Renal transplant pathology and factors determining the rate of its progression

The structure of allograft dysfunction is heterogeneous, and the peculiarities of its course depend on the underlying pathological process as well as other factors that influence how quickly it progresses. The most significant of these factors are the prevalence of interstitial fibrosis and tubular atrophy. Objective: to evaluate the factors influencing the rate of nephropathy progression depending on the nature of dysfunction. Materials and methods. The study included 189 kidney transplant recipients with morphologically verified renal graft dysfunction. Patients were divided into five categories based on their morphological pictures: Group 1, acute tubular necrosis (ATN) (n = 20); Group 2, cellular rejection (CR) (n = 50); Group 3, antibody-mediated rejection (AMR) (n = 61); Group 4, interstitial fibrosis and tubular atrophy (IFTA) (n = 41); Group 5, recurrent or de novo glomerulonephritis (GN) (n = 17). Results. Even though graft function tended to improve with treatment, The CR and AMR groups had the lowest long-term graft survival rates at 12 months, amounting to 64% and 54%, respectively, while the IFTA and GN groups had the highest, 79% and 86%, respectively. ATN patients (94%) showed the best 1-year survival. In the multivariate analysis performed in the Cox regression model, only two factors – creatinine level at the time of biopsy and IFTA prevalence – were found to be independent predictors of prognosis, regardless of the underlying mechanism of injury. A prognostic model that incorporates both characteristics demonstrated significantly higher prognostic accuracy. A combination of creatinine level ≥200 μmol/L and an interstitial fibrosis prevalence ≥20% of the parenchyma area showed the strongest correlation with prognosis. This model had a 91% sensitivity and a 28% specificity (p < 0.01 95% CI: 0.74–0.89). Conclusion. When assessing the risk of graft loss, it is necessary to consider the entire set of potential prognostic factors, such as the nature of the underlying disease, severity of graft dysfunction and prevalence of background interstitial fibrosis. 

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