Delayed Graft Function and Cast Nephropathy Associated with Tacrolimus Plus Rapamycin Use
Kelly D. Smith*,
Lucile E. Wrenshall,
Roberto F. Nicosia*,¶,
Raimund Pichler,
Christopher L. Marsh,
Charles E. Alpers*,
Nayak Polissar and
Connie L. Davis
Departments of *Pathology, Surgery, Medicine, and Division of Transplantation, University of Washington Medical Center, Seattle, Washington; The Mountain-Whisper-Light Statistical Consulting, Seattle, Washington; ¶Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
Correspondence to Dr. Connie L. Davis, Box 356174, 1959 NE Pacific St., Seattle, WA 98195. Phone: 206-598-6079; Fax: 206-598-6706;
ABSTRACT. Delayed graft function (DGF) occurs in 15 to 25% (range,10 to 62%) of cadaveric kidney transplant recipients and upto 9% of living donor recipients. In addition to donor, recipient,and procedural factors, the choice of immunosuppression mayinfluence the development of DGF. The impact of immunosuppressionon DGF was studied. The frequency of DGF was evaluated in firstcadaveric or living donor kidney allograft recipients (n = 144)transplanted at the University of Washington from November 1999through September 1, 2001. Donor, recipient, and proceduralfactors, as well as biopsy results, were compared between patientswho developed DGF and those who did not. DGF was more commonin patients treated with rapamycin than without (25% versus8.9%, P = 0.02) and positively correlated with rapamycin dose(P = 0.008). In those developing DGF, the duration of posttransplantdialysis increased with donor age (P = 0.003) but decreasedwith mycophenolate mofetil use (P = 0.01). All biopsies duringepisodes of DGF demonstrated changes of acute tubular injury.Of the patients with tubular injury, 12 treated with rapamycinand tacrolimus developed intratubular cast formation indistinguishablefrom myeloma cast nephropathy. Histologic, immunohistochemical,and ultrastructural studies indicated that these casts werecomposed at least in part of degenerating renal tubular epithelialcells. These findings suggest that rapamycin therapy exertsincreased toxicity on tubular epithelial cells and/or retardshealing, leading to an increased incidence of DGF. Additionally,rapamycin treatment combined with a calcineurin inhibitor maylead to extensive tubular cell injury and death and a uniqueform of cast nephropathy. E-mail: cdavis@u.washington.edu
Delayed graft function in renal allografts occurs most frequentlydue to peritransplant ischemic injury or toxic medication exposure(1–5). Several donor factors (increased age, hypertension>10 yr, creatinine clearance <80 cc/min, vascular sclerosis,weight, female gender, nontraumatic death), recipient factors(pre-sensitization, ethnicity, pretransplant pro-inflammatorycytokine levels, pretransplant anuria, pretransplant mean arterialpressure <100 mHg, American Society of Anesthesiology physicalstatus category IV), and transplant procedural factors (coldischemia times, anastomotic times, selection of preservationsolution) are associated with an increased occurrence of DGF.Immunologic factors (rejection) and coagulant mechanisms (thrombosis)also influence the development of DGF. Furthermore, immunosuppressivemedications have been shown to affect DGF. The cytokine releasesyndrome produced by OKT3 or anti-thymocyte globulins and high-dosecalcineurin inhibitor use immediately after transplantationare associated with an increased risk for DGF (6,7). Calcineurininhibitors may contribute to acute injury by promoting renalallograft ischemia (8) and perhaps by enhancing renal tubularepithelial cell apoptosis (9). The use of mycophenolate mofetilhas not been shown to influence the development of DGF (10).
Rapamycin is being used increasingly as a maintenance immunosuppressiveagent with designs to decrease steroid and/or calcineurin inhibitorexposure (11–13). When used without a calcineurin inhibitor,rapamycin has been demonstrated to spare renal function; however,when rapamycin is used in combination with calcineurin inhibitors,serum creatinine levels often increase (11,14,15). Blood andtissue concentrations of both cyclosporine and rapamycin areincreased when used in combination, possibly resulting fromboth drugs similar route of metabolism by cytochrome P450 3A4and P-glycoprotein (15–18). Because tacrolimus is metabolizedby the same metabolic pathways, the same may be true for combinedrapamycin and tacrolimus therapy. Although, pharmacokineticstudies indicate that simultaneous administration of tacrolimusand rapamycin does not elevate blood levels of these drugs (13),increased intrarenal cellular concentrations of cyclosporineor tacrolimus are hypothesized to cause the impaired renal functionseen during the combined use of calcineurin inhibitors withrapamycin (14,15,19).
