Biopsy-Based Transcriptomics May Be Precisely What Is Needed in Post-Kidney Transplant Care

For a kidney warrior like me who has not taken a science course since high school, transcriptomics might be an intimidating word to spell, let alone discuss. Fortunately, my progression from being a health literacy-challenged person with kidney failure in 2009 to becoming an activated kidney patient less than a year later, a grateful recipient of a transplanted kidney from a deceased donor in 2015, and the devoted patient advocate that I am today continually inspires me to learn more about leveraging the latest advances in medical science to ensure that people living with kidney transplants receive the best care there is.

I thank the authors of the article “Systematic biopsy-based transcriptomics and diagnosis of antibody-mediated kidney transplant rejection in clinical practice” for their thoughtful, compelling analysis that explores expanding the usage of biopsy-based transcriptomics (the molecular analysis of the RNA that is present in a cell, tissue, or organ sample at a given time)¹ in clinical practice to determine whether antibody-mediated rejection is present in a transplanted kidney.²

I was diagnosed with mild kidney rejection twice early on in my journey as a kidney transplant warrior—both times because of post-kidney transplant protocol biopsies—and I must admit that I have always found the term mild rejection to be a little amusing, admittedly in a slightly morbid way (trust me, a mild rejection does not feel that way when you have been told you are experiencing one). In both cases, the prescribed treatment (steroid infusions coupled with adjustments to my immunosuppressant regimen) was straightforward, and my transplanted kidney, Hercules's functioning soon returned to normal. Hercules is working better than ever now, but I know that our future together is uncertain, and I have grown used to tucking away in the back of my mind the fact that Hercules has an unknown expiration date.

Living with a kidney transplant can be frightening at times. Still, it is and has been a wonderfully transformative experience for me and for so many other kidney transplant warriors, as well as for our families and loved ones. However, many unknowns still exist in post-kidney transplant care, and expanded use of kidney biopsy transcriptomics could reduce the number of unknowns. The authors noted that additional research is needed to confirm the study's findings, which may be challenging from an availability perspective,² but given the attention that kidney transplant outcomes are currently receiving from policymakers in the United States,^3,4 should not improving death-censored graft survival rates be prioritized as well? We need to explore every option for maintaining the health and extending the longevity of transplanted kidneys. I welcome the authors' call for further investigation to determine whether biopsy-based transcriptomics can be a useful tool to help transplant nephrologists improve graft survival outcomes and prolong the improved quality of life that their patients deserve. We should also explore methods of making the necessary technology cheaper to improve scalability.

Dandonneau et al. note several limitations of their study (it was conducted at a single transplant center using a relatively small number of biopsies, there are not many transplant centers that can do molecular testing of kidney biopsies, and the random sampling produced an unequal distribution of the timings of biopsy samplings among groups, among others).² Nevertheless, because biopsy-based transcriptomics may be able to consistently determine whether antibody-mediated rejection is present in a kidney biopsy sample in a way that standard clinical practice cannot,² the potential impact of their study is undeniable.

My transplant nephrologist's answers to my questions often include the word data and for good reason. He uses it to help draw conclusions about the treatments he recommends for me and his other patients, as do hundreds of his colleagues in the United States⁵ and worldwide. I propose that the kidney transplant community build on the authors' findings by funding a randomized clinical trial to examine further the reliability of biopsy-based transcriptomics in identifying antibody-mediated kidney transplant rejection in clinical practice. If better technology is available to maintain the health and longevity of transplanted kidneys, we should maximize the potential benefit.

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/B976.

Funding

None.

Author Contributions

Conceptualization: David M. White.

Writing – original draft: David M. White.

Writing – review & editing: David M. White.