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Broch K, Lemström KB, Gustafsson F, Eiskjær H, Karason K, Gjesdal G, Fagerland MW, Pentikainen M, Lommi J, Gude E, Andreassen AK, Clemmensen TS, Christiansen EH, Bjørkelund E, Berg ES, Arora S, Gullestad L. Randomized Trial of Cholesterol Lowering With Evolocumab for Cardiac Allograft Vasculopathy in Heart Transplant Recipients. JACC. HEART FAILURE 2024; 12:1677-1688. [PMID: 38934968 DOI: 10.1016/j.jchf.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Cardiac allograft vasculopathy is characterized by increased coronary intimal thickness and is a leading cause of death in heart transplant (HTx) recipients despite the routine use of statins. The experience with inhibitors of proprotein convertase subtilisin-kexin type 9 in HTx recipients is limited. Our hypothesis was that lowering cholesterol with the proprotein convertase subtilisin-kexin type 9inhibitor evolocumab would reduce coronary intimal thickness in these patients without compromising safety. OBJECTIVES This double blind, randomized trial was conducted to test whether evolocumab reduces the burden of cardiac allograft vasculopathy. METHODS Patients who had received a cardiac allograft at 1 of the Nordic transplant centers within the prior 4 to 8 weeks were randomized to monthly subcutaneous injections of evolocumab 420 mg or matching placebo. The primary endpoint was the baseline-adjusted maximal intimal thickness as measured by intracoronary ultrasound after 12 months' treatment. RESULTS The trial enrolled 128 patients between June 2019 and May 2022. Matched pairs of coronary ultrasound images were available for 56 patients assigned to evolocumab and 54 patients assigned to placebo. At 12 months, the adjusted mean difference in the maximal intimal thickness between the 2 arms was 0.017 mm (95% CI: -0.006 to 0.040; P = 0.14). The mean reduction in low-density lipoprotein cholesterol with evolocumab compared with placebo was 1.11 mmol/L (95% CI: 0.86-1.37 mmol/L). The use of evolocumab was not associated with an increase in adverse events. CONCLUSIONS Twelve months of treatment with evolocumab substantially reduced low-density lipoprotein cholesterol but did not reduce maximal coronary intimal thickness in HTx recipients. (Cholesterol Lowering With EVOLocumab to Prevent Cardiac Allograft Vasculopathy in De-novo Heart Transplant Recipients [EVOLVD]; NCT03734211).
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Affiliation(s)
- Kaspar Broch
- Oslo University Hospital Rikshospitalet, Oslo, Norway; KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway.
| | - Karl B Lemström
- Helsinki University Hospital Heart and Lung Center and University of Helsinki, Helsinki, Finland
| | - Finn Gustafsson
- Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Kristjan Karason
- Transplant Institute, Sahlgrenska University Hospital and Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Grunde Gjesdal
- Cardiology Unit, Department of Clinical Sciences, Lund University and Department of Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Morten W Fagerland
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Markku Pentikainen
- Helsinki University Hospital Heart and Lung Center and University of Helsinki, Helsinki, Finland
| | - Jyri Lommi
- Helsinki University Hospital Heart and Lung Center and University of Helsinki, Helsinki, Finland
| | - Einar Gude
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | | | | | | | - Erlend S Berg
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Satish Arora
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Oslo University Hospital Rikshospitalet, Oslo, Norway; KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
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Farcas AO, Stoica MC, Maier IM, Maier AC, Sin AI. Heart Transplant Rejection: From the Endomyocardial Biopsy to Gene Expression Profiling. Biomedicines 2024; 12:1926. [PMID: 39200392 PMCID: PMC11351478 DOI: 10.3390/biomedicines12081926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 08/13/2024] [Accepted: 08/20/2024] [Indexed: 09/02/2024] Open
Abstract
Heart transplant prolongs life for patients with end-stage heart failure but rejection remains a complication that reduces long-term survival. The aim is to provide a comprehensive overview of the current status in HT rejection. EMB is an invasive diagnostic tool, consisting in the sampling of a fragment of myocardial tissue from the right ventricular septum using fluoroscopic guidance. This tissue can later be subjected to histopathological, immunohistochemical or molecular analysis, providing valuable information for cardiac allograft rejection, but this procedure is not without complications. To increase the accuracy of the rejection diagnosis, EMB requires a systematic evaluation of endocardium, myocardium, interstitium and intramural vessels. There are three types of rejection: hyperacute, acute or chronic, diagnosed by the histopathological evaluation of EMB as well as by new diagnostic methods such as DSA, ddcfDNA and gene expression profiling, the last having a high negative predictive value. More than 50 years after the introduction of EMB in medical practice, it still remains the "gold standard" in monitoring rejection in HT recipients but other new, less invasive diagnostic methods reduce the number of EMBs required.
