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Okamoto T, Hatakeyama S, Hamaya T, Matsuura T, Saito M, Nishida H, Maita S, Murakami R, Tomita H, Saitoh H, Tsuchiya N, Habuchi T, Obara W, Ohyama C. Impact of timing of rejection episode on cardiovascular events in living donor kidney transplantation: a multicenter retrospective study. J Nephrol 2023; 36:2613-2620. [PMID: 37938544 DOI: 10.1007/s40620-023-01811-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/14/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Cardiovascular diseases are still highly prevalent after kidney transplantation. However, little is known about the impact of the timing of rejection episodes on cardiovascular disease. The study aimed to analyze the influence of the timing of rejection episodes on cardiovascular events in recipients of living donor kidney transplantation. METHODS We studied 572 living donor kidney transplant recipients from the Michinoku Renal Transplant Network (MRTN), which includes 6 centers in the Tohoku region of Japan. Fine-Gray proportional hazards regression analysis with time-dependent variables was used to assess the effect of rejection episode on cardiovascular events. Recipients were divided into three groups: those without rejection (non-rejection, 370 patients), rejection within 6 months after transplantation (early rejection, 99 patients), and rejection after 6 months (late rejection, 103 patients). The effect of timing on cardiovascular events was evaluated using Fine-Gray proportional hazards regression analysis. RESULTS During a median follow-up of 77 months, 70 patients experienced cardiovascular events. Rejection episodes were significantly associated with cardiovascular events (hazard ratio [HR]: 2.08, 95% confidence interval [CI]: 1.26-3.43, P = 0.004), along with age and dialysis vintage. The 5-year cumulative incidence of cardiovascular events was significantly higher in the late rejection group than in the early rejection group (15% vs. 3.3%, P = 0.021). However, no significant difference in 5-year cumulative cardiovascular event incidence was observed between the early rejection and non-rejection groups. Late rejection was significantly associated with cardiovascular events (HR: 2.40, 95% CI: 1.38-4.18, P = 0.002), whereas early rejection was not significantly correlated with cardiovascular event risk (HR: 1.18, P = 0.670). CONCLUSIONS Rejections occurring more than 6 months after transplantation is significantly associated with risk of cardiovascular events. TRIAL REGISTRATION NUMBER 2019-099-1, date of registration; 3 Dec. 2019, retrospectively registered.
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Affiliation(s)
- Teppei Okamoto
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Shingo Hatakeyama
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Tomoko Hamaya
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Tomohiko Matsuura
- Department of Urology, Iwate Medical University, 1-1-1 Idaidori, Yahaba-Cho, Shiwa-Gun, Morioka, Iwate, 028-3694, Japan
| | - Mitsuru Saito
- Department of Urology, Akita University School of Medicine, 1-1-1, Hondo, Akita, 010-8543, Japan
| | - Hayato Nishida
- Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata, 990-9885, Japan
| | - Shinya Maita
- Department of Urology, Iwate Prefectural Isawa Hospital, 61 Mizusawaryuugababa, Oshu, Iwate, 023-0864, Japan
| | - Reiichi Murakami
- Department of Cardiology and Nephrology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hisao Saitoh
- Department of Urology, Oyokyo Kidney Research Institute, 90 Kozawa Yamazaki, Hirosaki, Aomori, 036-8243, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata, 990-9885, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University School of Medicine, 1-1-1, Hondo, Akita, 010-8543, Japan
| | - Wataru Obara
- Department of Urology, Iwate Medical University, 1-1-1 Idaidori, Yahaba-Cho, Shiwa-Gun, Morioka, Iwate, 028-3694, Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
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Fernando SC, Polkinghorne KR, Lim WH, Mulley WR. Early Versus Late Acute AMR in Kidney Transplant Recipients-A Comparison of Treatment Approaches and Outcomes From the ANZDATA Registry. Transplantation 2023; 107:2424-2432. [PMID: 37322595 DOI: 10.1097/tp.0000000000004700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft failure and demonstrates different properties depending on whether it occurs early (<6 mo) or late (>6 mo) posttransplantation. We aimed to compare graft survival and treatment approaches for early and late AMR in Australia and New Zealand. METHODS Transplant characteristics were obtained for patients with an AMR episode reported to the Australia and New Zealand Dialysis and Transplant Registry from January 2003 to December 2019. The primary outcome of time to graft loss from AMR diagnosis, with death considered a competing risk, was compared between early and late AMR using flexible parametric survival models. Secondary outcomes included treatments used, response to treatment, and time from AMR diagnosis to death. RESULTS After adjustment for other explanatory factors, late AMR was associated with twice the risk of graft loss relative to early AMR. The risk was nonproportional over time, with early AMR having an increased early risk. Late AMR was also associated with an increased risk of death. Early AMR was treated more aggressively than late with more frequent use of plasma exchange and monoclonal/polyclonal antibodies. There was substantial variation in treatments used by transplant centers. Early AMR was reported to be more responsive to treatment than late. CONCLUSIONS Late AMR is associated with an increased risk of graft loss and death compared with early AMR. The marked heterogeneity in the treatment of AMR highlights the need for effective, new therapeutic options for these conditions.
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Affiliation(s)
- Sanduni C Fernando
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - William R Mulley
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
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Karthikeyan B, Sharma RK, Mehrotra S, Gupta A, Kaul A, Bhaudauria DS, Prasad N. Comparative Analysis of Determinants and Outcome of Early and Late Acute Antibody Mediated Rejection (ABMR). Indian J Nephrol 2023; 33:22-27. [PMID: 37197045 PMCID: PMC10185016 DOI: 10.4103/ijn.ijn_375_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/26/2020] [Accepted: 10/10/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Antibody-mediated rejection (ABMR) is one of the major determinants of graft survival. Although diagnostic precision and treatment options have improved, response to therapy and graft survival has not improved very significantly. The phenotypes of early and late acute ABMR differ in many ways. In this study, we assessed the clinical characteristics, response to therapy, DSA positivity, and outcomes of early and late ABMR. Methods During the study period, 69 patients with acute ABMR diagnosed on renal graft histopathology were included with a median follow-up of 10 months after rejection. Recipients were stratified into early acute ABMR (<3 months of transplant; n = 29) and late acute ABMR (>3 months of transplant; n = 40). Graft survival, patient survival, response to therapy, and doubling of serum creatinine were assessed and compared between the two groups. Results Baseline characteristics and immunosuppression protocols were comparable between the early and late ABMR groups. Late acute ABMR had an increased risk of doubling of serum creatinine than the early ABMR group (P = 0.002). Graft and patient survival were not statistically different between the two groups. Response to therapy was inferior in the late acute ABMR group (P = 0.00). Pretransplant DSA was present in 27.6% in the early ABMR group. Late acute ABMR was frequently associated with nonadherence or suboptimal immunosuppression and low DSA positivity (15%). Infections such as CMV, bacterial, and fungal infections were similar in the earlier and late ABMR groups. Conclusion Late acute ABMR group had a poor response to anti-rejection therapy and also an increased risk of doubling of serum creatinine compared to the early acute ABMR group. There was also a tendency toward increased graft loss in late acute ABMR patients. Late acute ABMR patients are more frequently associated with nonadherence/suboptimal immunosuppression. There was also a low incidence of anti-HLA DSA positivity in late ABMR.
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Affiliation(s)
- Balasubramanian Karthikeyan
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Raj K. Sharma
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sonia Mehrotra
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anupama Kaul
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Dharmendra S. Bhaudauria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Bertacchi M, Parvex P, Villard J. Antibody-mediated rejection after kidney transplantation in children; therapy challenges and future potential treatments. Clin Transplant 2022; 36:e14608. [PMID: 35137982 PMCID: PMC9286805 DOI: 10.1111/ctr.14608] [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: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
Antibody‐mediated rejection (AMR) remains one of the most critical problems in renal transplantation, with a significant impact on patient and graft survival. In the United States, no treatment has received FDA approval jet. Studies about treatments of AMR remain controversial, limited by the absence of a gold standard and the difficulty in creating large, multi‐center studies. These limitations emerge even more in pediatric transplantation because of the limited number of pediatric studies and the occasional use of some therapies with unknown and poorly documented side effects. The lack of recommendations and the unsharp definition of different forms of AMR contribute to the challenging management of the therapy by pediatric nephrologists. In an attempt to help clinicians involved in the care of renal transplanted children affected by an AMR, we rely on the latest recommendations of the Transplantation Society (TTS) for the classification and treatment of AMR to describe treatments available today and potential new treatments with a particular focus on the pediatric population.
