1
|
Budhiraja P, Nguyen M, Heilman R, Kaplan B. The Role of Allograft Nephrectomy in the Failing Kidney Transplant. Transplantation 2023; 107:2486-2496. [PMID: 37122077 DOI: 10.1097/tp.0000000000004625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Patients with failed renal allografts have associated increased morbidity and mortality. The individualization of immunosuppression taper is the key element in managing these patients to avoid graft intolerance and sensitization while balancing the risk of continued immunosuppression. Most patients with uncomplicated chronic allograft failure do not require allograft nephrectomy (AN), and there is no clear evidence that it improves outcomes. The AN procedure is associated with variable morbidity and mortality. It is reserved mainly for early technical graft failure or in symptomatic cases associated with allograft infection, malignancy, or graft intolerance syndrome. It may also be considered in those who cannot tolerate immunosuppression and are at high risk for graft intolerance. AN has been associated with an increased risk of sensitization due to inflammatory response from surgery, immunosuppression withdrawal with allograft failure, and retained endovascular tissue. Although it is presumed that for-cause AN after transplant failure is associated with sensitization, it remains unclear whether elective AN in patients who remain on immunotherapy may prevent sensitization. The current practice of immunosuppression taper has not been shown to prevent sensitization or increase infection risk, but current literature is limited by selection bias and the absence of medication adherence data. We discuss the management of failed allografts based on retransplant candidacy, wait times, risk of graft intolerance syndrome, and immunosuppression side effects. Many unanswered questions remain, and future prospective randomized trials are needed to help guide evidence-based management.
Collapse
Affiliation(s)
| | | | | | - Bruce Kaplan
- Department of Medicine, Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado, Aurora, CO
| |
Collapse
|
2
|
Vlachopanos G, El Kossi M, Aziz D, Halawa A. Association of Nephrectomy of the Failed Renal Allograft With Outcome of the Future Transplant: A Systematic Review. EXP CLIN TRANSPLANT 2021; 20:1-11. [PMID: 34775942 DOI: 10.6002/ect.2021.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Kidney allograft failure is a significant complication in kidney transplant recipients, and the surgical decision to perform allograft nephrectomy poses a strong dilemma because it is associated with significant morbidity and mortality. There is a debate over the effect of allograft nephrectomy on the development of allosensitization and the impact on potential retransplantation. Moreover, the use of immunosuppression may contribute to antibody allosensitization as allograft nephrectomy and immunosuppression act jointly and interdependently toward antibody formation. Because more and more patients with kidney allograft failure are entering wait lists for repeat transplant procedures, a review of available evidence on the field is required. Here, we performed a literature search using multiple medical databases to identify relevant studies that assessed the effects of allograft nephrectomy on important retransplant endpoints such as allograft and patient survival; furthermore, secondary outcomes such as alloantibody sensitization were also evaluated. A total of 15 studies were identified; all were retrospective, single-center studies. The rate of allograft nephrectomy in patients with retransplant varied widely (from 20% to 80%). The average allograft nephrectomy rate in included studies was 43% (allograft nephrectomy number/number of repeat transplantations: 2351/5431). Most studies did not observe an allograft survival benefit after retransplant for patients with allograft nephrectomy with the exception of 4 studies that found worse allograft survival after allograft nephrectomy. Interestingly, 1 study found that, in the patient subgroup with early kidney allograft failure (<12 months posttransplant), allograft nephrectomy may be associated with better allograft survival. Available data suggested that allograft nephrectomy may be associated with a higher risk of increasing anti-HLA antibody levels. The quality of the included studies suffered from nonrandomized design, potential confounding, and small sample size. To conclude, further randomized controlled trials are required to delineate the role of allograft nephrectomy on retransplant outcomes.
