Acute Renal Transplant Rejection Research Articles

Assessment of Donor Derived Cell Free DNA (dd-cfDNA) at Surveillance and at Clinical Suspicion of Acute Rejection in Renal Transplantation.

In our prospective, unicenter cohort study, we collected blood samples from 30 newly kidney transplanted patients, at month 1, 2, 3, and 5 for dd-cfDNA analysis, along with creatinine/eGFR and DSA monitoring, and from 32 patients who underwent an indication biopsy and whose dd-cfDNA levels were measured at the time of biopsy and 1month afterwards. Fourteen of 32 (43.8%) patients in the biopsy group were diagnosed with TCMR and 5 of 32 (15.6%) with ABMR. Dd-cfDNA proved to be better than creatinine in diagnosing rejection from non-rejection in patients who were biopsied. When a dd-cfDNA threshold of 0.5% was chosen, sensitivity was 73.7% and specificity was 92.3% (AUC: 0.804, 0.646-0.961). In rejection patients, levels of dd-cfDNA prior to biopsy (0.94%, 0.3-2.0) decreased substantially after initiation of treatment with median returning to baseline already at 1month (0.33%, 0.21-0.51, p = 0.0036). In the surveillance group, high levels of dd-cfDNA (>0.5%) from second month post-transplantation were correlated with non-increasing eGFR 1year post-transplantation. The study used AlloSeq kit for kidney transplant surveillance for first time and confirmed dd-cfDNA's ability to detect rejection and monitor treatment, as well as to predict worse long-term outcomes regarding eGFR.

The Flow Cytometric Analysis of Peripheral Blood Lymphocytes and Expression of HLA II Molecules in Lymphocyte During Acute Rejection After Renal Transplantation.

To investigate the changes in the proportion of peripheral blood lymphocytes and the expression of HLA II molecules in lymphocytes during acute rejection after renal transplantation. Thirty-five patients who had undergone renal transplantation were selected. Eighteen patients with clinical and pathological confirmed acute rejection were selected as the test group, and twelve patients without clinical acute rejection symptoms were selected as the control group. Flow cytometry analysis was used to determine the proportion of peripheral blood lymphocytes. The mRNA and protein expression of HLA II molecules on peripheral blood lymphocytes were detected using real-time fluorescence quantification and immunoblotting, respectively. The proportion of T lymphocytes, B lymphocytes, and CD4CD8 double positive T cells in the Control Group were 67.48% ± 5.35%, 10.82% ± 1.26%, and 0.88% ± 0.06%, respectively, and in the Test Group were 87.52% ± 6.28%, 3.36% ± 0.26%, and 0.34% ± 0.03%, with a significant difference respectively. The mRNA and protein expressions of HLA II molecules of peripheral blood B lymphocytes in the control group were significantly higher that these in the test group. The proportion of peripheral blood T lymphocytes, B lymphocytes, CD4CD8 double positive T cells, and the expression of HLA II molecules of peripheral blood lymphocytes can all indicate the occurrence of acute renal transplantation rejection, which were exceedingly useful to clinicians in judging the acute rejection of renal transplantation in the early stages.

232.6: Assessment of Donor Derived Cell Free DNA (ddcfDNA) at Surveillance and at Clinical Suspicion of Acute Rejection in Renal Transplantation

232.6: Assessment of Donor Derived Cell Free DNA (ddcfDNA) at Surveillance and at Clinical Suspicion of Acute Rejection in Renal Transplantation

404.7: Study on the Regulatory Effect of iPS-Derived Exosomes on the Local Immune Microenvironment in DCD Kidney Transplanted Rats

