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Friedmann J, Schuster A, Reichelt-Wurm S, Banas B, Bergler T, Steines L. Serum IL-6 predicts risk of kidney transplant failure independently of immunological risk. Transpl Immunol 2024; 84:102043. [PMID: 38548029 DOI: 10.1016/j.trim.2024.102043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024]
Abstract
Interleukin-6 (IL-6) is an important immune mediator and a target for novel antibody therapies. In this study, we aimed to determine whether serum IL-6 levels are associated with immunological risk, allograft rejection and outcomes in kidney transplant (Ktx) patients. We retrospectively analyzed the data of 104 patients who underwent Ktx at our center between 2011 and 2015. The patients were divided into high- and low-risk groups (n = 52 per group) based on panel reactive antibody (PRA) percentage ≥ 35%, the existence of pre-Ktx donor-specific antibodies (DSA), or a previous transplant. IL-6 concentrations were measured before and at 3 months, 12 months, and 3 years after Ktx. Serum IL-6 levels tended to be higher in high-risk patients than in low-risk patients prior to Ktx and at 12 months after Ktx; however, the difference did not reach statistical significance (pre-Ktx, high-risk: 1.995 ± 2.79 pg/ml vs. low-risk: 1.43 ± 1.76 pg/ml, p = 0.051; 12 mo. high-risk: 1.16 ± 1.87 pg/ml vs. low-risk: 0.78 ± 1.13 pg/ml, p = 0.067). IL-6 levels were correlated with the types (no rejection, T cell mediated rejection (TCMR), antibody-mediated rejection (ABMR), or both) and time (<1 year vs. >1 year after Ktx) of rejection, as well as patient and graft survival. Patients with both TCMR and ABMR had significantly higher IL-6 levels at 3 months (14.1 ± 25.2 pg/ml) than patients with ABMR (3.4 ± 4.8 pg/ml, p = 0.017), with TCMR (1.7 ± 1.3 pg/ml, p < 0.001), and without rejection (1.7 ± 1.4 pg/ml, p < 0.001). Three years after Ktx, patients with AMBR had significantly higher IL-6 levels (5.30 ± 7.66 pg/ml) than patients with TCMR (1.81 ± 1.61 pg/ml, p = 0.009) and patients without rejection (1.19 ± 0.95 pg/ml; p = 0.001). Moreover, three years after Ktx IL-6 levels were significantly higher in patients with late rejections (3.5 ± 5.4 pg/ml) than those without rejections (1.2 ± 1.0 pg/ml) (p = 0.006). The risk of death-censored graft failure was significantly increased in patients with elevated IL-6 levels at 12 months (IL-6 level > 1.396 pg/ml, HR 4.61, p = 0.007) and 3 years (IL-6 level > 1.976 pg/ml, HR 6.75, p = 0.003), but elevated IL-6 levels were not associated with a higher risk of death. Overall, our study highlights IL-6 as a risk factor for allograft failure and confirms that IL-6 levels are higher in patients developing ABMR compared to TCMR alone or no rejection.
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Affiliation(s)
- Julius Friedmann
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Antonia Schuster
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany; Department of Nephrology, Hospital Ingolstadt, Ingolstadt, Germany
| | - Louisa Steines
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany.
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Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
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Jung HY, Ryu JH, Kim MG, Huh KH, Lee KW, Jung HY, Kang KP, Ro H, Han S, Yang J. Association of Serum Activin Levels with Allograft Outcomes in Patients with Kidney Transplant: Results from the KNOW-KT. Am J Nephrol 2024; 55:245-254. [PMID: 38198780 DOI: 10.1159/000536198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Serum activin A has been reported to contribute to vascular calcification and kidney fibrosis in chronic kidney disease. We aimed to investigate whether higher serum activin levels were associated with poor allograft outcomes in patients with kidney transplantation (KT). METHODS A total of 860 KT patients from KNOW-KT (Korean Cohort Study for Outcome in Patients with Kidney Transplantation) were analyzed. We measured serum activin levels pre-KT and 1 year after KT. The primary outcome was the composite of a ≥50% decline in estimated glomerular filtration rate and graft failure. Multivariable cause-specific hazard model was used to analyze association of 1-year activin levels with the primary outcome. The secondary outcome was coronary artery calcification score (CACS) at 5 years after KT. RESULTS During the median follow-up of 6.7 years, the primary outcome occurred in 109 (12.7%) patients. The serum activin levels at 1 year were significantly lower than those at pre-KT (488.2 ± 247.3 vs. 704.0 ± 349.6). When patients were grouped based on the median activin level at 1 year, the high-activin group had a 1.91-fold higher risk (95% CI, 1.25-2.91) for the primary outcome compared to the low-activin group. A one-standard deviation increase in activin levels as a continuous variable was associated with a 1.36-fold higher risk (95% CI, 1.16-1.60) for the primary outcome. Moreover, high activin levels were significantly associated with 1.56-fold higher CACS (95% CI, 1.12-2.18). CONCLUSION Post-transplant activin levels were independently associated with allograft functions as well as coronary artery calcification in KT patients.
