Kidney Transplantation. Arrival of the Next Frontier

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The short period of 2020 to 2022 has felt like its own era in the field of kidney transplantation, with significant advances in the field on various fronts. The next two editions of Kidney News will highlight some of these advances in kidney transplantation, which push the barriers of science and society. This first and current edition will focus on racial inequities in transplantation and measures to address them, the new kidney transplant allocation system, updates from the Apolipoprotein L1 (APOL1) Long-term Kidney Transplantation Outcomes (APOLLO) study, and groundbreaking advances in xenotransplantation and finally, will review increasingly encountered oxalosis in patients with kidney transplantation.

…2020 to 2022 has felt like its own era in the field of kidney transplantation, with significant advances in the field…

Structural racism impedes equitable access to transplantation. Drs. Chan and McElroy provide a background on how racial inequities afflict transplantation. They propose the use of social determinants of health data (social conditions with broad-ranging effects on individuals' health, functioning, and quality of life) to begin to address these inequities and outline suggestions for improving data infrastructure. These recommendations align with a report from the National Academies of Sciences, Engineering, and Medicine to improve equitable organ allocation (1).

The recognition of the association of APOL1 kidney-risk variants and chronic kidney disease has been one of most significant discoveries in nephrology in the past decade (2). Living kidney donors with APOL1 high-risk variants have reduced kidney function post-donation and higher risk of progression to end stage kidney disease. In addition, the Kidney Donor Risk Index (KDRI) scores improve dramatically with replacement of race with the donor APOL1 genotype (3). As high KDRI organs are more likely to be discarded, changes in its calculation are likely to impact organ allocations. Dr. Freedman et al. summarize the APOLLO study, which seeks to determine outcomes in recipients of deceased donor kidneys based on APOL1 genotypes.

The United Network for Organ Sharing/Organ Procurement and Transplantation Network kidney allocation policy has undergone significant changes to improve equitable distribution of deceased donor allografts (4). Dr. Vella discusses these changes, with a focus on the Kidney Donor Profile Index and Estimated Post Transplant Survival scores, as well as the elimination of regional allocation rule variations.

This issue of Kidney News would be incomplete without discussion of the groundbreaking advances in xenotransplantation. Albeit first done in 1964, xenotransplantation has not become standard practice, given significant immunologic barriers, concern for zoonoses, and lack of a steady organ source (5). Dr. Killian et al. describe how these challenges may potentially be overcome with the use of genetically edited porcine allografts. They share their preliminary experience with this novel practice in a human model, along with associated issues and potential measures to mitigate them (6).

This issue concludes with a discussion of hyperoxaluria—an increasingly recognized cause of delayed graft function in kidney allografts (7). Dr. Krishnamoorthy discusses various clinical scenarios, including primary hyperoxaluria, enteric oxalosis, and delayed graft function, in patients with kidney transplants, along with recommended management strategies.

Significant strides of kidney transplantation have continued not only in the areas described here but also in the realm of genomics, biomarkers, new insights into thrombotic microangiopathy, focal segmental glomerulosclerosis recurrence in transplantation, and updates on the use of belatacept. Stay tuned for the August edition of Kidney News, where we turn our attention to these topics.