Introduction: Ischemia reperfusion injury (IRI) of donation After Cardiac death (DCD) transplanted kidney is the key factor of acute renal injury, acute and chronic rejection of renal transplantation and transplanted kidney disease.The latest researches show that mesenchymal stem cells (MSCs) have the function of protecting damaged tissues and organs and strong immune regulation. Induced pluripotent stem (iPS) cells have higher proliferative capacity and exosome secretion potential than MSCs. In addition to the functions of stem cells, exosomes have the unique ability to cross the blood-brain barrier and deliver remotely, which means that exosomes have better advantages in clinical disease treatment compared with the therapeutic potential of stem cells. Therefore, the main purpose of this study is to clarify the role of IPS derived exosomes in protecting the IRI of DCD transplanted kidney and regulating its local immune microenvironment. Methods: The iPS cells were passaged to the third passage and massively expanded. After 48 hours of culture, 100 mL of cell culture supernatant was collected and exosomes were extracted from the supernatant by the kit method, and the morphology and surface membrane marker proteins of the exosomes were identified. The SD rats were established with DCD renal transplantation model and 10, 50, and 100 μg of exosomes were infused into that SD rats respectively, and a PBS control group was set at the same time. On the 3rd, 5th, 7th, 14th and 28th days after transplantation, the content of cytokines in the serum of the recipient rats, the proportion of lymphocyte subsets CD4+CD25+Foxp3+Tregs in the spleen and the relative expression of Foxp3 mRNA were detected. The proliferation of renal tubular cells was detected by PCNA immunofluorescence. The pathological changes of renal tissue were determined by HE staining, and the apoptosis of renal tubular epithelial cells was detected by Tunel staining. The infiltration of inflammatory cells was detected by immunohistochemistry. The expression changes of regulatory T cells in renal tissue and macrophage phenotypic characteristics were analyzed by flow cytometry. Results: The experimental amount of exosomes was successfully obtained, and the morphology was observed by transmission electron microscope. The exosomes were round or oval membranous vesicles with uniform size, and the edges were clearly visible. The TSG101, CD63, and CD9 proteins were highly expressed on the exosome membrane surface by western-blot. A DCD rat kidney transplantation model was successfully established. The expression levels of IL-12, IL-2, IFN-γ, and TNF-α in the serum of each group were increased to varying degrees from the 3rd day after operation. On the 3rd and 7th days, the levels of IL-12, IL-2, IFN-γ, and TNF-α in the 100 μg exosome infusion group were significantly lower than those in the 10 μg, 50 μg and PBS groups (P<0.05), and the expression level of IL-10 in the 100 μg exosome infusion group was significantly higher than 10μg, 50μg and PBS groups (P<0.05). On the 28th day, the expression level of IL-10 in the 100 μg exosome infusion group was significantly higher than other groups (P<0.01). Compared with other groups, the CD4+CD25+Tregs and CD4+CD25+Foxp3+Tregs accounted for the highest proportion of CD4+T cells in the spleen of the 100μg infusion group (P<0.05). On the 28th day, the expression level of Foxp3 mRNA in the 100 μg infusion group was significantly higher than that in the 50 μg group (P<0.05). The stainings of PCNA, HE and Tunel showed that SD rats infused with 100μg exosomes could significantly reduce the pathological damage, inflammatory response and apoptosis of renal tubular epithelial cells in the transplanted kidney, promote the proliferation of renal tubular epithelial cells, and have a protective effect on IRI kidney. On the 28th day, the expression of CD4+CD25+Foxp3+Tregs cells in the transplanted kidney tissue was significantly increased, which further promoted the differentiation of macrophages into the immunomodulatory M2 subset. Conclusions: The infusion of iPS-derived high-dose exosomes is involved in the protection of the DCD kidney transplant during IRI process, and alleviates the acute and chronic injury of the DCD kidney transplant, and promotes the formation of the local immunosuppressive microenvironment in the DCD kidney transplantation. The National Natural Science Foundation of China (No.81900686).

Regulatory and transitional B cells: potential biomarkers and therapeutic targets in organ transplantation.

Regulatory B cells (Bregs) play a prominent role in various disease settings. While progress has been hindered by the lack of a specific Breg marker, new findings highlight their role modulating the alloimmune response and promoting allograft survival. Herein, we focus on the recent advances in Breg biology and their role in transplantation. We review studies showing that T-cell immunoglobulin and mucin domain 1 (TIM-1) is an inclusive and functional Breg marker in mice that may have human relevance. We highlight the utility of the B cell interleukin-10/tumor necrosis factor-alpha (IL-10/TNFα) ratio in identifying underlying immunological reactivity and predicting clinical outcomes in kidney transplantation. This may identify patients requiring more immunosuppression and provide insight into potential therapeutic approaches that can modulate the Breg: B effector cell (Beff) balance. Emerging data support Bregs as potent modulators of immune responses in humans. Their ability to promote allograft survival must await development of approaches to expand Bregs in vitro/in vivo . The low IL-10/TNFα ratio reflecting decreased Breg/Beff balance, predicts acute rejection (AR) and poorer outcomes in renal transplantation. It remains to be determined whether this paradigm can be extended to other allografts and whether therapy aiming to correct the relative deficiency of Bregs will improve outcomes.

Cytotoxic T-lymphocyte associated-protein-4 +49A/G-allele (rs231775) single nucleotide polymorphisms are associated with acute allograft renal transplantation rejection: A multilevel modelling of meta-analysis

