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Comai G, Corradetti V, Bini C, Tondolo F, Hu L, Valente S, Pasquinelli G, Malvi D, Vasuri F, Ravaioli M, Provenzano M, La Manna G. Histological findings of diabetic kidneys transplanted in non-diabetic recipients: a case series. Int Urol Nephrol 2023; 55:2611-2619. [PMID: 36940004 PMCID: PMC10499976 DOI: 10.1007/s11255-023-03552-x] [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: 01/16/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Diabetic donors are recognized as a reliable source of organs, although the discard rate of kidneys is still high. Few data are available on the histological evolution of these organs especially on kidneys transplanted into non-diabetic patients who remain euglycemic. METHODS We describe the histological evolution of ten kidney biopsies performed on non-diabetic recipients of diabetic donors. RESULTS Mean donor age was 69 ± 7 years, 60% were males. Two donors were treated with insulin, eight with oral antidiabetic drugs. Mean recipient age was 59.9 ± 7 years, 70% were males. The pre-existing diabetic lesions identified in the pre-implantation biopsies, encompassed all histological classes, and were associated with mild IF/TA and vascular damages. The median follow-up was 59.5 [IQR 32.5-99.0] months; at follow-up, 40% of cases did not change histologic classification, two patients with class IIb downgraded to IIa or I and one with class III downgraded to IIb. Conversely, three cases showed a worsening, from class 0 to I, I to IIb or from IIa to IIb. We also observed a moderate evolution of IF/TA and vascular damages. At follow-up visit, estimated GFR was stable (50.7 mL/min vs. 54.8 at baseline) and proteinuria was mild (51.1 ± 78.6 mg/day). CONCLUSIONS Kidneys from diabetic donors show variable evolution of the histologic features of diabetic nephropathy after transplant. This variability may be associated to recipients characteristics such as euglycemic milieu, in case of improvement, or obesity and hypertension, in case of worsening of histologic lesions.
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Affiliation(s)
- Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Lilio Hu
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Sabrina Valente
- Biotechnology and Methods in Laboratory Medicine, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gianandrea Pasquinelli
- Biotechnology and Methods in Laboratory Medicine, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Deborah Malvi
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Francesco Vasuri
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Matteo Ravaioli
- General Surgery and Transplantation Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Mas-Sarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy.
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy.
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Blanco T, Musayeva A, Singh RB, Nakagawa H, Lee S, Alemi H, Gonzalez-Nolasco B, Ortiz G, Wang S, Kahale F, Dohlman TH, Chen Y, Dana R. The impact of donor diabetes on corneal transplant immunity. Am J Transplant 2023; 23:1345-1358. [PMID: 37245642 PMCID: PMC10527508 DOI: 10.1016/j.ajt.2023.05.027] [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: 03/03/2023] [Revised: 05/12/2023] [Accepted: 05/24/2023] [Indexed: 05/30/2023]
Abstract
Corneal transplantation is the most common form of solid tissue grafting, with an approximately 80% to 90% success rate. However, success rates may decline when donor tissues are derived from patients with a history of diabetes mellitus (DM). To evaluate the underlying immunopathologic processes that cause graft rejection, we used streptozotocin-induced type 1 DM (DM1) and transgenic Lepob/ob type 2 DM (DM2) diabetic murine models as donors and nondiabetic BALB/c as recipients. DM resulted in an increased frequency of corneal antigen-presenting cells (APCs) with an acquired immunostimulatory phenotype. Following transplantation, recipients that received either type of diabetic graft showed increased APC migration and T helper type 1 alloreactive cells, impaired functional regulatory T cells, and graft survival. Insulin treatment in streptozotocin-induced diabetic mice led to an increased tolerogenic profile of graft APC, lower T helper type 1 sensitization, and a higher frequency of functional regulatory T cells with high suppressive capacity, reflected in increased graft survival. We conclude that both DM1 and DM2 in donors can impact corneal APC functional phenotype, rendering the tissue more immunogenic and thereby increasing the risk of graft failure.
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Affiliation(s)
- Tomás Blanco
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Aytan Musayeva
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohan Bir Singh
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hayate Nakagawa
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Seokjoo Lee
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hamid Alemi
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruno Gonzalez-Nolasco
- Transplant Research Center, Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gustavo Ortiz
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Shudan Wang
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Francesca Kahale
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas H Dohlman
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Yihe Chen
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Dana
- Laboratory of Corneal Immunology, Transplantation, and Regeneration, Schepens Eye Research Institute of Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.
