Management of interstitial fibrosis and tubular atrophy in renal transplantation [1] Interstitial fibrosis and tubular atrophy (IFTA) is a major cause of chronic allograft nephropathy and long-term renal allograft loss. [2] IFTA can be caused by both immunological factors like acute rejection and chronic antibody-mediated rejection as well as non-immunological factors like CNI toxicity, viral infections, ischemia-reperfusion injury and hypertension. [3] Clinical management of IFTA focuses on assessing and addressing the underlying causes, tight blood pressure and glucose control, lipid management, and modulating immunosuppression when appropriate.

1. Management of interstitial fibrosis
and tubular atrophy in renal
transplantation
K. HARZALLAH
The 12th Congress of the Middle East Society for
Organ Transplantation 2010
Novartis Symposium

2. Lack of improvement in long
term Renal Allograft Survival
Early ant late acute rejection RR of death-censored graft loss
Meier-Kreische AJT 2004; 4: 378

3. Good or poor donor kidney:
same finality ?
Chapman, JASN 2005

4. 4
Arteriolar
hyalinosis
Interstitial fibrosis
and tubular atrophy
GBM double
contours
Arteriolosclerosis
CAN, chronic allograft nephropathy;
IFTA, interstitial fibrosis and tubular atrophy; GBM, glomerular basement membrane
CAN / IFTA: a non-specific descriptive
entity defined by pathology
Fletcher JT et al. Pediatric
Nephrol 2009;24:1465–71

5. Histologic criteria of Chronic
Allograft Nephropathy (CAN)
Grade Histology Interstitial
Fibrosis
Tubular
Atrophy
I Mild ci1*
6-25 % of
cortical area
ct1
Up to 25 % of
cortical tubules
II Moderate ci2
26-50 %
ct2
26-50 %
III Severe ci3
> 50 %
ct3
> 50 %
*: 0-5 % fibrosis acceptable

6. • Hypertension
• Proteinuria
– Typically in the non-
nephrotic range (300 mg-3
g/24)
• Renal failure
– Rise in serum creatinine
(mean rate of decline -10
to -4 ml/min/year).
• Onset:
– months to years post
transplantation
Clinical features of CAN

7. Antigen Dependent
Acute Rejection
Alloantibody
Allorecognition
Viral Infection
Tissue Antigen Independent
Insuffisant renal mass
Graft ischemia/
Reperfusion Injury
Older donor age
CNIs
Infiltration,
Inflammatory cells,
lymphocytes, monocytes
Cytokines,
Chemokines,
Growth Factors
Proliferation,
Inflammatory cells,
Fibroblasts, TECs
Extracellular Matrix Deposition
FIBROSIS
Injury
EMT
MatrixPhaseFibrogenesisPhaseInitiationPhase

8. Allo-immunity CNI toxicity
Interstitial fibrosis
and
tubular atrophy
De novo DM
Chronic
obstruction
Recurrent
disease
CAN, chronic allograft nephropathy;
IFTA, interstitial fibrosis and tubular atrophy;
CNI, calcineurin inhibitor; CMV, cytomegalovirus;
I/R, ischaemia / reperfusion; DM, diabetes mellitus
Multiple factors contribute to early
CAN / IFTA
Hypertension
Polyoma-virus
CMV
Donor
factors
I/R-injury
Adapted from Calvin RB. NEJM 2003; 349: 2003

9. Immunologic associations
of Chronic Allograft Nephropathy

10. Immunologic associations of
Chronic Allograft Nephropathy
• Acute Rejection:
– Humans:
• Association of graft rejection with decreased graft half-life.
(Hariharan, 2000)
• Lymphocytic infiltrates on protocol biopsies associated with
developement of CAN (Rush 1999)
• Bw4/Bw6 epitope mismatch ?
– Mechanism:
• Antibody production
• Ongoing cellular immune response
• Reduction in nephron mass due to immune
response/inflammation

11. « Chronic antibody mediated
rejection »
• Morphological
evidence of transplant
glomerulopathy
• C4d deposition in the
glomerulus (paraffin
sections) and/or
peritubular capillaries.

12. • Serologic evidence of antidonor AC
antiHLA.
• The prevalence of C4d:
– 91% of biopsies with transplant
glomerulopathy.
– 12 to 61% in cases of chronic rejection with
impaired renal function.
– 2 % in the protocols of systematic biopsies.
• The role of non-HLA immunity.
« Chronic antibody mediated
rejection »

15. Viral Infections
• CMV infection post-transplantation is associated
with graft failure (1984).
• CMV infection is a contributing factor to cardiac
and hepatic arteriosclerosis (Transpl Int 1994)
• CMV infection is associated with transplant
glomerulopathy (NEJM 1981, Am J Pathol 1987)
• BK virus nephropathy
– Mechanism: generalized immune activation and
inflkammation of the vasculature.