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Affiliation(s)
- Anca Otilia Farcas
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540142 Targu Mures, Romania;
- Department of Cell Biology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540139 Targu Mures, Romania;
| | - Mihai Ciprian Stoica
- Department of Nephrology/Internal Medicine, Mures County Clinical Hospital, 540103 Targu Mures, Romania
- Department of Internal Medicine, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540139 Targu Mures, Romania
| | | | - Adrian Cornel Maier
- Emergency Military Hospital, 800150 Galati, Romania;
- Faculty of Medicine and Pharmacy, Dunarea de Jos University, 800008 Galati, Romania
| | - Anca Ileana Sin
- Department of Cell Biology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Department of Pathology, Clinical County Emergency Hospital, 540136 Targu Mures, Romania
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Wright LK, Gajarski RJ, Hayes E, Parekh H, Yester JW, Nandi D. DQB1 antigen matching improves rejection-free survival in pediatric heart transplant recipients. J Heart Lung Transplant 2024; 43:816-825. [PMID: 38232791 DOI: 10.1016/j.healun.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Presence of donor-specific antibodies (DSAs), particularly to class II antigens, remains a major challenge in pediatric heart transplantation. Donor-recipient human leukocyte antigen (HLA) matching is a potential strategy to mitigate poor outcomes associated with DSAs. We evaluated the hypothesis that antigen mismatching at the DQB1 locus is associated with worse rejection-free survival. METHODS Data were collected from Scientific Registry of Transplant Recipients for all pediatric heart transplant recipients 2010-2021. Only transplants with complete HLA typing at the DQB1 locus for recipient and donor were included. Primary outcome was rejection-free graft survival through 5 years. RESULTS Of 5,115 children, 4,135 had complete DQB1 typing and were included. Of those, 503 (12%) had 0 DQB1 donor-recipient mismatches, 2,203 (53%) had 1, and 1,429 (35%) had 2. Rejection-free survival through 5 years trended higher for children with 0 DQB1 mismatches (68%), compared to those with 1 (62%) or 2 (63%) mismatches (pairwise p = 0.08 for both). In multivariable analysis, 0 DQB1 mismatches remained significantly associated with improved rejection-free graft survival compared to 2 mismatches, while 1 DQB1 mismatch was not. Subgroup analysis showed the strongest effect in non-Hispanic Black children and those undergoing retransplant. CONCLUSIONS Matching at the DQB1 locus is associated with improved rejection-free survival after pediatric heart transplant, particularly in Black children, and those undergoing retransplant. Assessing high-resolution donor typing at the time of allocation may further corroborate and refine this association. DQB1 matching may improve long-term outcomes in children stabilized either with optimal pharmacotherapy or supported with durable devices able to await ideal donors.
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Affiliation(s)
- Lydia K Wright
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio.
| | - Robert J Gajarski
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Emily Hayes
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Hemant Parekh
- Clinical Histocompatibility Laboratory, The Ohio State University, Columbus, Ohio
| | - Jessie W Yester
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio
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Grutter G, Bianculli AG, Azeka E, Giustiniani P, Iodice FG, Amodeo A, Andreani M. Role of HLA in cardiothoracic transplantation. HLA 2024; 103:e15428. [PMID: 38450875 DOI: 10.1111/tan.15428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/07/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
In current clinical practice, transplant clinicians create collaborative working relationships with histocompatibility laboratory scientists to identify the risk of long-term graft failure, which may assist in establishing strategies for treatment and surveillance. Transplant immunology research also focuses on optimizing human leukocyte antibody tissue typing and defines the most effective test for detecting the presence of donor-specific antibodies. Although several studies have been conducted, data on pediatric heart transplant recipients are limited. Epitope load information may be utilized to identify donors with permissible human leukocyte antibody mismatches to increase transplant success. Although current guidelines do not consider human leukocyte antibody epitope-based matching tools, these guidelines could be useful for identifying recipients at a high risk of donor-specific antibody production, which would be appropriate for routine donor-specific antibody screening to initiate early interventions to prevent antibody-mediated rejection. Human leukocyte antibody matching at the epitope level offers an effective approach for identifying acceptable mismatches in sensitized patients and provides information about epitope loads. In the future, eplet matching may be used to define the best immunosuppressive therapy protocol for cardiothoracic organ transplantation. This report provides an overview of the role of human leukocyte antibodies in heart and lung transplantation.
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Affiliation(s)
- Giorgia Grutter
- Heart Failure, Transplantation, Cardiorespiratory Mechanical Assistance Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Estela Azeka
- Unidade de Cardiologia Pediatrica e Cardiopatia Congenitas do Adulto, Departamento de Cardiologia, Instituto do Coração (InCor) Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paola Giustiniani
- Laboratory of Transplantation Immunogenetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Giovanna Iodice
- Department of Paediatric Cardiac Anesthesia and Intensive Care, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplantation, Cardiorespiratory Mechanical Assistance Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Andreani
- Laboratory of Transplantation Immunogenetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Clemmensen TS, Hjort Baatrup J, Bjerre KP, Lichscheidt E, Nielsen PK, Eiskjaer H. Routine screening for HLA Antibodies in Heart Transplant patients-Does it affect clinical decision making? Clin Transplant 2024; 38:e15281. [PMID: 38504577 DOI: 10.1111/ctr.15281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND We aimed to assess outcomes in patients with and without donor specific antibodies (DSA) and to evaluate the relationship between DSA presence and graft function, cardiac allograft vasculopathy (CAV), and mortality. METHODS The study population comprises 193 consecutive long-term heart transplanted (HTx) patients who underwent DSA surveillance between 2016 and 2022. The patients were prospectively screened for CAV through serial coronary angiograms, graft function impairment through serial echocardiograms, and cardiac biomarkers. The patients were followed from the first DSA measurement until death, 5 years follow-up or right censuring on the 30th of June 2023. RESULTS DSAs were detected in 50 patients using a cut-off at MFI ≥1000 and 45 patients using a cut-off at ≥2000 MFI. The median time since HTx was 9.0 years [3.0-14.4]. DSA positive patients had poorer graft function and higher values of NT-proBNP and troponin T, and more prevalent CAV than DSA negative patients. In total, 25 patients underwent endomyocardial biopsies due to DSA presence while another eight patients underwent endomyocardial biopsies for other reasons. Histological antibody mediated rejection (AMR) signs were seen in three biopsies. During a median follow-up of five years [4.7-5], a total of 41 patients died. Mortality rates did not differ between DSA positive and DSA negative patients (HR 1.2, 95% CI .6-2.4). DSA positive patients were more likely to experience CAV progression than DSA negative patients (HR 2.7, 95% CI 1.5-4.8) CONCLUSIONS: Routine screening reveals DSA in approximately 25% of long-term HTx patients but is rarely related to histopathological AMR signs. DSA presence was associated with poorer graft function and more prevalent and progressive CAV. However, DSA positive patients had similar survival rates to DSA negative patients.
