1. © 2014 Direct One Communications, Inc. All rights reserved. 1 Finding Solutions to Improving Long-Term Outcomes Imran Javed, MD University of Washington Medical Center, Seattle, Washington A REPORT FROM THE 2014 WORLD TRANSPLANT CONGRESS

2. © 2014 Direct One Communications, Inc. All rights reserved. 2 Pathology of Chronic Graft Loss Chronic renal allograft rejection is the second most common cause of graft loss, following death of a patient with a working graft. On tissue biopsy, chronic renal allograft rejection is associated with: » Interstitial fibrosis » Tubular atrophy » Glomerular changes: Glomerular double contours Peritubular capillary basement membrane multilayering Fibrous intimal thickening in arteries

3. © 2014 Direct One Communications, Inc. All rights reserved. 3 Pathology of Chronic Graft Loss continued Banff criteria for chronic allograft nephropathy Chronic renal allograft rejection is also characterized by complement split product positivity (C4d+) and the presence of circulating antidonor antibodies. However, these graft changes can present with organ dysfunction despite histologic findings that are negative for the presence of C4d or donor-specific antibody (DSA).

4. © 2014 Direct One Communications, Inc. All rights reserved. 4 Pathology of Chronic Graft Loss continued Interstitial fibrosis and tubular atrophy presenting with interstitial inflammation are much stronger predictors of renal graft loss than is interstitial fibrosis or tubular atrophy alone. Interstitial inflammation in areas of interstitial fibrosis and tubular atrophy is predictive of reduced time to graft failure, even after adjustment for serum creatinine level. Fibrosis also has been linked to the use of calcineurin inhibitors (CNIs) for immunosuppression; however, CNI toxicity usually is the diagnosis of exclusion when associated changes on biopsy are nonspecific. Haas M. Curr Opin Nephrol Hypertens. 2014;23:245; Matas AJ et al. Am J Transplant. 2010;10:315

5. © 2014 Direct One Communications, Inc. All rights reserved. 5 Pathology of Chronic Graft Loss continued El-Zoghby et al concluded that not all renal grafts experience chronic injury, and different causes may be identified among those that do. Glomerulopathy was the leading cause of graft failure, whereas alloimmunity was the mechanism for the kidney graft loss. The fibrosis was not related to CNI toxicity. For most biopsies performed at the time of allograft dysfunction, de novo DSA formation appears to be a more common cause of later graft loss, although inflammation also may continue to play a role. El-Zoghby ZM et al. Am J Transplant. 2009;9:527

6. © 2014 Direct One Communications, Inc. All rights reserved. 6 Pathology of Chronic Graft Loss continued Stegall et al analyzed the prevalence and progression of histologic changes in protocol surveillance biopsies of 447 patients who received solitary kidney transplants between 1998 and 2004 and were using tacrolimus for maintenance immunosuppression. Moderate-to-severe interstitial fibrosis was uncommon at both 1 and 5 years (13% and 17%, respectively). Mild fibrosis involving up to 25% of the interstitium was relatively common (37%) at 1 year, but it rarely progressed to more severe fibrosis by 5 years. Stegall MD et al. Am J Transplant. 2011;11:698

7. © 2014 Direct One Communications, Inc. All rights reserved. 7 Pathology of Chronic Graft Loss continued Subclinical inflammation is seen in up to 15% of renal allografts at 1 year and is related to the development of interstitial fibrosis or graft loss. It is unclear whether this subclinical inflammation stimulates cell-mediated alloimmunity against the allograft that may not meet Banff criteria for acute cell-mediated rejection. An increased rate of transplant glomerulopathy also has been seen in kidney grafts with prior subclinical inflammation; thus, there may be a link between the cellular alloimmune response and DSA development. Cosio FG et al. Am J Transplant. 2005;5:2464; Naesens M et al. Am J Transplant. 2013;13:86; El Ters M et al. Am J Transplant. 2013;13:2334

