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II. ХИРУРГИЯ
DETECTION OF CMV INFECTION BY BIOPSY IN RECIPIENTS WITH KIDNEY GRAFT DYSFUNCTION
Baimakhanov B.B., Ibragimov R.P., Enin E.A., Madadov I.K., Syrymov Zh.M., Belgibaev E.B., Dabyltaeva K.S.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan
Abstract
Kidney transplantation is the most effective and preferable treatment option of terminal stage of chronic kidney disease. Nowadays kidney transplantation is well-developed modality and early graft and patient survival rates overall the world greatly increased. But improvement of graft and patient survival rates in long-term period remains to be problem. Beside the immunologic factors that causes either acute or chronic graft rejection, there are another etiologic factors of graft rejection. Infections, particularly wide-spread in solid organ recipients - cytomegalovirus infection (CMV), appears to be one of this etiologic factors. Mechanism of injury of graft by cytomegalovirus remains to be unclear. Diagnostics of CMV is also a difficult objective. In our institution we conducted an investigation aimed the detection of CMV by graft biopsy in patients with graft dysfunction. The main objective of this investigation is the demonstration of efficacy of biopsy in diagnostics of CMV infection in graft dysfunction.
БYЙрек трансплантатыньщ дисфункциясы бар реципиенттерде биопсия аркылы ЦМВ инфекциясын аныктау
МРНТИ 76.29.43
Баймаханов Б.Б., Ибрагимов Р.П., Енин Е.А., Мададов И.К., Сырымов Ж.М., Белгибаев Е.Б., Дабылтаева К.С.
А.Н. Cbi3FaHOB атындаы Улттык, ?ылыми хирургия орталы^ы, Алматы, Казахстан
Ацдатпа
БYЙрек трансплантациясы созылмалы бYЙрек ауруыньщ терминальд сатысынын ен эффективт жэне тандаулы емдеу методы болып саналады. Kазiргi танда бYЙрек трансплантациясы жорары денгейде дамыран жэне ерте периодтары трансплантаттын т'р калу керсеткiштерi бYкiл дYние бойынша катты жаксарды. Б'рак, узак мерз'шдеп трансплантаттыр т'р калу кврсеткiштерiнжаксарту киын мэселе болып табылады. Трансплантатты жедел жэне созылмалы кабылдамау реакциясына себеп болатын иммуно-логиялык себептерден баска да себептер бар. Сол себептерге инфекция, эсресе бундай наукастар арасында кен тарапран, цитомегаловирусты инфекция жатады. Цитомегаловирусты инфекциянын трансплантатты закымдату механизм! каз^рп танда шешлмеген мэселе болып табылады. Цитомегаловирусты инфекциянын диагностикасы да ете киын тапсырма болып саналады. Бiздiн ортапырымызда жасалып жаткан зерттеудiн максаты бYЙрек трансплантатынын дисфункциясы бар наукастарда биопсия аркылы ЦМВ инфекция аныктау. Бул зерттеудiн басты максаты трансплантат биопсиясынын ЦМВ инфекциясынын аныктаудары тмдшш дэлелдеу.
ABOUT THEАUTHORS
B.B.Baimakhanov - professor, transplant-surgeon, chairman of Board of JSC «NSCS named after A.N.Syzganov» (info@baimakhanov.kz, 87017223381). R.P. Ibragimov - urologist, transplant-surgeon, head of kidney transplantation, urology and nephrology department, scientific manager. (rava747@mail.ru 87017472070) E.A. Enin - pathomorphologist, head of department of pathomorphology (enin66@mail.ru 87018555666). I.K. Madadov - urologist, kidney transplantation, urology and nephrology department (dominic89@mail.ru 87478397110) Zh.M. Syrymov - urologist, kidney transplantation, urology and nephrology department (syrymov89@mail.ru 87072727002) E.B.Belgibaev - urologist, kidney transplantation, urology and nephrology department (dr_beb@mail.ru87759776773) K.S. Dabyltaeva - nephrologist, kidney transplantation, urology and nephrology department. (d_kuralay_s@mail.ru 87027651566)
Keywords
cytomegalovirus, graft dysfunction, biopsy, kidney transplantation.
