after kidney transplantation, and strategies for prevention and treatment of post-transplant aHUS recurrence.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Reiser J, Nast CC, Alachkar N. Permeability factors in focal and segmental glomerulosclerosis. Adv Chronic Kidney Dis 2014; 21:417-21. [PMID: 25168830 DOI: 10.1053/j.ackd.2014.05.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/30/2014] [Accepted: 05/30/2014] [Indexed: 01/30/2023]
Abstract
Focal and segmental glomerulosclerosis (FSGS) represents a group of glomerular disorders, identified on kidney biopsy, that progress in the histopathologic pattern of sclerosis in parts of some glomeruli. Damage to podocytes usually marks the beginning of the disease, most evident in primary FSGS. In addition to genetic predisposition, there are many acquired causes that disturb normal podocyte homeostasis and allow for the development of FSGS. The aim of this review was to summarize recent findings of the most relevant circulating permeability factors that may serve as biomarkers of active primary idiopathic FSGS and aid in the diagnosis and prediction of recurrent FSGS after kidney transplantation.
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Chen P, Sun Q, Huang Y, Atta MG, Turban S, Segev DL, Marr KA, Naqvi FF, Alachkar N, Kraus ES, Womer KL. Blood dendritic cell levels associated with impaired IL-12 production and T-cell deficiency in patients with kidney disease: implications for post-transplant viral infections. Transpl Int 2014; 27:1069-76. [PMID: 24963818 DOI: 10.1111/tri.12381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/03/2014] [Accepted: 06/18/2014] [Indexed: 11/30/2022]
Abstract
Reduced pretransplant blood myeloid dendritic cell (mDC) levels are associated with post-transplant BK viremia and cytomegalovirus (CMV) disease after kidney transplantation. To elucidate potential mechanisms by which mDC levels might influence these outcomes, we studied the association of mDC levels with mDC IL-12 production and T-cell level/function. Peripheral blood (PB) was studied in three groups: (i) end stage renal disease patients on hemodialysis (HD; n = 81); (ii) chronic kidney disease stage IV-V patients presenting for kidney transplant evaluation or the day of transplantation (Eval/Tx; n = 323); and (iii) healthy controls (HC; n = 22). Along with a statistically significant reduction in mDC levels, reduced CD8(+) T-cell levels were also demonstrated in the kidney disease groups compared with HC. Reduced PB mDC and monocyte-derived DC (MoDC) IL-12 production was observed after in vitro LPS stimulation in the HD versus HC groups. Finally, ELISpot assays demonstrated less robust CD3(+) INF-γ responses by MoDCs pulsed with CMV pp65 peptide from HD patients compared with HC. PB mDC level deficiency in patients with kidney disease is associated with deficient IL-12 production and T-cell level/function, which may explain the known correlation of CD8(+) T-cell lymphopenia with deficient post-transplant antiviral responses.
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Affiliation(s)
- Ping Chen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Diabetes mellitus (DM) is the most common cause of chronic kidney disease and end stage renal disease. New onset diabetes mellitus after transplant (NODAT) has been described in approximately 30% of non-diabetic kidney-transplant recipients many years post transplantation. DM in patients with kidney transplantation constitutes a major comorbidity, and has significant impact on the patients and allografts' outcome. In addition to the major comorbidity and mortality that result from cardiovascular and other DM complications, long standing DM after kidney-transplant has significant pathological injury to the allograft, which results in lowering the allografts and the patients' survivals. In spite of the cumulative body of data on diabetic nephropathy (DN) in the native kidney, there has been very limited data on the DN in the transplanted kidney. In this review, we will shed the light on the risk factors that lead to the development of NODAT. We will also describe the impact of DM on the transplanted kidney, and the outcome of kidney-transplant recipients with NODAT. Additionally, we will present the most acceptable data on management of NODAT.
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Affiliation(s)
- Vasil Peev
- Department of Medicine, Rush University School of Medicine, Chicago, IL, USA
| | - Jochen Reiser
- Department of Medicine, Rush University School of Medicine, Chicago, IL, USA
- *Correspondence: Jochen Reiser, Rush University Medical Center, 1735 West Harrison Street, Cohn Building, Suite 724, Chicago, IL 60612, USA e-mail:
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
T-lymphocyte activation antigen CD80 is a B-cell costimulator and podocyte injury marker originally described in lupus nephritis; CD80 blockade with abatacept disappointed in a lupus nephritis trial. A study now suggests abatacept efficacy in focal and segmental glomerulosclerosis. Small patient numbers and concurrent treatment regimens call for more definitive studies regarding this therapeutic strategy.
