Kidney transplantation is a lifesaving treatment for end stage kidney disease that offers considerable benefits to recipients in terms of survival and quality of life. The growing demand for transplants to treat conditions stemming from a rising prevalence of end stage renal disease, diabetes and cardiovascular diseases has to be met increasingly with donors who are older with a high incidence of comorbid conditions. Organs obtained from these higher risk donors are more likely to have either suboptimal short and long-term transplant outcomes or even fail to function altogether. Transplant clinicians, who have to balance the risk of patients dying while waiting for a transplant against the uncertainty of outcomes, often decline organs as transplants. These clinical challenges entail difficult decisions, and more refined tools to assess and quantify the risks of marginal donor organs are lacking. Diagnostic markers of donor kidney quality that can predict transplantation outcomes are highly desirable in order to discriminate the suboptimal from those allografts that will recover and have good long-term function. My doctoral research using donor samples collected within the Quality of Organ Donation (QUOD) programme has shown for first time that it is possible, on the basis of a tissue proteomic profile, to discriminate donor kidneys at the time of retrieval that will have suboptimal allograft function from those kidneys that could recover and have good function at three and 12 months post transplantation. Despite AKIN classification and Remuzzi scoring showing no evidence of acute kidney injury or chronic kidney disease in the analysed biopsies, quantitative mass spectrometry and degredomics experiments with a subsequent validation analysis on an independent cohort of biopsy samples confirmed the increased levels of inflammation and pro-fibrotic proteins in the allografts with suboptimal function, while increased levels of cytoprotective proteins were detected in the kidneys that recovered with a good function one year after transplantation. Furthermore, the kidneys with suboptimal function demonstrated enhanced degradation of cytoskeletal proteins that are vital in sustaining the glomerular basement membrane cytoskeleton. In addition, I conducted a pilot study using proteomic analysis of serum and urine of donors whose kidneys either developed delayed graft function or functioned immediately. This study confirmed that is feasible to identify alterations in the blood and urine proteome that are biologically meaningful. In preparation of the discovery and development of diagnostic biomarkers of long-term outcome after kidney transplantation using QUOD plasma samples, I assessed the pre-analytical variability associated with the processing of whole blood during QUOD sample collection in order to identify a baseline proteomic and peptidomic profile against which candidate protein markers relevant for clinical correlates can be selected. Based on the findings reported in this thesis, future work should aim to identify and develop better diagnostic tools that can more reliably predict donor organ quality. In addition, novel intervention strategies can be explored that either attenuate pro-fibrotic and proteolytic activities or enhance antioxidant and cytoprotective mechanisms in deceased donor kidneys prior to transplantation.

Transplantate von nichtverwandten Lebendspendern zeigen unabhängig von der immunologischen Kompatibilität eine signifikant bessere Kurzzeit- und Langzeitfunktion im Vergleich zu Transplantaten von hirntoten Organspendern. Die Tatsache, dass das Überleben von Nierentransplantaten von nichtverwandten Lebendspendern identisch mit dem Organüberleben von verwandten Lebendspendern ist, demonstriert die Bedeutung Antigen-unabhängiger Faktoren und relativiert die Rolle von HLA-Unterschieden. Die Vermutung, dass das unterschiedliche Organüberleben nach Transplantation von Leichen- und Lebendspenderorganen auf pathophysiologischen und weniger auf genetischen Unterschieden beruht, führte zu Untersuchungen funktioneller und struktureller Veränderungen, assoziiert mit unspezifischer Organschädigung. Unsere Untersuchungen zeigten, dass Transplantate sowohl von marginalen Spendern als auch von hirntoten Organspendern zum Zeitpunkt der Entnahme immunologisch aktiviert sind. Somit initiieren oder amplifizieren sie zum Zeitpunkt der Transplantation die Immunantwort des Organempfängers. Das potenziell aktivierte Organ provoziert eine Interaktion zwischen unspezifischen proinflammatorischen Schäden und der zum Zeitpunkt der Reperfusion einsetzenden Immunantwort. Die Trigger dieser Interaktion können Spender-assoziierte Risikofaktoren