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BackgroundEarly graft loss following kidney transplantation is mainly a result of acute rejection or surgical complications, while long-term kidney allograft loss is more complex. We examined the association between systemic inflammation early after kidney transplantation and long-term graft loss, as well as correlations between systemic inflammation scores and inflammatory findings in biopsies 6 weeks and 1 year after kidney transplantation.MethodsWe measured 21 inflammatory biomarkers 10 weeks after transplantation in 699 patients who were transplanted between 2009 and 2012 at Oslo University Hospital, Rikshospitalet, Norway. Low-grade inflammation was assessed with predefined inflammation scores based on specific biomarkers: one overall inflammation score and five pathway-specific scores. Surveillance or indication biopsies were performed in all patients 6 weeks after transplantation. The scores were tested in Cox regression models.ResultsMedian follow-up time was 9.1 years (interquartile range 7.6-10.7 years). During the study period, there were 84 (12.2%) death-censored graft losses. The overall inflammation score was associated with long-term kidney graft loss both when assessed as a continuous variable (hazard ratio 1.03, 95% CI 1.01-1.06, P = 0.005) and as a categorical variable (4th quartile: hazard ratio 3.19, 95% CI 1.43-7.10, P = 0.005). In the pathway-specific analyses, fibrogenesis activity and vascular inflammation stood out. The vascular inflammation score was associated with inflammation in biopsies 6 weeks and 1 year after transplantation, while the fibrinogenesis score was associated with interstitial fibrosis and tubular atrophy.ConclusionIn conclusion, a systemic inflammatory environment early after kidney transplantation was associated with biopsy-confirmed kidney graft pathology and long-term kidney graft loss. The systemic vascular inflammation score correlated with inflammatory findings in biopsies 6 weeks and 1 year after transplantation.

Background Early diagnosis of kidney amyloidosis is essential for optimal treatment and improved outcomes. This large, nationwide cohort spanning three decades, explores the changing epidemiology and clinical presentation of kidney amyloidosis in Norway, aiming to raise amyloid awareness. Methods In the 30-year period (1988–2017), we identified 479 patients with biopsy-confirmed kidney amyloidosis from national registries. Past medical records were reviewed for additional amyloid relevant data and cases were divided into groups of non-AA and AA amyloidosis. Results Overall amyloid biopsy incidence in the registries was stable around 4%, but a shift in types occurred. The AL-dominated non-AA group increased from 1.9% to 2.8% ( p  = 0.014) while the AA group decreased from 2.6% to 1.3% ( p  < 0.001). The change in AA was related to less rheumatic disease, partly compensated by an increase in AA in people who inject drugs. The scope and accuracy of amyloid typing improved in the study period, significantly reducing undetermined cases ( p  < 0.001) and providing more robust diagnoses. Clinical presentation was diverse, but proteinuria was present in 94%. Non-AA patients more often than AA had nephrotic syndrome (70% vs 51%, p  < 0.001) and better-preserved kidney-function (median (IQR) eGFR 53(55) vs 27(34) ml/min/1.73 m 2 , p  < 0.001). AA patients were younger ( p  < 0.001) with higher prevalence of hypertension (53% vs 38%, p  < 0.001). Notably, AA in people who inject drugs was more advanced and near half presented with end-stage kidney disease. In recent years, non-AA presented with significantly improved serum albumin ( p  = 0.002), haemoglobin ( p  = 0.020) and erythrocyte sedimentation ratio ( p  = 0.029). Additionally, the percentage of non-AA with end-stage kidney disease fell from 26.8% to 8.7% ( p  = 0.005), possibly indicating earlier diagnosis. Conclusion The epidemiology of kidney amyloidosis has changed over the past 30 years. Biopsy incidence of non-AA is increased, and findings may suggest an earlier diagnosis. Amyloid typing has improved over time and is reflected in more precise amyloid diagnoses and reduced number of undetermined cases in recent years. Although AA related to rheumatic disease is declining, AA amyloidosis in people who inject drugs represents a growing challenge. The changing epidemiology of kidney amyloidosis may impact clinical presentation and future healthcare needs, emphasising the need for amyloid awareness.