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Affiliation(s)
| | - Paloma Parvex
- Division of Pediatric Nephrology, University Children Hospital of Geneva, Geneva, Switzerland
| | - Jean Villard
- Division of Nephrology, University Hospital of Geneva, Geneva, Switzerland.,Division of Transplantation Immunology, University Hospital of Geneva, Geneva, Switzerland
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Lan JH, Gjertson D, Zheng Y, Clark S, Reed EF, Cecka JM. Clinical utility of complement-dependent C3d assay in kidney recipients presenting with late allograft dysfunction. Am J Transplant 2018; 18:2934-2944. [PMID: 29659162 PMCID: PMC6506230 DOI: 10.1111/ajt.14871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/01/2018] [Accepted: 04/04/2018] [Indexed: 01/25/2023]
Abstract
The objective of this study was to evaluate the utility of a complement-dependent C3d assay to risk stratify donor-specific antibodies (DSA) in a multicenter cohort of kidney recipients presenting with new-onset clinical dysfunction. A total of 106 subjects with evidence of DSA at a mean period of 5.3 ± 5.0 years posttransplant underwent testing using C3d reagents. C3d positivity was strongly associated with both the peak and sum IgG DSA MFI, with 98.3% (n = 57/58) of strongly reactive sera (peak MFI > 10 000) eliciting a positive signal. Patients with C3d+ DSA had a higher creatinine (P = .03), more significant graft fibrosis (P = .035), and a faster rate of graft loss posttest compared to those with C3d- DSA (P = .05). Subanalysis of patients with low-moderate level DSA confirmed the inferior outcome associated with C3d positivity. Despite the prognostic value of C3d as a stand-alone test, the assay did not provide independent risk prediction after incorporation of graft fibrosis in a multivariate model (P = .94). Overall, C3d offered limited discriminatory value for strong DSA with peak IgG MFI > 10 000 and in patients where histologic data is available, but its utilization may be considered in those with low-moderate level DSA and where an allograft biopsy is not accessible.
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Affiliation(s)
- James H Lan
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada,Corresponding author: James H Lan, MD, FRCP(C), D(ABHI), 2775 Laurel Street, Gordon and Leslie Diamond Health Care Center, 5 floor, Vancouver, British Columbia, Canada, V5Z 1M9.
| | - David Gjertson
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Ying Zheng
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Stephanie Clark
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, University of California, Los Angeles, Los Angeles, California, USA
| | - J Michael Cecka
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, University of California, Los Angeles, Los Angeles, California, USA
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Zhang J, Qiu J, Chen GD, Wang CX, Wang C, Yu SJ, Chen LZ. Etiological analysis of graft dysfunction following living kidney transplantation: a report of 366 biopsies. Ren Fail 2018; 40:219-225. [PMID: 29619905 PMCID: PMC6014316 DOI: 10.1080/0886022x.2018.1455592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/03/2018] [Accepted: 03/15/2018] [Indexed: 11/18/2022] Open
Abstract
AIM The aim of this study is to investigate the clinical features of graft dysfunction following living kidney transplantation and to assess its causes. METHODS We retrospectively analyzed a series of 366 living kidney transplantation indication biopsies with a clear etiology and diagnosis from July 2003 to June 2016 at our center. The classifications and diagnoses were performed based on clinical and pathological characteristics. All biopsies were evaluated according to the Banff 2007 schema. RESULTS Acute rejection (AR) occurred in 85 cases (22.0%), chronic rejection (CR) in 62 cases (16.1%), borderline rejection (BR) in 12 cases (3.1%), calcineurin inhibitor (CNI) toxicity damage in 41 cases (10.6%), BK virus-associated nephropathy (BKVAN) in 43 cases (11.1%), de novo or recurrent renal diseases in 134 cases (34.7%), and other causes in nine cases (2.3%); additionally, 20 cases had two simultaneous causes. The 80 cases with IgA nephropathy (IgAN) had the highest incidence (59.7%) of de novo or recurrent renal diseases. After a mean ± SD follow up of 3.7 ± 2.3 years, the 5-year graft cumulative survival rates of AR, CR, CNI toxicity, BKVAN, and de novo or recurrent renal diseases were 60.1%, 31.2%, 66.6%, 66.9%, and 67.1%, respectively. CONCLUSIONS A biopsy is helpful for the diagnosis of graft dysfunction. De novo or recurrent renal disease, represented by IgAN, is a major cause of graft dysfunction following living kidney transplantation.
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Affiliation(s)
- Jin Zhang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiang Qiu
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guo-Dong Chen
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chang-Xi Wang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chang Wang
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuang-Jin Yu
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Zhong Chen
- Department of Organ Transplant, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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7
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Van Loon E, Lerut E, Naesens M. The time dependency of renal allograft histology. Transpl Int 2017; 30:1081-1091. [DOI: 10.1111/tri.13042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/05/2017] [Accepted: 08/21/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Elisabet Van Loon
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
| | - Evelyne Lerut
- Translational Cell and Tissue Research; Department of Imaging and Pathology; KU Leuven; Leuven Belgium
- Department of Morphology and Molecular Pathology; University Hospitals Leuven; Leuven Belgium
| | - Maarten Naesens
- Laboratory of Nephrology; Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
- Department of Nephrology and Renal Transplantation; University Hospitals Leuven; Leuven Belgium
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Mulley WR, Huang LL, Ramessur Chandran S, Longano A, Amos LAR, Polkinghorne KR, Nikolic-Paterson DJ, Kanellis J. Long-term graft survival in patients with chronic antibody-mediated rejection with persistent peritubular capillaritis treated with intravenous immunoglobulin and rituximab. Clin Transplant 2017. [DOI: 10.1111/ctr.13037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- William R. Mulley
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Louis L. Huang
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
| | - Sharmila Ramessur Chandran
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Anthony Longano
- Department of Anatomical Pathology; Monash Medical Centre; Clayton Vic. Australia
| | - Liv A. R. Amos
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Prahran Vic. Australia
| | - David J. Nikolic-Paterson
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - John Kanellis
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
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9
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Trailin AV, Ostapenko TI, Nykonenko TN, Nesterenko SN, Nykonenko OS. Peritransplant Soluble CD30 as a Risk Factor for Slow Kidney Allograft Function, Early Acute Rejection, Worse Long-Term Allograft Function, and Patients' Survival. DISEASE MARKERS 2017; 2017:9264904. [PMID: 28694560 PMCID: PMC5485490 DOI: 10.1155/2017/9264904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/27/2017] [Accepted: 04/11/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND We aimed to determine whether serum soluble CD30 (sCD30) could identify recipients at high risk for unfavorable early and late kidney transplant outcomes. METHODS Serum sCD30 was measured on the day of kidney transplantation and on the 4th day posttransplant. We assessed the value of these measurements in predicting delayed graft function, slow graft function (SGF), acute rejection (AR), pyelonephritis, decline of allograft function after 6 months, and graft and patient survival during 5 years of follow-up in 45 recipients. RESULTS We found the association between low pretransplant serum levels of sCD30 and SGF. The absence of significant decrease of sCD30 on the 4th day posttransplant was characteristic for SGF, early AR (the 8th day-6 months), late AR (>6 months), and early pyelonephritis (the 8th day-2 months). Lower pretransplant and posttransplant sCD30 predicted worse allograft function at 6 months and 2 years, respectively. Higher pretransplant sCD30 was associated with higher frequency of early AR, and worse patients' survival, but only in the recipients of deceased-donor graft. Pretransplant sCD30 also allowed to differentiate patients with early pyelonephritis and early AR. CONCLUSIONS Peritransplant sCD30 is useful in identifying patients at risk for unfavorable early and late transplant outcomes.