Background: Acute renal transplant rejection is believed to be an immunological phenomenon and is one of the most serious consequences of transplantation as a treatment for end-stage renal illness. In recent decades, numerous research has been conducted to investigate the relationship between cytotoxic T-lymphocyte antigen 4 +49A/G (CTLA-4 +49A/G) single nucleotide polymorphisms (SNPs) with the likelihood of rejection; nevertheless, the results are still controversial, and inconsistency has been documented among investigations. Consequently, the purpose of the present investigation was to conduct a study on the relation between CTLA-4 +49A/G polymorphism and risk of transplant rejection. Methods: The study was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Retrospective and prospective analytical randomized control trial (RCTs) published prints from Embase, PubMed, Cochrane, and Web of science were included to the study in accordance with the PRISMA guidelines. The search was conducted on February 2nd, 2022, using the search term (cytotoxic-T-lymphocyte-antigen-4 OR CTLA-4) AND (gene polymorphism OR single nucleotide polymorphisms OR allele OR alleles OR genotype OR genotypes) AND (renal OR kidney) AND (transplant OR transplantation) AND (acute rejection). Results: The CTLA-4 G-allele/GG-genotype was more likely to be related to renal transplantation rejection risk. It was found with odds ratio (OR) in overall analysis of G vs. A-allele was 1.22 (95%CI 1.05-1.42; p-value=0.01) and the OR of GG vs. AG+AA-genotype was 1.47 (95%CI 1.14-1.89; p-value=0.003). However, the AA-genotype was not associated with renal transplantation rejection risk. The interesting finding in this study was the association of the SNPs and rejection of renal transplantation was especially found in Asian sub-analysis. Conclusions: Consequently, the CTLA-4 G-allele/GG-genotype is related to the likelihood of rejection in patients underwent renal transplantation.

Preliminary Investigation of the Biomarkers of Acute Renal Transplant Rejection Using Integrated Proteomics Studies, Gene Expression Omnibus Datasets, and RNA Sequencing.

A kidney transplant is often the best treatment for end-stage renal disease. Although immunosuppressive therapy sharply reduces the occurrence of acute allograft rejection (AR), it remains the main cause of allograft dysfunction. We aimed to identify effective biomarkers for AR instead of invasive kidney transplant biopsy. We integrated the results of several proteomics studies related to AR and utilized public data sources. Gene ontology (GO) and pathway analyses were used to identify important biological processes and pathways. The performance of the identified proteins was validated using several public gene expression omnibus (GEO) datasets. Samples that performed well were selected for further validation through RNA sequencing of peripheral blood mononuclear cells of patients with AR (n = 16) and non-rejection (n = 19) from our medical center. A total of 25 differentially expressed proteins (DEPs) overlapped in proteomic studies of urine and blood samples. GO analysis showed that the DEPs were mainly involved in the immune system and blood coagulation. Pathway analysis showed that the complement and coagulation cascade pathways were well enriched. We found that immunoglobulin heavy constant alpha 1 (IGHA1) and immunoglobulin κ constant (IGKC) showed good performance in distinguishing AR from non-rejection groups validated with several GEO datasets. Through RNA sequencing, the combination of IGHA1, IGKC, glomerular filtration rate, and donor age showed good performance in the diagnosis of AR with ROC AUC 91.4% (95% CI: 82–100%). Our findings may contribute to the discovery of potential biomarkers for AR monitoring.

MO1005: Analysis of Expression of Immune System Genes that are Responsible for Activation and Inhibition of T-Cell Immune Response in Renal Transplant Recipients after Extracorporeal Photochemotherapy

Abstract BACKGROUND AND AIMS Due to the increasing need for kidney transplantation, there is a demand for new methods of preventing rejection of the transplant based on the mechanisms of natural regulation of the immune response. Extracorporeal photopheresis (ECP) is one of these technologies whose clinical efficacy in the prevention and treatment of acute renal transplant rejection has been confirmed by many studies, but the mechanism of its effect has not been fully understood. Characterization of the genes responsible for the activation and inhibition of the immune response during ECP is an important step towards the modification of immunosuppressive therapy. The aim of this study was to analyze the changes in the expression level of the genes responsible for the activation and inhibition of the T-cell response in the recipients of the renal graft after ECP. METHOD An open cohort randomized trial was conducted with 20 patients who underwent a single group cadaver kidney transplantation from an unrelated donor. The recipients of the compared groups received standard immunosuppressive therapy and the same therapy in combination with ECP procedures, according to the study protocol. Each recipient of the main group received 15 sessions of ECP within 6 months. The level of gene expression was analyzed by real-time RT-PCR. Comparison of the study groups was carried out at point 1 (1st–4th day) and 2 (30th day). RESULTS The analysis of clinical data did not show statistically significant clinical differences, but in the specific consideration of each pair of cases, the tendency to some improvement in the transplant organ engraftment rate in the early terms after the transplant, and better survival of the graft and the recipient was revealed. For instance, patients of the main group revealed no transplant rejection by clinical laboratory signs as well as the results of histological examination of biopsy specimens. In the comparison group, acute graft rejection was clinically diagnosed and was confirmed by histological examination as humoral type rejection. The level of expression of genes involved in immune response regulation (CD28, CTLA4, PDL1 and FOXP3) and cytokine genes (TNFA, IL1, IL2, IL10 and IFNG) in the studied groups was determined. A decrease in the level of expression of the genes for the proinflammatory cytokines IL1, IL2 and IFNG was noted by the 30th day after transplantation. At the same time, the expression of the genes PDL1 and FOXP3, which regulate the development of the regulatory response, significantly increased by the 30th day after transplantation. Correlations of the level of gene expression with the presence/absence of rejection episodes have not been established. To assess the effect of the ECP on these gene expression, a comparison was made of the level sof transcript representation of patients receiving standard immunotherapy and immunotherapy in combination with ECP, and a significant increase in the expression of PDL1 and FOXP3 genes (Fig. 1A and B) was found in the group of patients who underwent ECP procedures (P = .0009 and .0013, respectively). CONCLUSION According to the results of comparative analysis, the level of expression of pro-inflammatory cytokines' genes IL1, IL2 and IFNG decreased to the 30th day after transplantation. A 30-day comparison between groups shows an increase in the expression level of the PDL1 and FOXP3 genes. Increased expression of these genes may be associated with the activation of regulatory T-cells and the development of peripheral tolerance and can become a criterion for the modification of immunosuppressive therapy.