An inflammatory environment following kidney transplantation is associated with increased risk of graft loss and mortality, however, evaluation of systemic inflammation is not implemented in structured risk assessment in kidney transplant recipients. Long-term results after transplantation are not satisfactory, and thus tools addressing these issues are needed. In this study, we tested the associations and predictive abilities of a predefined systemic inflammation score one year after transplantation on death-censored graft loss and mortality. We included 805 patients who underwent kidney transplantation between 2013 and 2017 at the Oslo University Hospital, Rikshospitalet. The inflammation score included five specifically selected biomarkers known to reflect various inflammatory pathways and to be associated with adverse outcomes following transplantation. The score was assessed in relation to outcomes in models with established risk factors. Discriminatory analyses were performed using Harrell´s C-statistic, and model assessment were evaluated using internal validation, calibration, and likelihood ratio tests. The median follow-up time was 6.4 years. There were 168 deaths (20.9%) and 42 graft losses (5.2%). The inflammation score one year after transplantation was significantly associated with graft loss (P<0.001) and mortality (P<0.001). The diagnostic performance of the model for graft loss revealed a c-statistic of 0.77 both with and without histological data. The diagnostic performance for mortality displayed a c-statistic of 0.79. In all tested scenarios, the model fit significantly improved after including the inflammation score. These results suggest a strong association between systemic inflammation one year after transplantation and both graft loss and mortality. Predictive models including the inflammation score and established risk factors were particularly informative when considering mortality. Evaluation of systemic inflammation using this score could be an important tool for risk-assessment after transplantation.

Cytomegalovirus (CMV) infection remains a challenge following kidney transplantation (KTx). Currently, CMV-IgG serostatus at transplantation is used to individualize CMV preventive strategies. We assessed the clinical utility of CMV-IGRA for predicting CMV infection following KTx. We performed a nationwide prospective cohort study from August 2016 until December 2022. Data from all adult KTx recipients in Norway, n=1,546 (R+; n=1,157, D+/R-; n=260, D-/R-; 129), were included with a total of 3,556 CMV-IGRA analyses (1,375 at KTx, 1,188 at eight weeks, 993 one-year after KTx) and 35,782 CMV DNAemia analyses. In R+ recipients CMV-IGRA status, measured at any of the time-points, could not identify any differential risk of later CMV infection. D+/R- recipients remaining CMV-IGRA negative 1-year after transplantation (regardless of positive CMV DNAemia and/or CMV IgG status at that time) had increased risk of developing later CMV infection compared to D+/R- recipients who had become CMV-IGRA positive (14% vs. 2%, p=0.01). Knowledge of pre-transplant CMV-IGRA status did not provide additional information to CMV-IgG serostatus that could improve current post-transplant CMV treatment algorithms. However, D+/R- recipients with a persisting negative CMV-IGRA one-year after transplantation remained at increased risk of experiencing later CMV infection. Therefore we advocate post-transplant CMV-IGRA monitoring in these patients.