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Affiliation(s)
- Andriy V. Trailin
- Department of Laboratory Diagnostics and General Pathology, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 20 Winter Boulevard, Zaporizhzhia 69096, Ukraine
| | - Tetyana I. Ostapenko
- Department of Transplantology, Endocrine Surgery and Cardiovascular Surgery, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, Zaporizhzhia Regional Hospital, 10 Orikhiv Highway, Zaporizhzhia 69050, Ukraine
| | - Tamara N. Nykonenko
- Institute of Cardiovascular Surgery and Transplantology, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 20 Winter Boulevard, Zaporizhzhia 69096, Ukraine
| | - Svitlana N. Nesterenko
- Immunological Laboratory, Zaporizhzhia Regional Hospital, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, 10 Orikhiv Highway, Zaporizhzhia 69050, Ukraine
| | - Olexandr S. Nykonenko
- Department of Transplantology, Endocrine Surgery and Cardiovascular Surgery, State Institution “Zaporizhzhia Medical Academy of Postgraduate Education Ministry of Health of Ukraine”, Zaporizhzhia Regional Hospital, 10 Orikhiv Highway, Zaporizhzhia 69050, Ukraine
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10
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Zhou Y, Li X, Liu Y, Sun Q. Maintenance immunosuppressants in the management of antibody-mediated renal allograft rejection: which regimen is best? Immunotherapy 2016; 9:47-55. [PMID: 28000532 DOI: 10.2217/imt-2016-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Antibody-mediated rejection (AMR) is a pivotal cause of long-term graft failure following renal transplantation. De novo donor-specific antibody reduction is essential to prevent AMR and improve long-term graft survival in renal transplant recipients. Although the number of early AMR episodes can be successfully controlled by attenuating de novo donor-specific antibodies, the long-term outcomes are unsatisfactory. Numerous studies have focused on new strategies to reverse AMR, but the available evidence suggests that maintenance immunosuppressive agents play important roles. This article reviews data on the use of various maintenance immunosuppressive strategies in the management of AMR, with a focus on antibody-mediated kidney transplant rejection. Its aim is to help provide options benefitting long-term graft survival in renal transplant recipients.
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Affiliation(s)
- Yiqun Zhou
- Medical Department, Shanghai Roche Pharmaceuticals Ltd, Shanghai 201203, China
| | - Xiaolan Li
- Medical Department, Shanghai Roche Pharmaceuticals Ltd, Shanghai 201203, China
| | - Yun Liu
- Medical Department, Shanghai Roche Pharmaceuticals Ltd, Shanghai 201203, China
| | - Qiquan Sun
- Department of Renal Transplantation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510530, China
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11
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Pearl MH, Nayak AB, Ettenger RB, Puliyanda D, Palma Diaz MF, Zhang Q, Reed EF, Tsai EW. Bortezomib may stabilize pediatric renal transplant recipients with antibody-mediated rejection. Pediatr Nephrol 2016; 31:1341-8. [PMID: 27048228 PMCID: PMC5590841 DOI: 10.1007/s00467-016-3319-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Current therapeutic strategies to effectively treat antibody-mediated rejection (AMR) are insufficient. Thus, we aimed to determine the benefit of a therapeutic protocol using bortezomib for refractory C4d + AMR in pediatric kidney transplant patients. METHODS We examined seven patients with treatment-refractory C4d + AMR. Immunosuppression included antithymocyte globulin or anti-CD25 monoclonal antibody for induction therapy with maintenance corticosteroids, calcineurin inhibitor, and anti-metabolite. Estimated glomerular filtration rate (eGFR) calculated by the Schwartz equation, biopsy findings assessed by 2013 Banff criteria, and human leukocyte antigen (HLA) donor-specific antibodies (DSA) performed using the Luminex single antigen bead assay were monitored pre- and post- bortezomib therapy. RESULTS Seven patients (86 % male, 86 % with ≥6/8 HLA mismatch, and 14 % with pre-formed DSA) age 5 to 19 (median 15) years developed refractory C4d + AMR between 1 and 145 (median 65) months post-transplantation. All patients tolerated bortezomib. One patient had allograft loss. Of the six patients with surviving grafts (86 %), mean pre-bortezomib eGFR was 42 ml/min/1.73 m(2) and the mean 1 year post-bortezomib eGFR was 53 ml/min/1.73 m(2). Five of seven (71 %) had improvement of histological findings of AMR, C4d staining, and/or acute cellular rejection. Reduction in HLA DSAs was more effective for class I than class II. CONCLUSIONS Bortezomib appears safe and may correlate with stabilization of eGFR in pediatric kidney transplant patients with refractory C4d + AMR.
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Affiliation(s)
- Meghan H Pearl
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA.
| | - Anjali B Nayak
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Robert B Ettenger
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Dechu Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Miguel Fernando Palma Diaz
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Eileen W Tsai
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
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Yilmaz VT, Suleymanlar G, Koksoy S, Ulger BV, Ozdem S, Akbas H, Akkaya B, Kocak H. Therapy Modalities for Antibody Mediated Rejection in Renal Transplant Patients. J INVEST SURG 2016; 29:282-8. [PMID: 27002854 DOI: 10.3109/08941939.2016.1154626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The aim of our study was to determine the effectiveness of immunoglobulin, rituximab and plasmapheresis in renal transplant patients with antibody mediated rejection (AMR). PATIENTS AND METHODS Fourteen renal transplant patients with AMR were included in this study. The mean age of the patients was 33.9 ± 10.3 years and 10 (71.4%) of them were male. Lymphocyte cross match was negative for all patients and 10 (71.4%) of them were living donor transplants. Six patients were administered tacrolimus, three patients cyclosporine, two patients everolimus, and three patients sirolimus for immunosuppression. The patients with AMR were administered IVIG, rituximab and plasmapheresis. RESULTS Patient survival rate was 100%, graft survival rate after AMR was 50% in the first year and 33% in the 2nd and third years. AMR developed 31.9 ± 25.9 months after transplantation. Seven (50%) patients lost their grafts. Delayed graft function was observed in 28.6%, chronic allograft dysfunction in 78.5%, diabetes after transplantation in 14.3%, and cytomegalovirus infection in 7.1% of the patients. At the last follow-up, the mean blood creatinine was 3.1 ± 1.4, the mean proteinuria was 2300 (1300-3300) mg/day and the mean GFR was 34.5 ± 17.6 ml/min. C4d was positive in peritubullar capillaries in all patients, while neutrophil accumulation in peritubular and glomerular capillaries was observed in 8 patients. Chronic allograft vasculopathy was observed in 12 patients. CONCLUSION AMR leads to progressive loss of renal function and has low graft survival. More effective treatment alternatives are needed for this clinical issue.