The immunosuppressive effects of rapamycin are derived fromthe inhibition of cytokine- and growth factor-mediated signaltransduction in T and B lymphocytes. Rapamycin acts throughthe FKBP12 protein to inhibit the mammalian target of rapamycin(mTOR), a critical regulator of cell growth and survival inresponse to cytokines, growth factors, and nutrients (20). Althoughthe effects of rapamycin have been most thoroughly investigatedin lymphocytes (21,22), other cells in the body also are potentialtargets, including fibroblasts, endothelial cells, hepatocytes,and smooth muscle cells (23–25). Additionally, rapamycinhas been shown to have a direct effect on renal proximal tubularcell function. Rapamycin inhibits murine proximal tubular epithelialcell insulin signaling in vitro (26). Several cytokines andgrowth factors have been shown to facilitate recovery from ARF,through promoting tubular epithelial cell proliferation (27).Repair from ischemic acute renal failure involves stimulationof tubular epithelial cell proliferation (28). Agents that impairthe ability of renal epithelium to proliferate, especially inthe face of ongoing injury (e.g., calcineurin inhibitor inducedischemia) may result in prolonged periods of acute renal failureor failure of recovery.
Recent studies of ischemic ARF have shown augmented injury anddelayed repair when rapamycin is given around the time of injury(29–32). The mechanism appears to involve a combinationof enhanced necrosis, increased apoptosis, and decreased proliferationof renal tubular epithelial cells (32). Recently, after initiatinga protocol of steroid-free immunosuppression using rapamycinat transplantation with tacrolimus delayed until the serum creatininefell to 3 mg/dl, we noted an increase in DGF (from 9% to 25%)in association with an unusual renal histology. This level ofDGF was reminiscent of the incidence in rapamycin treated patients(17% rapamycin versus 7% control; P = NS) in the study reportedby Groth et al. (11), in which high-dose (16 to 24 mg/m2 perd) rapamycin was administered within 24 h of transplantation.We therefore reviewed our patients transplanted after October1999 for the development of and risk factors for DGF, includingperioperative immunosuppression. We report a previously unreportedtoxicity of rapamycin in clinical transplantation, both independentof and in association with a calcineurin inhibitor.
Immunosuppressive Therapy
All patients who had undergone a primary renal transplant atthe University of Washington Medical Center from October 1,1999, through September 1, 2001, were retrospectively reviewedand included in this report. Patients receiving a second ormultiorgan transplant were not included. This study was approvedby the institutional review board of the University of Washington.During the study period, conventional immunosuppression wasadministered to high-risk patients, and three different steroidavoidance protocols were available for low-risk patients. Prednisone,mycophenolate mofetil, and cyclosporine or tacrolimus were administeredto high-risk patients, defined as those with a steroid responsivesystemic or native renal disease or a high panel reactive antibody(group 4). Patients receiving steroid-free immunosuppressionwere given in a nonrandomized fashion one of the following immunosuppressiveregimens: (1) induction (Dicluzamab or Thymoglobulin), tacrolimus,and rapamycin (FK/RAPA) (group 1); (2) induction Thymoglobulin,rapamycin, mycophenolate mofetilm, and tacrolimus (FK/RAPA/MMF)(group 2); or (3) induction (Dicluzamab or Thymoglobulin), cyclosporine(or tacrolimus) and mycophenolate mofetil (CSA/MMF) (group 3).Rapamycin was given immediately before surgery or upon returnfrom the operating room. Tacrolimus or cyclosporine administrationwas delayed until the serum creatinine fell to 3.0 mg/dl inregimens 1, 3, and 4, and tacrolimus was initiated at 14 d inregimen 2. All patients received at least three doses of Thymoglobulinat 1.5 mg/kg starting at the time of surgery. Solumedrol (1mg/kg) was given with the first two doses of Thymoglobulin,all doses of Thymoglobulin were accompanied by acetaminophenand diphenhydramine.