The major reason for graft loss is chronic tissue damage, as interstitial fibrosis and tubular atrophy (IF/TA), where complement activation may serve as a mediator. The association of complement activation in a stable phase early after kidney transplantation with long-term outcomes is unexplored. We examined plasma terminal C5b-9 complement complex (TCC) 10 weeks posttransplant in 900 patients receiving a kidney between 2007 and 2012. Clinical outcomes were assessed after a median observation time of 9.3 years [interquartile range (IQR) 7.5-10.6]. Elevated TCC plasma values (≥0.7 CAU/ml) were present in 138 patients (15.3%) and associated with a lower 10-year patient survival rate (65.7% . 75.5%,  < 0.003). Similarly, 10-year graft survival was lower with elevated TCC; 56.9% . 67.3% ( < 0.002). Graft survival was also lower when censored for death; 81.5% . 87.3% (  = 0.04). In multivariable Cox analyses, impaired patient survival was significantly associated with elevated TCC [hazard ratio (HR) 1.40 (1.02-1.91), = 0.04] along with male sex, recipient and donor age, smoking, diabetes, and overall survival more than 1 year in renal replacement therapy prior to engraftment. Likewise, elevated TCC was independently associated with graft loss [HR 1.40 (1.06-1.85), = 0.02] along with the same covariates. Finally, elevated TCC was in addition independently associated with death-censored graft loss [HR 1.69 (1.06-2.71), = 0.03] as were also HLA-DR mismatches and higher immunological risk. Early complement activation, assessed by plasma TCC, was associated with impaired long-term patient and graft survival.

Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10–20% of patients with kidney transplants and in 20–40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.Post-transplant diabetes mellitus (PTDM) is a common complication of solid organ transplantation that can result in increased mortality. This Review outlines the pathogenesis, diagnosis, treatment and prevention of PTDM.

Background The use of HbA1c ≥6.5% for diagnosis of diabetes has been challenged for post-transplantation diabetes mellitus (PTDM) also known as new onset diabetes after transplantation (NODAT) due to a low sensitivity early after renal transplantation. PTDM diagnosed with an oral glucose tolerance test (OGTT) is highly predictable for long-term patient mortality. HbA1c was introduced for diagnosis based on the risk of developing diabetic retinopathy. The utility of HbA1c measures versus glucose criteria has not been widely assessed in stable transplant patients but still HbA1c is widely used in this population. The aim of the present analyses was to validate the utility of fasting plasma glucose (FPG) together with HbA1c in diagnosing PTDM in stable renal transplant recipients (RTRs). Methods OGTT’s were performed one year after transplantation in 494 consecutive RTRs without diabetes. FPG and HbA1c were obtained the same day, before starting the OGTT. Validation was performed using C-statistics and logistic regression analyses. Results PTDM was diagnosed in 51 patients (10.3%) by glucose criteria, 38 (74%) patients were diagnosed by FPG ≥7.0 mmol/L [126.1 mg/dl], and 13 (26%) only by 2-h plasma glucose. Six of the latter had HbA1c ≥6.5%. Only seven patients out of the 51 (13.7%) PTDM patients remained undiagnosed when HbA1c ≥6.5% was used together with FPG, and five of these regressed to normal after a median follow-up of 14 months. ROC curves including FPG and HbA1c versus OGTT derived criteria revealed an AUC of 0.858. Conclusions Combining standard diagnostic FPG and HbA1c criteria captured almost all patients with persistent PTDM in stable RTRs. The combined use of the criteria appears to be an applicable diagnostic strategy for PTDM without the need of an OGTT one year post-transplant. Trial registration Retrospectively registered.

Following a successful renal transplantation circulating markers of inflammation may remain elevated, and systemic inflammation is associated with worse clinical outcome in renal transplant recipients (RTRs). Vitamin D-receptor (VDR) activation is postulated to modulate inflammation and endothelial function. We aimed to explore if a synthetic vitamin D, paricalcitol, could influence systemic inflammation and immune activation in RTRs. Newly transplanted RTRs were included in an open-label randomized controlled trial on the effect of paricalcitol on top of standard care over the first post-transplant year. Fourteen pre-defined circulating biomarkers reflecting leukocyte activation, endothelial activation, fibrosis and general inflammatory burden were analyzed in 74 RTRs at 8 weeks (baseline) and 1 year post-engraftment. Mean changes in plasma biomarker concentrations were compared by t -test. The expression of genes coding for the same biomarkers were investigated in 1-year surveillance graft biopsies (n = 60). In patients treated with paricalcitol circulating osteoprotegerin levels increased by 0.19 ng/ml, compared with a 0.05 ng/ml increase in controls (p = 0.030). In graft tissue, a 21% higher median gene expression level of TNFRSF11B coding for osteoprotegerin was found in paricalcitol-treated patients compared with controls (p = 0.026). Paricalcitol treatment did not significantly affect the blood- or tissue levels of any other investigated inflammatory marker. In RTRs, paricalcitol treatment might increase both circulating and tissue levels of osteoprotegerin, a modulator of calcification, but potential anti-inflammatory treatment effects in RTRs are likely very modest. [NCT01694160 (2012/107D)]; [ www.clinicaltrials.gov ].