16. Non Immunologic Causes
of Chronic Allograft Nephropathy

17. Non immunologic causes of
Chronic Allograft Nephropathy
• Graft ischemia/reperfusion injury
– Studies in humans have demonstrated that delayed
graft function leads to shortened graft survival.
– Mechanisms:
• Reduced nephron mass
• Upregulation of MHC antigens on ischemic renal tubules
may allow for non-professional antigen presentation.
• Upregulation of adhesion molecules ICAM 1, VCAM 1, on
ischemic endotthelium and tubular endothelium: E- and P-
selectin on endothelial cells: integrins LFA-1, Mac-1 and
VLA-4.
• Enhanced expression of proinflammatory cytokines IL1, IL2,
IFNγ, TNFα, IL-10.

18. Age 19
Age 45
+ 11 years
+ 7 years
Melk et al. AJT 5:1375, 2005
Senescence- Associated Biomarkers
p16INK4a
Donor Biopsy Graft Biopsy

19. CNI Toxicity
• Vasoconstriction of
preglomerular afferent
arterioles and injury of
vascular endothelial cells.
• Tubular vacuolation and
hyalinization.
• Intimal Fibrosis.

20. Epithelial-Mesenchymal
Transformation (EMT)
• Role in IF/TA and
CAN demonstrated in
dans l’AT et la FI:
– Role of the host (Grimm
et al. NEJM 2001)
– May be immune
mediated in man
(Roberston et al. JASN 2004)
– In human biopsies with
IF/TA (Vongiwawatana et al.
AJT 2005)
– Rat model (Djamali et al.
AJT 2005)
Donor IF/TA
E-cadherin
Vimentin
S100A4
α-SMA
Vonawiwatana AJT 2005

22. Clinical Management of IFTA

23. Chronic Allograft Nephropathy
Clinical management
• Assess the causative agent
• BP control
• Lipid management
• Tight blood sugar control if diabetic
• Manipulate immunosuppression

24. Chronic Allograft Nephropathy
Clinical management
• Assess the causative agent
• BP controlBP control
• Lipid managementLipid management
• Tight blood sugar control if diabeticTight blood sugar control if diabetic
• Manipulate immunosuppressionManipulate immunosuppression

25. Allo-immunity CNI toxicity
Interstitial fibrosis
and
tubular atrophy
De novo DM
Chronic
obstruction
Recurrent
disease
CAN, chronic allograft nephropathy;
IFTA, interstitial fibrosis and tubular atrophy;
CNI, calcineurin inhibitor; CMV, cytomegalovirus;
I/R, ischaemia / reperfusion; DM, diabetes mellitus
act against the responsible
factors…
Hypertension
Polyoma-virus
CMV
Donor
factors
I/R-injury
Adapted from Calvin RB. NEJM 2003; 349: 2003

26. Chronic Allograft Nephropathy
Clinical management
• Assess the causative agentAssess the causative agent
• BP control (ACE inhibitors, ARBs)
• Lipid managementLipid management
• Tight blood sugar control if diabeticTight blood sugar control if diabetic
• Manipulate immunosuppressionManipulate immunosuppression

27. ACEI/ARBs improve Survival

28. Lack of impact of RAS blockade on
Graft Survival
17 % ACEI 1996
20 % ACEI 2000
46 % ACEI 2004

29. Deleterious effect of HTN on Graft
survival

30. Chronic Allograft Nephropathy
Clinical management
• Assess the causative agentAssess the causative agent
• BP controlBP control
• Lipid management
• Tight blood sugar control if diabeticTight blood sugar control if diabetic
• Manipulate immunosuppressionManipulate immunosuppression

31. Assessment of Fluvastatin in renal
transplantation (ALERT) n= 2102
• No impact of fluvastatin
40/80 mg/d on calculated
renal function or
proteinuria.
• No difference on graft
loss.
• Reduction in risk of
cardiac death or nonfatal
myocardial infarction (MI)
by 35 % compared with
placebo.

