Therapy in the Course of Kidney Graft Rejection—Implications for the Cardiovascular System—A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
3. Antibody-Mediated Rejection
3.1. Active ABMR
3.2. Chronic Active ABMR
3.3. Chronic (Inactive) ABMR
3.4. Evidence-Based Treatment Approaches in Active and Chronic Active ABMR
3.4.1. Plasma Exchange and IVIG
3.4.2. Complement Inhibitors
3.4.3. Rituximab
3.4.4. Imlifidase
3.4.5. Interleukin-6 Inhibitors
3.4.6. Splenectomy
4. T-Cell-Mediated Rejection
4.1. Acute TCMR—Treatment
4.2. Chronic Active TCMR—Treatment
5. Borderline Rejection—Treatment
6. Mixed Rejection—Treatment
- Cyclosporine A (CsA), MMF and steroids;
- Tac, MMF and steroids.
- MMF—the initial dose was 1.5 g per day.
- Calcineurin inhibitors—administered when the serum creatinine level decreased to 50% of pre-transplant levels. The initial dose of Tac was 0.6 mg/kg per day, while CsA was initiated at 4 mg/kg per day. Both were gradually raised in accordance with the restoration of graft function. Tac and CsA maintenance doses were adjusted to trough levels: 6–12 ng/mL for Tac during the first 6 months, followed by 4–8 ng/mL for the next 6 months; 150–250 ng/mL for CsA during the first 6 months, followed by 100–200 ng/mL for the following 6 months.
- Standard corticosteroid tapering—methylprednisolone IV (500 mg) on days 0–2, followed by oral prednisone 80 mg/day on day 3, which was then decreased to 10 mg/day increments to 20 mg/day. The dose of corticosteroid was then reduced slowly to 5 mg/day.
7. Long-Term Implications for the Cardiovascular System Caused by Treatment Methods Applied in Kidney Rejection Treatment
7.1. Prevention of Acute Graft Rejection
7.2. ABMR
7.3. TCMR
7.4. Borderline Rejection
- Tachycardia—Basiliximab 28 (8%) vs. placebo 21 (6%);
- Hypertension—Basiliximab 97 (27%) vs. placebo 93 (26%);
- Hypotension—Basiliximab 30 (8%) vs. placebo 38 (11%) [120].
8. Discussion
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- Selection bias: One potential limitation of our study is the possibility of selection bias in the included references. Despite our best efforts to conduct an extensive literature search, it is possible that some relevant studies were inadvertently excluded.
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- Publication bias: Another potential limitation is the presence of publication bias, whereby studies with positive or significant results are more likely to be published than those with negative or nonsignificant findings. This bias can impact the overall assessment of the therapy’s efficacy and safety.
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- Heterogeneity of study designs: The studies included in our review may exhibit heterogeneity in terms of study design, patient populations, therapeutic interventions and outcome measures. This heterogeneity could affect the comparability and synthesis of the results, potentially limiting the strength of our conclusions.
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- Time constraints and knowledge cutoff: Our review article was completed within a specific time frame, and the data collection was limited to the available literature up until May 2023. Newer studies published after this cutoff date may exist, potentially impacting the comprehensiveness of our review.