Patients with DGF received Thymoglobulin until the serum creatininestarted to decline or a maximum of seven doses was reached;tacrolimus was initiated by 2 wk after transplantation for allregimens. The target level for tacrolimus in those receivingtacrolimus plus rapamycin was 7 to 10 ng/ml. The targeted bloodlevel for rapamycin was 10 ng/ml. The targeted cyclosporineblood level within the first 30 d after transplant was 250 ng/mlby HPLC. Standard antimicrobial prophylaxis included trimethoprim-sulfamethoxazole,clotrimazole troches, and oral gancyclovir. Acyclovir was administeredif the recipient and donor were CMV-negative.
Patient Data
Patient charts were reviewed for the development of DGF (definedas the need for hemodialysis beyond 24 h after transplantation).Dialysis was performed for the development of hyperkalemia,acidosis, or volume overload. Patients who had anuria, hyperkalemia,acidosis, or volume overload for more than 1 wk were placedon a regular dialysis schedule until renal function showed signsof recovery. Also evaluated were immunosuppressive medications,medication doses, dose timing, drug levels, donor and recipientage, donor and recipient gender, recipient renal disease, coldand warm ischemia times, panel reactive antibody status, transplanttype (cadaveric verses living donor), serum creatinine, andcreatinine clearance and urinary protein excretion between days15 and 30 posttransplant. The timing of the urinary testingwas determined by graft stability and need to return to theirlocal care provider. Patients with DGF underwent biopsy approximately7 d after transplant. Other biopsies were performed per protocolor for episodes of renal dysfunction.
Histology and Electron Microscopy
Biopsies were prepared using standard procedures in the histologylaboratory and electron microscopy facility of the Universityof Washington Department of Pathology.
Immunocytochemical Studies
These studies were performed on Formalin-fixed, paraffin-embeddedtissue, using standard heat-induced antigen retrieval protocols,and the following antibodies: anti-CD68 (KP-1, DAKO), anti-pancytokeratin(AE1/AE3 cocktail, Chemicon), anti-FKBP12 (FKBP12 N19, SantaCruz Biotech), and anti-FRAP/mTOR (FRAP C19, Santa Cruz Biotech).
Statistical Analyses
Descriptive statistics are presented as counts, means and SD,and percentages. The association between delayed graft function(DGF, coded as occurring versus not occurring) and each independentvariable was determined using logistic regression. The jointeffect of multiple independent variables was modeled using multivariatelogistic regression. Results are presented as odds ratios andtheir 95% confidence interval (CI). Among those patients whoexperienced delayed graft function, the association betweenindependent variables and duration (days) of posttransplantdialysis was determined using Spearman correlation (for continuousindependent variables) and the Mann-Whitney test (for dichotomousvariables). The joint effect of independent variables on durationwas modeled using multivariate linear regression. Residualsfrom regression analysis were consistent with a normal distribution.Associations with P < 0.05 were considered statisticallysignificant in all analyses.
The final multivariate logistic regression model for DGF andthe final multivariate linear regression model for durationof dialysis were determined separately by considering all modelsthat included all or a subset of the significant variables fromthe respective univariate analyses. The final multivariate regressionmodel included the fewest independent variables such that allvariables were statistically significant. For the DGF analysis,this was a unique model, whereas for the duration analysis,two models each with two independent variables fit the criteria,and the model with the largest value of R2 was chosen.
