Hepatitis C and renal transplantation in era of new antiviral agents

Data from World Health Organization estimates that the hepatitis C virus(HCV) prevalence is 3% and approxi-mately 71 million persons are infected worldwide. HCV infection is particularly frequent among patients affected by renal diseases and among those in dialysis treatment. In addition to produce a higher rate of any cause of death, HCV in renal patients and in renal transplanted patients produce a deterioration of liver disease and is a recognized cause of transplant glomerulopathy, new onset diabetes mellitus and lymphoproliferative disorders. Treatment of HCV infection with interferon alpha and/or ribavirin had a poor efficacy. The treatment was toxic, expensive and with limited efficacy. In the post-transplant period was also cause of severe humoral rejection. In this review we have highlighted the new direct antiviral agents that have revolutionized the treatment of HCV both in the general population and in the renal patients. Patients on dialysis or with low glomerular filtration rate were particularly resistant to the old therapies, while the direct antiviral agents allowed achieving a sustained viral response in 90%- 100% of patients with a short period of treatment. This fact to date allows HCV patients to enter the waiting list for transplantation easier than before. These new agents may be also used in renal transplant patients HCV -positive without relevant clinical risks and achieving a sustained viral response in almost all patients. New drug appears in the pipeline with increased profile of efficacy and safety. These drugs are now the object of several phases Ⅱ, Ⅲ clinical trials.

Current protocols and outcomes of ABO-incompatible kidney transplantation

One of the principal obstacles in transplantation from living donors is that approximately 30%are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system.The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation.Two different strategies are used to overcome these barriers:desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs.The largest part of this review is dedicated to describing the techniques of desensitization.Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980,the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs.Rituximab has substantially replaced splenectomy.The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects.Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.

Microbiota,renal disease and renal transplantation

Aim of this frontier review has been to highlight the role of microbiota in healthy subjects and in patients affected by renal diseases with particular reference to renal transplantation.The microbiota has a relevant role in conditioning the healthy status and the diseases.In particular gut microbiota is essential in the metabolism of food and has a relevant role for its relationship with the immune system.The indigenous microbiota in patients with chronic renal failure is completely different than that of the healthy subjects and pathobionts appear.This abnormality in microbiota composition is called dysbiosis and may cause a rapid deterioration of the renal function both for activating the immune system and producing large quantity of uremic toxins.Similarly,after renal transplantation the microbiota changes with the appearance of pathobionts,principally in the first period because of the assumption of immunosuppressive drugs and antibiotics.These changes may deeply interfere with the graft outcome causing acute rejection,renal infections,diarrhea,and renal interstitial fibrosis.In addition,change in the microbiota may modify the metabolism of immunosuppressive drugs causing in some patients the need of modifying the immunosuppressant dosing.The restoration of the indigenous microbiota after transplantation is important,either to avoiding the complications that impair the normal renal graft,and because recent studies have documented the role of an indigenous microbiota in inducing tolerance towards the graft.The use of prebiotics,probiotics,smart bacteria and diet modification may restore the indigenous microbiota,but these studies are just at their beginning and more data are needed to draw definitive conclusions.

New Year's greeting and overview of World Journal of Transplantation in 2021

World Journal of Transplantation(WJT)was launched in December 2011.While we are celebrating WJT’s 10-year anniversary,we are very proud to share with you that since its first issue,WJT has published 312 articles,which have been cited 2786 times(average cites per article of 9.0).Together with an excellent team effort by our authors,Editorial Board members,independent expert referees,and staff of the Editorial Office,WJT advanced in 2020.In this editorial,we summarize the journal’s bibliometrics,including its citation report,published articles in 2020,peer review rate and manuscript invitation metrics,as well as its Editorial Board members and existing problems of WJT.The overall aim of this editorial is to promote the development of WJT in 2021.We appreciate the continuous support and submissions from authors and the dedicated efforts and expertise by our invited reviewers.This collective support will allow us to be even more productive in 2021.In addition,we commit to working with you all to raise the academic influence of WJT over the upcoming year.Finally,on behalf of WJT,we wish you and your families the best for the New Year.

Histological and clinical evaluation of marginal donor kidneys before transplantation: Which is best?

Organ shortage represents one of the major limitations to the development of kidney transplantation.To increase the donor pool and to answer the ever increasing kidney request,physicians are recurring to marginal kidneys as kidneys from older donors,from hypertensive or diabetic donors and from nonheart beating donors.These kidneys are known to have frequently a worse outcome in the recipients.To date major problem is to evaluate such kidneys in order to use or to discard them before transplantation.The use of such kidneys create other relevant question as whether to use them as single or dual transplant and to allocate them fairly according transplant programs.The pre-transplant histological evaluation,the clinical evaluation of the donor or both the criteria joined has been used and according the time each criterion prevailed over the others.Aim of this review has been to examine the advantages and the drawbacks of any criterion and how they have changed with time.To date any criterion has several limitations and several authors have argued for the development of new guidelines in the field of the kidney evaluation for transplantation.Several authors argue that the use of omic technologies should improve the organ evaluation and studies are ongoing to evaluate these technologies either in the donor urine or in the biopsies taken before transplantation.

Therapeutic apheresis in kidney transplantation: An updated review

Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased-or living-donor transplantation. Postoperatively,additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.