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Affiliation(s)
| | | | | | - Emil Lichscheidt
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
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Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Martini L, Mandoli GE, Pastore MC, Pagliaro A, Bernazzali S, Maccherini M, Henein M, Cameli M. Heart transplantation and biomarkers: a review about their usefulness in clinical practice. Front Cardiovasc Med 2024; 11:1336011. [PMID: 38327491 PMCID: PMC10847311 DOI: 10.3389/fcvm.2024.1336011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/12/2024] [Indexed: 02/09/2024] Open
Abstract
Advanced heart failure (AdvHF) can only be treated definitively by heart transplantation (HTx), yet problems such right ventricle dysfunction (RVD), rejection, cardiac allograft vasculopathy (CAV), and primary graft dysfunction (PGD) are linked to a poor prognosis. As a result, numerous biomarkers have been investigated in an effort to identify and prevent certain diseases sooner. We looked at both established biomarkers, such as NT-proBNP, hs-troponins, and pro-inflammatory cytokines, and newer ones, such as extracellular vesicles (EVs), donor specific antibodies (DSA), gene expression profile (GEP), donor-derived cell free DNA (dd-cfDNA), microRNA (miRNA), and soluble suppression of tumorigenicity 2 (sST2). These biomarkers are typically linked to complications from HTX. We also highlight the relationships between each biomarker and one or more problems, as well as their applicability in routine clinical practice.
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Affiliation(s)
- L. Martini
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - G. E. Mandoli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - M. C. Pastore
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - A. Pagliaro
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - S. Bernazzali
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Maccherini
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - M. Cameli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
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Webber SA, Chin H, Wilkinson JD, Armstrong BD, Canter CE, Dipchand AI, Dodd DA, Feingold B, Lamour JM, Mahle WT, Singh TP, Zuckerman WA, Rossano JW, Morrison Y, Diop H, Demetris AJ, Bentlejewski C, Mohanakumar T, Odim J, Zeevi A. Impact of donor-specific anti-HLA antibody on cardiac hemodynamics and graft function 3 years after pediatric heart transplantation: First results from the CTOTC-09 multi-institutional study. Am J Transplant 2023; 23:1893-1907. [PMID: 37579817 PMCID: PMC10841212 DOI: 10.1016/j.ajt.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 08/16/2023]
Abstract
The aim of this study (CTOTC-09) was to assess the impact of "preformed" (at transplant) donor-specific anti-HLA antibody (DSA) and first year newly detected DSA (ndDSA) on allograft function at 3 years after pediatric heart transplantation (PHTx). We enrolled children listed at 9 North American centers. The primary end point was pulmonary capillary wedge pressure (PCWP) at 3 years posttransplant. Of 407 enrolled subjects, 370 achieved PHTx (mean age, 7.7 years; 57% male). Pre-PHTx sensitization status was nonsensitized (n = 163, 44%), sensitized/no DSA (n = 115, 31%), sensitized/DSA (n = 87, 24%), and insufficient DSA data (n = 5, 1%); 131 (35%) subjects developed ndDSA. Subjects with any DSA had comparable PCWP at 3 years to those with no DSA. There were also no significant differences overall between the 2 groups for other invasive hemodynamic measurements, systolic graft function by echocardiography, and serum brain natriuretic peptide concentration. However, in the multivariable analysis, persistent first-year DSA was a risk factor for 3-year abnormal graft function. Graft and patient survival did not differ between groups. In summary, overall, DSA status was not associated with worse allograft function or inferior patient and graft survival at 3 years, but persistent first-year DSA was a risk factor for late graft dysfunction.
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Affiliation(s)
- Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA.