Patient characteristics are shown in Table 1 (n = 144). Associationsamong DGF and donor, recipient, and procedural factors are displayedin Tables 2 to 4. DGF developed more frequently in those receivingrapamycin compared with those not receiving the drug (25% [22of 88] versus 8.9% [5 of 56]; P = 0.02; Table 2). Furthermore,increasing rapamycin dose led to increased risk of DGF as indicatedby an odds ratio (OR) of 1.10 per mg (P = 0.008; Table 2). Thus,each additional milligram of rapamycin increased the risk (odds)of developing DGF by a factor of 1.10 on the average. The prevalenceof DGF in patients not treated with rapamycin (8.9%) matchedthat seen in earlier years at UWMC: 7.2% in 1997, 7.6% in 1998,and 8.7% in 1999. In the univariate analysis, cold and totalischemia times were more prolonged in those who developed DGF(P = 0.01 and 0.004, respectively; Table 2). DGF developed lessfrequently in the living donor recipient (P = 0.02) and in thosewith a T cell PRA greater than 0%. The use of ATG was not significantlyassociated with the risk of DGF, though users had a higher estimatedrisk than non-users (OR = 2.0; 95% confidence interval, 0.6to 6.3; P = 0.2; Table 2). This weak association could be dueto protocol design as all patients determined to have DGF receivedATG to delay treatment with calcineurin inhibitors.
Table 4. Multivariate analysis of the duration of delayed graft function, linear regression; final model, n = 27
Multivariate analysis revealed that the development of DGF wasvery significantly associated with an increasing dose of rapamycinadministered at the time of transplant (as indicated by an oddsratio greater than 1.0; specifically, OR = 1.13 per additionalmg of rapamycin; P = 0.004) and negatively associated with livingdonor transplant (OR = 0.18; P = 0.01) and a T cell PRA over0% (OR = 0.23; P = 0.03), Table 3. Cold and total ischemic timeswere no longer significant because of the close associationwith the type of transplant. Ischemic times of cadaveric donorswere more prolonged and very similar to those of patients developingDGF, whereas ischemic times of living donors were short andsimilar to those without DGF. The continued association of a0% T cell PRA with DGF cannot be explained by an analysis ofthe factors included in this study, including the absolute percentagefor the T cell PRA, and could be due to study size. However,this association is likely a consequence of subtle differencesin the treatment of more highly sensitized patients; for instance,more frequent treatment of patients with a PRA above 0 withATG in combination with delayed use of calcineurin inhibitors.Rapamycin levels before 7 d after transplantation were not availablein sufficient numbers to analyze for an association with DGF.There was no significant association between the developmentof DGF and donor age, donor gender, B cell PRA, number of HLAmismatches, use of ATG, or time on dialysis before transplantation.The rate of DGF in the 108 patients who did not receive Dicluzamabwas slightly larger but not significantly different from theDGF rate in the 36 patients receiving Dicluzamab (20% versus14%, respectively; P = 0.5, Fisher exact test).
Increasing donor age was associated in multivariate analysiswith more prolonged posttransplant DGF (1.05 additional daysof DGF per additional year of age; P = 0.01; Table 4). In thesame multivariate analysis, the dose of mycophenolate mofetilwas negatively correlated with DGF duration (0.010 fewer daysof DGF per additional mg of MMF, or, equivalently, 10 d lessDGF per 1000 mg of MMF; P = 0.02; Table 4). The mean durationof dialysis was 27.6 ± 33 (SD) d in patients receivingrapamycin compared with 6.4 ± 7.1 d in those not receivingthe drug (P = 0.03), but the difference was not statisticallysignificant in a multivariate analysis controlling for donorage and dose of MMF. Patients receiving an initial dose of rapamycinof 0, 1 to 2, 3 to 4, 5, or 15 mg developed DGF in 8.9%, 26.7%,15%, 22.2%, and 36%, respectively. The creatinine clearancebetween 15 to 30 d after transplantation was negatively correlatedwith donor age (Spearman correlation, rho = -0.32; P = 0.001)and prolonged cold ischemia time (rho = -0.20, P = 0.04). Thisanalysis did not include patients with DGF still on dialysis.Urinary protein excretion between 15 to 30 d after transplantationcorrelated positively with the use of rapamycin (0.80 ±0.76 with and 0.5 g/d ± 0.35 without rapamycin; P = 0.04)and rapamycin dose (rho = 0.29; P = 0.005).