Effects of antirejection therapies for early subclinical acute rejection in renal transplant protocol biopsies

BackgroundAlthough recently strengthened immunosuppression protocols have decreased the incidence of clinical acute rejection of renal transplants, subclinical acute rejection and borderline changes remain problematic. This study was performed to evaluate the effects of antirejection therapies for early subclinical acute rejection and borderline changes.MethodsIn total, 269 renal transplant patients who received 3-month and 1-year protocol biopsies after renal transplantation were enrolled this study and divided into those with normal findings (Group A) and those with ≥ borderline changes (Group B) according to the 3-month pathological results. Pathological changes, graft function, and graft survival were evaluated at 1 year.ResultsThe 3-month protocol biopsy revealed normal findings in 166 patients (Group A) and borderline changes and subclinical acute rejection in 103 patients (Group B). In Group A, 65.1% (n = 108) of the patients maintained normal findings at 1 year, while 30.1% (n = 50) deteriorated to ≥ borderline changes. In Group B, 52.4% (n = 54) of patients improved to normal. Among patients with subclinical acute rejection, 25.0% (n = 5) maintained subclinical acute rejection at 1 year despite antirejection therapy. The mean estimated glomerular filtration rate decreased from 60.4 ± 24.5 to 58.3 ± 19.0 mL/min/1.73 m2 in Group A and from 57.2 ± 28.2 to 53.7 ± 20.3 mL/min/1.73 m2 in Group B (p = 0.417). The 3-, 5-, and 7-year graft survival rates were 99.4%, 99.4%, and 97.6% in Group A and 100.0%, 98.6%, and 98.6% in Group B, respectively (p = 0.709).ConclusionsSubclinical acute rejection is likely to recur. However, intervention for subclinical acute rejection in the early period after transplantation may help to prevent subsequent histological changes.

SLAMF8 Participates in Acute Renal Transplant Rejection via TLR4 Pathway on Pro-Inflammatory Macrophages.

BackgroundAcute rejection (AR) in kidney transplantation is an established risk factor that reduces the survival rate of allografts. Despite standard immunosuppression, molecules with regulatory control in the immune pathway of AR can be used as important targets for therapeutic operations to prevent rejection.MethodsWe downloaded the microarray data of 15 AR patients and 37 non-acute rejection (NAR) patients from Gene Expression Omnibus (GEO). Gene network was constructed, and genes were classified into different modules using weighted gene co-expression network analysis (WGCNA). Kyoto Encyclopedia of Genes and Genomes (KEGG) and Cytoscape were applied for the hub genes in the most related module to AR. Different cell types were explored by xCell online database and single-cell RNA sequencing. We also validated the SLAMF8 and TLR4 levels in Raw264.7 and human kidney tissues of TCMR.ResultsA total of 1,561 differentially expressed genes were filtered. WGCNA was constructed, and genes were classified into 12 modules. Among them, the green module was most closely associated with AR. These genes were significantly enriched in 20 pathway terms, such as cytokine–cytokine receptor interaction, chemokine signaling pathway, and other important regulatory processes. Intersection with GS > 0.4, MM > 0.9, the top 10 MCC values and DEGs in the green module, and six hub genes (DOCK2, NCKAP1L, IL2RG, SLAMF8, CD180, and PTPRE) were identified. Their expression levels were all confirmed to be significantly elevated in AR patients in GEO, Nephroseq, and quantitative real-time PCR (qRT-PCR). Single-cell RNA sequencing showed that AR patient had a higher percentage of native T, CD1C+_B DC, NKT, NK, and monocytes in peripheral blood mononuclear cells (PBMCs). Xcell enrichment scores of 20 cell types were significantly different (p<0.01), mostly immune cells, such as B cells, CD4+ Tem, CD8+ T cells, CD8+ Tcm, macrophages, M1, and monocytes. GSEA suggests that highly expressed six hub genes are correlated with allograft rejection, interferon γ response, interferon α response, and inflammatory response. In addition, SLAMF8 is highly expressed in human kidney tissues of TCMR and in M1 phenotype macrophages of Raw264.7 cell line WGCNA accompanied by high expression of TLR4.ConclusionThis study demonstrates six hub genes and functionally enriched pathways related to AR. SLAMF8 is involved in the M1 macrophages via TLR4, which contributed to AR process.