| | - Hyunsook Chin
- Rho Federal Systems Division, Durham, North Carolina, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA
| | | | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anne I Dipchand
- Labatt Family Heart Center, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Debra A Dodd
- Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt, Nashville, Tennessee, USA
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, USA
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Tajinder P Singh
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Joseph W Rossano
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yvonne Morrison
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Helena Diop
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Anthony J Demetris
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carol Bentlejewski
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Rahman A, Golombeck D, Malhame K, Rossi D, Wallach F, Avila M, Maybaum S. Letter to the Editor: Immunogenicity After the Third Dose of COVID-19 Vaccine in Cardiac Transplantation. Transplantation 2023; 107:e370-e372. [PMID: 37899474 PMCID: PMC10664776 DOI: 10.1097/tp.0000000000004843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/14/2023] [Accepted: 07/26/2023] [Indexed: 10/31/2023]
Affiliation(s)
- Afsana Rahman
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - David Golombeck
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - Kathryn Malhame
- Department of Cardiothoracic Surgery, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - Dora Rossi
- Department of Cardiothoracic Surgery, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - Frances Wallach
- Department of Medicine, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - Maria Avila
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
| | - Simon Maybaum
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra, Northwell, North Shore University Hospital, Manhasset, NY
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Kaskinen AK, Tainio J, Pihkala JI, Peräsaari JP, Lauronen J, Raissadati A, Merenmies JM, Jalanko HJ, Jahnukainen T. Recurrent Mild Acute Rejections and Donor-specific Antibodies as Risk Factors for Cardiac Allograft Vasculopathy in a National Pediatric Heart Transplant Cohort. Transplant Direct 2023; 9:e1534. [PMID: 37745950 PMCID: PMC10513139 DOI: 10.1097/txd.0000000000001534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/24/2023] [Indexed: 09/26/2023] Open
Abstract
Background Immune-mediated factors such as acute cellular rejections and donor-specific antibodies (DSAs) are risk factors for cardiac allograft vasculopathy (CAV). We studied a national cohort with a unified setting and thorough protocol endomyocardial biopsy (EMB) data for an association between cellular rejections, especially when mild and recurrent, and DSAs with CAV in pediatric heart transplant (HTx) patients. Methods This is a retrospective, national cohort study of 94 pediatric HTxs performed between 1991 and 2019 and followed until December 31, 2020. Diagnosis of CAV was based on reevaluation of angiographies. Protocol and indication EMB findings with other patient data were collected from medical records. Associations between nonimmune and immune-mediated factors and CAV were analyzed with univariable and multivariable Cox regression analyses. Results Angiographies performed on 76 patients revealed CAV in 23 patients (30%). Altogether 1138 EMBs (92% protocol biopsies) were performed on 78 patients (83%). During the first posttransplant year, grade 1 rejection (G1R) appeared in 45 patients (58%), and recurrent (≥2) G1R findings in 14 patients (18%). Pretransplant DSAs occurred in 13 patients (17%) and posttransplant DSAs in 37 patients (39%). In univariable analysis, pretransplant DSAs, appearance and recurrence of G1R findings, and total rejection score during the first posttransplant year, as well as recurrent G1R during follow-up, were all associated with CAV. In multivariable analysis, pretransplant DSAs and recurrent G1R during the first posttransplant year were found to be associated with CAV. Conclusions Our results indicate that pretransplant DSA and recurrent G1R findings, especially during the first posttransplant year, are associated with CAV after pediatric HTx.
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Affiliation(s)
- Anu K. Kaskinen
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juuso Tainio
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jaana I. Pihkala
- Department of Pediatric Cardiology, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha P. Peräsaari
- Finnish Red Cross Blood Service, Histocompatibility Laboratory, Helsinki, Finland
| | - Jouni Lauronen
- Finnish Red Cross Blood Service, Histocompatibility Laboratory, Helsinki, Finland
| | - Alireza Raissadati
- Division of Cardiology, Department of Pediatrics, Stanford School of Medicine, Helsinki, Finland
| | - Jussi M. Merenmies
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu J. Jalanko
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Kobashigawa J, Hall S, Shah P, Fine B, Halloran P, Jackson AM, Khush KK, Margulies KB, Sani MM, Patel JK, Patel N, Peyster E. The evolving use of biomarkers in heart transplantation: Consensus of an expert panel. Am J Transplant 2023; 23:727-735. [PMID: 36870390 PMCID: PMC10387364 DOI: 10.1016/j.ajt.2023.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
In heart transplantation, the use of biomarkers to detect the risk of rejection has been evolving. In this setting, it is becoming less clear as to what is the most reliable test or combination of tests to detect rejection and assess the state of the alloimmune response. Therefore, a virtual expert panel was organized in heart and kidney transplantation to evaluate emerging diagnostics and how they may be best utilized to monitor and manage transplant patients. This manuscript covers the heart content of the conference and is a work product of the American Society of Transplantation's Thoracic and Critical Care Community of Practice. This paper reviews currently available and emerging diagnostic assays and defines the unmet needs for biomarkers in heart transplantation. Highlights of the in-depth discussions among conference participants that led to development of consensus statements are included. This conference should serve as a platform to further build consensus within the heart transplant community regarding the optimal framework to implement biomarkers into management protocols and to improve biomarker development, validation and clinical utility. Ultimately, these biomarkers and novel diagnostics should improve outcomes and optimize quality of life for our transplant patients.
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Affiliation(s)
- Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA.
| | - Shelley Hall
- Department of Cardiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Palak Shah
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Barry Fine
- Department of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Phil Halloran
- Department of Medicine Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Annette M Jackson
- Department of Surgery, Duke University, Durham, North Carolina, USA; Department of Immunology, Duke University, Durham, North Carolina, USA
| | - Kiran K Khush
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Kenneth B Margulies
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maryam Mojarrad Sani
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nikhil Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Eliot Peyster
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Akhtar W, Peterzan MA, Banya W, Olwell B, Aghouee FV, Brookes P, Dunning J, Dar O. Donor specific antibodies association with survival and adverse events after heart transplantation: A single center retrospective study between 2006 and 2021. Clin Transplant 2023; 37:e14914. [PMID: 36630276 DOI: 10.1111/ctr.14914] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/23/2022] [Accepted: 01/08/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Newly detected donor HLA-specific antibodies (DSA) are historically known to be associated with reduced survival in heart transplant patients. Our objective is to clarify the modern incidence of DSA and determine its relationship with survival and MACE. METHODS This retrospective study included all patients undergoing orthotopic heart transplantation at Harefield Hospital, London between January 1, 2006 and May 31, 2021. We identified patients who developed DSA at any point post heart transplantation and its effect on survival and MACE (defined as rejection, coronary event, stroke, and arrhythmia. RESULTS In total of 232 patients were included with a median follow up time of 4.7 years post heart transplantation. 23.7% of patients included developed DSA post heart transplantation. There was a significantly increased risk of death in patients developing DSA versus not (sub distribution hazard ratio [SHR] 1.83, 95% confidence interval 1.03-3.24, p = .04). At the time of detection of DSA, 38.2% of the cohort had rejection necessitating treatment. A MACE event had occurred in 48.1% by 2 years and 53.7% by 3 years in the DSA cohort. There was a significantly increased risk of MACE in patients developing DSA versus not (SHR 2.48 [1.58-3.89, p < .0001]). CONCLUSIONS This study showed an increased risk of death and MACE in patients developing DSA post heart transplantation. Further research is required into the optimal management of these patients.