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Affiliation(s)
- Jochen Reiser
- Department of Medicine, Rush University Medical Center, 1735 West Harrison Street, Cohn Building, Suite 724, Chicago, IL 60612, USA
| | - Nada Alachkar
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 Wolfe Street, Brady 502, Baltimore, MD 21287, USA
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Alachkar N, Wei C, Arend LJ, Jackson AM, Racusen LC, Fornoni A, Burke G, Rabb H, Kakkad K, Reiser J, Estrella MM. Podocyte effacement closely links to suPAR levels at time of posttransplantation focal segmental glomerulosclerosis occurrence and improves with therapy. Transplantation 2013; 96:649-56. [PMID: 23842190 DOI: 10.1097/tp.0b013e31829eda4f] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation in more than 30% of cases and can lead to allograft loss. Serum soluble urokinase-type plasminogen activator receptor (suPAR) is implicated in the pathogenesis of native and recurrent FSGS. METHODS We conducted a retrospective study of 25 adults with posttransplantation FSGS. We investigated the relationship between suPAR levels and podocyte changes and the impact of therapy on podocyte structure. We assessed response to therapy by improvement in proteinuria, allograft function, and resolution of histologic changes. RESULTS A median (interquartile range) of 15 (10-23) plasmapheresis sessions was administered; 13 of the subjects also received rituximab. Median pretreatment suPAR levels were higher among those with severe (≥75%) versus those with mild (≤25%) podocyte foot process effacement (13,030 vs. 4806 pg/mL; P=0.02). Overall, mean±SD of proteinuria improved from 5.1±3.8 to 2.1±2.8 mg/dL (P=0.003), mean podocyte effacement decreased from 57%±33% to 22%±22% (P=0.0001), estimated glomerular filtration rates increased from median (interquartile range) of 32.9 (20.6-44.2) to 39.3 (28.8-63.4; P<0.0001), and suPAR levels decreased from a median of 6.781 to 4.129 pg/mL (P=0.02) with therapy. CONCLUSIONS Podocyte effacement is the first pathologic manifestation of FSGS after transplantation. The degree of podocyte effacement correlates with suPAR levels at time of diagnosis. Response to therapy results in significant reduction of suPAR levels and complete or significant improvement of podocyte effacement.
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Affiliation(s)
- Nada Alachkar
- 1 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 2 Department of Medicine, Rush University Medical Center, Chicago, IL. 3 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD. 4 Department of Medicine, University of Miami Miller School of Medicine, Miami, FL. 5 Department of Surgery, University of Miami Miller School of Medicine, Miami, FL. 6 Department of Medicine, Union Memorial Hospital, Baltimore, MD. 7 Address correspondence to: Nada Alachkar, M.D., Department of Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 971, Baltimore, MD 21205 and Jochen Reiser, M.D., Ph.D., Department of Medicine, Rush University Medical Center, Cohn Research Building, Suite 724, 1735 W. Harrison Street, Chicago, IL 60612
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Abstract
Live kidney donor transplantation across immunological barriers, either blood group or positive crossmatch [ABO- and human leucocyte antigens (HLA)-incompatible kidney transplantation, respectively], is now practised widely across many transplant centres. This provides transplantation opportunities to patients that hitherto would have been deemed contra-indicated and would subsequently have waited indefinitely for a suitably matched kidney. Protocols have evolved with time as experience has grown and now a variety of desensitization strategies are currently practised to overcome such immunological barriers. In addition, desensitization protocols are complemented by kidney paired donation exchange schemes and therefore incompatible patients now have strategies to either confront or bypass immunological barriers, respectively. As the field expands it is clear that non-transplant clinicians will be exposed to incompatible kidney transplant recipients outside of experienced centres. It is therefore timely to review the evolution of practice that have led to current desensitization modalities, contrast protocols and outcomes of current regimens and speculate on future direction of incompatible kidney transplantation.