Biopsies performed for evaluation of poor allograft functionshowed evidence of acute tubular injury in all patients withDGF. In addition, of the 22 DGF patients treated with rapamycin,12 patients had biopsies demonstrating a heretofore undescribedcast nephropathy. Cast nephropathy was only seen in biopsiesperformed after the third week posttransplantation, when thesepatients were being treated with a combination of FK506 andrapamycin. Many of the casts consisted of amorphous eosinophilicmaterial, which had sharply defined irregular contours, occasionalfracture lines, and in some instances were associated with acellular reaction that included focal multinucleated giant cellformation (Figure 1). Immunohistochemistry demonstrated thatthe cells infiltrating tubular segments and adhering to thesurface of casts were CD68-expressing monocyte/macrophages (Figure 1).Because of the histologic resemblance to myeloma cast nephropathy,two of the initial cast nephropathy patients were evaluatedfor multiple myeloma; serum and urine electrophoresis and immunoelectrophoresisfailed to demonstrate any abnormalities. Some casts were lesswell developed and consisted of eosinophilic bodies, often withprominent amphophilic staining of the borders, and membranousrings, histologically consistent with cells in various stagesof degeneration (Figure 2). Immunohistochemistry confirmed thatthe eosinophilic bodies were cytokeratin-positive epithelialcells (Figure 2). Electron microscopy demonstrated the presenceof degenerating cells and revealed that the membranous ringsrepresented cellular membranes with prominent accumulation ofosmiophilic material. There were also cell fragments withinthe tubular lumens, and some cells contained lysosomes withheterogeneous inclusions (tertiary lysosomes). Similar tertiarylysosomes were present in the intact tubular epithelium, furthersignifying the tubular epithelial cell component of the castmaterial. Tubular epithelial cells also demonstrated simplificationof the basolateral membranes, an ultrastructural feature oftubular epithelial cell injury.
Figure 1. Histologic findings in patients with prolonged delayed graft function. (a) Early biopsies (less than2 wk) showed features of acute tubular injury/"acute tubular necrosis," characterized by tubular epithelial cell loss of brush border and accumulation of debris in tubular lumina. (b and c) Later biopsies (>2 wk) showed additional features of prominent intratubular cast formation. The casts had irregular sharply demarcated contours, occasional fracture lines, and in some instances were associated with prominent cellular reaction and multinucleate giant cell formation. (d) Immunohistochemical studies demonstrated that the cellular reaction to the cast material consisted of CD68-positive macrophages.
Figure 2. Intratubular casts are composed of degenerating renal tubular epithelial cells. (a) Membranous rings and eosinophilic bodies, suggestive of degenerating cells fill tubules and occasional tubules, contain intact eosinophilic silhouettes of tubular epithelium. (b) Cell bodies stain positive for pan-cytokeratin, indicating their epithelial cell origin. (c and d) Ultrastructural studies show membranous rings are composed of plasma membrane from degenerating cells, which have accumulated masses of osmiophilic material. Additional cells and cell fragments in various states of degeneration are also visible, some containing lysosomes with heterogeneous inclusions (tertiary lysosomes). Similar tertiary lysosomes are present within the intact tubular epithelium. Tubular epithelial cells also demonstrate simplification of the basolateral membranes.
One possible explanation for the tubular epithelial cell injuryand death was that rapamycin was directly contributing to renalepithelial cell toxicity. We therefore analyzed the kidney distributionof rapamycin binding protein FKBP12 and the target of rapamycin(mTOR/FRAP). Immunohistochemistry demonstrated that in normalkidneys these proteins are expressed ubiquitously and can bedetected in epithelial cells, mesangial cells, endothelial cells,and mesenchymal cells. The most prominent staining was detectedin the renal tubular epithelial cells of the distal nephrons(Figure 3), providing evidence for a pathway of rapamycin influencein human renal tissue.
Figure 3. Targets of rapamycin are expressed ubiquitously in the kidney and are detected in occasional epithelial cells, mesangial cells, endothelial cells, and mesenchymal cells. The most prominent and uniform expression was detected in epithelial cells of the distal nephrons in normal kidneys. A subset of tubules, with low cuboidal epithelium, morphologically consistent with distal nephron epithelium, show cytoplasmic staining for FKBP12 (a) and nuclear staining for FRAP/mTOR (b). Tubules with collecting duct morphology show similar staining patterns for FKBP12 (c) and FRAP/mTOR (d).