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Affiliation(s)
- Vural Taner Yilmaz
- a Department of Internal Medicine, Division of Nephrology , Akdeniz University Medical School , Antalya , Turkey
| | - Gultekin Suleymanlar
- a Department of Internal Medicine, Division of Nephrology , Akdeniz University Medical School , Antalya , Turkey
| | - Sadi Koksoy
- b Department of Microbiology, Division of Immunology , Akdeniz University Medical School , Antalya , Turkey
| | - Burak Veli Ulger
- c Department of General Surgery , Dicle University Medical School , Diyarbakir , Turkey
| | - Sebahat Ozdem
- d Department of Biochemistry , Akdeniz University Medical School , Antalya , Turkey
| | - Halide Akbas
- d Department of Biochemistry , Akdeniz University Medical School , Antalya , Turkey
| | - Bahar Akkaya
- e Department of Patology , Akdeniz University Medical School , Antalya , Turkey
| | - Huseyin Kocak
- a Department of Internal Medicine, Division of Nephrology , Akdeniz University Medical School , Antalya , Turkey
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Lee H, Min JW, Kim JI, Moon IS, Park KH, Yang CW, Chung BH, Oh EJ. Clinical Significance of HLA-DQ Antibodies in the Development of Chronic Antibody-Mediated Rejection and Allograft Failure in Kidney Transplant Recipients. Medicine (Baltimore) 2016; 95:e3094. [PMID: 26986147 PMCID: PMC4839928 DOI: 10.1097/md.0000000000003094] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
With the development of the single antigen beads assay, the role of donor specific alloantibody (DSA) against human leukocyte antigens in kidney transplantation (KT) has been highlighted. This study aimed to investigate the clinical significance of DQ-DSA detected at renal allograft biopsy. We evaluated 263 KT recipients who underwent allograft biopsy and DSA detection at the same time. Among them, 155 patients who were nonsensitized before transplantation were selected to investigate the role of de-novo DQ-DSA. Both the total and nonsensitized subgroup was categorized into 4 groups each according to DSA results as: DQ only, DQ + non-DQ, non-DQ, and no DSA. In the total patient group, post-KT DSA was positive in 79 (30.0%) patients and DQ-DSA was most prevalent (64.6%). In the nonsensitized subgroup, de-novo DSAs were detected in 45 (29.0%) patients and DQ-DSA was also most prevalent (73.3%). The DQ only group showed a significantly longer post-KT duration compared to the other groups (P < 0.05). The overall incidence of antibody-mediated rejection (AMR) was 17.9%. B-DSA, DR-DSA, and DQ-DSA were associated with AMR (P < 0.05), but in the analysis for chronic AMR, only DQ-DSA showed significance in both the total and the nonsensitized subgroup (P < 0.05). On comparison of Banff scores among groups, those representing humoral immunity were significantly dominant in all DSA positive groups compared to the no DSA group (P < 0.05), and higher scores of markers representing chronic tissue injury were more frequently detected in the groups with DQ-DSA. The worst postbiopsy survival was seen in the DQ + non-DQ group of the total patient group, and patients with de-novo DQ-DSA showed poorer graft survival in the nonsensitized subgroup compared to the no DSA group (P < 0.05). In the multivariate analysis, de-novo DQ-DSA was the only significant risk factor associated with late allograft failure (P < 0.05). Our study is the first to demonstrate the association of DQ-DSA with detailed histological findings representing chronic AMR. These findings suggest that the detection of DQ-DSA in nonsensitized patients is significantly associated with the development of chronic AMR and late allograft failure. Therefore monitoring of DQ-DSA not only in sensitized patients, but also nonsensitized patients may be necessary to improve long-term allograft outcomes.
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Affiliation(s)
- Hyeyoung Lee
- From the Department of Laboratory Medicine (HL, E-JO); Division of Nephrology, Department of Internal Medicine (JWM, CWY, BHC); Department of Surgery, Seoul St. Mary's Hospital, College of Medicine (J-IK, I-SM); and Department of Biomedical Science (K-HP), Graduate School, Catholic University of Korea, Seoul, Republic of Korea
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14
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King KE, Montgomery RA. Therapeutic plasma exchange for kidney transplantation: the problem of antibody-mediated rejection. Transfusion 2016; 55:696-9. [PMID: 26840785 DOI: 10.1111/trf.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Karen E King
- Hemapheresis and Transfusion Support Service, Department of Pathology
| | - Robert A Montgomery
- Comprehensive Transplant Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
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15
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16
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Koo EH, Jang HR, Lee JE, Park JB, Kim SJ, Kim DJ, Kim YG, Oh HY, Huh W. The impact of early and late acute rejection on graft survival in renal transplantation. Kidney Res Clin Pract 2015; 34:160-4. [PMID: 26484041 PMCID: PMC4608868 DOI: 10.1016/j.krcp.2015.06.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 11/20/2022] Open
Abstract
Background Advances in immunosuppression after kidney transplantation have decreased the influence of early acute rejection (EAR) on graft survival. Several studies have suggested that late acute rejection (LAR) has a poorer effect on long-term graft survival than EAR. We investigated whether the timing of acute rejection (AR) influences graft survival, and analyzed the risk factors for EAR and LAR. Methods We performed a retrospective cohort study involving 709 patients who underwent kidney transplantation between 2000 and 2009 at the Samsung Medical Center, Seoul, Korea. Patients were divided into three groups: no AR, EAR, and LAR. EAR and LAR were defined as rejection before 1 year and after 1 year, respectively. Differences in graft survival between the three groups and risk factors of graft failure were analyzed. Results Of the 709 patients, 198 (30%) had biopsy-proven AR [EAR=152 patients (77%); LAR=46 patients (23%)]. A total of 65 transplants were lost. The 5-year graft survival rates were 97%, 89%, and 85% for patients with no AR, EAR, and LAR, respectively. These differences were significant (P<0.001 for both by log-rank test). In time-dependent Cox regression analysis, EAR (hazards ratio, 3.37; 95% confidence interval, 1.90–5.99) and LAR (hazards ratio, 5.32; 95% confidence interval, 2.65–10.69) were significantly related to graft failure. When we set LAR as standard and compared it with EAR, there was no statistical difference between EAR and LAR (P=0.21). Conclusion AR, regardless of its timing, significantly worsened graft survival. Treatments to reduce the incidence of AR and improve prognosis are needed.
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Affiliation(s)
- Eun Hee Koo
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Ryoun Jang
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Joong Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Goo Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Young Oh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Corresponding author. Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea.
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Improving arteriovenous fistula patency: Transdermal delivery of diclofenac reduces cannulation-dependent neointimal hyperplasia via AMPK activation. Vascul Pharmacol 2015; 71:108-15. [PMID: 25866325 PMCID: PMC4534710 DOI: 10.1016/j.vph.2015.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/02/2015] [Accepted: 02/18/2015] [Indexed: 11/24/2022]
Abstract
Creation of an autologous arteriovenous fistula (AVF) for vascular access in haemodialysis is the modality of choice. However neointimal hyperplasia and loss of the luminal compartment result in AVF patency rates of ~ 60% at 12 months. The exact cause of neointimal hyperplasia in the AVF is poorly understood. Vascular trauma has long been associated with hyperplasia. With this in mind in our rabbit model of AVF we simulated cannulation autologous to that undertaken in vascular access procedures and observed significant neointimal hyperplasia as a direct consequence of cannulation. The neointimal hyperplasia was completely inhibited by topical transdermal delivery of the non-steroidal anti-inflammatory (NSAID) diclofenac. In addition to the well documented anti-inflammatory properties we have identified novel anti-proliferative mechanisms demonstrating diclofenac increases AMPK-dependent signalling and reduced expression of the cell cycle protein cyclin D1. In summary prophylactic transdermal delivery of diclofenac to the sight of AVF cannulation prevents adverse neointimal hyperplasic remodelling and potentially offers a novel treatment option that may help prolong AVF patency and flow rates.