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Affiliation(s)
- A Sharif
- Renal Institute of Birmingham, Queen Elizabeth Hospital, Edgbaston, Mindelsohn Way, Birmingham, B15 2WB, UK.
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Sharif A, Lonze B, Hillier J, Zachary A, Leffell M, Alachkar N, Kraus E, Dagher N, Desai N, Segev D, Montgomery R. Outcomes from Combining Kidney Paired Donation and Desensitization: An Approach to Kidney Transplantation for the Most Highly Sensitized Patients. Transplantation 2012. [DOI: 10.1097/00007890-201211271-00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Delville M, Sigdel T, Li L, Canaud G, Naessens M, Jackson A, Alachkar N, Legendre C, Anglicheau D, Minnie S. Une signature IgG prédictive de la récidive de hyalinose segmentaire et focale après la transplantation. Nephrol Ther 2012. [DOI: 10.1016/j.nephro.2012.07.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Latt N, Alachkar N, Gurakar A. Hepatitis C virus and its renal manifestations: a review and update. Gastroenterol Hepatol (N Y) 2012; 8:434-445. [PMID: 23293553 PMCID: PMC3533219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Hepatitis C virus (HCV) causes chronic systemic infection, primarily affecting the liver. Although HCV mainly causes hepatitis, a significant portion of chronic HCV patients manifests with at least 1 extrahepatic involvement during the course of their illness. Chronic HCV infection can cause various types of renal diseases. The most common renal manifestations of HCV infection are essential mixed cryoglobulinemia leading to membranoproliferative glomerulonephritis (MPGN), MPGN without cryoglobulinemia, and membranous glomerulonephritis. On the other hand, patients with end-stage kidney disease are at an increased risk of acquiring HCV due to their frequent exposure to potentially contaminated devices in dialysis units and their long-term use of vascular access. Among dialysis patients or patients undergoing renal transplantation, the presence of HCV is associated with higher rates of mortality. The optimal antiviral therapy in patients with severe renal insufficiency is not yet well established and, in most cases, is associated with serious adverse effects. Randomized controlled trials looking at treatment options are lacking. This article reviews the pathophysiology of renal manifestations of chronic HCV infection, discusses recent insights into diagnostic and treatment options for HCV-induced glomerulopathies and HCV-infected dialysis patients, and describes the work-up of HCV-positive renal transplant candidates.
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Affiliation(s)
- Nyan Latt
- Dr. Latt is a Resident Physician in the Internal Medicine Department at Greater Baltimore Medical Center in Baltimore, Maryland. Dr. Alachkar is an Assistant Professor of Medicine in the Division of Nephrology and Dr. Gurakar is an Associate Professor of Medicine in the Division of Gastroenterology & Hepatology and Medical Director of Liver Transplantation, both at Johns Hopkins University School of Medicine in Baltimore, Maryland
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Sharif A, Alachkar N, Bagnasco S, Geetha D, Gupta G, Womer K, Arend L, Racusen L, Montgomery R, Kraus E. Incidence and outcomes of BK virus allograft nephropathy among ABO- and HLA-incompatible kidney transplant recipients. Clin J Am Soc Nephrol 2012; 7:1320-7. [PMID: 22626962 DOI: 10.2215/cjn.00770112] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES ABO-incompatible kidney transplant recipients may have a higher incidence of BK virus allograft nephropathy (BKVAN) compared with ABO-compatible recipients. It is unclear whether HLA-incompatible recipients share this risk or whether this phenomenon is unique to ABO-incompatible recipients. DESIGN, SETTING, PARTICIPATION, MEASUREMENTS: This study analyzed adult incompatible kidney transplant recipients from 1998 to 2010 (62 ABO-incompatible and 221 HLA-incompatible) and identified patients in whom BKVAN was diagnosed by biopsy (per protocol or for cause). This was a retrospective analysis of a prospectively maintained database that compared BKVAN incidence and outcomes between ABO- and HLA-incompatible recipients, respectively. BKVAN link to rejection and graft accommodation phenotype were also explored. The Johns Hopkins Institutional Review Board approved this study. RESULTS Risk for BKVAN was greater among ABO-incompatible than HLA-incompatible patients (17.7% versus 5.9%; P=0.008). Of BKVAN cases, 42% were subclinical, diagnosed by protocol biopsy. ABO-incompatibility and age were independent predictors for BKVAN on logistic regression. C4d deposition without histologic features of glomerulitis and capillaritis (graft accommodation-like phenotype) on 1-year biopsies of ABO-incompatible patients with and without BKVAN was 40% and 75.8%, respectively (P=0.04). Death-censored graft survival (91%) and serum creatinine level among surviving kidneys (1.8 mg/dl) were identical in ABO- and HLA-incompatible patients with BKVAN (median, 1399 and 1017 days after transplantation, respectively). CONCLUSIONS ABO-incompatible kidney recipients are at greater risk for BKVAN than HLA-incompatible kidney recipients. ABO-incompatible recipients not showing the typical graft accommodation-like phenotype may be at heightened risk for BKVAN, but this observation requires replication among other groups.