Integrate Proteomics Studies, GEO Datasets and RNA Sequencing to Preliminary Investigate the Biomarkers of Acute Renal Transplant Rejection

Integrate Proteomics Studies, GEO Datasets and RNA Sequencing to Preliminary Investigate the Biomarkers of Acute Renal Transplant Rejection

550 ARTACUS: An open-label, multicenter, phase 1b/2 study of RP1 in solid organ transplant recipients with advanced cutaneous malignancies

BackgroundSolid organ transplantation (SOT) has emerged as an important lifesaving procedure for patients with a wide range of end-organ diseases characterized by dysfunction or specific organ function failure. SOT rejection is a major complication requiring patients (pts) to undergo lifelong immunosuppression to prevent allograft rejection.1Skin cancers (SCs) including cutaneous squamous cell carcinoma (CSCC) are common post transplant malignancies.2 SC in SOT pts is generally managed with surgical resection, radiation therapy and chemotherapy or targeted therapy. Use of immune checkpoint inhibitors in SOT recipients has improved outcomes but are associated with the high risk of allograft rejection.3–5 Thus, there is a high unmet need for a safe and effective treatment that also protects pts from allograft rejection. RP1 is an oncolytic virus (HSV-1) that expresses a fusogenic glycoprotein (GALV-GP R-) and granulocyte macrophage colony stimulating factor (GM-CSF). In preclinical studies, RP1 induced immunogenic tumor cell death and provided potent systemic anti-tumor activity6 and clinical data in combination with nivolumab has demonstrated a high rate of deep and durable response in patients with advanced SCs.7 The objective of this study is to assess the safety and efficacy of single agent RP1 in kidney and liver transplant recipients with SCs, with focus on CSCC. After determining the safety and tolerability in the initial cohort with kidney and liver transplants the study may also enroll heart and lung transplant recipients.MethodsThis study will enroll up to 65 evaluable allograft transplantation pts with locally advanced or metastatic SCs. Key inclusion criteria are pts with confirmed recurrent, locally advanced or metastatic CSCC and up to 10 pts with non-CSCC SC, stable allograft function and ECOG performance status of ≤1. Pts with prior systemic anti-cancer treatment are allowed. Key exclusion criteria are prior treatment with an oncolytic therapy, active herpetic infections or prior complications of HSV-1 infection and a history of organ graft rejection within 12 months. Pts will receive an initial dose of 1 x 10^6 plaque-forming units (PFU) of RP1. Two weeks later they will receive 1 x 10^7 PFU of RP1 and continue every two weeks until pre-specified study endpoints are met. RP1 will be administered by intra-tumoral injection including through imaging guidance as clinically appropriate. The primary objective of the trial is to assess efficacy determined by ORR and safety of single agent RP1. Additional secondary endpoints include DOR, CR, DCR, PFS and OS.Trial RegistrationNCT04349436ReferencesFrohn C, Fricke L, Puchta JC, Kirchner H. The effect of HLA-C matching on acute renal transplant rejection. Nephrol Dial Transplant 2001;16(2):355–60.Madeleine MM, Patel NS, Plasmeijer EI, Engels EA, Bouwes Bavinck JN, Toland AE, Green AC; the Keratinocyte Carcinoma Consortium (KeraCon) Immunosuppression Working Group. Epidemiology of keratinocyte carcinomas after organ transplantation. Br J Dermatol 2017;177(5):1208–1216.Spain L, Higgins R, Gopalakrishnan K, Turajlic S, Gore M, Larkin J. Acute renal allograft rejection after immune checkpoint inhibitor therapy for metastatic melanoma. Ann Oncol 2016;27(6):1135–1137.Herz S, Höfer T, Papapanagiotou M, Leyh JC, Meyenburg S, Schadendorf D, Ugurel S, Roesch A, Livingstone E, Schilling B, Franklin C. Checkpoint inhibitors in chronic kidney failure and an organ transplant recipient. Eur J Cancer 2016;67:66-72.Kittai AS, Oldham H, Cetnar J, Taylor M. Immune checkpoint inhibitors in organ transplant ptss. J Immunother 2017;40(7):277–281.Thomas S, Kuncheria L, Roulstone V, Kyula JN, Mansfield D, Bommareddy PK, Smith H, Kaufman HL, Harrington KJ, Coffin RS. Development of a new fusion-enhanced oncolytic immunotherapy platform based on herpes simplex virus type 1. J Immunother Cancer 2019 10;7(1):214.Middleton M, Aroldi F, Sacco J, Milhem M, Curti B, Vanderwalde A, Baum S, Samson A, Pavlick A, Chesney J, Niu J, Rhodes T, Bowles T, Conry R, Olsson-Brown A, Earl-Laux D, Kaufman H, Bommareddy P, Deterding A, Samakoglu S, Coffin R, Harrington K. 422 An open-label, multicenter, phase 1/2 clinical trial of RP1, an enhanced potency oncolytic HSV, combined with nivolumab: updated results from the skin cancer cohorts. J Immunother Cancer 2020;8(3): doi: 10.1136/jitc-2020-SITC2020.0422Ethics ApprovalThe study was approved by institutional review board or the local ethics committee at each participating site. Informed consent was obtained from patients before participating in the trial.

