Thrombotic microangiopathy after kidney transplantation: what is behind the pathology pattern? Review

Thrombotic microangiopathy (TMA) of the renal transplant is a clinical and morphological phenomenon characterized by specific damage of glomerular capillaries and medium-small arteries in the form of endothelial cells edema, expansion of the subendothelial space with a sharp narrowing of the vessels lumen, in some cases with blood clots. In the chronic TMA, a morphological picture of the "onion peel" is formed. TMA of a transplanted kidney develops de novo or as a recurrent pathology, may be systemic or localized in the transplant, but in all cases decreases the survival of the recipients and grafts. Morphological examination is necessary to confirm TMA of a renal transplant, but kidney biopsy does not always help to establish the etiology of TMA. The most common causes of de novo TMA are the toxicity of calcineurin inhibitors and antibody-mediated transplant rejection, and recurrent TMA is a relapse of atypical hemolytic-uremic syndrome (aHUS). Mutations in the genes of complement regulatory proteins play an important role not only in the recurrent aHUS after kidney transplantation (KT), but also in some cases of de novo TMA. To treat de novo TMA its causes should be eliminated. Plasma exchange and intravenous immunoglobulin are also used. In some cases of de novo TMA with uncontrollable activation of the complement system, resistant to standard therapy, it is advisable to use complement-blocking therapy. In all patients with recurrent aHUS after KT the first-line therapy is eculizumab. If a patient is diagnosed with aHUS and identified as high risk of relapse after KT through genetic testing and assessing of clinical features, prevention of disease recurrence with "endothelial protection regimen" and eculizumab is necessary. In general, the problem of TMA after KT requires further studies with the development of reliable predictors of its development and new approaches to prevention and treatment.

трансплантация почки, тромботическая микроангиопатия, токсичность ингибиторов кальцинейрина, антитело-опосредованное отторжение, активация комплемента, атипичный гемолитико-уремический синдром, плазмообмен, экулизумаб, kidney transplantation, thrombotic microangiopathy, CNI-toxicity, antibody-mediated rejection, complement activation, atypical HUS, plasma exchange, eculizumab

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