Survival Benefit of Kidney Transplantation in Patients With End-Stage Kidney Disease and Prior Acute Myocardial Infarction.

Patients with end stage kidney disease (ESKD) and a previous acute myocardial infarction (AMI) have less access to KT. Data on ESKD patients with an AMI history who underwent first KT or dialysis between January 2007 and December 2018 were extracted from the Korean National Health Insurance Service. Patients who underwent KT (n = 423) were chronologically matched in a 1:3 ratio with those maintained on dialysis (n = 1,269) at the corresponding dates, based on time-conditional propensity scores. The 1, 5, and 10 years cumulative incidences for all-cause mortality were 12.6%, 39.1%, and 60.1% in the dialysis group and 3.1%, 7.2%, and 14.5% in the KT group. Adjusted hazard ratios (HRs) of KT versus dialysis were 0.17 (95% confidence interval [CI], 0.12-0.24; p < 0.001) for mortality and 0.38 (95% CI, 0.23-0.51; p < 0.001) for major adverse cardiovascular events (MACE). Of the MACE components, KT was most protective against cardiovascular death (HR, 0.23; 95% CI, 0.12-0.42; p < 0.001). Protective effects of KT for all-cause mortality and MACE were consistent across various subgroups, including patients at higher risk (e.g., age >65 years, recent AMI [<6 months], congestive heart failure). KT is associated with lower all-cause mortality and MACE than maintenance dialysis patients with a prior AMI.

Up-regulation of VSIG4 alleviates kidney transplantation-associated acute kidney injury through suppressing inflammation and ROS via regulation of AKT signaling.

Prolonged cold ischemia (CI) is a risk factor for acute kidney injury (AKI) after kidney transplantation (KT). AKI is an abrupt and rapid reduction in renal function due to multi-factors, including inflammation, oxidative stress and apoptosis. V-set immunoglobulin-domain-containing 4 (VSIG4) is a B7 family-related protein and specifically expressed in resting tissue-resident macrophages to mediate various cellular events. In the study, we attempted to explore the effects of VSIG4 on CI/KT-induced AKI in a mouse model. Our results showed that VSIG4 expression was markedly down-regulated in serum of kidney transplant recipients with acute rejection, and in renal tissues of cold ischemia-reperfusion (IR)-operated mice with AKI, which was confirmed in murine macrophages stimulated by oxygen glucose deprivation/reoxygenation (OGD/R). We then found that exogenous VSIG4 markedly ameliorated histological changes in kidney of CI/KT mice by suppressing inflammation and apoptosis through restraining nuclear factor-κB (NF-κB) and Caspase-3 activation, respectively. Oxidative stress and reactive oxygen species (ROS) accumulation in renal tissues were also mitigated by exogenous VSIG4 in CI/KT mice through improving nuclear factor-erythroid 2 related factor 2 (Nrf2) nuclear expression. The inhibitory effects of VSIG4 on inflammation, ROS generation and cell death were confirmed in OGD/R-treated macrophages, which further ameliorated oxidative damage and apoptosis in podocytes. More in vivo and in vitro studies showed that CI/KT- and OGD/R-induced AKI was further accelerated by VSIG4 knockdown. Mechanistically, VSIG4 directly interacted with AKT, and AKT activation was necessary for VSIG4 to govern all these above mentioned cellular processes. Collectively, our findings demonstrated that VSIG4 could mitigate AKI in a CI/KT mouse model, and we identified VSIG4/AKT axis as a promising therapeutic target for the treatment of the disease.

Literature review of allograft adenovirus nephritis and a case presenting as mass lesions in a transplanted kidney without symptoms of urinary tract infection or acute kidney injury.

Adenovirus (AdV) infection is a common complication in bone marrow/hematopoietic stem cell transplant and solid organ transplant recipients. AdV infection usually presents as hemorrhagic cystitis, but sometimes it can progress to acute kidney injury showing AdV nephritis (AdVN). We present the case of a 52-year-old Japanese female who had received a living kidney transplantation (KT) from her husband. At 21 months post-KT, the patient presented with a fever, but no renal dysfunction and no abnormal urine findings. A contrast-enhanced computed tomography (CT) scan revealed a few mass lesions with hypoperfusion in the transplanted kidney. An enhanced CT-guided biopsy targeting one of these lesions revealed a necrotizing tubulointerstitial nephritis suggesting AdVN. The polymerase chain reaction tests for ADV were negative in a urine sample but positive in the sera and the frozen kidney biopsy samples. AdVN can manifest as an unusual pattern of acute lobar nephritis/acute focal bacterial nephritis-like localization without symptoms of acute kidney injury or urinary tract infection. Enhanced CT can provide clues for clinical diagnosis.

Impact of kidney transplant morbidity on elderly recipients' outcomes.

BACKGROUND AND AIMS: Nowadays, advanced age does not represent an absolute contraindication to kidney transplantation (KT). However, aging is frequently associated with multiple comorbidities and lower performance status, making KT candidates less surgically fit. Limited data are available on the impact of KT morbidity on elderly recipients' outcomes. METHODS: Retrospective study on a single center cohort of 130 KT recipients over 65 years old, representing 16.2% of KT clinical series, during the period 2000-2018. Number and severity of comorbidities were evaluated with the Charlson Comorbidity index (CCI). RESULTS: The median age at transplantation was 67 [IQR66-71] years and median CCI was 5 [IQR4-6]. The prevalence of postoperative complications with a Clavien-Dindo (C-D) severity score > 2 was 29%. Increasing age did not predict KT morbidity in terms of C-D score > 2, infectious, respiratory, cardiologic, urologic or vascular complications, delayed graft function, symptomatic lymphocele, bleeding, acute or chronic rejection. Conversely, CCI score was a predictor of overall complications with C-D score > 2, cardiologic, respiratory and vascular complications, and bleeding. Among others, CCI score, post-KT cardiologic complications, C-D score > 2 were identified as significant predictors of both early mortality and graft loss in univariate analysis. Increasing recipient age did not correlate with graft loss risk and graft loss did not impact patient survival. C-D score > 2 was a predictor of poor survival even in multivariate analysis. CONCLUSIONS: Elderly recipients showed a significant vulnerability to KT morbidity which correlates with CCI. While graft loss did not impact recipient survival, severe postoperative complications (C-D > 2) were independently associated increased mortality.

Detection of transplant renal artery stenosis with contrast-enhanced ultrasound.

Transplant renal artery stenosis (TRAS) is a vascular complication occurring during the first 2 years after kidney transplantation, with an incidence and a prevalence ranging from 1% to 23%, and from 1.5% to 4%, respectively. Detection of TRAS is the key, since most stenoses may progress to renal graft loss, however it may be difficult to detect due to its nonspecific clinical manifestations. Although Doppler ultrasound has become a primary imaging technique, digital subtraction angiography (DSA) remains the gold standard for diagnosing TRAS. We present a case of delayed graft function following kidney transplantation complicated by a lateral by-pass with prosthesis upstream and downstream of renal anastomosis, TRAS criteria were unclear using Doppler ultrasound, contrast-enhanced computed tomography-scan, and DSA. Only contrast-enhanced ultrasound (CE-US), observing a delayed and pulsating contest impregnation of renal parenchyma, supported the hypothesis of TRAS that was confirmed by the measurement of trans-anastomosis pressure gradient during DSA.

Prediction of clinical outcomes after kidney transplantation from deceased donors with acute kidney injury: a comparison of the KDIGO and AKIN criteria.

BACKGROUND: Acute kidney injury (AKI) is frequently detected in deceased donors (DDs), and it could be associated with adverse clinical outcomes in corresponding kidney transplant recipients (KTRs). In this regard, we sought to identify which criteria is better between the KDIGO and AKIN criteria for the diagnosis of AKI in DDs in the prediction of clinical outcomes after kidney transplantation (KT). METHODS: Two hundred eighty-five cases of deceased donor kidney transplantation (DDKT) were included. We divided them into three groups; the non-AKI by both KDIGO and AKIN criteria group (n = 120), the AKI by KDIGO only group (n = 61), and the AKI by both criteria group (n = 104) according to the diagnosis of AKI using the KDIGO and AKIN criteria in the corresponding 205 DDs. We compared the development of delayed graft function (DGF), the change in allograft function, the allograft survival among the three groups. RESULTS: The incidence of DGF was significantly higher in the AKI by KDIGO only and the AKI by both criteria groups than in the non-AKI by both criteria group (P < 0.05 each). But no difference was detected between the AKI by KDIGO only group and the AKI by both criteria group (P > 0.05). Therefore, the KDIGO criteria had a better predictive value for DGF occurrence than the AKIN criteria (Area under the curve = 0.72 versus 0.63, P < 0.05) in Receiver Operation Characteristic analysis. On comparison of allograft function, the AKI by KDIGO only and the AKI by both criteria groups showed a significantly deteriorating pattern by 6 months after KT in comparison with the non-AKI by both criteria group (P < 0.05). However, the differences disappeared at 1 year from KT and long-term allograft survival did not differ among the three groups. AKI stage either by KDIGO or AKIN in DDs did not affect long-term allograft survival in corresponding KTRs as well. CONCLUSIONS: The KDIGO criteria may be more useful for predicting DGF than the AKIN criteria. However, AKI or AKI stage by either criteria in DDs failed to affect long-term allograft outcomes in KTRs.