Influence of TGFB1 and CTLA4 polymorphisms on calcineurin inhibitors dose and risk of acute rejection in renal transplantation

Organ transplant is often the treatment of choice as it extends and improves patient life. Immunosuppressive treatment, which prevents acute rejection of the organ, is used in transplant patients to prevent the loss of transplant. The aim of the study was to determine the impact of the CTLA4 (+49A>G, rs231775) and the TGF-β1 (−800G>A, rs1800468) polymorphisms on the therapeutic effect of immunosuppressive drugs (cyclosporine—CsA, tacrolimus—TAC) and the risk of acute rejection in renal transplant patients. The analysis of the CTLA4 +49A>G and the TGF-β1 −800G>A polymorphisms was carried out in 392 patients after kidney transplant using real-time PCR. The CTLA4 +49A>G polymorphism did not affect CsA or TAC dose, ratio of drug concentration to dose (C/D), and blood concentrations. As for the TGF-β1 -800G>A polymorphism, patients with the GA genotype required lower TAC doses compared to the GG genotype (TAC 12 h: 3.63 mg vs 5.3 mg, TAC 24 h: 2.38 mg vs 3.29 mg). Comparing the C/D ratio in both groups (TAC 12 h and TAC 24 h), higher C/D ratio was observed in patients with the GA genotype. These results indicate that patients with the A allele require slightly lower doses of TAC. The results suggest that the TGF-β1 −800 G>A polymorphism may influence the TAC dose, while the +49A>G polymorphism of the CTLA4 gene does not correlate with the dose of CsA or TAC. The analysis of the biochemical parameters of the renal profile showed no impact of the CTLA4 and the TGF-β1 polymorphisms on the risk of organ rejection.

Kidney transplantation in Kazakhstan: the burden of organ shortage

Kidney transplantation has been the best replacement therapy for end-stage kidney disease for over 60 years. The Republican Coordination Center for Transplantation reports that as of January 29, 2020, there were 2675 people on the kidney transplant waiting list in the Republic of Kazakhstan. The issue of deceased donation in Kazakhstan is problematic for various reasons. Over the past couple of years, the already low rates of deceased donors have fallen by more than 2 times.Objective: to objectively assess the effectiveness of deceased-donor kidney transplant in order to indicate the need for development of cadaveric donation and reduce the number of patients in the transplant waitlist.Materials and methods. Fifty-two kidney transplants from a deceased donor were performed at the National Research Oncology Center (NROC) from 2010 to 2020. The age group of recipients ranged from 20 to 75 years old. In most cases, end-stage chronic renal failure resulted in chronic glomerulonephritis (76%), pyelonephritis (1.9%), polycystic kidney disease (9.6%) and diabetic nephropathy (11.5%).Results. The 1-year and 5-year survival rates were 96% and 86%, respectively. There was delayed graft function in 13 of cases. In one case (1.92%), there was intraoperative hyperacute rejection of the kidney transplant that could not be treated with high doses of glucocorticosteroids; the kidney graft was removed. Two patients (3.8%) in the early postoperative period, on days 2 and 7 after surgery, developed a clinic of acute renal transplant rejection; after the rejection crisis was stopped by drug therapy, graft function was restored. One patient (1.92%) died as a result of bilateral pneumonia, which led to sepsis and death.Conclusion. Graft and recipient survival rates after deceased-donor kidney are comparable to those after living-donor kidney transplantation. The solution to the problems of increasing the number of deceased organ transplants should not rest entirely on the shoulders of transplant doctors; this task must also be addressed at the government level with constant propaganda to explain to the citizens the need for a deceased organ donation program.

A Three-Gene Peripheral Blood Potential Diagnosis Signature for Acute Rejection in Renal Transplantation.