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Long-standing donor diabetes and pathologic findings are associated with shorter allograft survival in recipients of kidney transplants from diabetic donors. Mod Pathol 2022; 35:128-134. [PMID: 34584213 DOI: 10.1038/s41379-021-00927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/09/2022]
Abstract
Approximately 6% of deceased kidney donors (DKDs) are diabetic; their kidneys may be associated with worse allograft survival, but published studies suggest that recipient diabetes status has a greater impact on mortality and survival. Since biopsy findings are the most common reason for organ discard, we sought to understand histologic and clinical factors that influence graft survival in patients who receive a kidney from a diabetic DKD. We retrospectively reviewed our institutional experience from 2005 to 2019, and re-evaluated pre-implantation and earliest post-transplant biopsies. Histologic findings were compared against a control cohort of non-diabetic DKD. Of 829 adult DKD transplants, 37 (4.5%) came from diabetic donors. There was no significant difference in diabetic vs. non-diabetic DKD graft survival for all-comers; however, when stratified by duration of donor diabetes, donor diabetes ≥6 years was associated with graft failure. In 25 patients with post-transplant biopsies available, diabetic DKD allografts had significantly greater non-glomerular chronic injury than non-diabetic DKD allografts. Moderate arteriolar hyalinosis (in 24%), moderate tubular atrophy and interstitial fibrosis (IFTA, in 36%), and diabetic glomerulopathy (in 24%) on early post-transplant biopsy were associated with allograft failure. Pre-implantation frozen section discrepancies were more common in long-standing donor diabetes, and arteriolar hyalinosis and IFTA scores on frozen accurately prognosticated graft loss. There was no morphologic improvement in lesions of diabetic nephropathy on short-term follow-up. In conclusion, donor diabetes ≥6 years, and histologic findings on frozen section and early post-transplant biopsy are associated with diabetic DKD allograft loss.
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Hsu CT, Wen MC, Chiu HF, Tsai SF, Yu TM, Yang CK, Wu MJ, Chen CH. Ongoing donor-transmitted diabetic kidney disease in kidney transplant recipients with fair sugar control: a single center retrospective study. BMC Nephrol 2020; 21:458. [PMID: 33143634 PMCID: PMC7640448 DOI: 10.1186/s12882-020-02132-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022] Open
Abstract
Background Transplantation with a diabetic donor kidney may have some benefits compared to remaining on the waitlist for selected patients. However, we found that some kidney transplant recipients have ongoing donor-transmitted diabetic kidney disease (DT-DKD) despite fair blood sugar control. This study aimed to survey the incidence and clinical pattern of DT-DKD in kidney transplant recipients. Methods We retrospectively reviewed the medical records of kidney transplantations in our hospital. We found 357 kidney transplantations from February 2006 to April 2018. Among these, 23 (6.4%) diabetic donor kidney transplantations were done in the study period. Results Among the 23 recipients, 6 (26.1%) displayed biopsy-proven DKD. Recipients with biopsy-proven DKD had longer dialysis vintage, higher proteinuria amount, lower last estimated glomerular filtration rate (eGFR), and a more rapid decline in the eGFR. The median fasting blood sugar level in the biopsy-proven DKD group was unexpectedly lower than the non-DKD group. Most of the pre-implantation frozen sections in biopsy-proven DKD group showed diabetic lesions worse than diabetic nephropathy (DN) class IIa. In the biopsy-proven DKD group, 5 recipients had no history of diabetes before or after transplantation. Among the 23 recipients, 5 (21.7%) were diagnosed with DT-DKD. Serial post-transplant biopsies showed the histological progression of allograft DN. Conclusions To the best of our knowledge, this is the first study to report the phenomenon of ongoing DT-DKD in kidney transplant recipients with fair blood sugar control. The zero-time pre-transplant kidney biopsy may be an important examination before the allocation of diabetic donor kidneys. Further study is needed to elucidate the possible mechanism of ongoing DT-DKD in non-diabetic recipients with fair blood sugar control as well as the impaction of pre-implantation diabetic lesion on the graft outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02132-w.
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Affiliation(s)
- Chia-Tien Hsu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mei-Chin Wen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsien-Fu Chiu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tung-Min Yu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
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Howard RJ. We listed patients and we should transplant them. Clin Transplant 2020; 34:e13882. [PMID: 32294274 DOI: 10.1111/ctr.13882] [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: 02/10/2020] [Revised: 03/19/2020] [Accepted: 04/07/2020] [Indexed: 11/27/2022]
Abstract
Twenty percent of kidneys recovered for transplantation are discarded. The most common reason for not transplanting these kidneys is to organ quality and biopsy findings. Yet, organ quality measures are not associated with discard rates and kidneys with poorer quality measures lead to greater life span for the recipient compared to staying on dialysis. Biopsy findings are not correlated with graft survival in most cases. The risk aversion of transplant centers from using "high-risk" kidneys can be, in part at least, attributed to negative consequences of poor graft survival with possible program sanctions or possible loss of insurance contracts. CMS has taken a first step by eliminating short-term graft survival as a performance measure for transplant centers. Many of the discarded kidneys will provide good results if transplanted and would recognize that patients value getting a transplant above graft survival.
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