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Affiliation(s)
- Hui-Yun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Jung-Hwa Ryu
- Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Republic of Korea
| | - Myung-Gyu Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Kyo Won Lee
- Department of Surgery, Sungkyunkwan University, Seoul Samsung Medical Center, Seoul, Republic of Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Kyung Pyo Kang
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Han Ro
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Republic of Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
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Kawabe M, Yamamoto I. Current Status and Perspectives on Recurrent IgA Nephropathy after Kidney Transplantation. Nephron Clin Pract 2023; 147 Suppl 1:9-13. [PMID: 36966530 DOI: 10.1159/000530341] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/21/2023] [Indexed: 06/18/2023] Open
Abstract
IgA nephropathy (IgAN) is the most common form of glomerulonephritis worldwide. IgAN progresses to end-stage kidney disease in 20-40% of patients within 20 years of diagnosis. Kidney transplantation is the most effective option for patients with end-stage kidney disease caused by IgAN, but recurrence can occur in the transplanted kidney. The IgAN recurrence rate varies from 1% to 10% per year and varies according to the follow-up period, diagnostic modality, and biopsy criteria. Of note, studies based on protocol biopsies have reported a higher incidence of recurrence, which also occurred earlier after transplantation. In addition, recent data show that recurrence of IgAN is a more significant cause of allograft failure than previously believed. Little is known about the pathophysiology of IgAN recurrence, but several potential biomarkers have been investigated. Among them, galactose-deficient IgA1 (Gd-IgA1), IgG anti-Gd-IgA1 antibodies, and soluble CD89 could play a pivotal role in disease activity. This review aims to describe the current status of recurrent IgAN, including the incidence, clinical characteristics, risk factors, and future perspectives, with a focus on the available therapeutic approaches.
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Affiliation(s)
- Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan,
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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Senev A, Van Loon E, Lerut E, Coemans M, Callemeyn J, Daniëls L, Kerkhofs J, Koshy P, Kuypers D, Lamarthée B, Sprangers B, Tinel C, Van Craenenbroeck AH, Van Sandt V, Emonds MP, Naesens M. Association of Predicted HLA T-Cell Epitope Targets and T-Cell-Mediated Rejection After Kidney Transplantation. Am J Kidney Dis 2022; 80:718-729.e1. [PMID: 35690154 DOI: 10.1053/j.ajkd.2022.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 04/09/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE The relationship between human leukocyte antigen (HLA) molecular mismatches and T-cell-mediated rejection (TCMR) is unknown. We investigated the associations between the different donor HLA-derived T-cell targets and the occurrence of TCMR and borderline histologic changes suggestive of TCMR after kidney transplantation. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS All kidney transplant recipients at a single center between 2004 and 2013 with available biopsy data and a DNA sample for high-resolution HLA donor/recipient typing (N = 893). EXPOSURE Scores calculated by the HLA matching algorithm PIRCHE-II and HLA eplet mismatches. OUTCOME TCMR, borderline changes suggestive of TCMR, and allograft failure. ANALYTICAL APPROACH Multivariable cause-specific hazards models were fit to characterize the association between HLA epitopes targets and study outcomes. RESULTS We found 277 patients developed TCMR, and 134 developed only borderline changes suggestive of TCMR on at least 1 biopsy. In multivariable analyses, only the PIRCHE-II scores for HLA-DRB1 and HLA-DQB1 were independently associated with the occurrence of TCMR and with allograft failure; this was not the case for HLA class I molecules. If restricted to rejection episodes within the first 3 months after transplantation, only the T-cell epitope targets originating from the donor's HLA-DRB1 and HLA-DQB1, but not class I molecules, were associated with the early acute TCMR. Also, the median PIRCHE-II score for HLA class II was statistically different between the patients with TCMR compared to the patients without TCMR (129 [IQR, 60-240] vs 201 [IQR, 96-298], respectively; P < 0.0001). These differences were not observed for class I PIRCHE-II scores. LIMITATIONS Observational clinical data and residual confounding. CONCLUSIONS In the absence of HLA-DSA, HLA class II but not class I mismatches are associated with early episodes of acute TCMR and allograft failure. This suggests that current immunosuppressive therapies are largely able to abort the most deleterious HLA class I-directed alloimmune processes; however, alloresponses against HLA-DRB1 and HLA-DQB1 molecular mismatches remain insufficiently suppressed. PLAIN-LANGUAGE SUMMARY Genetic differences in the human leukocyte antigen (HLA) complex between kidney transplant donors and recipients play a central role in T-cell-mediated rejection (TCMR), which can lead to failure of the transplanted kidney. Evaluating this genetic disparity (mismatch) in the HLA complex at the molecular (epitope) level could contribute to better prediction of the immune response to the donor organ posttransplantation. We investigated the associations of the different donor HLA-derived T-cell epitope targets and scores obtained from virtual crossmatch algorithms with the occurrence of TCMR, borderline TCMR, and graft failure after kidney transplantation after taking into account the influence of donor-specific anti-HLA antibodies. This study illustrates the greater importance of the molecular mismatches in class II molecules compared to class I HLA molecules.