Background: Acute rejection (AR) remains a major issue that negatively impacts long-term allograft survival in renal transplantation. The current study aims to apply machine learning methods to develop a non-invasive diagnostic test for AR based on gene signature in peripheral blood. Methods: We collected blood gene expression profiles of 251 renal transplant patients with biopsy-proven renal status from three independent cohorts in the Gene Expression Omnibus database. After differential expression analysis and machine learning algorithms, selected biomarkers were applied to the least absolute shrinkage and selection operator (LASSO) logistic regression to construct a diagnostic model in the training cohort. The diagnostic ability of the model was further tested in validation cohorts. Gene set enrichment analysis and immune cell assessment were also conducted for further investigation. Results: A novel diagnostic model based on three genes (TSEN15, CAPRIN1 and PRR34-AS1) was constructed in the training cohort (AUC = 0.968) and successfully verified in the validation cohort (AUC = 0.925) with high accuracy. Moreover, the diagnostic model also showed a promising value in discriminating T cell-mediated rejection (TCMR) (AUC = 0.786). Functional enrichment analysis and immune cell evaluation demonstrated that the AR model was significantly correlated with adaptive immunity, especially T cell subsets and dendritic cells. Conclusion: We identified and validated a novel three-gene diagnostic model with high accuracy for AR in renal transplant patients, and the model also performed well in distinguishing TCMR. The current study provided a promising tool to be used as a precise and cost-effective non-invasive test in clinical practice.

Pulse dose steroid experience among hospitalized patients with systemic lupus erythematosus: a single-center feasibility study.

Pulse intravenous (IV) methylprednisolone (MEP) is often used for severe SLE manifestations requiring hospitalization. However, the accuracy of pulse dose documentation extracted from the electronic health record (EHR) is unknown. We assessed the feasibility to study pulse steroid dosing among hospitalized patients with SLE at our institution. Using the Stanford Medicine Research Data Repository (STARR) extracted from the EHR, we identified patients with ≥ 1 SLE ICD code before/during hospitalization receiving steroids (1/2008-12/2017). SLE diagnosis required rheumatologist confirmation. For our feasibility study, we randomly sampled 40/747 patients meeting search criteria. Pulse IV MEP was defined as ≥ 200 mg. Pharmacy dispensation data required EHR confirmation. Forty adult and pediatric subjects were identified, passing initial criteria screen; 6 pediatric patients were excluded as EHR pharmacy confirmation was unavailable. Of the 34 adults, 14 had SLE confirmed. Among 5 adult SLE patients with pulse documentation, 3 occurred while hospitalized, for the following indications: acute renal transplant rejection (2 patients, 2 hospitalizations) and lupus flare (1 patient, 2 hospitalizations). No discrepancies were observed in pharmacy dispensation documentation of pulse dosing between EHR and STARR for all 4 hospitalizations. Assessment of pulse steroid dose dispensation among hospitalized patients with SLE can be reliably ascertained from the extracted portion of the EHR designed for research. Reliance on a single ICD code for SLE in the EHR may lead to high rate of false-positive diagnoses of SLE among hospitalized patients. We document the importance of supplementing one ICD code with additional clinical information when confirming SLE diagnosis. Key Points • Assessment of pulse steroid dosing dispensation among hospitalized patients with SLE can be reliably determined from the extracted portion of the EHR designed for research purposes. • Reliance on a single ICD code contributes to a high rate of false positive diagnoses of SLE among hospitalized patients. • Supplementing ICD coding with additional clinical information is vital when confirming SLE diagnosis.

Pre-emptive immunosuppression using tacrolimus monotherapy does not reduce the rate of early acute rejection in renal transplantation from live donors: a comparative cohort study.

The planned nature of live donor kidney transplantation allows for immunosuppression to be initiated in the pretransplant period. The aim of this study was to determine the effect of pre-emptive immunosuppression on acute rejection rates after live donor kidney transplantation. In two consecutive cohorts of live donor kidneys transplants, 99 patients received pre-emptive immunosuppression with tacrolimus monotherapy for 2weeks prior to transplantation (PET group - first era) and 100 patients received tacrolimus-based immunosuppression commencing on the day of transplantation (control group - second era). The main outcome measure was the incidence of biopsy-proven acute rejection (BPAR) in the first 3months post-transplantation. Tacrolimus levels were significantly higher in the PET group at day 4 post-transplant (PET 9.08±4.57 vs. control 5.92±3.64ng/ml; P<0.0001), but there were no significant differences in tacrolimus levels at day 7 (PET 8.22±3.58 vs. control 7.63±3.56ng/ml; P=0.2452). BPAR was numerically higher in the PET group, but this difference did not reach statistical significance (PET 13/99 vs. control 6/100; P=0.097). There were no differences in allograft function measured by serum creatinine at 1year (PET 130±36 vs. control 142±69μmol/l; P=0.6829). Graft survival at 1year was equivalent in both groups (PET 96.9 vs. control 97.0%; P=0.9915). This study suggests that there is little role for the use of pre-emptive tacrolimus monotherapy in ABO blood group and HLA-compatible live donor kidney transplantation in patients on triple maintenance immunosuppression.