Collapse
Affiliation(s)
- Georgios Vlachopanos
- From the Department of Nephrology, General Hospital of Nikea, Athens, Greece.,From the School of Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Science, University of Liverpool, Liverpool, United Kingdom
| | | | | | | |
Collapse
|
3
|
Verghese PS, Luckritz KE, Moudgil A, Chandar J, Ranch D, Barcia J, Lin JJ, Grinsell M, Zahr R, Engen R, Twombley K, Fadakar PK, Jain A, Al-Akash S, Bartosh S. Practice patterns and influence of allograft nephrectomy in pediatric kidney re-transplantation: A pediatric nephrology research consortium study. Pediatr Transplant 2021; 25:e13974. [PMID: 33512738 DOI: 10.1111/petr.13974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are no guidelines regarding management of failed pediatric renal transplants. MATERIALS & METHODS We performed a first of its kind multicenter study assessing prevalence of transplant nephrectomy, patient characteristics, and outcomes in pediatric renal transplant recipients with graft failure from January 1, 2006, to December 31, 2016. RESULTS Fourteen centers contributed data on 186 pediatric recipients with failed transplants. The 76 recipients that underwent transplant nephrectomy were not significantly different from the 110 without nephrectomy in donor or recipient demographics. Fifty-three percent of graft nephrectomies were within a year of transplant. Graft tenderness prompted transplant nephrectomy in 91% (P < .001). Patients that underwent nephrectomy were more likely to have a prior diagnosis of rejection within 3 months (43% vs 29%; P = .04). Nephrectomy of allografts did not affect time to re-listing, donor source at re-transplant but significantly decreased time to (P = .009) and incidence (P = .0002) of complete cessation of immunosuppression post-graft failure. Following transplant nephrectomy, recipients were significantly more likely to have rejection after re-transplant (18% vs 7%; P = .03) and multiple rejections in first year after re-transplant (7% vs 1%; P = .03). CONCLUSIONS Practices pertaining to failed renal allografts are inconsistent-40% of failed pediatric renal allografts underwent nephrectomy. Graft tenderness frequently prompted transplant nephrectomy. There is no apparent benefit to graft nephrectomy related to sensitization; but timing / frequency of immunosuppression withdrawal is significantly different with slightly increased risk for rejection following re-transplant.
Collapse
Affiliation(s)
- Priya S Verghese
- Division of Pediatric Nephrology, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kera E Luckritz
- Department of Pediatrics, C.S. Mott Children's Hospital Michigan Medicine, Ann Arbor, MI, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children National Hospital, Washington, DC, USA
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine and Miami Transplant Institute, Miami, FL, USA
| | - Daniel Ranch
- Department of Pediatrics, Division of Pediatric Nephrology, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - John Barcia
- Division of Pediatric Nephrology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jen-Jar Lin
- Department of Pediatrics Nephrology, Wake Forest University Baptist Health, Winston-Salem, NC, USA
| | - Matthew Grinsell
- Division of Nephrology and Hypertension, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rima Zahr
- Division of Pediatric Nephrology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rachel Engen
- Division of Pediatric Nephrology, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katherine Twombley
- Acute Dialysis Units, Pediatric Kidney Transplant, Medical University of South Carolina, Charleston, SC, USA
| | - Paul K Fadakar
- Pediatric Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amrish Jain
- Division of Pediatric Nephrology, Department of Pediatrics, Central Michigan University College of Medicine and Children's Hospital of Michigan, Detroit, MI, USA
| | - Samhar Al-Akash
- Division of Pediatric Nephrology, Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Sharon Bartosh
- Division of Pediatric Nephrology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
4
|
Gavriilidis P, O'Callaghan JM, Hunter J, Fernando T, Imray C, Roy D. Allograft nephrectomy versus nonallograft nephrectomy after failed renal transplantation: a systematic review by updated meta-analysis. Transpl Int 2021; 34:1374-1385. [PMID: 34062020 DOI: 10.1111/tri.13901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/21/2021] [Accepted: 05/03/2021] [Indexed: 01/22/2023]
Abstract
There is limited evidence regarding the impact of allograft nephrectomy (AN) on the long-term outcome of subsequent kidney re-transplantation compared with no prior allograft nephrectomy. The aim of the present study was to conduct a systematic review and meta-analysis to estimate the accumulation of evidence over time. Primary outcomes were 5-year graft and patient survival. Cochrane library, Google scholar, PubMed, Medline and Embase were systematically searched. Meta-analysis was conducted using both fixed- and random-effects models. Study quality was assessed in duplicate using the Newcastle-Ottawa scale. Sixteen studies were included, with a total of 2256 patients. All included studies were retrospective and comparative. There was no significant difference in 5-year graft survival (GS) [Hazard Ratio (HR) = 1.11, 95% Confidence Intervals (CI): 0.89, 1.38, P = 0.37, I2 = 10%) or in 5-year patient survival (PS; HR = 0.70, 95% CI: 0.45, 1.10, P = 0.12, I2 = 0%]. Patients in the AN cohort were significantly younger than patients in the nonallograft nephrectomy (NAN) cohort by one year. Prior allograft nephrectomy was associated with a significantly higher risk of delayed graft function (DGF), acute rejection, primary nonfunction (PNF), per cent of panel reactive antibodies (% PRA) and allograft loss of the subsequent transplant. Although, DGF, % PRA, acute rejection and primary nonfunction rates were significantly higher in the AN cohort, allograft nephrectomy prior to re-transplantation had no significant association with five-year graft and patient survival.