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Clinicopathologic features and treatment response of early acute antibody-mediated rejection in Thai kidney transplant recipients: a single-center experience. Transplant Proc 2014; 46:474-6. [PMID: 24655992 DOI: 10.1016/j.transproceed.2013.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/28/2013] [Accepted: 12/10/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute antibody-mediated rejection (AMR) is a major cause of early kidney allograft dysfunction. This study was conducted to examine the clinicopathologic features and long-term outcomes of early AMR in our center. METHODS We retrospectively reviewed all patients who underwent kidney transplantation between January 2005 and December 2012. Patients who had histopathologic features of AMR within 3 months after transplantation were enrolled. RESULTS Of 444 patients, early acute AMR was diagnosed in 25 patients (5.36%). Seventeen patients (68%) were highly sensitized. Histological analysis revealed acute vascular rejection and thrombotic microangiopathy in 21 (84%) and 6 (24%) patients, respectively. Staining of C4d in peritubular capillaries was detected in 6/20 patients (12%). All patients received plasma exchange (PE) 1.5 blood volume for 1-5 sessions followed by intravenous immunoglobulin (IVIG) 2 g/kg. Sixteen patients (64%) received 1-2 doses of rituximab 375 mg/m(2). We repeated treatment with PE and IVIG in refractory cases. Allografts could be rescued in 20 patients (80%) whereas 5 patients (20%) lost their grafts. Kaplan-Meier survival analysis revealed lower cumulative graft survival in the early AMR group compared with patients without early AMR (1 year survival rate of 80% vs 96% and 3 survival of 64% vs 80%; P < .001). After median follow-up time of 25 months, 7/20 patients (33%) developed late AMR. CONCLUSION ABMR is a serious early complication after KT. Early detection and intensive treatment is mandatory for salvaging the graft. After surpassing from early AMR, long-term close monitoring is also necessary.
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Late antibody-mediated rejection in renal allografts: outcome after conventional and novel therapies. Transplantation 2014; 97:1240-6. [PMID: 24937198 DOI: 10.1097/01.tp.0000442503.85766.91] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although several strategies for treating early antibody-mediated rejection (AMR) in kidney transplants have been investigated, evidence on treatment of late AMR manifesting after 6 months is sparse. In this single-center series, we present data on 23 consecutive patients treated for late AMR. METHODS Late AMR was diagnosed using Banff 2007 criteria along with presence of donor-specific antibodies (DSA) and acute rise in serum creatinine (SCr). Response to therapy was assessed by improvement in SCr, histologic improvement, and decline in DSA strength. RESULTS Overall, 17% (4/23) had documented nonadherence while 69% (16/23) had physician-recommended reduction in immunosuppression before AMR. Eighteen patients (78%) were treated with plasmapheresis or low-dose IVIg+rituximab; 11 (49%) with refractory AMR also received one to three cycles of bortezomib. While there was an improvement (P=0.02) in mean SCr (2.4 mg/dL) at the end of therapy compared with SCr at the time of diagnosis (2.9 mg/dL), this improvement was not sustained at most recent follow-up. Eleven (48%) patients had no histologic resolution on follow-up biopsy. Lack of histologic response was associated with older patients (odds ratio [OR]=3.17; P=0.04), presence of cytotoxic DSA at time of diagnosis (OR=200; P=0.04), and severe chronic vasculopathy (cv≥2) on index biopsy (OR=50; P=0.06). CONCLUSIONS A major setting in which late AMR occurred in our cohort was reduction or change in immunosuppression. Our data demonstrate an inadequate response of late AMR to current and novel (bortezomib) therapies. The benefits of therapy need to be counterweighed with potential adverse effects especially in older patients, large antibody loads, and chronic allograft vasculopathy.
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20
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Zhao YG, Shi BY, Qian YY, Bai HW, Xiao L, He XY. Clinical efficacy of rituximab for acute rejection in kidney transplantation: a meta-analysis. Int Urol Nephrol 2013; 46:1225-30. [DOI: 10.1007/s11255-013-0599-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 10/30/2013] [Indexed: 10/26/2022]
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21
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Late and chronic antibody-mediated rejection: main barrier to long term graft survival. Clin Dev Immunol 2013; 2013:859761. [PMID: 24222777 PMCID: PMC3816029 DOI: 10.1155/2013/859761] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/03/2013] [Indexed: 12/02/2022]
Abstract
Antibody-mediated rejection (AMR) is an important cause of graft loss after organ transplantation. It is caused by anti-donor-specific antibodies especially anti-HLA antibodies. C4d had been regarded as a diagnosis marker for AMR. Although most early AMR episodes can be successfully controlled or reversed, late and chronic AMR remains the leading cause of late graft loss. The strategies which work in early AMR have limited effect on late/chronic episodes. Here, we reviewed the lines of evidence that late/chronic AMR is the leading cause of late graft loss, characteristics of late AMR, and current strategies in managing late/chronic AMR. More effort should be put on the management of late/chronic AMR to make a better long term graft survival.
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Jiqiu W, Jinsong C, Dongrui C, Mingchao Z, Shuming J, Zhi-Hong L. CD20+ B-cell infiltration is related to the time after transplant and poor prognosis of acute cellular rejection in renal transplant. EXP CLIN TRANSPLANT 2013; 11:412-7. [PMID: 23428174 DOI: 10.6002/ect.2012.0143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study sought to determine the relation between CD20+ B-cell infiltration and time after transplant and outcome of acute cellular rejection in renal allografts. MATERIALS AND METHODS Fifty-five patients with acute cellular rejection were categorized into 3 groups: very early, early, and late rejection. The density of CD4+, CD8+, CD20+, and CD68+ cells and HLA-DR expression were characterized and quantified using immunohistochemical staining. Histologic changes were compared between high-density and low-density CD20+ B-cell groups. Poor prognosis factors were analyzed with Cox proportional regression. RESULTS Density of CD20+ cells in the very-early rejection group was lower than it was in the early- and late-acute rejection groups (P = .03); the density of CD4+, CD8+, and CD68+ cells and HLA-DR expression did not differ between the groups. Mesangial matrix increase, tubular atrophy, arteriolar hyaline thickening, and tubulitis were more prevalent in the high CD20+ density group. Cox regression analysis demonstrated that HLA-DR expression on the tubules, arteriolar hyaline thickening, and CD20+ cell density were associated with an elevated risk of acute cellular rejection. CONCLUSIONS Expansion aggregation of CD20+ B cells occurred mostly after 2 weeks. When combined with HLA-DR expression and arteriolar hyaline thickening, these influence the outcome of acute cellular rejection in renal allograft.
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Affiliation(s)
- Wen Jiqiu
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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The implications of acute rejection for allograft survival in contemporary U.S. kidney transplantation. Transplantation 2012; 94:369-76. [PMID: 22836133 DOI: 10.1097/tp.0b013e318259407f] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We examined the frequency and clinical impact of acute rejection (AR) in contemporary U.S. kidney transplantation. METHODS Data for Medicare-insured kidney transplant recipients in 2000 to 2007 (n=48,179) were drawn from the United States Renal Data System. AR events were ascertained from Organ Procurement and Transplantation Network reports. AR was subclassified as antibody (Ab)-treated AR or other management (non-Ab-treated AR). Associations of AR with subsequent all-cause graft loss were estimated with time-varying Cox regression. Covariates included recipient, donor, and transplant factors in the United Network for Organ Sharing Kidney Allocation Review Committee survival model. RESULTS The frequencies of non-Ab-treated AR per 100 graft-years at risk among standard criteria donor recipients over the first 6, 12, 24, and 36 months after transplantation were 9.93, 8.43, 5.71, and 4.70, respectively. Non-Ab-treated AR was consistently more than twice as common as Ab-treated AR by risk period and donor type. Development of Ab-treated AR predicted a greater risk of graft loss than non-Ab-treated AR. The relative risk for graft loss from Ab-treated AR continuously increased with later timing of AR after transplantation, whereas risk associated with non-Ab-treated AR peaked for events reported in months 13 to 24 after kidney transplantation. Regardless of the diagnosis time, the relative risk of graft loss was higher in the first 89 days after a given AR report compared with 90 days and beyond. CONCLUSIONS AR events recognized later after transplantation have more serious graft loss implications, especially within the first 89 days after AR reporting. This observation may reflect reduced intensity of monitoring, delays in diagnosis, or clinicopathologic features of late AR.