Four patients receiving FK/RAPA had prolonged DGF lasting morethan 2 mo posttransplant. Serial biopsies performed during thecourse of delayed graft function showed a similar trend amongthese four individuals. Early biopsies (less than 2 wk posttransplant)demonstrated tubular injury with few casts. Later biopsies (greaterthan 2 wk posttransplant) demonstrated increasing numbers ofcasts and cast nephropathy. In three patients, FK/RAPA was discontinuedand Thymoglobulin (1 to 1.5 mg/kg) was given every other dayfor 2 wk while monitoring the CD3 count. Renal function improvedstarting between 2 and 3 wk after FK/RAPA withdrawal. All biopsiesperformed after withdrawal of rapamycin showed resolution ofthe cast nephropathy (Figure 4). At the end of 2 wk, FK, MMF,and prednisone were initiated. The current serum creatininesfor three of the patients are 1.4, 1.4, and 2.7 mg/dl. The fourthindividual was the very first case of severe, prolonged DGFand cast nephropathy, and the potential reversibility of thelesion was not recognized. This recipient underwent four allograftbiopsies over a 6-wk period, showing tubular injury and castnephropathy with no evidence of rejection. The histologic findingsat nephrectomy 2 mo after transplant included persistent tubularinjury and mild focal tubulitis. Lastly, two stable patientstreated with FK/RAPA developed cast nephropathy during episodesof severe volume depletion that resolved after fluid resuscitationand decreasing the rapamycin dose.
Figure 4. Withdrawal of rapamycin leads to clinical resolution of delayed graft function and histologic resolution of cast nephropathy. This patient is representative of one of three patients with prolonged delayed graft function with serial kidney biopsies. The graph shows serum creatinine as a function of day posttransplant. The "rapamycin" bar denotes the period during which the patient was on steroid avoidance immunosuppression, and the "hemodialysis" bar denotes the period during which the patient required hemodialysis. The arrows indicate the time of kidney biopsy (at 2, 5, 8, and 15 wk posttransplant). All three patients demonstrated clinical and histologic resolution after withdrawal of rapamycin therapy.
This study reveals a distinct correlation between the developmentof DGF and peritransplant immunosuppressive agents. Delayedgraft function increased in prevalence from 8.9% to 25% whenrapamycin was administered at the time of transplant. Calcineurininhibitors did not contribute to the development of DGF, astheir administration was delayed until renal function was establishedor until seven doses of Thymoglobulin had been given. However,a calcineurin inhibitor plus rapamycin administered to a patientwith DGF resulted in prolonged posttransplant dialysis timeswith 5 (23%) of 22 requiring dialysis for over 30 d posttransplant.Furthermore, all patients requiring prolonged dialysis had renalbiopsies demonstrating cast nephropathy. This is in contrastto the average reported duration of DGF of 10 to 15 d, and theDGF prevalence of 14% at 2 wk, 9.5% at 3 wk, and 1.7% at 1 moposttransplant (33–36). The histologic abnormalitiesreported herein are also more severe than that normally seenin poorly functioning allografts, as it reveals a distinct castnephropathy. Thus, the prevalence and duration of DGF in ourtransplant recipients receiving rapamycin were clearly increasedabove national and prior internal norms and were associatedwith unique allograft pathology.
Rapamycin binds FKBP12, and this complex inhibits mTOR, a centralcontroller of cell growth and survival (20,37). In the settingof immunostimulation after transplant, rapamycin decreases lymphocyteproliferation and reduces rejection. However, in the settingof renal injury, where organ repair depends on tubular cellproliferation and well-orchestrated apoptosis, this may be harmful(28,32). In the setting of experimental renal injury, rapamycinhas recently been demonstrated to inhibit proliferation andincrease apoptosis of renal tubular epithelial cells in vitroand in vivo (32). Furthermore, it appears to directly causerenal injury in salt-depleted and renal ischemic rat models(30,32,38). Pharmacokinetic interactions between rapamycinand calcineurin inhibitors could augment ischemic injury andinhibit tissue repair when used in combination (15,39). Ourpatient data support the premise that injury sustained by renalallografts may be augmented and not fully recover under rapamycinfollowed by tacrolimus therapy. The pathologic alterations indicatethat there is enhanced tubular epithelial cell death, reducedepithelial cell regeneration, and perhaps an alteration of macrophageclearance of apoptotic cells. These risks of enhanced injuryand decreased repair involve not only the immediate posttransplantperiod, but they may also carry over to long-term events causingrenal injury, such as volume depletion and urinary tract obstruction.
