Guidelines for Immune Monitoring in Kidney Transplantation: A Focus on Prevention

In recent years, with the steady increase in the number of organ donations and transplants, my country has become the second largest country in organ transplantation in the world, with kidney transplants accounting for the largest proportion. How to help transplanted kidneys and transplant recipients survive long-term has become a new challenge in transplant clinical practice. The risk of rejection or infection caused by improper active or passive immunity is an important cause of kidney transplant loss. Although there are standardized and feasible treatments for rejection and infection, the damage caused to the transplanted kidney is irreversible. Immune monitoring after kidney transplantation is particularly important, and "prevention is better than cure" needs to be achieved.

Recently, the "Clinical Diagnosis and Treatment Guidelines for Kidney Transplantation Immune Monitoring" (hereinafter referred to as the "Guidelines"), which was discussed and formulated by transplantation clinical experts organized by the Organ Transplantation Branch of the Chinese Medical Association, was officially released. This Guideline comprehensively considers factors such as the current status of kidney transplantation in my country, testing costs, pros and cons, etc., and puts forward recommendations that are consistent with the clinical diagnosis and treatment practice of kidney transplantation immune monitoring in my country.

The "Guidelines" use the 2009 version of the evidence grading and recommendation strength standards of the Oxford University Center for Evidence-Based Medicine to grade the quality of evidence and strength of recommendations for issues such as the detection and clinical application of HLA-DSA, non-HLA antibodies, donor-derived cell-free DNA (dd-cf DNA) and other indicators of clinical concern, providing a unified evidence-based basis for clinical immune monitoring after kidney transplantation.

dd-cf DNA is an emerging immune monitoring indicator after transplantation. Currently, all well-known transplant centers in China carry out dd-cf DNA monitoring, but different transplant centers have different maturity levels in using this indicator. The "Guidelines" provide guidance on the monitoring indicator dd-cf DNA from the aspects of clinical significance, diagnostic value and result determination. It is believed that persistently low levels of dd-cf DNA highly indicate that the transplanted kidney is not damaged and may avoid unnecessary needle biopsy and anti-rejection treatment (recommendation strength B, evidence level 2b). Dynamic monitoring of dd-cf DNA during anti-rejection treatment may help evaluate the recovery and prognosis of kidney transplants (Strength of Recommendation B, Level of Evidence 2b). Combined plasma and urine dd-cf DNA testing has certain reference value for identifying AMR and TCMR, as well as BK virus infection and BK virus-related nephropathy (recommendation strength B, evidence level 2b). Combining the percentage and absolute values ​​of plasma and urine dd-cf DNA can help provide more comprehensive diagnostic information (strength of recommendation B, level of evidence 2b).

At the same time, the "Guidelines" also point out that elevated plasma dd-cf DNA alone has a high diagnostic value for AMR, but its diagnostic value for TCMR is limited. It is recommended that when clinical suspicion of TCMR is high, even if the plasma dd-cf DNA is at a low level, TCMR cannot be ruled out, and a transplanted kidney biopsy should be performed if necessary to confirm the diagnosis (recommendation strength B, evidence level 2b).

Long-term management after kidney transplantation has a long way to go. The comprehensive use of new and old immune monitoring indicators can help early detection of rejection risk or infection risk, help guide clinical adjustments to the intensity of immunosuppression in a timely manner, and help improve the long-term survival of transplanted kidneys and transplant recipients.

To read the full text of the guide, click on the linkhttps://rs.yiigle.com/cmaid/1495645