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Affiliation(s)
- Waqas Akhtar
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Mark A Peterzan
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Winston Banya
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Brian Olwell
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Farveh Vakilian Aghouee
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Paul Brookes
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - John Dunning
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Owais Dar
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
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13
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Magnetta DA, Hoch VL, Pinelli D, Monge M, Pahl E, Thrush PT. Donor-specific antibodies after heart transplantation for Fontan-associated protein-losing enteropathy. Pediatr Transplant 2023:e14458. [PMID: 36591815 DOI: 10.1111/petr.14458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/22/2022] [Accepted: 10/04/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite ubiquitous exposure to sensitizing events, most Fontan PLE patients have low panel reactive antibodies (PRA). To assess whether they are at risk for donor-specific antibody (DSA) memory response following heart transplantation (HT) when their PLE resolves, DSA profiles, incidence of rejection, and graft outcomes in Fontan recipients with and without PLE were compared. METHODS Patient characteristics, appearance of newly detected DSA (nDSA), and graft outcomes were compared between patients with and without PLE using Wilcoxon rank-sum and Chi-squared tests. DSA burden was quantified using titers and time to nDSA, incidence of rejection, and graft outcomes were compared using Kaplan-Meier curves and the log-rank test. RESULTS Characteristics of patients with and without PLE were similar. Lymphocyte and albumin levels were lower in the PLE group, and flow PRA were comparable. Graft failure, CAV, and ACR were similar between the two groups, but AMR occurred more frequently in the PLE group (p = .03). Nearly 50% of PLE patients experienced class II nDSA by 1-year post-HT, compared to 30% of non-PLE patients, but this difference was statistically not significant. Antibody burden did not differ between groups. CONCLUSIONS In this cohort, PLE was associated with AMR within the first-year post-HT, despite no significant difference in nDSA. Small patient numbers limited statistical comparison of nDSA in this cohort. PLE may be a risk factor for AMR post-HT, and the possibility of a clinically important DSA memory response remains. Larger studies are necessary to better understand these preliminary findings.
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Affiliation(s)
- Defne A Magnetta
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Virginia L Hoch
- Internal Medicine-Pediatrics, ChristianaCare Health System, Newark, Delaware, USA
| | - David Pinelli
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Monge
- Pediatric Cardiothoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Elfriede Pahl
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Philip T Thrush
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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14
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Li C, Wang G. Liquid Biopsy, a Potential New Detection Method in Heart Allograft Rejection. Methods Mol Biol 2023; 2695:309-315. [PMID: 37450128 DOI: 10.1007/978-1-0716-3346-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Allografts rejection remains the most important reason causing allograft dysfunction in heart transplantation recipients. Currently, the golden standard for detecting graft rejection is endomyocardial biopsy (EMB). As a new noninvasive technique, liquid biopsy emerges along with the great developments of droplet-based digital PCR and the various optimizations of next-generation sequencing technologies, which is also cheaper than EMB. This review introduces several types of liquid biopsy and its application in heart transplantation.
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Affiliation(s)
- Chenghao Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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15
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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16
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 125] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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17
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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18
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Significance of HLA-matching and anti-HLA antibodies in heart transplant patients receiving induction therapy? Transpl Immunol 2022; 75:101706. [PMID: 36113729 DOI: 10.1016/j.trim.2022.101706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Though Human Leukocyte Antigen (HLA) matching benefits are demonstrated in renal transplantation, evidence in heart transplantation is lacking, and its clinical feasibility is uncertain. Post-transplantation anti-HLA antibodies are being increasingly studied in organ transplantation, with diverging conclusions between transplantated organs. METHODS We analyzed retrospectively the influence of HLA matching and anti-HLA antibodies on overall survival, acute rejection and chronic allograft vasculopathy in 309 patients receiving induction therapy and triple-drug immunosuppression. RESULTS The average number of HLA-A/B/DR mismatches between donor and recipient was 4.9 ± 1. The majority of mismatches was for Class I HLA-A/B with an average of 3.3, then for Class I HLA-DR with an average of 1.6. Overall, the HLA-A/-B/-DR mismatches had no influence on the cardiac allograft survival (p = 0.28). However, HLA-DR mismatches were negatively correlated to severe cellular and/or humoral allograft rejection (p = 0.04). Our analysis found anti-HLA antibodies in 27% of recipients, de novo anti-HLA antibodies in 16% of recipients, and donor-specific anti-HLA (DSA) antibodies in 8% of recipients. Furthermore, de novo DSA had no influence on the 5-year survival (78% with DSA vs. 92% without DSA; p = 0.49), which may be masked by the limited number of recipients in analysis By univariable analysis, anti-HLA antibodies (preexisting or de novo) unrelated or related to the donor had no influence on severe cellular and/or humoral rejection or on chronic allograft vasculopathy. CONCLUSIONS HLA-DR mismatch was negatively correlated to severe cellular and/or humoral allograft rejection but had no influence on cardiac allograft survival. In this study, anti-HLA antibodies (preexisting or de novo) unrelated or related to the donor had no influence on cellular and/or humoral rejection or on chronic allograft vasculopathy. The results of this study add to the controversy on the impact of allo-antibodies in heart transplant recipients receiving induction therapy and contemporary immunosuppression.
