Protocol biopsy-driven interventions after pediatric renal transplantation.
ABSTRACT The therapeutic value of protocol biopsies (PBs) in renal transplant recipients remains unclear. We performed protocol biopsies in 57 children six months after transplantation. We increased the CNI dose in patients with borderline findings. In cases of Banff grade Ia, six prednisolone IV-pulses were given and the CNI dose was increased. CNI toxicity and polyomavirus nephropathy led to a reduction in the CNI dose. GFR was compared with a control group of 51 children with no PBs transplanted in the same period. Forty-two percent of PBs had no pathological changes, 24% IF/TA. Borderline findings were detected in 11%, Banff grade Ia in 15% (CNI), toxicity in 8%, and one case showed polyomavirus nephropathy. GFR after 1.5 and 2.5 yr was similar in both groups. GFR 3.5 yr after transplantation was significantly higher in the intervention group (57 ± 17 vs. 46 ± 20). Patients treated with low-dose CNI and everolimus had a significantly lower number of pathological findings in PBs. The performance of protocol biopsies followed by a standardized treatment algorithm led to better graft function 3.5 yr after transplantation. Prospective randomized studies to confirm our findings are needed.
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ABSTRACT: Acute antibody-mediated rejection is a diagnostic challenge in renal transplantation medicine. However, it is an important diagnosis to make, since chronic antibody-mediated rejection (CAMR) is the main cause of long-term graft loss. Antibody-mediated rejection is diagnosed by detecting donor-specific antibodies (DSAs) in the blood in combination with observing typical histomorphological signs in kidney biopsy, as described in the Banff classification. Therapy is based on the removal of DSAs by administering intravenous immunoglobulins (IVIGs), plasmapheresis, or immunoadsorption. Reoccurrence of antibodies is diminished by the use of rituximab, increased immunosuppression, and in some cases additional experimental substances. A combination of these techniques has been shown to be successful in the majority of cases of acute and chronic antibody-mediated rejection. Routine DSA monitoring is warranted for early detection of antibody-mediated rejection.Pediatric Nephrology 05/2014; 30(3). DOI:10.1007/s00467-014-2851-2 · 2.88 Impact Factor
Pediatric Transplantation 06/2014; 18(4):323-4. DOI:10.1111/petr.12268 · 1.63 Impact Factor
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ABSTRACT: Predicting graft outcome after renal transplantation based on donor histological features has remained elusive and is subject to institutional variability. We have shown in a retrospective study that the Maryland Aggregate Pathology Index score reliably predicts graft outcome. We sought to validate the scoring system in our center and a second transplant center. We analyzed 140 deceased donor kidneys pre-implantation biopsies from center1 and 65 from center2. The patients had a mean follow up of 695±424 and 656±305 days respectively. Although MAPI scores were similar, there were significant differences in donor and recipient parameters between both centers. Despite this, MAPI was predictive of graft outcome for both centers by Cox univariate, multivariate and time dependent ROC analysis. For center1 and 2, three year graft survival within each MAPI group was statistically equivalent. The 3 year graft survival at center1 for low, intermediate and high MAPI groups were 84.3%, 56.5% and 50.0% respectively, p= <0.0001, and at center2 were 83.3%, 33.3%, and 33.3%, p= 0.006. MAPI which is based on a pre-implantation biopsy demonstrated similar predictive and outcome results from both centers. As ECD criteria have redefined marginal kidneys, MAPI has the potential to further define ECD kidneys, increase utilization and ultimately improve outcomes. This article is protected by copyright. All rights reserved.Clinical Transplantation 06/2014; 28(8). DOI:10.1111/ctr.12400 · 1.49 Impact Factor