wie z.B. Alter, Hypertension, Diabetes mellitus oder die systemischen Effekte des Spender-Hirntodes darstellen. Der Hirntod stellt einen Antigen-unabhängigen Leichenspender-spezifischen Risikofaktor dar, der bislang unzureichend berücksichtigt wurde. In nahezu allen experimentellen Studien zu transplantationsrelevanten Fragestellungen dienen junge, gesunde Lebendspendertiere als Organspender, im Gegensatz zur klinischen Situation, in der überwiegend Organe hirntoter Organspender zur Transplantation zur Verfügung stehen. Der hirntote Organspender erleidet typischerweise eine plötzliche, irreversible und ausgeprägte Schädigung des zentralnervösen Systems. In Tiermodellen wurde demonstriert, dass die Funktion und Struktur peripherer Organe durch den Faktor Hirntod signifikant beeinflusst wird und von der Genese des Hirntodes abhängt. In einer Serie experimenteller Arbeiten wurden die Mechanismen der Schädigung und die Auswirkungen des Hirntodes auf die Transplantatqualität sowie auf das Ergebnis nach Transplantation untersucht. Diese Studien trugen wesentlich zum Verständnis des Risikofaktors Hirntod bei. Wir zeigten erstmalig in experimentellen Modellen, dass der Hirntod des Spenders den Ischämie/Reperfusionsschaden sowie die Frequenz und Intensität sowohl der akuten als auch der chronischen Abstossungsreaktion nach allogener Nierentransplantation signifikant beeinflusst. Pathophysiologisch konnte ein Prozess postuliert werden, bei dem der unspezifischen Aktivierung durch den Spender-Hirntod eine verstärkte immunologische Empfängerantwort nach Transplantation folgt. Dieser Mechanismus zeigt die enge Interaktion zwischen Antigen-unabhängigen und -abhängigen Faktoren in der Destruktion des Transplantates. Die vorgestellten experimentellen Ergebnisse werden durch eine Reihe klinischer Untersuchungen bestätigt. Morphologische Untersuchungen nach klinischer Nierentransplantation demonstrieren anhand von Biopsien, dass die Frequenz akuter Abstossungsreaktionen nach Transplantation von Leichennieren im Vergleich zu Lebendspendernieren signifikant höher ist. Eigene klinische Untersuchungen an sequentiellen humanen Leberbiopsien bestätigen ebenfalls die experimentellen Beobachtungen. In einem Konzept der Vorbehandlung des hirntoten Spenders wurden erste experimentelle Therapieansätze zur Optimierung der Spenderorganqualität untersucht. Hierbei zeigten sich vielversprechende Ergebnisse bei der Vorbehandlung mit Steroiden, der Blockade von Adhäsionsmolekülen und der Induktion protektiver Gene. Durch Vorbehandlungsstrategien kann die Organqualität signifikant verbessert werden, jedoch nicht der optimale Organstatus nach Lebendspende erreicht werden. Zur Zeit erfolgt die Evaluierung der Therapieansätze in klinischen Studien. Zusammengefasst trugen unsere Untersuchungen wesentlich zu einem besseren Verständnis der Transplantatqualität bei. Unsere Befunde erklären teilweise die klinische Beobachtung, dass Transplantate von Lebendspendern trotz eines ausgeprägteren MHC-mismatches einen besseren Kurz- und Langzeitverlauf zeigen. Die Definition der durch den Spenderhirntod verursachten Veränderungen sowie deren Therapie ermöglichen eine gezielte Verbesserung der Transplantatqualität und somit des Transplantationsergebnisses. / The ultimate goal in transplantation - to provide long-term treatment for an irreversible process - has not been achieved; the rate of attrition over time has not changed appreciably throughout the entire experience. Although recurrent disease, de novo infections, malignancies and other factors may contribute to late graft deterioration, brain death of the donor remains one of the factors which is not investigated yet. Despite well-characterized functional and morphological changes, the mechanisms leading to chronic rejection remain poorly understood. Its pathophysiology has been conceptualized as stemming from both antigen-dependent and independent risk factors. Whereas immune-mediated events are considered to be primarily responsible for the late graft changes it appears increasingly that the influence of non-immunological events has been underestimated. This concept has been emphasized by recent pooled UNOS data which show that the survival rates of kidneys from living unrelated and one haplotype-matched living related donors are identical despite potentially important differences in genetic relationship with the given recipient. In addition, organs from all living donors demonstrate consistently superior results to those from cadaver sources over both the short-and long-term. Various non-immunological factors which might explain this striking discrepancy include the effects of initial ischemia/reperfusion