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19
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Nair N. Vascular rejection in cardiac allograft vasculopathy: Impact on graft survival. Front Cardiovasc Med 2022; 9:919036. [PMID: 35990962 PMCID: PMC9386065 DOI: 10.3389/fcvm.2022.919036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/14/2022] [Indexed: 11/24/2022] Open
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20
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De Novo Complement-Binding Anti-HLA Antibodies in Heart Transplanted Patients Is Associated with Severe Cardiac Allograft Vasculopathy and Poor Long-Term Survival. J Clin Med 2022; 11:jcm11133731. [PMID: 35807015 PMCID: PMC9267850 DOI: 10.3390/jcm11133731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: De novo anti-HLA donor specific antibodies (DSA) have been inconsistently associated with cardiac allograft vasculopathy (CAV) and long-term mortality. We tested whether C3d-binding de novo DSA were associated with CAV or long-term-survival. Methods: We included 282 consecutive patients without preformed DSA on coronary angiography between 2010 and 2012. Angiographies were classified according to CAV ISHLT grading. The primary outcome was a composite criterion of severe CAV or mortality. As the impact of de novo antibodies should be assessed only after appearance, we used a Cox regression with time-dependent covariables. Results: Of the 282 patients, 51(18%) developed de novo DSA during follow-up, 29 patients had DSA with C3d-binding ability (DSA+C3d+), and 22 were without C3d-binding ability (DSA+C3d-). Compared with patients without DSA, DSA+C3d+ patients had an increased risk for the primary outcome of severe CAV or mortality (adjusted HR = 4.31 (2.40−7.74) p < 0.001) and long-term mortality (adjusted HR = 3.48 (1.97−6.15) p < 0.001) whereas DSA+C3d- did not (adjusted HR = 1.04 (0.43−2.47) p = 0.937 for primary outcome and HR = 1.08 (0.45−2.61) p = 0.866 for mortality). Conclusion: According to this large monocentric study in heart transplant patients, donor specific antibodies were associated with worse clinical outcome when binding complement. DSA and their complement-binding ability should thus be screened for to optimize heart transplant patient follow-up.
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21
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Donovan DJ, Richmond ME, Bacha EA, Addonizio LJ, Zuckerman WA. Association between homograft tissue exposure and allosensitization prior to heart transplant in patients with congenital heart disease. Pediatr Transplant 2022; 26:e14201. [PMID: 34889487 DOI: 10.1111/petr.14201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical repair for patients with congenital heart disease (CHD) often incorporates homograft tissue or other foreign material that can lead to allosensitization. We sought to identify the relationship between pre-sensitization prior to heart transplant and exposure to homograft tissue in CHD patients. METHODS Retrospective chart review of all CHD patients who underwent heart transplant at a major pediatric transplant center between 1/1/2011-3/31/18. Operative records determined use of homograft tissue or foreign material. Panel reactive antibody (PRA) and LuminexTM single-antigen bead (SAB) testing results were reviewed. Statistical analysis determined odds of pre-sensitization in patients exposed to homograft tissue. RESULTS Fifty-six CHD patients underwent transplant during the review period. Thirteen patients (23%) were pre-sensitized by PRA>10%. By SAB testing, 33 patients (59%) developed any anti-HLA antibody >0 MFI, 30 patients (54%) >2000 MFI, and 19 patients (34%) >6000 MFI. Patients with homografts were more likely to be pre-sensitized by PRA (OR = 7.31, p = .007), and to have developed any anti-HLA antibody at various levels, >0 (OR = 4.52, p = .034), >2000 (OR = 8.59, p = .003), and >6000 (OR = 8.50, p = .004). Of patients with homografts, those pre-sensitized by PRA had longer exposure times (9.80 vs 4.96 years, p = .025). There was no difference in exposure time with relation to pre-sensitization by SAB testing. CONCLUSIONS Previous exposure to homograft tissue appears to increase the odds of pre-sensitization by either the PRA or SAB testing. Longer exposure time to homograft tissue prior to transplant is associated with increased pre-sensitization at transplant as determined by PRA, though not by SAB testing.