АВТОРЛАР ТУРАЛЫ
Б.Б. Баймаханов - профессор, трансплантолог дэрiгерi, А.Н. Сызганов атындаы «Улттык гылыми хирургия орталыгы» АК^-нын баскарма теарагасы (тШЬа/такЬапоV.к!,, 87017223381). Р. П. Ибрагимов - уролог-транспланто-логдэрiгерi, буйрек трансплантациясы, урология жэне нефрология белiмшесiнiн менгерушс, гылыми жетекшi (rava747@mail.ru 87017472070) Е. А. Енин - паторморфологдэргер, патоморфология белiмшесiнiн менгеруша (enin66@mail.ru 87018555666). И.К. Мададов - уролог дэрiгерi, буйрек трансплантациясы, урология жэне нефрология белiмшесi, кiшi гылыми кызметкер (dominic89@mail.ru 87478397110) Ж.М. Сырымов - уролог дэргер, буйрек трансплантациясы, урология жэне нефрология белiмшесi ^угутоу89@таИ т 87072727002)
Е.Б. Белгибаев - уролог дэргер, буйрек трансплантациясы, урология жэне нефрология белiмшесi (dr_beb@mail.ru 87759776773) %.С. Дабылтаева - нефрологдэргер, буйрек трансплантациясы, урология жэне нефрология белiмшесi (d_kuralay_s@mail.ru 87027651566)
Туйш сездер
цитомегаловирус, трансплантаттыр дисфункциясы, биопсия, буйрек трансплантациясы.
Выявление инфекции ЦМВ с помощью биопсии у реципиентов с дисфункцией почечного трансплантата
ОБ АВТОРАХ
Б.Б.Баймаханов - профессор, трансплантолог, председатель правления АО «Национального научного центра хирургии им. А.Н. Сызганова» (тО@Ьатак11апоу.
к!, 87017223381). Р. П. Ибрагимов - уролог-трансплантолог, заведующий отделением трансплантации почек, урологии и нефрологии, руководитель исследования (тауа747@ mai1.ru 87017472070) Е.А. Енин - патоморфолог, заведующий отделением патоморфологии (впт66@ таП.П! 87018555666). И.К. Мададов - уролог, отделение трансплантации почек, урологии и нефрологии, младший научный сотрудник (domiпic89@ mai1.ru 87478397110) Ж.М. Сырымов - уролог, отделение трансплантации почек, урологии и нефрологии, ($угутт89@таП.П1 87072727002) E.Б.Белгибаев - уролог, отделение трансплантации почек, урологии и нефрологии(dr_beb@mail.ru 87759776773) К.С.Дабылтаева - нефролог, отделение трансплантации почек, урологии и нефрологии, (d_kuralay_s@mail.ru 87027651566)
Ключевые слова
цитомегаловирус, дисфункция трансплантата, биопсия, трансплантация почки.
Баймаханов Б.Б., Ибрагимов Р.П., Енин Е.А., Мададов И.К., Сырымов Ж.М., Белгибаев Е.Б., Дабылтаева К.С.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Аннотация
Трансплантация почки является наиболее эффективным и предпочитаемым методом лечения терминальной стадии хронической болезни почек. На сегодняшний день трансплантация почек развита на высшем уровне и ранняя выживаемость трансплантата и пациента по всему миру значительно возросла. Однако остается проблемой улучшение показателей выживаемости трансплантата и пациента в отдаленном периоде. Помимо иммунологических факторов, влияющих на развитие как острого, так и хронического отторжения трансплантата, имеются и другие причины развития реакции отторжения. К таким факторам можно отнести инфекцию, и, в частности, наиболее распространенную среди данной категории пациентов, цитомегаловирусная инфекция. Остается нерешенным вопросом механизм повреждения трансплантата цитомегаловирусной инфекцией. Также сложной задачей является диагностика цитомегаловирусной инфекции. На базе нашего центра мы провели исследование, целью которой является выявление ЦМВ инфекции с помощью биопсии почечного трансплантата у пациентов с дисфункцией трансплантата. Главной задачей исследования является доказательство эффективности биопсии трансплантата в диагностике ЦМВ инфекции при дисфункциях трансплантата.