Collapse
Affiliation(s)
- Paschalis Gavriilidis
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - John Matthew O'Callaghan
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - James Hunter
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tyrrel Fernando
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Christopher Imray
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Deb Roy
- Department of Vascular Access and Renal Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
5
|
Bunthof KLW, Steenbergen EJ, Hilbrands LB. Histopathological examination of removed kidney allografts: Is it useful? A retrospective cohort study. Transpl Int 2020; 33:1693-1699. [PMID: 32852855 PMCID: PMC7756776 DOI: 10.1111/tri.13724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/11/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
The incidence and relevance of histological findings in removed allografts is unknown. In this study, we investigated the outcome of routine histopathological examination of removed allografts. We performed a retrospective cohort study in patients with kidney graft failure ≥3 months after transplantation. In this cohort, 244 allograft nephrectomies were performed. We routinely sent removed grafts for histopathological examination. In 197 cases, a pathology report was available for analysis. In 21 of the 197 grafts, gross necrosis precluded adequate interpretation. Signs of rejection were reported in 163 of the remaining 176 allografts. Recurrences of the original disease were found in 13 cases. These were all known from prior biopsies. Relevant secondary findings were present in eight cases: renal cell carcinoma (n = 2), urothelial cell carcinoma, candida pyelonephritis (n = 2), post‐transplant lymphoproliferative disease, polyomavirus inclusions, and membranous nephropathy. All conditions were diagnosed before graft nephrectomy, except for one case of papillary renal cell carcinoma of 0.8 cm. As expected, signs of acute and/or chronic rejection are the main histopathological finding in grafts that are removed after late graft failure. Unexpected secondary findings are very rare. Therefore, it is justifiable to restrict histopathological examination of removed kidney allografts to specific cases.
Collapse
Affiliation(s)
- Kim L W Bunthof
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands
| | - Eric J Steenbergen
- Department of Pathology, Radboud university medical center, Nijmegen, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands
| |
Collapse
|
6
|
Immunosuppression with Calcineurin Inhibitor after Renal Transplant Failure Inhibits Allosensitization. Biomedicines 2020; 8:biomedicines8040072. [PMID: 32231087 PMCID: PMC7235765 DOI: 10.3390/biomedicines8040072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/16/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
Immunosuppression withdrawal after graft failure seems to favor sensitization. A high percentage of calculated panel-reactive antibody (cPRA) and the development of de novo donor specific antibodies (dnDSA) indicate human leukocyte antigen (HLA) sensitization and may hinder the option of retransplantation. There are no established protocols on the immunosuppressive treatment that should be maintained after transplant failure. A retrospective analysis including 77 patients who lost their first renal graft between 1 January 2006–31 December 2015 was performed. Two sera were selected per patient, one immediately prior to graft loss and another one after graft failure. cPRA was calculated by Single Antigen in all patients. It was possible to analyze the development of dnDSA in 73 patients. By multivariate logistic regression analysis, the absence of calcineurin inhibitor (CNI) at 6 months after graft failure was related to cPRA > 75% (OR 4.8, CI 95% 1.5–15.0, p = 0.006). The absence of calcineurin inhibitor (CNI) at 6 months after graft loss was significantly associated with dnDSA development (OR 23.2, CI 95% 5.3–100.6, p < 0.001). Our results suggest that the absence of CNI at the sixth month after graft loss is a risk factor for sensitization. Therefore, maintenance of an immunosuppressive regimen based on CNI after transplant failure should be considered when a new transplant is planned, since it seems to prevent HLA allosensitization.