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Affiliation(s)
- Aleksandar Senev
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Elisabet Van Loon
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Jasper Callemeyn
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Johan Kerkhofs
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Priyanka Koshy
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Baptiste Lamarthée
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Ben Sprangers
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Claire Tinel
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium
| | - Amaryllis H Van Craenenbroeck
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Marie-Paule Emonds
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- KU Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven University, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Husain SA, King KL, Adler JT, Mohan S, Perotte R. Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis. Am J Kidney Dis 2022; 79:354-361. [PMID: 34562524 PMCID: PMC8881308 DOI: 10.1053/j.ajkd.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. STUDY DESIGN Decision analysis informed by clinical registry data. SETTING & POPULATION We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. INTERVENTION Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. OUTCOME Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. MODEL, PERSPECTIVE, & TIMEFRAME We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. RESULTS Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). LIMITATIONS Lack of empirical evidence supporting the proposed impact of such a policy change. CONCLUSIONS A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Joel T. Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA,Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Rimma Perotte
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ,Department of Biomedical Informatics, Columbia University Medical Center, New York, NY
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8
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Divers J, Mohan S, Brown WM, Pastan SO, Israni AK, Gaston RS, Bray R, Islam S, Sakhovskaya NV, Mena-Gutierrez AM, Reeves-Daniel AM, Julian BA, Freedman BI. Employment status at transplant influences ethnic disparities in outcomes after deceased donor kidney transplantation. BMC Nephrol 2022; 23:6. [PMID: 34979953 PMCID: PMC8722061 DOI: 10.1186/s12882-021-02631-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background African American (AA) recipients of deceased-donor (DD) kidney transplants (KT) have shorter allograft survival than recipients of other ethnic groups. Reasons for this disparity encompass complex interactions between donors and recipients characteristics. Methods Outcomes from 3872 AA and 19,719 European American (EA) DDs who had one kidney transplanted in an AA recipient and one in an EA recipient were analyzed. Four donor/recipient pair groups (DRP) were studied, AA/AA, AA/EA, EA/AA, and EA/EA. Survival random forests and Cox proportional hazard models were fitted to rank and evaluate modifying effects of DRP on variables associated with allograft survival. These analyses sought to identify factors contributing to the observed disparities in transplant outcomes among AA and EA DDKT recipients. Results Transplant era, discharge serum creatinine, delayed graft function, and DRP were among the top predictors of allograft survival and mortality among DDKT recipients. Interaction effects between DRP with the kidney donor risk index and transplant era showed significant improvement in allograft survival over time in EA recipients. However, AA recipients appeared to have similar or poorer outcomes for DDKT performed after 2010 versus before 2001; allograft survival hazard ratios (95% CI) were 1.15 (0.74, 1.76) and 1.07 (0.8, 1.45) for AA/AA and EA/AA, compared to 0.62 (0.54, 0.71) and 0.5 (0.41, 0.62) for EA/EA and AA/EA DRP, respectively. Recipient mortality improved over time among all DRP, except unemployed AA/AAs. Relative to DDKT performed pre-2001, employed AA/AAs had HR = 0.37 (0.2, 0.69) versus 0.59 (0.31, 1.11) for unemployed AA/AA after 2010. Conclusion Relative to DDKT performed before 2001, similar or worse overall DCAS was observed among AA/AAs, while EA/EAs experienced considerable improvement regardless of employment status, KDRI, and EPTS. AA recipients of an AA DDKT, especially if unemployed, had worse allograft survival and mortality and did not appear to benefit from advances in care over the past 20 years. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02631-4.