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Affiliation(s)
- Adnan Sharif
- Renal Institute of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
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Alachkar N, Bagnasco SM, Montgomery RA. Eculizumab for the treatment of two recurrences of atypical hemolytic uremic syndrome in a kidney allograft. Transpl Int 2012; 25:e93-5. [PMID: 22591029 DOI: 10.1111/j.1432-2277.2012.01497.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Radionuclide imaging of the kidneys with gamma cameras involves the use of labeled molecules seeking functionally critical molecular mechanisms to detect the pathophysiology of the diseased kidneys and achieve an early, sensitive, and accurate diagnosis. The most recent imaging technology, positron emission tomography, permits quantitative imaging of the kidney at a spatial resolution appropriate for the organ. H(2)(15)O, (82)RbCl, and [(64)Cu] ETS are the most important radiopharmaceuticals for measuring renal blood flow. The renin angiotensin system is the most important regulator of renal blood flow; this role is being interrogated by detecting angiotensin receptor subtype angiotensin subtype 1 receptor by the use of in vivo positron emission tomography. Membrane organic anion transporters are important for the function of the tubular epithelium; therefore, Tc99m MAG3 as well as some novel radiopharmaceuticals, such as copper-64 labeled mono oxo-tetraazamacrocyclic ligands, have been used for molecular renal imaging. In addition, other radioligands that interact with the organic cation transporters or peptide transporters have been developed. Focusing on early detection of kidney injury at the molecular level is an evolving field of great significance. Potential imaging targets are the kidney injury molecule 1, which is highly expressed in kidney injury and renal cancer but not in normal kidneys. Although pelvic clearance, in addition to parenchymal transport, is an important measure in obstructive nephropathy, techniques that focus on up-regulated molecules in response to tissue stress resulting from obstruction will be of great implication. Monocyte chemoattractant protein-1 is a well-suited molecule here. The greatest advances in molecular imaging of the kidneys have been recently achieved in detecting renal cancer. In addition to the ubiquitous [(18)F] fluorodeoxyglucose, other radioligands, such as [(11)C] acetate and anti-1-amino-3-[18F]fluorocyclobutane-1-carboxylic acid, have emerged. Radioimmunoimaging with [(124)I] G250 could lead to radioimmunotherapy for renal cancer. Considering the increasing age of general population, the incidence of kidney diseases, such as atherosclerosis, diabetic nephropathy, and cancer, is expected to increase. Successful management of these diseases offers an opportunity and a challenge for development of novel molecular imaging technologies.
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Affiliation(s)
- Zsolt Szabo
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins University School of Medicine, 601 N. CarolineStreet, Baltimore, MD 21287, USA.
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Alachkar N, Rabb H, Jaar BG. Urinary Biomarkers in Acute Kidney Transplant Dysfunction. ACTA ACUST UNITED AC 2011; 118:c173-81; discussion c181. [DOI: 10.1159/000321381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sperati CJ, Alachkar N, Rodriguez R, Haas M, Choi MJ. Incidental discovery of a renal cell carcinoma on native kidney biopsy. Am J Kidney Dis 2009; 56:175-80. [PMID: 19880231 DOI: 10.1053/j.ajkd.2009.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 08/25/2009] [Indexed: 11/11/2022]
Affiliation(s)
- C John Sperati
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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