Clinical perspectives towards improving risk stratification strategy for renal transplantation outcomes in Indian patients

Vijay Kher; Vivek B Kute; Sarbeswar Sahariah; Deepak S Ray; Dinesh Khullar; Sandeep Guleria; Shyam Bansal; Sishir Gang; Anil Kumar Bhalla; Jai Prakash; Abi Abraham; Sunil Shroff; Madan M Bahadur; Pratik Das; Urmila Anandh; Arpita Ray Chaudhury; Manoj Singhal; Jatin Kothari; Sree Bhushan Raju; Dilip Kumar Pahari; G Vishwanath Siddini; G Sudhakar; Santosh Varughese; Tarun K Saha

doi:10.4103/ijot.ijot_28_21

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EXPERT OPINION

Year : 2022 \| Volume : 16 \| Issue : 2 \| Page : 145-154

Clinical perspectives towards improving risk stratification strategy for renal transplantation outcomes in Indian patients Vijay Kher¹, Vivek B Kute², Sarbeswar Sahariah³, Deepak S Ray⁴, Dinesh Khullar⁵, Sandeep Guleria⁶, Shyam Bansal¹, Sishir Gang⁷, Anil Kumar Bhalla⁸, Jai Prakash⁹, Abi Abraham¹⁰, Sunil Shroff¹¹, Madan M Bahadur¹², Pratik Das⁴, Urmila Anandh¹³, Arpita Ray Chaudhury¹⁴, Manoj Singhal¹⁵, Jatin Kothari¹⁶, Sree Bhushan Raju¹⁷, Dilip Kumar Pahari¹⁸, G Vishwanath Siddini¹⁹, G Sudhakar¹⁹, Santosh Varughese²⁰, Tarun K Saha²¹ ¹ Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurugram, Haryana, India ² Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India ³ Department of Transplantation Surgery, KIMS Hospital, Hyderabad, India ⁴ Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India ⁵ Department of Nephrology, Max Saket Complex, Max Super Speciality Hospital, Saket, Delhi, India ⁶ Department of Transplantation Surgery, Indraprastha Apollo Hospital, Varanasi, Uttar Pradesh, India ⁷ Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India ⁸ Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India ⁹ Department of Nephrology, Banaras Hindu University, Varanasi, Uttar Pradesh, India ¹⁰ Department of Nephrology, VPS Lakeshore Hospital, Kochi, Kerala, India ¹¹ Managing Trustee, MOHAN Foundation, Chennai, Tamil Nadu, India ¹² Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, Maharastra, India ¹³ Department of Nephrology, Yashoda Hospitals, Secunderabad, Telangana, India ¹⁴ Department of Nephrology, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India ¹⁵ Department of Nephrology, Max Super Specialty Hospital, Vaishali, Ghaziabad, India ¹⁶ Department of Nephrology, Nanavati Max Hospital, Mumbai, Maharastra, India ¹⁷ Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India ¹⁸ Department of Nephrology, Medica Super Specialty Hospital, Kolkata, West Bengal, India ¹⁹ Department of Nephrology, Manipal Hospital, Bengaluru, Karnataka, India ²⁰ Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India ²¹ Department of Nephrology, Apollo Hospital, Secunderabad, Telangana, India Correspondence Address: Dr. Vivek B Kute IKDRC-ITS, Ahmedabad, Gujarat India Source of Support: None, Conflict of Interest: None DOI: 10.4103/ijot.ijot_28_21

Graft loss and rejections (acute/chronic) continue to remain important concerns in long-term outcomes in kidney transplant despite newer immunosuppressive regimens and increased use of induction agents. Global guidelines identify the risk factors and suggest a framework for management of patients at different risk levels for rejection; however, these are better applicable to deceased donor transplants. Their applicability in Indian scenario (predominantly live donor program) could be a matter of debate. Therefore, a panel of experts discussed the current clinical practice and adaptability of global recommendations to Indian settings. They also took a survey to define risk factors in kidney transplants and provide direction toward evidence- and clinical experience-based risk stratification for donor/recipient and transplant-related characteristics, with a focus on living donor transplantations. Several recipient related factors (dialysis, comorbidities, and age, donor-specific antibodies [DSAs]), donor-related factors (age, body mass index, type – living or deceased) and transplantation related factors (cold ischemia time [CIT], number of transplantations) were assessed. The experts suggested that immunological conflict should be avoided by performing cytotoxic cross match, flow cross match in all patients and DSA-(single antigen bead) whenever considered clinically relevant. HLA mismatches, presence of DSA, along with donor/recipient age, CIT, etc., were associated with increased risk of rejection. Furthermore, the panel agreed that the risk of rejection in living donor transplant is not dissimilar to deceased donor recipients. The experts also suggested that induction immunosuppression could be individualized based on the risk stratification.



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