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Sun Q, Zhang M, Xie K, Li X, Zeng C, Zhou M, Liu Z. Endothelial injury in transplant glomerulopathy is correlated with transcription factor T-bet expression. Kidney Int 2012; 82:321-9. [DOI: 10.1038/ki.2012.112] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Shimizu T, Tanabe T, Shirakawa H, Omoto K, Ishida H, Tanabe K. Acute vascular rejection after renal transplantation and isolated v-lesion. Clin Transplant 2012; 26 Suppl 24:2-8. [DOI: 10.1111/j.1399-0012.2012.01673.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Tomokazu Shimizu
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
| | - Tatsu Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
| | - Hiroki Shirakawa
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
| | - Kazuya Omoto
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
| | - Hideki Ishida
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo; Japan
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Upadhyay K, Midgley L, Moudgil A. Safety and efficacy of alemtuzumab in the treatment of late acute renal allograft rejection. Pediatr Transplant 2012; 16:286-93. [PMID: 22118373 DOI: 10.1111/j.1399-3046.2011.01615.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Safety and efficacy of alemtuzumab in the treatment of AR in children after renal transplantation is unknown. Five episodes of refractory late AR in three children (three episodes in patient 1 and a single episode in patients 2 and 3 occurring after 7-23 months of transplantation) were treated with one dose of alemtuzumab as a rescue therapy. Four episodes (Banff IA-IB) in patients 1 and 2 reversed fully or partially with alemtuzumab, whereas patient 3 with Banff IB-IIA AR failed to respond. Patient 1 had recurrent AR 5, 13, and 15 months later; first two episodes responded to retreatment with alemtuzumab, and the last episode was not treated causing allograft failure. Patient 2 had steroid-responsive AR after two months and had a functioning allograft 25 months later. A transient reduction in all lymphocyte subsets except natural killer cells occurred in all patients. Patient 3 (treated with steroids, Thymoglobulin(R) , intravenous immunoglobulin, and rituximab prior to alemtuzumab) suffered many bacterial infections during one-yr period after therapy. However, symptomatic viral infections were not observed in any of the children. Treatment with alemtuzumab may prolong allograft survival in multidrug-resistant AR but may not prevent recurrent AR in non-adherent children.
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Affiliation(s)
- Kiran Upadhyay
- Department of Nephrology, Children's National Medical Center, Washington, DC 20010, USA.
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27
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Early and Late Acute Antibody-Mediated Rejection Differ Immunologically and in Response to Proteasome Inhibition. Transplantation 2011; 91:1218-26. [DOI: 10.1097/tp.0b013e318218e901] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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28
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Sun Q, Cheng Z, Cheng D, Chen J, Ji S, Wen J, Zheng C, Liu Z. De novo development of circulating anti-endothelial cell antibodies rather than pre-existing antibodies is associated with post-transplant allograft rejection. Kidney Int 2010; 79:655-662. [PMID: 20980975 DOI: 10.1038/ki.2010.437] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anti-endothelial cell antibodies (AECAs) are thought to be involved in the development of renal allograft rejection. To explore this further, we determine whether AECAs play a role both in predicting the incidence of allograft rejection and long-term outcomes by analysis of serum samples from 226 renal allograft recipients for AECAs pre- and post-transplant. Surprisingly, the presence of pre-existing AECAs was not associated with either an increased risk of rejection or a detrimental impact on recipient/graft survival. Subsequent de novo AECAs, however, were associated with a significantly increased risk of early acute rejection. Moreover, these rejections tended to be more severe with a significantly increased incidence of both steroid-resistant and multiple episodes of acute rejection. The acute rejections associated with de novo AECAs did not correlate with C4d deposition at the time of renal biopsy, but did demonstrate an association with the presence of glomerulitis and peritubular capillary inflammation. Significantly more patients with de novo AECAs developed graft dysfunction. Thus, our prospective study suggests the emergence of de novo AECAs is associated with transplant rejection that may lead to allograft dysfunction.
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Affiliation(s)
- Qiquan Sun
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
| | - Zhen Cheng
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dongrui Cheng
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jinsong Chen
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shuming Ji
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jiqiu Wen
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Chunxia Zheng
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China. zhihong--
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, NSW 2145, Australia.
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30
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Arvizu-Hernández M, Morales-Buenrostro L, Vilatoba-Chapa M, Mancilla-Urrea E, Uribe-Uribe N, Avila-Casado M, de Leo C, Arvizu A, Gonzalez J, Torres J, Gabilondo B, Correa-Rotter R, Alberú J. Time of Occurrence of Kidney Acute Antibody-Mediated Allograft Rejection/Acute Cellular Rejection and Cell Senescence: Implications for Function Outcome. Transplant Proc 2010; 42:2486-92. [DOI: 10.1016/j.transproceed.2010.04.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 04/01/2010] [Indexed: 11/16/2022]
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Elster EA, Hawksworth JS, Cheng O, Leeser DB, Ring M, Tadaki DK, Kleiner DE, Eberhardt JS, Brown TS, Mannon RB. Probabilistic (Bayesian) modeling of gene expression in transplant glomerulopathy. J Mol Diagn 2010; 12:653-63. [PMID: 20688906 DOI: 10.2353/jmoldx.2010.090101] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transplant glomerulopathy (TG) is associated with rapid decline in glomerular filtration rate and poor outcome. We used low-density arrays with a novel probabilistic analysis to characterize relationships between gene transcripts and the development of TG in allograft recipients. Retrospective review identified TG in 10.8% of 963 core biopsies from 166 patients; patients with stable function were studied for comparison. The biopsies were analyzed for expression of 87 genes related to immune function and fibrosis by using real-time PCR, and a Bayesian model was generated and validated to predict histopathology based on gene expression. A total of 57 individual genes were increased in TG compared with stable function biopsies (P < 0.05). The Bayesian analysis identified critical relationships between ICAM-1, IL-10, CCL3, CD86, VCAM-1, MMP-9, MMP-7, and LAMC2 and allograft pathology. Moreover, Bayesian models predicted TG when derived from either immune function (area under the curve [95% confidence interval] of 0.875 [0.675 to 0.999], P = 0.004) or fibrosis (area under the curve [95% confidence interval] of 0.859 [0.754 to 0.963], P < 0.001) gene networks. Critical pathways in the Bayesian models were also analyzed by using the Fisher exact test and had P values <0.005. This study demonstrates that evaluating quantitative gene expression profiles with Bayesian modeling can identify significant transcriptional associations that have the potential to support the diagnostic capability of allograft histology. This integrated approach has broad implications in the field of transplant diagnostics.
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Affiliation(s)
- Eric A Elster
- Regenerative Medicine Department, Combat Casualty Care, Naval Medical Research Center, Silver Spring, Maryland 20910, USA.
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Workeneh BT, Mitch WE. Review of muscle wasting associated with chronic kidney disease. Am J Clin Nutr 2010; 91:1128S-1132S. [PMID: 20181807 DOI: 10.3945/ajcn.2010.28608b] [Citation(s) in RCA: 185] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Muscle wasting increases the morbidity and mortality associated with chronic kidney disease (CKD) and has been attributed to malnutrition. In most patients, this is an incorrect diagnosis because simply feeding more protein aggravates uremia. Instead, there are complex mechanisms that stimulate loss of skeletal muscle, involving activation of mediators that stimulate the ATP-dependent ubiquitin-proteasome system (UPS). Identified mediators of muscle protein breakdown include inflammation, metabolic acidosis, angiotensin II, and neural and hormonal factors that cause defects in insulin/insulin-like growth factor I (IFG-I) intracellular signaling processes. Abnormalities in insulin/IGF-I signaling activate muscle protein degradation in the UPS and caspase-3, a protease that disrupts the complex structure of muscle proteins to provide substrates for the UPS. During the cleavage of muscle proteins, caspase-3 leaves behind a characteristic 14-kD actin fragment in the insoluble fraction of muscle, and characterization of this fragment identifies the presence of muscle catabolism. Thus, it could become a marker of excessive muscle wasting, providing a method for early detection of muscle wasting. Another consequence of activation of caspase-3 in muscle is stimulation of the activity of the proteasome, which increases the degradation of muscle proteins. Treatment strategies for blocking muscle wasting include correction of metabolic acidosis, which can suppress muscle protein losses in patients with CKD who are or are not being treated by dialysis. Correcting acidosis also improves bone metabolism in CKD and hence should be a goal of therapy. Exercise training is a potentially beneficial approach, but more information is needed to optimize exercise regimens. Replacing testosterone deficits can improve muscle mass in men, but dosing and side effects in women have not been adequately tested. Although insulin resistance occurs early in the course of CKD, there are no effective means of correcting it. Consequently, new therapies that can safely suppress muscle wasting are needed.