injury, inadequate functioning nephron mass, viral infections and drug toxicity. Brain death is a rarely considered risk factor uniquely relevant to the cadaver donor, the primary source of solid organs for transplantation. Such individuals have suffered extensive and irreversible central nervous system damage secondary to trauma, hemorrhage or infarction. Multivariate analysis has emphasized that both initial and long-term results of engrafted cadaver organs may be dependent upon donor demographics and the etiology of the central injury. The observation that insults occurring around the time of organ transplantation, regardless of whether they are antigen-dependent or independent, become risk factors for late allograft failure suggests that the long-term changes may be programmed early in the process. It has been conceptualized that the events surrounding brain death, occurring before organ removal, may be important. In addition, non-specific events relating to circumstances surrounding the donor and the perfusion and storage of organs, may initiate an inflammatory response which in turn may acutely increase host immunological activity. We showed that as a consequence, organs from brain-dead donors could experience increased and more severe episodes of acute rejection after transplantation due to increased cytokine expression after brain death induction. This assumption would explain the apparent correlation noted clinically between the effects of initial delayed graft function and acute rejection episodes, as well as the different outcome of organs originating from brain-dead in comparison to living donors. In further experiments we investigated the effects of donor treatment on the outcome and the frequency of acute rejections after kidney transplantation. In summary our experiments partly explaine the observed difference in survival and function between living- and brain-dead donor grafts. Definition and understanding of these potential alterations may suggest therapeutic approaches that could be initiated even before the transplantation procedure itself.

Improving the short-term results of kidney transplantation did not result in improving the long-term function and survival of kidney allograft. Organ shortage and increasing number of marginal donors remains the key problem in transplant today. The quality of donor organ is critical for graft function development and survival. The aim is to improve understanding to ischemia/reperfusion injury and its consequences, predict delayed graft function and rejection, improve organ allocation strategy and identify patients suitable for safe drug minimization or complete withdrawal of immunosuppressive therapy. Analysis of donor kidneys identified poor tubular cell quality and low survival factor, Netrin-1 expression levels, to be associated with delayed graft function. We confirmed that reperfusion phase of ischemia/reperfusion injury leads to minimal morphological but significant molecular abnormalities. Dissociation observed in histology and molecular pathology finding calls for an integrated approach in donor quality organ evaluation and allocation for transplantation. Significant heterogeneity within donors with expanded criteria was shown and subgroup of organs at low risk of delayed graft function was identified. We suggested donor biopsies to be performed as a routine praxis in all kidneys...

Improving the short-term results of kidney transplantation did not result in improving the long-term function and survival of kidney allograft. Organ shortage and increasing number of marginal donors remains the key problem in transplant today. The quality of donor organ is critical for graft function development and survival. The aim is to improve understanding to ischemia/reperfusion injury and its consequences, predict delayed graft function and rejection, improve organ allocation strategy and identify patients suitable for safe drug minimization or complete withdrawal of immunosuppressive therapy. Analysis of donor kidneys identified poor tubular cell quality and low survival factor, Netrin-1 expression levels, to be associated with delayed graft function. We confirmed that reperfusion phase of ischemia/reperfusion injury leads to minimal morphological but significant molecular abnormalities. Dissociation observed in histology and molecular pathology finding calls for an integrated approach in donor quality organ evaluation and allocation for transplantation. Significant heterogeneity within donors with expanded criteria was shown and subgroup of organs at low risk of delayed graft function was identified. We suggested donor biopsies to be performed as a routine praxis in all kidneys...