32. Chronic Allograft Nephropathy
Clinical management
• Assess the causative agentAssess the causative agent
• BP controlBP control
• Lipid managementLipid management
• Tight blood sugar control if diabeticTight blood sugar control if diabetic
• Manipulate immunosuppression

33. CAN
Management of immunosuppression
• Treat ant acute inflammation ?
• Reduce/remove the CNI
• Consider addition of an
antiproliferative immunosuppressant
(MMF, Everolimus).

34. Serum creatinine: falsely
reassuring
Chapman, JASN 2005

35. Role of Subclinical Injury
• Early injury
associated with HLA
MM.
• Late Injury associated
with IS load.
• Associated with CAN
in several studies.
• Associated with short
graft survivals.
Prevalence of Subclinical
Rejection
Time of Bx 1-2 w
1-2 m
2-3 m 1 y
1a 17 % 29 % 17 % 18 %
Borderline 24 % 23 % 23 % 17 %
Nankivell et Chapman AJT 2006

36. Treating Subclinical Rejection
(SCR) ?
• Nankivell and Chapman
advocate high dose pulse
steroids, but note that of f/u
biopsies at 2-3 w have
persistent tubulitis.
• Non randomized studies
have suggested benefit in
serum creatinine in pediatric
patients (JASN 2003) and
serum creatinine and
reduced fibrosis at one year
(clin Transpl 2003)
Comparison of patients with
frequent Bx (1,2,3,6 and 12
months) and less frequent (6 and
12 months).

37. Everolimus with CsA minimisation provides similar
efficacy when compared with standard CsA
Data from 1 year post-transplant. Efficacy failure = acute rejection, death, graft loss or loss to follow-up
Standard
CsA
Low
CsA
Efficacy failure
(% patients)
p=0.012
Study B156: 12-month efficacy
BPAR
(% patients)
Creatinine
clearance (mL/min)
Standard
CsA
Low
CsA
Standard
CsA
Low
CsA
p=0.007
Nashan B et al. Transplantation 2004;78:1332–40
37
CsA, cyclosporin; BPAR, biopsy-proven acute rejection
28,3
8,6
0
10
20
30
17
6,9
0
5
10
15
20
53,5
60,9
0
20
40
60
80

38. 38
Very low tacrolimus
Everolimus (target C0 3–8 ng/mL)
+
tacrolimus (target C0 1.5–3.0 ng/mL)
+
steroids
Low tacrolimus
Everolimus (target C0 3–8 ng/mL)
+
tacrolimus (target C0 4–7 ng/mL)
+
steroids
ASSET (study A2426): investigating the potential
of everolimus for minimising tacrolimus
Month 12Month 3Day 1
Everolimus 1.5 mg bid
(target C0 3–8 ng/mL)
Steroids
Tacrolimus 0.1 mg/kg/day
(target C0 4–7 ng/mL)
IL2RA
Transplant
Day 0
1st dose of
everolimus
<24 hours
IL2RA, interleukin 2 receptor antagonist; bid, twice a day

39. 39
Safety population
ASSET: everolimus facilitates
tacrolimus minimisation1
16
14
12
10
8
6
4
2
0
Month 3Month 4 Month 6 Month 9 Month 12
Time
1. Vitko S et al. Presentation at ESOT 2009;
2. Ekberg H et al. N Engl J Med 2007;357:2562–75
Tacrolimus
C0
(ng/mL)
Very low tacrolimus (n=109)
Low tacrolimus (n=119)
ASSET: tacrolimus C0 levels
Tacrolimus C0 levels were ~50% lower than in the
Symphony study at 12 months2

40. 40
Everolimus and very low tacrolimus had clinically
meaningful improvement in renal function
1-sided α level 0.025
cGFR, calculated glomerular filtration rate;
MDRD, modification of diet in renal disease
∆ = 5.34
90
80
70
60
50
40
30
20
10
0
p=0.362 p=0.150 p=0.236 p=0.081 p=0.008 p=0.029
3 4 6 9 12
Time (months)
Very low tacrolimus (n=92)
Low tacrolimus (n=105)
Vitko S et al. Presentation at ESOT 2009
cGFR
(MDRD
formula)
(mL/min/
1.73m2
)
ASSET: cGFR over 12 months

41. 41
De novoDe novo Late conversionLate conversionEarly conversionEarly conversion
Month 1 Month 2–6 >6 months
Time points for initiating PSIs
Time post-transplantation
PSI, proliferation signal inhibitor