8. © 2014 Direct One Communications, Inc. All rights reserved. 8 Pathology of Chronic Graft Loss continued When biopsies are performed to evaluate new-onset graft dysfunction or proteinuria > 5 years after transplantation, results consistently indicate a major role for antibody-mediated late graft injury. In the DeKAF trial, renal-transplant recipients underwent biopsies an average of 7.5 ± 6.0 years post transplant to look for allograft dysfunction. Patients with evidence of de novo DSA formation and/or C4d+ status were at substantial risk of graft failure over 2 years following biopsy. The severity of clinical injury correlated with the intensity of the antibody response. Gaston RS et al. Transplantation. 2010;90:68

9. © 2014 Direct One Communications, Inc. All rights reserved. 9 Graft Quality and Organ Matching Younger grafts behave better than do older ones. Older living-donor kidney allografts do not perform better than standard-criteria donor organs, but living-donor kidney transplants have a greater long- term graft survival rate than deceased-donor kidneys taken primarily from brain-dead donors. Kidney grafts from expanded-criteria donors tend to have poorer survival than grafts from standard- criteria donors. » Expanded-criteria donors are > 60 years of age or meet two of the following three criteria: age = 50–59 years, history of hypertension, or serum creatinine level > 1.5 mg/dL. Lim WH et al. Transplantation. 2013;95:106

10. © 2014 Direct One Communications, Inc. All rights reserved. 10 Graft Quality and Organ Matching continued Five-year post-transplant outcomes of kidneys donated after cardiac death (DCD kidneys) are not significantly different from those of kidneys from brain-deceased donors in terms of patient (81%) or graft (67%) survival. Human leukocyte antigen (HLA) matching is critical and outweighs the detrimental effect of prolonged cold ischemia time on graft survival. » Regardless of the quality of donor organs, ischemia time is an independent factor for short- and long-term graft survival; the only way to reduce the impact of prolonged ischemia time resulting from transportation of the organ is to have better HLA typing.

11. © 2014 Direct One Communications, Inc. All rights reserved. 11 Sensitization The more an organ donor is exposed to antigens, the greater the chance that allograft rejection will occur, particularly in kidney-transplant recipients who have high panel-reactive antibody levels. Lefaucheur et al evaluated allograft survival among 43 patients with and 194 patients without preformed HLA alloantibodies (DSAs). Allograft survival was 68% among patients with preformed DSAs versus 77% among those without preformed DSAs. The incidence of antibody-mediated rejection was nine times higher for those with preformed DSAs. Lefaucheur C et al. Am J Transplant. 2008;8:324

12. © 2014 Direct One Communications, Inc. All rights reserved. 12 Early Graft Rejection Acute graft rejection within 1 year of transplant has an adverse impact on long-term graft survival. This consequence can be minimized by choosing a strong immunosuppressive induction agent. Use of antithymocyte immunoglobulin (ATG) is beneficial as an induction immunosuppressant for kidney transplantation, particularly for: » Patients with high panel-reactive antibody levels » African-Americans » Recipients of a second kidney allograft.

13. © 2014 Direct One Communications, Inc. All rights reserved. 13 Maintenance Immunosuppression Although long-term use of tacrolimus can induce hyalinosis and fibrosis, there is no better choice currently for maintenance immunosuppression. Sirolimus worsens proteinuria. Patients who do not adhere to immunosuppressive therapy begin to suffer failure of graft function. Teenagers and young adults tend to be less adherent than older patients. The recent advent of a once-daily formulation of tacrolimus appears to improve adherence while retaining the drug’s effectiveness. Nankivell BJ et al. N Engl J Med. 2003;349:2326

14. © 2014 Direct One Communications, Inc. All rights reserved. 14 Disease Recurrence and Comorbidities Mange et al showed that an increase of 10 mm Hg in mean arterial blood pressure resulted in a 1.3-fold higher risk of allograft failure 1 year post transplant. Proteinurea and elevated homocysteine levels also are associated with decreased allograft survival. Winkelmayer et al compared baseline fasting plasma total homocysteine levels with renal allograft survival over a median follow-up of 6.1 years. Elevated homocysteine levels (≥ 12 µmol/L) were associated with a 1.6-fold increased risk of allograft loss and 2.4-fold greater mortality. Mange KC et al. JAMA. 2000;283:633–638; Winkelmayer WC et al. JASN Express. 2005;16:255