Collapse
|
7
|
Ghyselen L, Naesens M. Indications, risks and impact of failed allograft nephrectomy. Transplant Rev (Orlando) 2019; 33:48-54. [DOI: 10.1016/j.trre.2018.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 02/07/2023]
|
8
|
Review: Management of patients with kidney allograft failure. Transplant Rev (Orlando) 2018; 32:178-186. [DOI: 10.1016/j.trre.2018.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/18/2018] [Accepted: 03/21/2018] [Indexed: 12/25/2022]
|
9
|
Lin J, Wang R, Xu Y, Chen J. Impact of renal allograft nephrectomy on graft and patient survival following retransplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2018; 33:700-708. [PMID: 29444290 DOI: 10.1093/ndt/gfx360] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/11/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jinwen Lin
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ying Xu
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
10
|
Lee SW, Kim YH, Chung W, Park SK, Chae DW, Ahn C, Kim YS, Sung SA. Serum Hepcidin and Iron Indices Affect Anemia Status Differently According to the Kidney Function of Non-Dialysis Chronic Kidney Disease Patients: Korean Cohort Study For Outcome in Patients with Chronic Kidney Disease (KNOW-CKD). Kidney Blood Press Res 2017; 42:1183-1192. [PMID: 29227972 DOI: 10.1159/000485865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS No studies have examined the association among serum hepcidin, iron indices, or anemia status based on the kidney function of non-dialysis chronic kidney disease (CKD) patients. METHODS We reviewed data of 2238 patients from a large-scale multicenter prospective Korean study (2011-2016) and excluded 198 patients with missing data regarding serum hepcidin, hemoglobin, transferrin saturation (TSAT), ferritin, and usage of erythropoiesis-stimulating agents (ESA) or supplemental iron and 363 patients using ESA or supplemental iron. Finally, 1677 patients were included. RESULTS The mean patient age was 53.5 years, and 65.4% were men. TSAT and serum hepcidin were significantly associated with anemia status, whereas serum ferritin was not, regardless of anemia severity. For patients with an estimated glomerular filtration rate (eGFR) ≥45 mL/min/1.73 m2, a 10% increase of TSAT was associated with hemoglobin <13 g/dL (odds ratio [OR], 0.628; 95% confidence interval [CI], 0.515-0.765; P<0.001) and hemoglobin <11.5 g/dL (OR, 0.672; 95% CI, 0.476-0.950; P=0.024), whereas a 10-ng/mL increase of serum hepcidin was associated with hemoglobin <11.5 g/dL (OR, 1.379; 95% CI, 1.173-1.620; P<0.001) and hemoglobin <10.0 g/dL (OR, 1.360; 95% CI, 1.115-1.659; P=0.002) for patients with eGFR <45 mL/min/1.73 m2 according to multivariate logistic analysis. CONCLUSIONS TSAT was associated with less severe anemia in early CKD patients. Serum hepcidin was associated with more severe anemia in advanced CKD patients.
Collapse
Affiliation(s)
- Sung Woo Lee
- Department of Internal Medicine, Seoul National University Postgraduate School, Seoul, Republic of Korea.,Department of Internal Medicine, Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Yeong Hoon Kim
- Department of Internal Medicine, Inje University, Busan Paik Hospital, Busan, Republic of Korea
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Republic of Korea
| | - Sue K Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Cancer Research Institute, Seoul National University, Seoul, Republic of Korea.,Department of Biomedical Science, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Dong Wan Chae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Su Ah Sung
- Department of Internal Medicine, Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| |
Collapse
|
11
|
Bunthof KLW, Verhoeks CM, van den Brand JAJG, Hilbrands LB. Graft intolerance syndrome requiring graft nephrectomy after late kidney graft failure: can it be predicted? A retrospective cohort study. Transpl Int 2017; 31:220-229. [DOI: 10.1111/tri.13088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/21/2017] [Accepted: 10/23/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Kim L. W. Bunthof
- Department of Nephrology; Radboud University Medical Center; Nijmegen The Netherlands
| | - Carmen M. Verhoeks
- Department of Nephrology; Radboud University Medical Center; Nijmegen The Netherlands
| | | | - Luuk B. Hilbrands
- Department of Nephrology; Radboud University Medical Center; Nijmegen The Netherlands
| |
Collapse
|