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Affiliation(s)
- Jasmin Divers
- Division of Health Services Research, Department of Foundations of Medicine, NYU Long Island School of Medicine, Mineola, NY, 11501, USA. .,Winthrop Research Institute, NYU Long Island School of Medicine, Mineola, NY, USA.
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, NY, NY, USA
| | - W Mark Brown
- Department of Biostatistics and Data Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ajay K Israni
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN, USA.,Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Robert S Gaston
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Robert Bray
- Department of Pathology & Lab Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Shahidul Islam
- Division of Health Services Research, Department of Foundations of Medicine, NYU Long Island School of Medicine, Mineola, NY, 11501, USA.,Winthrop Research Institute, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Natalia V Sakhovskaya
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alejandra M Mena-Gutierrez
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amber M Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Bruce A Julian
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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9
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Choi M, Bachmann F, Wu K, Lachmann N, Schmidt D, Brakemeier S, Duerr M, Kahl A, Eckardt KU, Budde K, Nickel P. Microvascular inflammation is a risk factor in kidney transplant recipients with very late conversion from calcineurin inhibitor-based regimens to belatacept. BMC Nephrol 2020; 21:354. [PMID: 32819287 PMCID: PMC7439694 DOI: 10.1186/s12882-020-01992-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/29/2020] [Indexed: 01/05/2023] Open
Abstract
Background In de novo kidney transplant recipients (KTR) treatment with belatacept has been established as a comparable option as maintenance immunosuppression, preferably as a strategy to convert from calcineurin inhibitor (CNI)- to belatacept-based immunosuppression. Switch to belatacept demonstrated improved renal function in patients with CNI-induced nephrotoxicity, but risk of transplant rejection and the development of donor-specific antibodies (DSA) are still a matter of debate. Only few data are available in patients at increased immunological risk and late after transplantation. Methods We analyzed 30 long-term KTR (including 2 combined pancreas-KTR) converted from CNI to belatacept > 60 months after transplantation with moderate to severe graft dysfunction (GFR ≤ 45 mL/min). Biopsies were classified according to the Banff 2015 criteria. Group differences were assessed in a univariate analysis using Mann Whitney U or Chi square test, respectively. Multivariate analysis of risk factors for treatment failure was performed using a binary logistic regression model including significant predictors from univariate analysis. Fifty-six KTR matched for donor and recipient characteristics were used as a control cohort remaining under CNI-treatment. Results Patient survival in belatacept cohort at 12/24 months was 96.7%/90%, overall graft survival was 76.7 and 60.0%, while graft survival censored for death was 79.3%/66.7%. In patients with functioning grafts, median GFR improved from 22.5 mL/min to 24.5 mL/min at 24 months. Positivity for DSA at conversion was 46.7%. From univariate analysis of risk factors for graft loss, GFR < 25 mL/min (p = 0.042) and Banff microvascular inflammation (MVI) sum score ≥ 2 (p = 0.023) at conversion were significant at 24 months. In the analysis of risk factors for treatment failure, a MVI sum score ≥ 2 was significant univariately (p = 0.023) and in a bivariate (p = 0.037) logistic regression at 12 months. DSA-positivity was neither associated with graft loss nor treatment failure. The control cohort had comparable graft survival outcomes at 24 months, albeit without increase of mean GFR in patients with functioning grafts (ΔGFR of − 3.6 ± 8.5 mL/min). Conclusion Rescue therapy with conversion to belatacept is feasible in patients with worsening renal function, even many years after transplantation. The benefit in patients with MVI and severe GFR impairment remains to be investigated.