Introduction
Kidney transplantation nowadays is the best therapeutic option for end-stage kidney disease. Allograft survival after transplantation has improved substantially over the past few decades dueto improvedtherapeutic management, more precise follow up and increased awareness of patients about their disease [1,2,3]. On the other hand, prevention of infectious complications are now more potent, despite more intense and efficacious immunosuppressive regimen [4].
Despite advances in short-term outcomes after transplantation, long-term allograft survival has improved only minimally. In a large US transplant registry, the yearly attrition rate for allograft failure at 5-10 years after transplant changed between 1989 and 2008, respectively, from 4.7% to 4.3% for liver, from 10.9% to 10.1% for lung and from 6.4% to 5.1% for kidney transplant recipients [5, 6].
In our experience there is also an improvement in graft and patient survival. For instance, 1-year graft survival increased from 59.4% in 2012 to 94.80 % in 2017. Similar increase was seen in rates of 1-year patient survival, from 75% in 2012 to 100 % in 2017.
Chronic allograft dysfunction has multifactorial etiology: immunological (acute and chronic antibody- and T cell-mediated rejection) and non-immunological factors (delayed allograft function,
infections, hypertension and others comorbidities) [7-9].
The great majority of renal transplant recipients have latent cytomegalovirus (CMV) infection [10], which in 20-60% of patients causes CMV disease with clinical signs and symptoms of fever, leucopenia and organ involvement [11].
Material and methods
We conducted a retrospective study of 54 kidney transplant patients with graft dysfunction. All patients presented with elevated creatinine, proteinuria,signs of graft rejection on ultrasound. Of all patients, 33 were male and 21 female patients. Mean age was 33.52y10.78 years. We performed graft biopsy with Pro*Mag TM Biopsy Needle 16G. All microslides were evaluated for CMV infection.
Biopsy material was sustained in 10% neutral formalin solution.
Furtherly samples were dehydrated by standard method in automatic tissue processor with closed contour Termo SCIENTIFIC Excelsior AS. 4-5em thick paraffin-embedded sections were made on rotational microtom SakuraAccu-Cut SRM 200.
For a review study hematoxylin staining was made on Termo SCIENTIFIC Gemini AS staining station. Luminescence: section of material was made on cryostat Leica CM 1950, with reagents from TermoFicher Company. Finished microslides
were reviewed by microscope: ZEISS AXIO Imager Z 2 (Germany) with camera Axiocam 506 color and software ZEISS ZEN Imaging Software. Luminescence was performed by Leica DM 4000 B with dark-field microscopy Leica DFC 310 - FX . Results
All patients were divided into 4 groups according to the results. First group were patients with acute graft rejection (TCMR) (n = 12), the second group - were patients with chronic graft rejection (n=22), the third group - chronic rejection associated with focuses of acute rejection (n=12) and the fourth group - patients with miscellaneous reasons of graft dysfunction (De novo glomerulonephritis, acute tubular necrosis, interstitial nephritis and etc.)(n=8).
All patients were evaluated for serological matchings as to the IgG status (D=donor and R=recipient): D+/R+=45.3%, D-/R+=24.7%, D+/ R-=17.4%, and D-/R-=12.6%.
In first group in 2 cases CMV infection was detected, whereas in second group no CMV infection was seen (Pic. 1-2). However, in third group, in patients with chronic graft rejection + focuses of acute rejection also in 2 cases CMV infection was detected (Pic. 3-4). In forth group no CMV infection was detected. Thus, CMV infection can be estimated as the one of the reasons of acute graft rejection, but not chronic rejection or other factors of graft rejection. The cases of acute graft rejection were T-cell mediated rejection (TCMR), that refers to as CMV infection contributes to T cell activation and further rejection, but it is not completely clear the exact mechanism by which it acts.
Discussion
The serological status is a long-term prognostic marker regardless of the development of the disease. When D+/R- are compared with D-/R-, there is a 28% increase in risk of graft loss, 36% in the risk of death due to all causes, and eightfold the risk of dying by a viral infection. Serological typing, therefore, is indicated for all donors and recipients [12, 13].