42. 42
CsA, cyclosporin; Tac, tacrolimus; MMF, mycophenolate
mofetil; Aza, azathioprine; CNI, calcineurin inhibitor
Transplant
surgery
6–120 months
prior to
randomisation
Group 1: Conversion to sirolimus
within 24 h of randomisation (n=555)
Group 2: Continuation of
CNI-based regimen (n=275)
CsA / Tac +
MMF / Aza +
steroids
for at least 12 weeks
prior to randomisation
2:1 randomisation
in groups 1 and 2
0
Duration of study
(months) 48
Lessons learned from late conversion: the
sirolimus renal conversion trial (CONVERT)
Schena F et al. Transplantation 2009;87:233–42

43. 43
CONVERT trial: GFR improves after conversion to
PSI only in patients with good renal function
*Values adjusted for baseline by analysis of covariance
GFR, glomerular filtration rate;
PSI, proliferation signal inhibitor, CNI, calcineurin inhibitor
0
20
40
60
80
100
61.3 61.7 63.4 61.9 63.6
61.1
64.7
61.2 62.6
59.9
p=0.056 p=0.006 p<0.001 p=0.009
Baseline* Month 6 Month 12 Month 18 Month 24
All patients with baseline >40 mL/min
GFR
(mL/min)
Sirolimus conversion
CNI continuation
Schena F et al. Transplantation 2009;87:233–42

44. TRANCEPT
A PROSPECTIVE OBSERVATIONAL CLINICAL
STUDY OF PATIENTS SWITCHED TO MMF
AT LEAST
6MONTHS AFTER RENAL
TRANSPLANTATION

45. Study Design
1710 patients were included
1256 patients had reached follow up for 1 year

46. Demographics and follow up

47. And the benefice?
24 %
48 %
38 %
+ de 50 % des cas ont eu une amélioration de la fonction rénale
après le switch

48. 48
CAN / IFTA develops frequently and early
after renal transplantation
Nankivell BJ et al. N Engl J Med 2003;349:2326–33
100
75
50
25
0
0 2 4 6 8 10
Years after transplantation
0 (120) 78 (114) 56 (92) 34 (70) 20 (48) 16 (29)No. of
patients
Patients
Grade I
Grade II
Grade III
CAN, chronic allograft nephropathy;
IFTA, interstitial fibrosis and tubular atrophy
~90% of patients have grade 1 CAN in year 1

49. “Gold
standard
used in
research
protocols”
All renal transplant recipients
Patients at a high risk
Measured GFR
Protocol biopsy
Monitor every month during the
first year post-transplant, then 3
monthly
Recognise
the clinical
syndrome
Histology +
physiology
Test new
non-
interventional
tests
Ultrasound ±
biopsy††
Other causes
Recurrent
glomerulonephritis
Renal artery stenosis
Ureteric obstruction
BK virus nephropathy
CAN (tubular atrophy + interstitial fibrosis)
OR
CAN + CNI nephrotoxicity
CAN + transplant vasculopathy
CAN + sub-clinical rejection
CAN + chronic antibody-mediated rejection
(including CTG, DSAb, C4d)
THERAPEUTIC INTERVENTION
Test novel
interventiona
l strategies
Absolute serum creatinine
Change of serum creatinine (%)
Estimated GFR
Slope of change of calculated GFR
Slope of 1/serum creatinine
Other indications of renal change
Proteinurie
Deterioration of blood pressure
Measures for early detection of CAN
JM Campistol et al
Clin Transplant 2009;23:769

50. High Desnity Array Transcriptional Analysis
To Define New Biomarkers

51. Suspicion of CAN/IFTA by Monitoring
• Absolute serum creatinine
–> 1,8 mg/dL (or > 130 µmol/L)
• Absolute GFR
–< 50 ml/min
• Change of serum creatinine
–Irreversible rise of 30% at 6 month post transplant
–Increase of 0,3 mg/dL (or 20 µmol/L) measured 3 x
over 3 months
–15-20% rise over one year
• Change of GFR
–10% deterioration over 3 months

52. Summary
• Chronic graft injury is a considerable long term
problem for kidney transplant recipients.
• The etiologies are multi-factorial and include both
antigen dependent and independent events,
culminating in injury and inflammation.
• Early detection appears to be critical issue for this
disorder. The role of protocol biopsy ans
management of SCR are under study.
• Treatment options are nonspecific and limited.
• Various immunosuppressive strategies avoiding or
limiting CNIs, biologics and anti-proliferatives are
under study.

53. Conclusions
• Despite marked improvements in short graft
survival and reduction in acute rejection rates,
long term graft function remains a critical issue.
• Current immunosuppressive regimens do not
adequately address the causes of long-term
allograft dysfunction and loss
• CNI-sparing regimens / strategies are urgently
required