Natalia Tomilina

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report

Background This article summarizes the 2012 European Renal Association—European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). Methods Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. Results In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3–60.0) which fell to 39.3% (95% CI: 38.7–39.9) in patients 65–74 years and 21.3% (95% CI: 20.8–21.9) in patients ≥75 years.

Hemodialysis practice patterns in the Russia Dialysis Outcomes and Practice Patterns Study (DOPPS), with international comparisons

Introduction: There is little comparable information about hemodialysis (HD) practices in low‐ and middle income countries, including Russia. Evaluation of HD in Russia and its international comparisons could highlight factors providing opportunities for improvement.

The Prognostic Value of Late Kidney Transplant Rejection Pathology Characteristics

Renal allograft rejection, represented by the wide spectrum of lesions with different pathogenesis, pathology patterns, clinical course and prognosis, still remains the most often cause of late graft dysfunction. Moreover, a combination of several factors, either of which may impact the post-transplant course, generally take place. We aimed to analyze the incidence of late renal allograft rejection variants, and to determine clinical factors and pathology features, influencing prognosis in the specific types of late renal allograft rejection. The data obtained from 361 patients with acute (n=227) or chronic (n=134) late allograft rejection (mean time after kidney transplantation 48.8 ± 46.1 months) were analyzed retrospectively. C4d expression was found in 34% cases of acute rejection and in 58% cases of chronic rejection (64% in chronic transplant glomerulopathy and 52% in transplant vasculopathy). 5-year graft survival comprised 48% and 24% for acute and chronic transplant rejection respectively (Р<0.01). Combination of acute cell-mediated rejection with chronic transplant rejection did not influence significantly the prognosis for the latter. Diffuse C4d expression on peritubular capillaries turned to be an independent prognostic factor regardless the pathology variant of renal allograft rejection. In contrast, focal C4d expression had no impact on the prognosis, which did not differ significantly from C4d-negative type. On the other hand, in acute rejection prognosis for C4dpositive forms was worse compared to C4d-negative (55% vs 25%; P <0.01), while in chronic rejection there was no difference between C4d-positive and C4d-negative forms (26% vs 24%; P=NS). In multivariate Cox-model analysis, the following factors appeared to influence the prognosis: presence of chronic transplant glomerulopathy, features of vasculitis, severity of tubulitis, presence of thrombotic micrioangiopathy and prominence of interstitial fibrosis.

МОРФОЛОГИЧЕСКАЯ СТРУКТУРА ПАТОЛОГИИ ПОЧЕЧНОГО АЛЛОТРАНСПЛАНТАТА И ЕЕ ВЛИЯНИЕ НА ОТДАЛЕННЫЙ ПРОГНОЗ

Aim: to analyze the frequency of different histological diagnoses and it simpact on graft survival in a cohort of patients with renal allograft dysfunction, and to determine pathology features, infl uencing prognosis. Materials and methods. The data obtained from 1470 biopsies, performed by indication at different time after kidney transplantation (48.8 ± 46.1 months) were analyzed retrospectively according to the Banff 2013 classifi cation. Results. The majority of graft dysfunction episodes were attributed to fi ve causes: acute (26,8%) and chronic (12,4%) rejection; chronic nephrotoxicity of СNI (19,3%), interstitial fi brosis/tubular atrophy (15,8%) and recurrent or de novo glomerulonephritis (10,6%). T-cell-mediated acute rejection and functional disorders were the most often cause of dysfunction during the fi rst year after transplantation (40,5% and 21% respectively) but decreased over time. On the other hand, the frequency of chronic rejection, interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity and recurrent or de novo glomerulonephritis increased from 13%, 26% and 5,5% at the fi rst year to 26,4%, 35,3% and 22,8% respectively at 8 year after transplantation. Chronic rejection represented a major risk for graft loss – 8-year graft survival did not exceed 5%. The prognosis of acute rejection as well as de novo or recurrent glomerular pathologies was more favorable (38% and 42% respectively). In cases of interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity 8-year graft survival was slightly lower than in the functional disorders (62% and 76%). In acute rejection prognosis for C4d-positive forms was worse compared to C4d-negative, while in chronic rejection there was no difference between C4d-positive and C4d-negative forms. The features of СNI nephrotoxicity did not infl uence the prognosis of non-specifi c interstitial fi brosis and tubular atrophy. Conclusion. Transplant pathology in patients with allograft dysfunction is heterogeneous and changes over time. Acute and chronic rejection; interstitial fi brosis/tubular atrophy with or without СNI nephrotoxicity and recurrent/ de novo glomerular pathology are the most often causes of graft dysfunction, but only rejection (mostly chronic) and glomerular pathology are associated with unfavorable prognosis.

Chronic Antibody Mediated Rejection of Renal Allograft - Efficacy of Combined Treatment with Plasma Exchanges, Intravenous Immunoglobulin and Rituximab (One Center Experience)

Chronic antibody mediated rejection (CAMR) is the main cause for late kidney transplant loss, and the results of its treatment are dissatisfying. In our one center study we evaluated the efficacy of combined treatment with plasma exchanges, intravenous immunoglobulin and rituximab on the top of standard immunosuppression in 24 patients with chronic transplant glomerulopathy (TG), compared to control group of 26 patients, who did not receive additional treatment. At the time of diagnosis baseline estimated glomerular filtration rate (eGFR) did not differ between treatment and control subgroups (44.9 ± 21.3 vs 41.2 ± 14.6 ml/min, P = 0.47), as well as any other laboratory or pathology data, and subsequent decline of allograft function was also found in both subgroups. However, the rate of eGFR decline was significantly lower in the patients from the treatment subgroup compared to the controls: -0.47 ± 0.6 ml/min/month and -1.31 ± 1.6 ml/min/month respectively (P = 0.02). Thus 3-year transplant survival turned to be 21.3% in the control subgroup vs 64.8% in the treatment subgroup (p = 0.01). Our study demonstrated, that TG, which is the most often variant of CAMR, is characterized by unfavorable prognosis regardless of its pathology features and activity at the time of diagnosis. Combined treatment, including plasma exchanges (PE), intravenous immunoglobulin (IVIG) and rituximab (Rtx) allows slowing down the rate of the disease progression at least in some proportion of patients with lately diagnosed CAMR.