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- Potential confounding factors: The impact of therapy on the cardiovascular system in the context of kidney graft rejection can be influenced by various confounding factors, such as comorbidities, concurrent medications and patient characteristics. It is challenging to control for all these factors in observational studies, which could introduce confounding biases that limit the strength of our conclusions.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations
ABMR | Antibody-mediated rejection |
TCMR | t-cell-mediated rejection |
IVIG | intravenous immunoglobulin |
HLA | human leukocyte antigen |
DSA | donor-specific antibodies |
CA | chronic active |
PLEX | plasma exchange |
KDIGO | Kidney Disease: Improving Global Outcomes |
IdeS | imlifidase |
ATG | anti-thymocyte globulin |
BCR | borderline cellular rejection |
BL-R | Borderline TCMR |
KT | kidney transplantation |
B-CLL | B-cell chronic lymphocytic leukemia |
MMF | mycophenolate mofetil |
AHR | acute humoral rejection |
Tac | tacrolimus |
CsA | cyclosporine A |
CNI | calcineurin inhibitor |
VT | ventricular tachycardia |
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In order to diagnose Active ABMR, all 3 of the following criteria must be met: | |
1. |
Histologic evidence of acute tissue injury, including 1 or more of the following:
|
2. |
Evidence of current/recent antibody interaction with vascular endothelium, including 1 or more of the following:
|
3. | Serologic evidence of donor-specific antibodies (DSA to HLA or other antigens). C4d staining or expression of validated transcripts/classifiers as noted above in criterion 2 may substitute for DSA; however, thorough DSA testing, including testing for non-HLA antibodies if HLA antibody testing is negative, is strongly advised whenever criteria 1 and 2 are met |
In order to diagnose Chronic Active ABMR, all 3 of the following criteria must be met: | |
1. |
Morphologic evidence of chronic tissue injury, including 1 or more of the following:
|
2. | Identical to criterion 2 for active ABMR above. |
3. | Identical to criterion 3 for active ABMR above, including strong recommendation for DSA testing whenever criteria 1 and 2 are met. Biopsies meeting criterion 1 but not criterion 2 with current or prior evidence of DSA (post transplant) may be stated as showing chronic ABMR; however, remote DSA should not be considered for diagnosis of chronic active or active ABMR. |
Chronic (inactive) ABMR | |
1. | cg > 0 and/or severe ptcml (ptcml1). |
2. | Absence of criterion 2 of current/recent antibody interaction with the endothelium. |
3. | Prior documented diagnosis of active or chronic active ABMR and/or documented prior evidence of DSA. |
i | t | v | |
---|---|---|---|
Grade IA | Interstitial inflammation involves more than 25% of non-sclerotic cortical parenchyma | Moderate tubulitis involving at least 1 tubule excluding severely atrophic tubules | - |
Grade IB | Interstitial inflammation involves more than 25% of non-sclerotic cortical parenchyma | Severe tubulitis involving at least 1 tubule excluding severely atrophic tubules | - |
Grade IIA | Interstitial inflammation can be present but does not have to | Tubulitis can be present but does not have to | Mild to moderate intimal arteritis |
Grade II B | Interstitial inflammation can be present but does not have to | Tubulitis can be present but does not have to | Severe intimal arteritis |
Grade III | Interstitial inflammation can be present but does not have to | Tubulitis can be present but does not have to | Transmural arteritis or/and arterial fibrinoid necrosis, which involve medial smooth muscle together with mononuclear cell intimal arteriris |
i-IFTA | ti | t | cv | |
---|---|---|---|---|
Grade IA | Interstitial inflammation involves not less than 25% of sclerotic cortical parenchyma | Interstitial inflammation involves not less than 25% of total cortical parenchyma | Moderate tubulitis involving at least 1 tubule excluding severely atrophic tubules | - |
Grade IB | Interstitial inflammation involves not less than 25% of sclerotic cortical parenchyma | Interstitial inflammation involves not less than 25% of total cortical parenchyma | Severe tubulitis involving at least 1 tubule excluding severely atrophic tubules | - |
Grade II | Chronic allograft arteriopathy including arterial intimal fibrosis together with mononuclear cell inflammation in fibrosis. Moreover, the formation of neointima |
To diagnose BCR, all 3 of the following criteria must occur: | |
1. | Foci of tubulitis (t1, t2 or t3). |
2. | Mild interstitial inflammation (i1), or mild (t1) tubulitis with moderate-severe interstitial inflammation (i2 or i3). |
3. | No intimal or transmural arteritis (v = 0). |
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Mizera, J.; Pilch, J.; Giordano, U.; Krajewska, M.; Banasik, M. Therapy in the Course of Kidney Graft Rejection—Implications for the Cardiovascular System—A Systematic Review. Life 2023, 13, 1458. https://doi.org/10.3390/life13071458
Mizera J, Pilch J, Giordano U, Krajewska M, Banasik M. Therapy in the Course of Kidney Graft Rejection—Implications for the Cardiovascular System—A Systematic Review. Life. 2023; 13(7):1458. https://doi.org/10.3390/life13071458
Chicago/Turabian StyleMizera, Jakub, Justyna Pilch, Ugo Giordano, Magdalena Krajewska, and Mirosław Banasik. 2023. "Therapy in the Course of Kidney Graft Rejection—Implications for the Cardiovascular System—A Systematic Review" Life 13, no. 7: 1458. https://doi.org/10.3390/life13071458