From the Guidelines
Predicting transplant glomerulopathy involves monitoring donor-specific antibodies (DSAs), particularly anti-HLA antibodies, and integrating clinical and histologic parameters, such as C1q-fixing DSAs, to identify patients at risk for increased transplant glomerulopathy and long-term kidney allograft loss. When assessing the risk of transplant glomerulopathy, several key factors should be considered, including:
- The presence and characteristics of DSAs, as discussed in the American Journal of Transplantation 1
- Clinical parameters such as serum creatinine, proteinuria, and estimated glomerular filtration rate (eGFR) trends
- Histologic parameters from protocol biopsies, which can detect early changes indicative of transplant glomerulopathy
- History of antibody-mediated rejection, inadequate immunosuppression, non-adherence to medication regimens, and prior transplantation The use of C1q-fixing DSAs integrated with clinical and histologic parameters may allow for the identification of patients at risk for increased transplant glomerulopathy and long-term kidney allograft loss, as noted in 1. Regular screening and monitoring of these factors can enable early detection and intervention, potentially slowing the progression of transplant glomerulopathy and improving patient outcomes. Key interventions may include optimized immunosuppression regimens, such as those including tacrolimus, mycophenolate, and steroids, as well as the use of therapies like plasmapheresis, Intravenous Immunoglobulin (IVIG), and rituximab, as mentioned in 1. By prioritizing the monitoring and management of these risk factors, clinicians can work to reduce the incidence and impact of transplant glomerulopathy, ultimately improving the quality of life and outcomes for kidney transplant recipients.
From the Research
Predicting Transplant Glomerulopathy
To predict transplant glomerulopathy (chronic transplant glomerulopathy), several factors and methods can be considered:
- Protocol biopsies can be useful in making an early diagnosis of subclinical rejection or chronic transplant glomerulopathy, as stated in 2.
- Histopathologic scoring may inform prognosis and help guide therapy, with higher-score groups being associated with the presence of concomitant antibody-mediated rejection, as seen in 3.
- Electron microscopy can contribute to the diagnosis of transplant glomerulopathy, especially in cases where light microscopy is not useful, as noted in 4 and 5.
- Ultrastructural examination of renal allograft biopsies is important for an early diagnosis of transplant glomerulopathy, when therapeutic intervention may be beneficial, as emphasized in 5.
Risk Factors and Indications
Certain clinical conditions may indicate the need for protocol biopsies to predict transplant glomerulopathy:
- Prolonged delayed graft function, as mentioned in 2.
- Patients at increased immunological risk, as stated in 2.
- Clinical trials performed to assess the safety and efficacy of new immunosuppressive drugs, as noted in 2.
- Presence of donor-specific antibodies, as associated with chronic antibody-mediated rejection, as discussed in 5.
Diagnostic Features and Stages
The diagnostic features and stages of transplant glomerulopathy can be identified through:
- Light microscopy, which may show glomerular basement membrane reduplications, as characterized in 5.
- Electron microscopy, which can diagnose the presence of changes associated with transplant glomerulopathy, as seen in 4 and 5.
- Histopathologic scoring, which may inform prognosis and guide therapy, as discussed in 3.