Efficacy of pre-emptive kidney transplantation for adults with end-stage kidney disease: a systematic review and meta-analysis

AbstractBackground Pre-emptive kidney transplantation (PEKT), i.e., transplantation performed before initiation of maintenance dialysis, is considered an ideal renal replacement therapy because there is no exposure to long-term dialysis therapy. Therefore, we summarized advantages/disadvantages of PEKT to assist in deciding whether kidney transplantation should be performed pre-emptively.Methods This study was registered with PROSPERO, CRD42021269163. Observational studies comparing clinical outcomes between PEKT and non-PEKT were included; those involving only pediatric recipients or simultaneous multi-organ transplantations were excluded. The PubMed/MEDLINE, Cochrane Library, and Ichushi-Web databases were searched on 1 August 2021. Studies were pooled using the generic inverse-variance method with random effects model, and risk of bias was assessed using ROBINS-I.Results Seventy-six studies were included in the systematic review (sample size, 23–121,853; enrollment year, 1968–2019). PEKT patients had lower all-cause mortality (adjusted HR: 0.78 [95% CI 0.66–0.92]), and lower death-censored graft failure (0.81 [0.67–0.98]). Unadjusted RRs for the following outcomes were comparable between the two patient groups: cardiovascular disease, 0.90 (0.58–1.40); biopsy-proven acute rejection, 0.75 (0.55–1.03); cytomegalovirus infection, 1.04 (0.85–1.29); and urinary tract infection, 0.89 (0.61–1.29). Mean differences in post-transplant QOL score were comparable in both groups. The certainty of evidence for mortality and graft failure was moderate and that for other outcomes was very low following the GRADE classification.Conclusions The present meta-analysis shows the potential benefits of PEKT, especially regarding patient and graft survival, and therefore PEKT is recommended for adults with end-stage kidney disease

Serological and histopathological assessment of galactose-deficient immunoglobulin A1 deposition in kidney allografts: A multicenter prospective observational study.

BackgroundRecurrent immunoglobulin A (IgA) nephropathy is an important risk factor for kidney allograft loss. However, there is no classification system for IgA deposition in kidney allografts based on serological and histopathological evaluation of galactose-deficient IgA1 (Gd-IgA1). This study aimed to establish a classification system for IgA deposition in kidney allografts based on serological and histological evaluation of Gd-IgA1.MethodsThis multicenter prospective study included 106 adult kidney transplant recipients in whom an allograft biopsy was performed. Serum and urinary Gd-IgA1 levels were investigated in 46 transplant recipients who were IgA-positive and classified into four subgroups according to the presence or absence of mesangial Gd-IgA1 (KM55 antibody) deposits and C3.ResultsMinor histological changes without an acute lesion were observed in recipients with IgA deposition. Fourteen (30%) of the 46 IgA-positive recipients were KM55-positive and 18 (39%) were C3-positive. The C3 positivity rate was higher in the KM55-positive group. Serum and urinary Gd-IgA1 levels were significantly higher in KM55-positive/C3-positive recipients than in the other three groups with IgA deposition. Disappearance of IgA deposits was confirmed in 10 of 15 IgA-positive recipients in whom a further allograft biopsy was performed. The serum Gd-IgA1 level at the time of enrollment was significantly higher in recipients in whom IgA deposition continued than in those in whom it disappeared (p = 0.02).ConclusionsThe population with IgA deposition after kidney transplantation is serologically and pathologically heterogeneous. Serological and histological assessment of Gd-IgA1 is useful for identifying cases that should be carefully observed

De novo focal segmental glomerulosclerosis and kidney hypertrophy associated with progressive obesity after kidney transplantation

Background: Obesity is an important problem associated with worsening cardiovascular disease and the progression of proteinuria in kidney transplant recipients. We describe a case of de novo focal segmental glomerulosclerosis (FSGS) associated with progressive obesity after kidney transplantation (KTx). Case Presentation: A 41-year-old male patient underwent an allograft kidney biopsy because of nephrotic range proteinuria. The donor was his father who was aged 70 years at transplantation. In addition, there was a substantial difference in body weight (BW) between the recipient and donor. At 56 months after kidney transplantation, the patient’s BW increased from 83.1 kg (BMI, 29.3 kg/m2 ) before kidney transplantation to 93.9 kg (BMI, 33.1 kg/m2 ). An allograft biopsy showed glomerular hypertrophy and focal segmental sclerotic lesions with partial epithelial cell hyperplasia. The histologic diagnosis was FSGS, not otherwise specified (NOS) variant. A comparison between the kidney volume before and after kidney transplantation, evaluated using volumetric computed tomography, revealed prominent kidney hypertrophy (1.77 times). Conclusions: Our case demonstrated that de novo FSGS after kidney transplantation is induced by progressive obesity, as manifested by glomerular hypertrophy as well as kidney hypertrophy. This is a hyperdynamic state contributed to the pathogenesis of de novo FSGS. Our report is important to understand the pathogenesis of FSGS