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Affiliation(s)
- Denis J Donovan
- Division of Pediatric Cardiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Marc E Richmond
- Division of Pediatric Cardiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Emile A Bacha
- Division of Pediatric Cardiac Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Linda J Addonizio
- Division of Pediatric Cardiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
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22
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Power A, Baez Hernandez N, Dipchand AI. Rejection surveillance in pediatric heart transplant recipients: Critical reflection on the role of frequent and long-term routine surveillance endomyocardial biopsies and comprehensive review of non-invasive rejection screening tools. Pediatr Transplant 2022; 26:e14214. [PMID: 35178843 DOI: 10.1111/petr.14214] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite significant medical advances in the field of pediatric heart transplantation (HT), acute rejection remains an important cause of morbidity and mortality. Endomyocardial biopsy (EMB) remains the gold-standard method for diagnosing rejection but is an invasive, expensive, and stressful process. Given the potential adverse consequences of rejection, routine post-transplant rejection surveillance protocols incorporating EMB are widely employed to detect asymptomatic rejection. Each center employs their own specific routine rejection surveillance protocol, with no consensus on the optimal approach and with high inter-center variability. The utility of high-frequency and long-term routine surveillance biopsies (RSB) in pediatric HT has been called into question. METHODS Sources for this comprehensive review were primarily identified through searches in biomedical databases including MEDLINE and Embase. RESULTS The available literature suggests that the diagnostic yield of RSB is low beyond the first year post-HT and that a reduction in RSB intensity from high-frequency to low-frequency can be done safely with no impact on early and mid-term survival. Though there are emerging non-invasive methods of detecting asymptomatic rejection, the evidence is not yet strong enough for any test to replace EMB. CONCLUSION Overall, pediatric HT centers in North America should likely be doing fewer RSB than are currently performed. Risk factors for rejection should be considered when designing the optimal rejection surveillance strategy. Noninvasive testing including emerging biomarkers may have a complementary role to aid in safely reducing the need for RSB.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA
| | - Nathanya Baez Hernandez
- Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA
| | - Anne I Dipchand
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
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23
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Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients Does Early-Onset Portend a Worse Prognosis? J Heart Lung Transplant 2022; 41:578-588. [DOI: 10.1016/j.healun.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/05/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
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Shotgun Immunoproteomics for Identification of Nonhuman Leukocyte Antigens Associated With Cellular Dysfunction in Heart Transplant Rejection. Transplantation 2021; 106:1376-1389. [PMID: 34923540 DOI: 10.1097/tp.0000000000004012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The International Society for Heart and Lung Transplant consensus panel notes that too little data exist regarding the role of non-HLA in allograft rejection. We developed a novel shotgun immunoproteomic approach to determine the identities and potential roles non-HLA play in antibody-mediated rejection (AMR) in heart transplant recipients. METHODS Serum was collected longitudinally from heart transplant recipients experiencing AMR in the absence of donor-specific anti-HLA antibodies (n = 6) and matched no rejection controls (n = 7). Antidonor heart affinity chromatography columns were formed by recipient immunoglobulin G immobilization at transplantation, acute rejection, and chronic postrejection time points. Affinity chromatography columns were used to capture antigens from individual patient's donor heart biopsies collected at transplantation. Captured proteins were subjected to quantitative proteomic analysis and the longitudinal response was calculated. RESULTS Overlap in antigen-specific response between AMR and non-AMR patients was only 8.3%. In AMR patients, a total of 155 non-HLAs were identified, with responses toward 43 high prevalence antigens found in ≥50% of patients. Immunofluorescence staining for representative high prevalence antigens demonstrated that their abundance increased at acute rejection, correlating with their respective non-HLA antibody response. Physiological changes in cardiomyocyte and endothelial cell function, following in vitro culture with patient immunoglobulin G, correlated with response toward several high prevalence antigens. CONCLUSIONS This work demonstrates a novel high-throughput strategy to identify clinically relevant non-HLA from donor endomyocardial biopsy. Such a technique has the potential to improve understanding of longitudinal timing of antigen-specific responses and their cause and effect relationship in graft rejection.
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25
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Ortega-Legaspi JM, Bravo PE. Diagnosis and management of cardiac allograft vasculopathy. Heart 2021; 108:586-592. [PMID: 34340994 DOI: 10.1136/heartjnl-2020-318063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/07/2021] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of death beyond the first year after heart transplantation is cardiac allograft vasculopathy (CAV). This review summarises the current understanding of its complex pathophysiology, detection and treatment, including the available data on non-invasive imaging modalities used for screening and diagnosis. A better understanding of this entity is crucial to improving the long-term outcomes of the growing population of patients with a heart transplant.
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Affiliation(s)
- Juan M Ortega-Legaspi
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Paco E Bravo
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Glinton K, DeBerge M, Fisher E, Schroth S, Sinha A, Wang JJ, Wasserstrom JA, Ansari MJ, Zhang ZJ, Feinstein M, Leventhal JR, Forbess JM, Lomasney J, Luo X, Thorp EB. Bone marrow-derived AXL tyrosine kinase promotes mitogenic crosstalk and cardiac allograft vasculopathy. J Heart Lung Transplant 2021; 40:435-446. [PMID: 33846079 PMCID: PMC8169599 DOI: 10.1016/j.healun.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 11/19/2022] Open
Abstract
Cardiac Allograft Vasculopathy (CAV) is a leading contributor to late transplant rejection. Although implicated, the mechanisms by which bone marrow-derived cells promote CAV remain unclear. Emerging evidence implicates the cell surface receptor tyrosine kinase AXL to be elevated in rejecting human allografts. AXL protein is found on multiple cell types, including bone marrow-derived myeloid cells. The causal role of AXL from this compartment and during transplant is largely unknown. This is important because AXL is a key regulator of myeloid inflammation. Utilizing experimental chimeras deficient in the bone marrow-derived Axl gene, we report that Axl antagonizes cardiac allograft survival and promotes CAV. Flow cytometric and histologic analyses of Axl-deficient transplant recipients revealed reductions in both allograft immune cell accumulation and vascular intimal thickness. Co-culture experiments designed to identify cell-intrinsic functions of Axl uncovered complementary cell-proliferative pathways by which Axl promotes CAV-associated inflammation. Specifically, Axl-deficient myeloid cells were less efficient at increasing the replication of both antigen-specific T cells and vascular smooth muscle cells (VSMCs), the latter a key hallmark of CAV. For the latter, we discovered that Axl-was required to amass the VSMC mitogen Platelet-Derived Growth Factor. Taken together, our studies reveal a new role for myeloid Axl in the progression of CAV and mitogenic crosstalk. Inhibition of AXL-protein, in combination with current standards of care, is a candidate strategy to prolong cardiac allograft survival.