Primo-infection refers to new-onset infection and reactivation is considered as activation previouslypersisting infection.CMV disease is characterized by the clinical syndrome in which there are symptoms, such as fever, asthenia, myalgia, leukopenia, thrombocytopenia, or hepatic enzyme alterations, or by the invasive disease, in which there is evidence of viral inclusion in cells of organs or tissues, such as in the gastrointestinal tract, liver, in the renal graft, lungs, bone marrow and retina. The effects of CMV infection can be classified as direct or indirect. The direct effects
are infection and disease, as mentioned above. The indirect effects observed are increased risk of secondary infections, such as pneumocystosis and other herpes viruses, and increased risk of acute rejection and of chronic graft dysfunction [14].
Fig. 1
PAS staining. Magnification x 200
Fig. 2
Azan trichome staining. Magnification x 200.
Fig. 3
Immunohistochemistry -C4d. Magnification x 200.
Fig. 4
Immune enzyme assay CMV g8
Quantitative blood polymerase chain reaction (PCR) for cytomegalovirus (CMV) is used to direct therapy in kidney transplant patients, but cytomegalic inclusions are rarely found in allograft renal biopsies even with an elevated serum creatinine and apparent CMV disease. The relationship between quantitative blood CMV and renal allograft pathology is unknown. Liapis H.et. al. have studied thirteen biopsy samples from patients suspected of CMV disease, who had a buffy coat CMV-PCR drawn within 2-5 days of a renal allograft biopsy for an elevated creatinine. All were evaluated for CMV pathologically, by light microscopy, immunohistochemistry, in situ hybridization and tissue PCR.Qualitative and quantitative buffy coat CMV-PCR were positive in 10/13 (77%) patients. Tissue CMV-PCR was positive in five (50%) biopsies, including two with CMV inclusions and three with no inclusions. Quantitative buffy coat CMV-PCR levels did not correlate with detection of CMV inclusions in renal tissue. Paradoxically, quantitative buffy coat CMV-PCR was low (239 and 538 copies/microg of
References
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DNA) when CMV inclusions were detected. All five biopsies with acute rejection were associated with CMV viraemia and two of the five with allograft CMV inclusions. A quantitative buffy coat CMV-PCR of <100 copies/microg of DNA ruled out disease with CMV inclusions [15]. Thus, CMV infection is important predisposing factor for acute allograft rejection after kidney transplantation. The control of CMV infection could decrease episodes of acute kidney rejection [16].
Conclusion
In our experience CMV infection was detected by biopsy only in 20% cases and only in patients with acute graft rejection. It is not completely clear the mechanism of direct effect of CMV in graft tissue but it's obvious that it can be the cause of acute graft rejection. Biopsy proven CMV didn't correlate with PCR results due clinical data but it appears to be essential to perform both graft biopsy and PCR in order to better detect the infection.
11. Hibberd PL, TolkoffyRubin NE, Cosimi AB et al. Symptomatic cytomegalovirus disease in the cytomegalovirus antibody seropositive renal transplant recipient treated with OKT3. Transplantation,2012;53:68-72.
12. KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary.Kasiske BL, Zeier MG, Chapman JR, Craig JC, Ekberg H, Garvey CA, Green MD, Jha V, Josephson MA, Kiberd BA, Kreis HA, McDonald RA, Newmann JM, Obrador GT, Vincenti FG, Cheung M, Earley A, Raman G, Abariga S, Wagner M, Balk EM, Kidney Disease: Improving Global Outcomes.Kidneylnt. 2010 Feb; 77(4):299-311.
13. Prevention of cytomegalovirus disease in recipients of solid-organ transplants.Paya CVClin Infect Dis. 2001 Feb 15; 32(4):596-603.
14. Kotton CN, Fishman JA.Viral infection in the renal transplant recipients. J Am SocNephrol. 2005;16(6):1758-1774. Review.
15. Liapis H1, Storch GA, Hill DA, Rueda J, Brennan DC.CMV infection of the renal allograft is much more common than the pathology indicates: a retrospective analysis of qualitative and quantitative buffy coat CMV-PCR, renal biopsy pathology and tissue CMV-PCR.NephrolDialTransplant. 2003 Feb;18(2):397-402.
16. Boshra Hasanzamani,* Maryam Hami, Vajihe Zol-faghari, Mahtab Torkamani, Mahin Ghorban Saba-gh, and Saiideh Ahmadi Simab "The effect of cytomegalovirus infection on acute rejection in kidney transplanted patients" J Renal Inj Prev. 2016; 5(2): 85-88.