Impact of early cytomegalovirus infection and disease on long-term recipient and kidney graft survival. The impact of cytomegalovirus (CMV) infection and disease on long-term outcome after kidney transplantation is still unsettled. Between 1994 and 1997, 397 consecutive first kidney graft recipients and 74 retransplants were included in the study and followed prospectively until December 31, 2001. CMV infection (CMV pp65 antigenemia) and CMV disease were recorded once weekly during the first 100 days after transplantation. No CMV prophylaxis or preemptive therapy was given. In a multiple Cox proportional hazard model allowing time-dependent covariates, the effects of asymptomatic CMV infection and CMV disease, recipient age and gender, retransplantation, living donor, panel-reactive cytotoxid antibodies, acute rejection, and graft loss were tested on overall mortality beyond 100 days post-transplantation. In a similar analysis, the effect of asymptomatic CMV infection and CMV disease plus other factors were tested on death censored graft loss beyond 100 days. Median (range) follow up time was 66.6 (<1–86.9) months. The incidence of CMV infection and disease during the first 100 days was 62.8% and 23.4%, respectively. The number of total deaths was 96 (20%), 82 occurred after the first 100 days. Independent risk factors for overall mortality beyond 100 days were asymptomatic CMV infection, RR = 2.90 (95% CI 1.61–5.22) (P = 0.001), CMV disease, RR = 2.50 (95% CI 1.31–4.79) (P = 0.006), both compared to no infection or disease, recipient age, RR = 1.066 per year (95% CI 1.048–1.084) (P < 0.001), and graft loss in the whole study period RR = 7.88 (95% CI 4.75–13.08) (P < 0.001). Asymptomatic CMV infection and CMV disease were not independent risk factors for death censored graft loss, but they significantly reduced graft survival uncensored for death, (log rank P = 0.001, respectively). Asymptomatic CMV infection and overt CMV disease during the first 100 days increase the risk of recipient mortality beyond 100 days. This raises the question whether CMV prophylaxis should be given routinely after kidney transplantation.

Human cytomegalovirus (CMV) infection is a substantial cause of morbidity and mortality in immunocompromised hosts and globally is one of the most important congenital infections. The nucleoside analogue ganciclovir (GCV), which requires initial phosphorylation by the viral UL97 kinase, is the mainstay for treatment. To date, CMV decay kinetics during GCV therapy have not been extensively investigated and its clinical implications not fully appreciated. We measured CMV DNA levels in the blood of 92 solid organ transplant recipients with CMV disease over the initial 21 days of ganciclovir therapy and identified four distinct decay patterns, including a new pattern exhibiting a transient viral rebound (Hump) following initial decline. Since current viral dynamics models were unable to account for this Hump profile, we developed a novel multi-level model, which includes the intracellular role of UL97 in the continued activation of ganciclovir, that successfully described all the decline patterns observed. Fitting the data allowed us to estimate ganciclovir effectiveness in vivo (mean 92%), infected cell half-life (mean 0.7 days), and other viral dynamics parameters that determine which of the four kinetic patterns will ensue. An important clinical implication of our results is that the virological efficacy of GCV operates over a broad dose range. The model also raises the possibility that GCV can drive replication to a new lower steady state but ultimately cannot fully eradicate it. This model is likely to be generalizable to other anti-CMV nucleoside analogs that require activation by viral enzymes such as UL97 or its homologues.