Eculizumab for Severe Thrombotic Microangiopathy Secondary to Surgical Invasive Stress and Bleeding

Atypical hemolytic uremic syndrome (aHUS) is an extremely rare condition caused by an excessive activation of the complement pathway based on genetic or acquired dysfunctions in complement regulation, leading to thrombotic microangiopathy (TMA). A complement-amplifying condition (CAC) can trigger aHUS occurrence along with complement abnormality. We herein report a case of severe TMA after laparoscopic myomectomy in a healthy woman. This case was eventually diagnosed as complement-mediated TMA secondary to surgical invasive stress as a CAC, with no definitive diagnosis of aHUS despite a genetic test. The patient fully recovered after several eculizumab administrations

RELATIONSHIP BETWEEN SALT INTAKE AND GNRI IN ELDERLY DIALYSIS PATIENTS

While the recommended salt intake in dialysis patients is no more than 5g/day in the KDOQI guideline, and 6g/day in the JSH 2009 guideline, reducing salt consumption is difficult on the traditional Japanese diet. If a patient is malnourished, a low-salt diet poses a risk of aggravating the nutritional deficiency. Since elderly dialysis patients have nutritional deficiencies underlying their condition, the recommended low-salt diet may prevent these patients from receiving adequate nutrition. In the present study, factors associated with nutritional status in the elderly were assessed using the Geriatric Nutritional Risk Index (GNRI), which is considered to correlate with predictor of mortality among dialysis patients. Participating patients were anuric, had been maintained on dialysis for at least 2 years, and were 65 years of age or older. Factors assessed for their possible correlations with GNRI were primary disease, presence of spouse, presence of cohabiting family, weight gain, and estimated salt intake. We analyzed 36 patients (age 74.3±5.4 years, 50% males). GNRI was 90.9±7.7, and salt intake (8.02±1.94) correlated with GNRI (r=0.41, P=0.02). No correlations were detected for the presence of spouse or cohabiting family, which would have contributed to nutrition. In conclusion, the higher the salt intake, the better GNRI tended to be. This raised the possibility that it would be advantageous to avoid excessive salt restriction in nutritional training

Early Mortality Was Highly and Strongly Associated with Functional Status in Incident Japanese Hemodialysis Patients: A Cohort Study of the Large National Dialysis Registry

<div><p>Background</p><p>Although dialysis is typically started in an effort to prolong survival, mortality is reportedly high in the first few months. However, it remains unclear whether this is true in Japanese patients who tend to have a better prognosis than other ethnicities, and if health conditions such as functional status (FS) at initiation of dialysis influence prognosis.</p><p>Methods</p><p>We investigated the epidemiology of early death and its association with FS using Japanese national registry data in 2007, which included 35,415 patients on incident dialysis and 7,664 with FS data. The main outcome was early death, defined as death within 3 months after initiation of hemodialysis (HD). The main predictor was FS at initiation of HD. Levels of functional disability were categorized as follows: severe (bedridden), moderate (overt difficulties in exerting basic activities of daily living), or mild/none (none or some functional disabilities).</p><p>Results</p><p>Early death remained relatively common, especially among elderly patients (overall: 7.1%; those aged ≥80 years: 15.8%). Severely and even only a moderately impaired FS were significantly associated with early death after starting dialysis (adjusted risk ratios: 3.93 and 2.38, respectively). The incidence of early death in those with impaired FS increased with age (36.5% in those with severely impaired FS and aged ≥80 years).</p><p>Conclusions</p><p>Early death after starting dialysis was relatively common, especially among the elderly, even in Japanese patients. Further, early death was significantly associated with impaired FS at initiation of HD.</p></div