Perforin A and granzyme B as non invasive markers in early acute rejection in pediatric renal transplantation

IntroductionIdentification of new non- invasive sensitive markers that can predict acute rejection (AR) will provide a better chance for early therapeutic intervention before full clinical picture of AR with its consequences had occurred. We aimed to measure perforin A and granzyme B mRNA levels in serum and urine of children underwent recent renal transplantation during the first three months after transplantation. MethodsThe study included 69 recently transplanted pediatric patients and 40 age and sex matched normal subjects. Quantification of perforin A and granzyme B expression using quantitative reverse transcriptase real time PCR, was done at 1 week, 1 month and 3 months after transplantation. Patients were followed up for development of AR during their first 3 months. ResultsTwelve patients developed AR (rejecters) and 57 patients did not develop AR (non-rejecters). Rejecters showed significantly elevated levels of perforin A and granzyme B expression in pre-rejection blood and urine samples (at 1st week and 1st month), compared to non-rejecter group (p < 0.001 for all comparisons). ROC curve analysis suggested that assessment of perforin A and granzyme B expression at 1 week and 1 month post-transplantation could be predictor markers for early AR with high discriminative power (AUC ranged between 0.79 and 0.98). ConclusionsEarly measurements of perforin A and granzyme B expression in blood and urine after renal transplantation could identify pediatric patients at risk of AR, suggesting these patients as candidates for biopsy or for initiation of anti-rejection therapy.

Acute rejection in pediatric renal transplantation: Retrospective study of epidemiology, risk factors, and impact on renal function

AR is a major relevant and challenging topic in pediatric kidney transplantation. Our objective was to evaluate cumulative incidence of AR in pediatric kidney transplant patient, risk factors for this outcome, and impact on allograft function and survival. A retrospective cohort including pediatric patients that underwent kidney transplantation between 2011 and 2015 was designed. Risk factors for AR were tested by competing risk analysis. To estimate its impact, graft survival and difference in GFR were evaluated. Two hundred thirty patients were included. As a whole, the incidence of AR episodes was 0.16 (95% CI=0.12-0.20) per person-year of follow-up. And cumulative incidence of AR was 23% in 1year and 39% in 5years. Risk factors for AR were number of MM (SHR 1.36 CI 1.14-1.63 P=.001); ISS with CSA, PRED, and AZA (SHR 2.22 CI 1.14-4.33 P=.018); DGF (SHR 2.49 CI 1.57-3.93 P<.001); CMV infection (SHR 5.52 CI 2.27-11.0 P<.001); and poor adherence (SHR 2.28 CI 1.70-4.66 P<.001). Death-censored graft survival in 1 and 5years was 92.5% and 72.1%. Risk factors for graft loss were number of MM (HR 1.51 CI 1.07-2.13 P=.01), >12years (HR 2.66 CI 1.07-6.59 P=.03), and PRA 1%-50% (HR 2.67 CI 1.24-5.73 P=.01). Although occurrence of AR did not influence 5-year graft survival, it negatively impacted GFR. AR was frequent in patients assessed and associated with number of MM, ISS regimen, DGF, CMV infection, and poor adherence, and had deleterious effect on GFR.

Key driver genes as potential therapeutic targets in renal allograft rejection.

Acute rejection (AR) in renal transplantation is an established risk factor for reduced allograft survival. Molecules with regulatory control among immune pathways of AR that are inadequately suppressed, despite standard-of-care immunosuppression, could serve as important targets for therapeutic manipulation to prevent rejection. Here, an integrative, network-based computational strategy incorporating gene expression and genotype data of human renal allograft biopsy tissue was applied, to identify the master regulators - the key driver genes (KDGs) - within dysregulated AR pathways. A 982-meta-gene signature with differential expression in AR versus non-AR was identified from a meta-analysis of microarray data from 735 human kidney allograft biopsy samples across 7 data sets. Fourteen KDGs were derived from this signature. Interrogation of 2 publicly available databases identified compounds with predicted efficacy against individual KDGs or a key driver-based gene set, respectively, which could be repurposed for AR prevention. Minocycline, a tetracycline antibiotic, was chosen for experimental validation in a murine cardiac allograft model of AR. Minocycline attenuated the inflammatory profile of AR compared with controls and when coadministered with immunosuppression prolonged graft survival. This study demonstrates that a network-based strategy, using expression and genotype data to predict KDGs, assists target prioritization for therapeutics in renal allograft rejection.