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Affiliation(s)
- Biruh T Workeneh
- Division of Nephrology, Baylor College of Medicine, Houston, TX, USA
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Reuter S, Reiermann S, Wörner R, Schröter R, Edemir B, Buck F, Henning S, Peter-Katalinic J, Vollenbröker B, Amann K, Pavenstädt H, Schlatter E, Gabriëls G. IF/TA-related metabolic changes--proteome analysis of rat renal allografts. Nephrol Dial Transplant 2010; 25:2492-501. [PMID: 20176611 DOI: 10.1093/ndt/gfq043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic allograft nephropathy, now more specifically termed interstitial fibrosis and tubular atrophy without evidence of any specific aetiology (IF/TA), is still an important cause of late graft loss. There is no effective therapy for IF/TA, in part due to the disease's multifactorial nature and its incompletely understood pathogenesis. METHODS We used a differential in-gel electrophoresis and mass spectrometry technique to study IF/TA in a renal transplantation model. Dark Agouti (DA) kidneys were allogeneically transplanted to Wistar-Furth (DA-WF, aTX) rats. Syngeneic grafts (DA-DA, sTX) served as controls. Nine weeks after transplantation, blood pressure, renal function and electrolytes were studied, in addition to real-time PCR, western blot analysis, histology and immunohistochemistry. RESULTS In contrast to sTX, the aTX developed IF/TA-dependent renal damage. Ten differentially regulated proteins were identified by 2D gel analysis and mass spectrometry, whereupon five proteins are mainly related to oxidative stress (aldo-keto reductase, peroxiredoxin-1, NAD(+)-dependent isocitrate dehydrogenase, iron-responsive element-binding protein-1 and serum albumin), two participate in cytoskeleton organization (l-plastin and ezrin) and three are assigned to metabolic functions (creatine kinase, ornithine aminotransferase and fructose-1,6-bisphosphatase). CONCLUSION The proteins related to IF/TA and involved in oxidative stress, cytoskeleton organization and metabolic functions may correspond with novel therapeutic targets.
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Affiliation(s)
- Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany.
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Viklicky O, Hribova P, Volk HD, Slatinska J, Petrasek J, Bandur S, Honsova E, Reinke P. Molecular phenotypes of acute rejection predict kidney graft prognosis. J Am Soc Nephrol 2009; 21:173-80. [PMID: 19797166 DOI: 10.1681/asn.2008121268] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Earlier detection of antibody-mediated rejection of kidney allografts may improve graft outcomes. Profiling of gene expression holds promise for the diagnosis and prognosis of antibody-mediated rejection. Here, we identified 730 patients who received kidney transplants during 2002-2005, including 21 patients (2.9%) who experienced early acute antibody-mediated rejection. We also identified a matched group of 43 patients with early acute T cell-mediated rejection to serve as controls. Compared with patients with T cell-mediated rejection, those with antibody-mediated rejection had significantly higher intrarenal mRNA expression of the cytoprotective heme oxygenase-1 but had lower expression of the regulatory T cell marker forkhead box P3 (FoxP3), the B cell marker CD20, and the chemokine regulated upon activation, normal T cell expressed and secreted (RANTES). T cell infiltration was similar in both groups of patients. Compared with grafts that had a favorable course, those that failed as a result of antibody-mediated rejection had expression profiles suggesting a lack of regulation (less FoxP3, TGF-beta1, RANTES, and CD20). Grafts that failed as a result of T cell-mediated rejection only revealed lower expression of CD20 mRNA. In summary, these data suggest that severe antibody-mediated rejection and T cell-mediated rejection result in graft loss by distinct mechanisms. Molecular phenotypes of early acute rejection might help to identify grafts with poor prognosis, allowing earlier application of additional therapies.
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Affiliation(s)
- Ondrej Viklicky
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Videnska 1958, 14021 Prague, Czech Republic.
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Kaposztas Z, Podder H, Mauiyyedi S, Illoh O, Kerman R, Reyes M, Pollard V, Kahan BD. Impact of rituximab therapy for treatment of acute humoral rejection. Clin Transplant 2009; 23:63-73. [PMID: 19200217 DOI: 10.1111/j.1399-0012.2008.00902.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Antibody mediated rejection (AMR) is associated with a greater incidence of allograft loss because traditional approaches - pulse steroid or anti-lymphocyte antibodies are usually ineffective. This retrospective analysis documented the benefit of rituximab administration in addition to plasmapheresis (PP). METHODS We retrospectively reviewed the data from 54 kidney transplant patients treated for AMR between 2001 and 2006, including 26 patients who received PP plus rituximab (Group A), versus 28 subjects who underwent PP without rituximab (Group B). Only patients whose serum IgG levels were below normal values received intravenous gamma globulin (IVIG). In addition to clinical and demographic variables we evaluated graft/patient survivals at two years post-diagnosis, Banff classification of rejections, serum creatinine and calculated GFR values at baseline, rejection, resolution as well as three, six, 12 and 24 months thereafter. RESULTS The demographic features of the cohorts showed no significant differences. The two-year graft survival for patients treated with rituximab plus PP was 90%, significantly better than 60% in the PP cohort (p = 0.005). Upon multivariate analysis administration of rituximab was the most significant factor (>or= 0.009); whereas, IVIG also produced a useful effect (p = 0.05). Neither the mean (>or= 0.42) nor the slope (p = 0.25) of GFR values showed a significant difference among salvaged kidneys over 24 months after completion of AMR treatment. The rates and types of infectious complications at three and six months did not show significant differences or impact on graft survival. CONCLUSION Addition of rituximab improved the outcomes of PP treatment of antibody mediated rejection episodes.
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Affiliation(s)
- Z Kaposztas
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas, USA
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Slatinska J, Honsova E, Burgelova M, Slavcev A, Viklicky O. Plasmapheresis and Intravenous Immunoglobulin in Early Antibody-Mediated Rejection of the Renal Allograft: A Single-Center Experience. Ther Apher Dial 2009; 13:108-12. [DOI: 10.1111/j.1744-9987.2009.00664.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sun Q, Liu Z, Chen J, Chen H, Wen J, Cheng D, Li L. Circulating anti-endothelial cell antibodies are associated with poor outcome in renal allograft recipients with acute rejection. Clin J Am Soc Nephrol 2008; 3:1479-86. [PMID: 18579669 DOI: 10.2215/cjn.04451007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Anti-endothelial cell antibody (AECA) can cause hyperacute rejection and immediate graft loss after renal transplantation; however, its prevalence and significance during acute rejection are unknown. Previous studies suggested that AECA may be detected in recipients with acute vascular rejection (AVR). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We retrospectively analyzed 653 cadaveric renal transplant recipients; circulating AECA was positive in 13 of 47 cases of AVR; another two cases of hyperacute rejection also had detectable AECA. Twenty-six cases of AVR without circulating AECA were selected as controls. RESULTS AECA-positive AVR usually occurred within 1 yr after transplantation and mostly was resistant to steroid treatment. Compared with the control group, the AECA-positive group was associated with a significantly lower 1-yr graft survival rate (46.7 versus 80.5%; P = 0.038), and more patients had histologic interstitial plasma cell infiltration (53.8 versus 11.5%; P = 0.005). More patients with AECA-positive AVR experienced another one or more episodes of acute rejection during 1 yr of follow-up (75.0 versus 13.0%; P = 0.003). AECA-positive AVR with C4d deposition in peri-tubular capillaries had the worst outcome in this cohort, and it accounted for 38.5% graft loss in AVR. AECA in turn accounted for 71.4% of graft loss in C4d(+) AVR. CONCLUSIONS Circulating AECA is associated with poor outcome in renal allograft recipients with acute rejection and should be monitored regularly.