15. © 2014 Direct One Communications, Inc. All rights reserved. 15 Disease Recurrence continued Recurrent glomerulonephritis is the third most common cause of allograft loss at 10 years. Hanrahan et al evaluated the outcomes of about 5,000 renal transplants documented in the Renal Allograft Disease Registry; in all, 167 patients had clinical and biopsy-proven evidence of recurrent or de novo glomerular disease. The risk ratio for allograft failure was 1.9 for those with glomerular disease. At 5 years, patients with glomerular disease had a much higher rate of allograft failure (60%) than did those without glomerular disease (32%). Hanrahan S et al. Transplantation. 1999;68:635

16. © 2014 Direct One Communications, Inc. All rights reserved. 16 Improving Long-Term Graft Survival The most important nonimmunologic factor affecting renal graft survival is patient nonadherence to the maintenance immunosuppressant regimen. Diabetes and hypertension must be well controlled; any change in baseline blood pressure should be evaluated thoroughly, and suspected renal artery stenosis should be addressed. Polyoma virus allograft nephropathy typically presents with subacutely progressive allograft dysfunction; a more specific diagnosis can be made by looking for the virus in blood or urine using the polymerase chain reaction.

17. © 2014 Direct One Communications, Inc. All rights reserved. 17 Monitoring for Disease Recurrence Recurrent primary disease should always be considered; clinicians should distinguish focal segmental glomerulosclerosis (FSGS) observed on transplant biopsy as a primary change or as a recurrence. The onset of proteinuria typically occurs within days or a few weeks in recurrent FSGS and develops rapidly. In comparison, protein excretion does not begin to increase until at least 3 months after transplantation and then rises slowly in chronic de novo disease.

18. © 2014 Direct One Communications, Inc. All rights reserved. 18 Biomarkers of Graft Function A high CD30 level in the presence of HLA class I or class II antibodies within 2 weeks post transplant predicts poor graft survival. High levels of post-transplant immunoglobulin A anti-Fab antibody are more frequently seen among patients with functioning grafts, correlated with decreased serum creatinine levels, and were associated with improved graft survival. The upregulation of transforming growth factor-  19 remains an inconsistent finding in kidney-graft recipients with biopsy-proven interstitial fibrosis and tubular atrophy (IF/TA). Amirzargar MA et al. Hum Immunol. 2014;75:47; Campistol JM et al. Nephrol Dial Transplant. 2001;16(suppl 1):114

19. © 2014 Direct One Communications, Inc. All rights reserved. 19 Biomarkers of Graft Function continued The serum  2-microglobulin level at discharge has been shown to be a strong predictor of long-term mortality and renal allograft loss. Preliminary urinary protein assays have shown that 14–19 proteins differ between patients with IF/TA and those with antibody-mediated processes. » Further analysis of these patient samples identified uromodulin at 638.03 m/z and a high expression of 642.61 m/z as diagnostic of chronic allograft dysfunction. Isolation and analysis of messenger RNA from urine specimens also is being studied as a noninvasive way to diagnose ongoing allograft pathology. Astor BC et al. Kidney Int. 2013;84:810; Quintana LF et al. Mol Cell Proteomics. 2009;8:1658; Quintana LF et al. J Am Soc Nephrol. 2009;20:428; Bañón-Maneus E et al. Transplantation. 2010;89:548; Li B et al. N Engl J Med. 2001;344:947

20. © 2014 Direct One Communications, Inc. All rights reserved. 20 Conclusion Long-term graft loss is not completely understood, but alloimmunity has a definite role in this phenomenon. Besides tissue diagnosis and measuring creatinine clearance, alaysis of certain biomarkers in serum and urine samples can predict the long-term outcome of renal allografts. More studies must be performed to evaluate the potential role of these biomarkers and to provide a better understanding of the exact mechanism of long-term graft loss than we have now.