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MESH Headings
- Adult
- Animals
- Bone Marrow Cells/metabolism
- Bone Marrow Cells/pathology
- Cell Proliferation
- Cells, Cultured
- Disease Models, Animal
- Echocardiography
- Flow Cytometry
- Gene Expression Regulation
- Graft Rejection/diagnosis
- Graft Rejection/genetics
- Graft Rejection/metabolism
- Graft Survival
- Heart Transplantation/adverse effects
- Humans
- Male
- Mice
- Mice, Inbred BALB C
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Cardiac/metabolism
- Myocytes, Cardiac/pathology
- Myocytes, Smooth Muscle
- Proto-Oncogene Proteins/biosynthesis
- Proto-Oncogene Proteins/genetics
- RNA/genetics
- Receptor Protein-Tyrosine Kinases/biosynthesis
- Receptor Protein-Tyrosine Kinases/genetics
- Transplantation, Homologous
- Axl Receptor Tyrosine Kinase
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Affiliation(s)
- Kristofor Glinton
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew DeBerge
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emily Fisher
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samantha Schroth
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Arjun Sinha
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jiao-Jing Wang
- The Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - J Andrew Wasserstrom
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mohammed Javeed Ansari
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Zheng Jenny Zhang
- The Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew Feinstein
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joseph R Leventhal
- The Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Jon Lomasney
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Xunrong Luo
- The Department of Nephrology, Duke University School of Medicine, Durham, North Carolina
| | - Edward B Thorp
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; The Heart Center, Stanley Manne Children's Research Institute, Lurie Children's Hospital, Chicago, Illinois.
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Schmitz R, Fitch ZW, Schroder PM, Choi AY, Jackson AM, Knechtle SJ, Kwun J. B cells in transplant tolerance and rejection: friends or foes? Transpl Int 2021; 33:30-40. [PMID: 31705678 DOI: 10.1111/tri.13549] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/14/2022]
Abstract
Our understanding of the role of B cells in organ transplantation remains incomplete and continues to grow. The majority of research has focused on the detrimental role of antibodies that drive the development of pathogenesis of the transplanted organ. However, it has been shown that not all donor-specific antibodies are harmful and in some circumstances can even promote tolerance through the mechanism of accommodation. Furthermore, B cells can have effects on transplanted organs through their interaction with T cells, namely antigen presentation, cytokine production, and costimulation. More recently, the role and importance of Bregs was introduced to the field of transplantation. Due to this functional and ontogenetic heterogeneity, targeting B cells in transplantation may bring undesired immunologic side effects including increased rejection. Therefore, the selective control of B cells that contribute to the humoral response against donor antigens will continue to be an important and challenging area of research and potentially lead to improved long-term transplant outcomes.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Zachary W Fitch
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Paul M Schroder
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Ashley Y Choi
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Annette M Jackson
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
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28
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Kiamanesh O, Toma M. The State of the Heart Biopsy: A Clinical Review. CJC Open 2021; 3:524-531. [PMID: 34027357 PMCID: PMC8129478 DOI: 10.1016/j.cjco.2020.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/23/2020] [Indexed: 12/16/2022] Open
Abstract
Endomyocardial biopsy (EMB) is an invaluable and underused diagnostic tool for myocardial disease. The primary indications are surveillance of cardiac allograft rejection and the diagnosis of inflammatory and infiltrative cardiomyopathies. EMB is typically performed by sampling the right ventricular septum via the right internal jugular vein using fluoroscopic guidance. The diagnostic yield of EMB is improved by sampling both ventricles and with the use of guidance from imaging or electroanatomic mapping. The risk of major cardiac complications is operator dependent and < 1% in experienced centres. EMB is the gold standard and most common form of cardiac allograft rejection surveillance, whereas advanced cardiac imaging and donor-specific antibody quantification provide complementary information. Gene expression profiling is an alternative surveillance strategy to EMB for low-risk patients. EMB is recommended for myocarditis and can guide therapy for giant-cell myocarditis, necrotizing eosinophilic myocarditis, sarcoidosis, and immune checkpoint inhibitor myocarditis. There is growing interest in using EMB to guide therapy for viral myocarditis, although the uptake of this approach is limited to specialized centres. EMB has been replaced as a first-line test for infiltrative cardiomyopathy by nonbiopsy diagnostic techniques, but is still useful to clarify the diagnosis or disease subtype. The miniaturization of bioptomes and advances in laboratory techniques such as microarrays promises to improve the safety and yield of EMB. We review the contemporary use of EMB for cardiac allograft rejection, inflammatory cardiomyopathy, and infiltrative cardiomyopathy.
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Affiliation(s)
- Omid Kiamanesh
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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29
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Guerrero-Miranda CY, Hall SA. Rethinking the future with evolving technology: It's time to empower change in heart transplantation. