The Kidney Transplant Lottery: A Highly Sensitized Patient, Without Mismatches and Vein Thrombosis of the Graft; A Case Report.

A kidney transplant is the best option for patients with end-stage renal disease. The waiting list period can be long, especially for highly sensitized patients. We describe a 60-year-old woman who received a second transplant and was highly sensitized to vascular access exhaustion, anuric, and performing peritoneal dialysis. At 27 days post-transplant, the patient developed thrombosis of the allograft vein, oliguria, and elevated serum creatinine. Fibrinolysis was attempted, but the patient remained oliguric and with acute graft dysfunction. She had a suction thrombectomy using the Penumbra System, allowing the removal of all thrombi and repermeabilization of the vein graft, resolving the acute graft dysfunction.

Renal arcuate vein thrombosis-induced acute kidney injury: a rare multiple-Hit-mediated disease.

Background: Renal arcuate vein thrombosis (RAVT) is a rare and recently recognized cause of acute kidney injury (AKI) in young adults. However, the precise incidence and underlying pathophysiologic mechanisms leading to AKI in these patients remain elusive. Methods: This study included all patients who underwent a kidney biopsy over a 40-month period sent to the pathology department of Necker-Enfants Malades Hospital, with evidence of RAVT. We performed coagulation tests, genetic testing for thrombophilia, complete urine toxicologic screening and kidney metagenomic sequencing to identify an underlying cause of thrombosis. Results: We report five pediatric cases of RAVT discovered on kidney biopsy performed in the setting of unexplained AKI. Investigations did not reveal an underlying cause of thrombosis but only a significant nonsteroidal anti-inflammatory drugs (NSAIDs) use was reported in 4/5 patients, supporting a potential link between NSAIDs use and RAVT. By performing metagenomic sequencing on kidney biopsy samples, we detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in the kidney of one patient. These results suggest that systemic SARS-CoV-2 infection may also be a key contributing factor of renal thrombosis, particularly by inducing potential endothelial disruption. Conclusions: In conclusion, RAVT-induced AKI appears to be a multiple hit-mediated disease in which NSAIDs consumption and viral infection such as SARS-CoV-2 may be crucial contributing factors. These findings may have significant public health implications given the prevalence of NSAIDs use in the general population. Increased awareness and additional study of future cases may lead to a better understanding of this rare cause of AKI in children and young adults.

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss.

An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review.

Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.

Kidney Retransplantation Outcomes: A Paired Recipient Control Study.

BACKGROUND: Despite progressive improvements in graft and patient survival after kidney transplantation over the last decades, an increasing number of patients are waitlisted for retransplantation. Identifying the risk factors for second graft failure can help us improve management for such patients. The aim of this study was to compare the outcomes of kidney retransplantation with those of first transplantation. METHODS: This retrospective study included all the recipients of a second kidney transplant between January 2008 and December 2019. For each patient with a second kidney transplant, we selected the paired recipient from the same donor. We excluded recipients of donations from living donors, patient-and-donor pairs with more than 1 transplant, and patients without a pair. The follow-up took place December 31, 2020. We included 152 patients, corresponding to 76 pairs of recipients. RESULTS: Patients who underwent a second transplant had significantly higher panel reactive antibody values and longer waiting time for retransplantation. Biopsy-proven acute rejection episodes were doubled in patients undergoing a second transplant (P = .12). There was a lower survival of second grafts at the first, fifth, and 10th year (P < .05). The main factor influencing graft loss for both groups was acute rejection, and, in patients, with a second transplant, acute rejection increased the risk of graft loss by 17 times (odds ratio, 17.5; 95% confidence interval, 4.19-98). CONCLUSIONS: The clinical results of second kidney transplants still fall short of first transplants, with the main factor of poor prognosis being acute rejection. In young patients, allocation and immunosuppression management should consider this risk to improve long-term outcomes.

Kidney Retransplant: Not Too Old for a Second Chance.

BACKGROUND: Kidney retransplant outcomes in the elderly are not well established. Our aim was to compare major clinical outcomes between patients older and younger than 60 years old at retransplant and between first and second kidney transplant (KT) for recipients older than 60 years old. METHODS: We performed a retrospective, longitudinal study that included all patients who underwent KT between January 2008 and December 2019. We defined 3 groups according to recipient age and retransplant status: group 1, patients ≥60 years old and retransplant; group 2, patients <60 years old and retransplant; group 3, patients ≥60 years old and first kidney transplant. We compared clinical outcomes such as acute rejection, death-censored graft survival, and patient survival between groups. RESULTS: We included 109 patients with a second KT, including 13 older than 60 years old (group 1) and 96 younger than 60 years old (group 2). There were no differences in death-censored graft survival or patient survival. There were no biopsy-proven acute rejections for older patients compared with 21 events in the younger group. Regarding differences between retransplant (group 1, n = 13) and first kidney transplant (group 3, n = 390) in patients older than 60 years old, there were no differences in death-censored graft survival at 1 and 5 years or in patient survival. CONCLUSIONS: In our study, major clinical outcomes of retransplant in the elderly were similar to those of their younger counterparts with a second graft and with those of older patients with a first graft.

Borderline Changes in Renal Transplantation: Are We Aware of the Real Impact in Graft Survival?

BACKGROUND: Borderline changes suspicious for acute T-cell-mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell-mediated rejection (aTCMR) and the influence of treating BC on graft outcomes. METHODS: A retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded. RESULTS: We included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m2, P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087). CONCLUSION: Our study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.

Nutcracker Syndrome: A Single-Center Experience.

Nutcracker syndrome, whose prevalence and natural history are still poorly known, is a clinical syndrome caused by left renal vein compression between the superior mesenteric artery and the aorta. Long-term results and treatment outcomes are not well known. Our group aimed to characterize 7 patients diagnosed with nutcracker syndrome in childhood and to describe their clinical manifestations, diagnostic approaches, and mostly their clinical evolution, rate of complications, and treatment outcomes.

A Case of Deficiency of Adenosine Deaminase 2: 28 years of Diagnostic Challenges.

Deficiency of adenosine deaminase 2 (DADA2) is a unique monogenic autoinflammatory disease caused by autosomal recessive loss-of-function mutations in the CECR1 gene which presents as childhood-onset small- and medium-vessel vasculitis. Previously, many of these patients were misdiagnosed and thought to have clinical features of systemic polyarteritis nodosum, which negatively influenced its outcome, since TNF inhibitors seem to have efficacy on the vasculitic phenotype of DADA2. We present a case of a 28-year-old woman with a lifelong unknown syndrome and unique clinical manifestations recently recognized as DADA2. The first manifestation, at 3 months of age, was an episode of facial paralysis during which renovascular hypertension was diagnosed. Later, she developed episodes of prolonged fever, polyarthritis, Raynaud's phenomenon, gastrointestinal bleeding, and intracerebral hemorrhage. This inflammatory state ultimately led to the development of amyloid A amyloidosis and renal insufficiency.