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Affiliation(s)
- Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Lachmann
- Tissue Typing Laboratory, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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10
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Schiano TD, Florman S, Fiel MI. Recurrent Idiopathic Liver Allograft Failure. Am J Clin Pathol 2019; 152:369-376. [PMID: 31139817 DOI: 10.1093/ajcp/aqz044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Many transplant programs have had patients who develop idiopathic recurrent liver allograft failure, necessitating serial transplants, and are deemed to have refractory or recurrent rejection. The frequency and the etiology of this immunologic dysfunction have not been well characterized. METHODS Herein, we illustrate the case of a patient who required three retransplants over a period of 20 years for recurrent liver allograft failure. By extensively compiling the patient's many liver biopsy specimens and explants over time, we demonstrate that antibody-mediated rejection (AMR) was a major contributing factor from the outset. We conducted a review of the Scientific Registry for Transplant Recipients database to estimate the potential frequency of AMR. RESULTS As illustrated by this case, AMR has varied histologic findings in the setting of elevated donor-specific antibody titers. CONCLUSIONS The cause of recurrent allograft failure in this patient was likely a combination of acute cellular rejection and AMR, manifestations of likely underlying immune dysregulation. Pathologists and transplant physicians should recognize the variable histologic presentations of AMR, which is imperative for its timely intervention. This case demonstrates how difficult the diagnosis of AMR can be to make, highlighting the need for strong clinical suspicion in patients having difficult-to-treat rejection and recurrent allograft failure.
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Affiliation(s)
- Thomas D Schiano
- The Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander Florman
- The Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Lohéac C, Aubert O, Loupy A, Legendre C. [Identifying the specific causes of kidney allograft loss: A population-based study]. Nephrol Ther 2018; 14 Suppl 1:S39-S50. [PMID: 29606262 DOI: 10.1016/j.nephro.2018.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Results of kidney transplantation have been improving but long-term allograft survival remains disappointing. The objective of the present study was to identify the specific causes of renal allograft loss, to assess their incidence and long-term outcomes. METHODS A total of 4783 patients from four French centres, transplanted between January 2004 and January 2014 were prospectively included. A total of 9959 kidney biopsies (protocol and for cause) performed between January 2004 and March 2015 were included. Donor and recipient clinical and biological parameters as well as anti-HLA antibody directed against the donor were included. The main outcome was the long-term kidney allograft survival, including the study of the associated causes of graft loss, the delay of graft loss according to their causes and the determinants of graft loss. RESULTS There were 732 graft losses during the follow-up period (median time: 4.51 years) with an identified cause in 95.08 %. Kidney allograft survival at 9 years post-transplant was 78 %. The causes of allograft loss were: antibody-mediated rejection (31.69 %), thrombosis (25.55 %), medical intercurrent disease (14.62 %), recurrence of primary renal disease (7.1 %), BK- or CMV-associated nephropathy (n=35, 4.78 %), T cell-mediated rejection (4.78 %), urological disease (2.46 %) and calcineurin inhibitor nephrotoxicity (1.09 %). CONCLUSION The main causes of allograft loss were antibody-mediated rejection and thrombosis. These results encourage efforts to prevent and detect these complications earlier in order to improve allograft survival.
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Affiliation(s)
- Charlotte Lohéac
- Service de transplantation rénale, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - Olivier Aubert
- Service de transplantation rénale, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - Alexandre Loupy
- Service de transplantation rénale, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - Christophe Legendre
- Service de transplantation rénale, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France.
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12
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Gómez Hidalgo J, Ruiz Gómez MÁ, Gamazo Laherrán C, Alonso Rodríguez M, Sainz Esteban A, Ruano Pérez R. Renogram in kidney transplant. Utility of delayed images with SPECT/CT in the diagnosis of urinary leak. Rev Esp Med Nucl Imagen Mol 2018; 38:46-49. [PMID: 30120068 DOI: 10.1016/j.remn.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 11/19/2022]
Abstract
Urinary leakage in patients with kidney transplantation is a relatively common surgical complication that requires early diagnosis and intervention. The isotopic renogram is a non-invasive and effective method to evaluate the perfusion and function of kidney transplantation, and allows us to diagnose urological complications such as urinary leakage. In these cases, it is useful to complete the study with planar images and delayed SPECT/CT to specify the diagnosis and locate the leak. We expose two cases diagnosed with urinary leak after performing a renogram with early and delayed planar images and delayed SPECT/CT a week after transplantation. In both cases, a percutaneous nephrostomy catheter was placed, as well as a double J catheter, resolving the surgical complication.
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Affiliation(s)
- J Gómez Hidalgo
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España.
| | - M Á Ruiz Gómez
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - C Gamazo Laherrán
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - M Alonso Rodríguez
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - A Sainz Esteban
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - R Ruano Pérez
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, España
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13
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Willicombe M, Rizzello A, Goodall D, Papalois V, McLean AG, Taube D. Risk factors and outcomes of delayed graft function in renal transplant recipients receiving a steroid sparing immunosuppression protocol. World J Transplant 2017; 7:34-42. [PMID: 28280693 PMCID: PMC5324026 DOI: 10.5500/wjt.v7.i1.34] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 10/07/2016] [Accepted: 12/09/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To analyse the risk factors and outcomes of delayed graft function (DGF) in patients receiving a steroid sparing protocol.