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Affiliation(s)
- Qiquan Sun
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
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Demirci C, Sen S, Sezak M, Sarsik B, Hoşcoşkun C, Töz H. Incidence and importance of c4d deposition in renal allograft dysfunction. Transplant Proc 2008; 40:174-7. [PMID: 18261578 DOI: 10.1016/j.transproceed.2007.11.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recent studies showed that peritubular capillary deposition of C4d is a marker of humoral immune responses directed against a renal allograft. The aim of this retrospective study was to investigate the incidence, clinical features, and prognostic implications of C4d deposition in renal allograft biopsy specimens. The biopsies had been performed due to acute graft dysfunction. This study of 104 renal allograft biopsies performed in 2004 classified histopathological findings according to Banff criteria. All paraffin-embedded biopsy samples were stained with an immunohistochemical method for C4d deposition. Demographic data, clinical findings, and biochemical findings were obtained from patients' charts. C4d staining was positive in 15/104 (14%) samples. The staining pattern was diffuse in 8 and focal in 7 patients. Nine patients were males. The overall mean age was 33 +/- 6 years. Ten received live-donor grafts. The biopsy occurred at a mean of 1007 +/- 1415 (range, 15-4712) days after the operation with a mean serum creatinine (SCr) level of 2.8 +/- 1.5 (1.25-6.0) mg/dL. Patients were divided into 2 groups according to the occurrence time: early (before 100 days) and late (after 100 days). Among the early group (n = 5), the mean SCr level was 2.8 +/- 1.5 mg/dL; a diffuse staining pattern was seen in 4 (80%) patients. Histological findings were acute rejection in 3, borderline changes in 1, or thrombotic microangiopathy in 1 patient. Two patients were treated with pulse steroids and 3 with ATG, intravenous immunoglobulin, and plasmapheresis. Three patients lost their grafts at the mean of 118 +/- 100 days after the biopsy. In the late group (n = 10), the mean SCr level was 2.8 +/- 1.7 mg/dL with a diffuse staining pattern in 4 (40%) patients. The histological findings included acute rejection in 6, chronic vascular rejection in 2, thrombotic microangiopathy in 1, and chronic allograft nephropathy in 1 patient. Six patients were treated with pulse steroids, and 3 with ATG and intravenous immunoglobulin. Five patients lost their grafts at a mean of 200 +/- 270 days. The overall incidence of C4d deposition was 14%; it was seen both in the early and late posttransplantation period. Although a diffuse staining pattern was more frequently seen in the early period, C4d deposition indicated a poor allograft prognosis in both periods. Introduction of C4d staining into the routine may guide more specific treatments directed toward the humoral alloresponse.
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Affiliation(s)
- C Demirci
- Nephrology Division, Ege University Medical School, Izmir, Turkey.
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Pascual J, Samaniego MD, Torrealba JR, Odorico JS, Djamali A, Becker YT, Voss B, Leverson GE, Knechtle SJ, Sollinger HW, Pirsch JD. Antibody-mediated rejection of the kidney after simultaneous pancreas-kidney transplantation. J Am Soc Nephrol 2008; 19:812-24. [PMID: 18235091 DOI: 10.1681/asn.2007070736] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The prevalence, risk factors, and outcome of antibody-mediated rejection (AMR) of the kidney after simultaneous pancreas-kidney transplantation are unknown. In 136 simultaneous pancreas-kidney recipients who were followed for an average of 3.1 yr, 21 episodes of AMR of the kidney allograft were identified. Eight episodes occurred early (</=90 d) after transplantation, and 13 occurred later. Histologic evidence of concomitant acute cellular rejection was noted in 12 cases; the other nine had evidence only of humoral rejection. In 13 cases, clinical rejection of the pancreas was diagnosed simultaneously, and two of these were biopsy proven and were positive for C4d immunostaining. Multivariate analysis identified only one significant risk factor: Female patients were three times more likely to experience AMR. Nearly all early episodes resolved with treatment and did not predict graft loss, but multivariate Cox models revealed that late AMR episodes more than tripled the risk for kidney and pancreas graft loss; therefore, new strategies are needed to prevent and to treat late AMR in simultaneous pancreas-kidney transplant recipients.
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Affiliation(s)
- Julio Pascual
- Department of Surgery, Division of Transplantation, University of Wisconsin Hospital and Clinics, H4/772 CSC, 600 Highland Avenue, Madison, WI 53792-7375, USA
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Truong LD, Barrios R, Adrogue HE, Gaber LW. Acute antibody-mediated rejection of renal transplant: pathogenetic and diagnostic considerations. Arch Pathol Lab Med 2007; 131:1200-8. [PMID: 17683182 DOI: 10.5858/2007-131-1200-aarort] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2007] [Indexed: 11/06/2022]
Abstract
CONTEXT Acute antibody-mediated rejection (AMR) has emerged recently as an important cause of graft failure. OBJECTIVE To review the pathogenetic, clinicopathologic, and diagnostic considerations of AMR. DATA SOURCES Review of literature and the authors' experience. CONCLUSIONS Acute antibody-mediated rejection is mediated by antibodies specific for donor antigens, which bind to target antigens and activate the complement system, culminating in tissue injury. The clinical manifestation of AMR is not specific, and transplant biopsy is needed for diagnosis. The glomeruli show thrombosis or neutrophils or mononuclear leukocytes in capillary lumens. The tubulointerstitial compartment shows edema, hemorrhage, necrosis, mild inflammation, and neutrophils or mononuclear leukocytes in the peritubular capillary lumens. The blood vessels show thrombosis, thrombotic microangiopathy, fibrinoid necrosis, or transmural vasculitis. Strong staining for C4d in the peritubular capillaries is characteristic. A definitive diagnosis of AMR requires (1) morphologic evidence of acute tissue injury, (2) immunopathologic evidence for antibody action, and (3) serologic evidence of circulating donor-specific antibodies. Acute antibody-mediated rejection should be suspected if some but not all 3 criteria are met. Since effective treatment is currently available, accurate and timely diagnosis of AMR is essential.
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Affiliation(s)
- Luan D Truong
- Department of Pathology, The Methodist Hospital, 6565 Fannin St, Houston, TX 77030, USA.
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Sun Q, Liu ZH, Cheng Z, Chen J, Ji S, Zeng C, Li LS. Treatment of early mixed cellular and humoral renal allograft rejection with tacrolimus and mycophenolate mofetil. Kidney Int 2006; 71:24-30. [PMID: 16969384 DOI: 10.1038/sj.ki.5001870] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This prospective study investigated the efficiency of the tacrolimus (Tac) combined with mycophenolate mofetil (MMF) alone without immunoadsorption (IA) or plasmapheresis (PPH) as treatment for early (within 2 weeks) acute humoral rejection (AHR) in non-sensitized renal allograft recipients. Of 160 patients enrolled in this prospective study, 11 patients had histologically and clinically confirmed early steroid-resistant acute rejection with an antibody response and received Tac-MMF therapy. No other aggressive rescue methods such as IA, PPH were used, according to the study design. Patients (n=11) were followed for 13.8+/-3.5 months; nine were females. The complement-dependent cytotoxicity crossmatch was negative before transplantation in all patients and only positive for panel-reactive antibody in one patient. Most of the rejection episodes were mixed with cellular rejection (four patients met Banff IIA criteria, five patients met Banff IIB, one patient met Banff IB, and one patient met Banff borderline). After 16.19+/-6.16 days of treatment, all rejection episodes were successfully reversed and all graft functions were stable, with a mean serum creatinine level of 1.12+/-0.32 mg/dl during follow-up. No patient suffered from severe infectious complications (except one case of urinary infection). Our investigation suggests that Tac combined with MMF alone is adequate to reverse early mixed cellular and humoral C4d-positive rejection in non-sensitized renal allograft recipients.
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Affiliation(s)
- Q Sun
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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