Practically, rapamycin is an excellent agent for the preventionof acute allograft rejection, as exemplified by the recentlypublished studies (11,12,14). Likewise, rapamycin has beenshown to be an excellent agent for the inhibition of intimalhyperplasia in coronary artery stenting (40–43), thusproviding hope that this agent may decrease chronic allograftnephropathy (44–47). However, because the very mechanismthat allows excellent immunosuppression may also impair tissuerepair mechanisms, and even increase tissue injury, a closeevaluation of this agent at times of allograft injury shouldbe undertaken. The use of rapamycin early posttransplant, especiallyin the company of a calcineurin inhibitor, should be re-evaluatedand guided by the state of renal function. Furthermore, renaland other allograft recipients who develop conditions that cancause acute renal failure, such as volume depletion, heart failure,renal artery stenosis or obstruction, should be monitored carefully.Rapamycin dosing should be altered if renal dysfunction develops,recognizing the prolonged intracellular half-life.
Mycophenolate mofetil use after transplantation has not beenassociated with the development of DGF. The results of our studyagree with this finding, and we also discovered an unexpectedassociation of MMF with shortened duration of dialysis. Theinfluence of MMF on the development and duration of ARF in othersettings has not been previously evaluated in humans. Recentstudies in an animal model of rapamycin-associated ARF haveshown that MMF impedes the development and duration of renalinjury (48). These experimental studies taken together withour clinical findings, suggest that a re-evaluation of MMF inthe setting of transplant associated renal failure is warranted.
Typical histologic findings in kidney transplant biopsies frompatients with DGF, include dilation of tubules, loss of proximaltubular epithelial cell brush border, epithelial cell necrosis/apoptosis,and cellular casts. The FK/RAPA–treated patients withDGF had similar findings, but a subset of those patients progressedto a state where numerous atypical eosinophilic casts filledtubular lumina. The histologic similarity of this FK/RAPA-associatedcast nephropathy to myeloma cast nephropathy was in some instancesstriking. In general, however, the leukocytic infiltration ofthe interstitium and the leukocytic reaction to the cast materialwas less pronounced in FK/RAPA-associated cast nephropathy.This may be the result of the increased level of immunosuppressionin the FK/RAPA renal transplant patients or differences in thenature of the casts. In addition, FK/RAPA-associated and myelomacast nephropathies demonstrate differences at the ultrastructurallevel. FK/RAPA-associated casts consist of a prominent epithelialcell component. Degenerate epithelial cells appear to play acentral role in cast formation and are a nucleation site forprecipitates that eventually obscure the underlying cellularcomponent. Whereas in myeloma casts, the paraprotein (monoclonalIg chain[s]) is prerequisite for cast formation and a majorcomponent of the cast material.
In conclusion, a new risk factor for the development of renalallograft DGF appears to include the early posttransplant useof rapamycin. The amount of rapamycin administered is important,but the threshold dose cannot be determined from this study.Furthermore, renal allograft biopsies demonstrating acute tubularinjury and, more specifically, the cast nephropathy reportedherein should alert practitioners to the significance of rapamycin/calcineurininhibitor interactions.
Acknowledgments
We thank Tom Barnou, Bob Berglin, Blazej Neradilek, ShiquanLiao, Richard King, Tracy Goodpastor, and the members of theimmunocytochemistry and electron microscopy laboratories.
Footnotes
Dr. William Bennett served as Guest Editor and supervised thereview and final disposition of this manuscript.
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Received for publication May 14, 2002.
Accepted for publication December 14, 2002.
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Abstract
Introduction