METHODS Four hundred and twenty-seven recipients of deceased donor kidney transplants were studied of which 135 (31.6%) experienced DGF. All patients received monoclonal antibody induction with a tacrolimus based, steroid sparing immunosuppression protocol.
RESULTS Five year patient survival was 87.2% and 94.9% in the DGF and primary graft function (PGF) group respectively, P = 0.047. Allograft survival was 77.9% and 90.2% in the DGF and PGF group respectively, P < 0.001. Overall rejection free survival was no different between the DGF and PGF groups with a 1 and 5 year rejection free survival in the DGF group of 77.7% and 67.8% compared with 81.3% and 75.3% in the PGF group, P = 0.19. Patients with DGF who received IL2 receptor antibody induction were at significantly higher risk of rejection in the early post-transplant period than the group with DGF who received alemtuzumab induction. On multivariate analysis, risk factors for DGF were male recipients, recipients of black ethnicity, circulatory death donation, preformed DSA, increasing cold ischaemic time, older donor age and dialysis vintage.
CONCLUSION Alemtuzumab induction may be of benefit in preventing early rejection episodes associated with DGF. Prospective trials are required to determine optimal immunotherapy protocols for patients at high risk of DGF.
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14
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Cheungpasitporn W, Thongprayoon C, Mitema DG, Mao MA, Sakhuja A, Kittanamongkolchai W, Gonzalez-Suarez ML, Erickson SB. The effect of aspirin on kidney allograft outcomes; a short review to current studies. J Nephropathol 2017; 6:110-117. [PMID: 28975088 PMCID: PMC5607969 DOI: 10.15171/jnp.2017.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/10/2017] [Indexed: 01/11/2023] Open
Abstract
CONTEXT The use of aspirin in chronic kidney disease (CKD) patients has been shown to reduce myocardial infarction but may increase major bleeding. However, its effects in kidney transplant recipients are unclear. EVIDENCE ACQUISITIONS A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception through September 2016. We included studies that reported odd ratios, relative risks or hazard ratios comparing outcomes of aspirin use in kidney transplant recipients. Pooled risk ratios (RR) and 95% confidence interval (CI) were assessed using a random-effect, generic inverse variance method. RESULTS We included 9 studies; enrolling 19759 kidney transplant recipients that compared aspirin with no treatment. Compared to no treatment, aspirin reduced the risk of allograft failure (4 studies; RR: 0.57, 95% CI: 0.33 to 0.99), allograft thrombosis (2 studies; RR: 0.11, 95% CI: 0.02 to 0.53), and major adverse cardiac events (MACEs) or mortality (2 studies; RR: 0.72, 95% CI: 0.59 to 0.88), but not allograft rejection (3 studies; RR: 0.86, 95% CI: 0.45 to 1.65) or delayed graft function (DGF) (2 studies; RR: 1.00, 95% CI: 0.58 to 1.72) in kidney transplant recipients. The data on risk of major or minor bleeding were limited. CONCLUSIONS Our meta-analysis demonstrates that administration of aspirin in kidney transplant recipients is associated with reduced risks of allograft failure, allograft thrombosis, and MACEs or mortality, but not allograft rejection or DGF. Future studies are needed to assess the risk of bleeding, and ultimately weigh the overall risks and benefits of aspirin use in specific kidney transplant patient populations.
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Affiliation(s)
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald G Mitema
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Ankit Sakhuja
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Stephen B Erickson
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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15
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Abstract
Allograft dysfunction after a kidney transplant is often clinically asymptomatic and is usually detected as an increase in serum creatinine level with corresponding decrease in glomerular filtration rate. The diagnostic evaluation may include blood tests, urinalysis, transplant ultrasonography, radionuclide imaging, and allograft biopsy. Whether it occurs early or later after transplant, allograft dysfunction requires prompt evaluation to determine its cause and subsequent management. Acute rejection, medication toxicity from calcineurin inhibitors, and BK virus nephropathy can occur early or later. Other later causes include transplant glomerulopathy, recurrent glomerulonephritis, and renal artery stenosis.
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Affiliation(s)
- Ryan J Goldberg
- Renal & Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ, USA.
| | - Francis L Weng
- Renal & Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Praveen Kandula
- Renal & Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ, USA
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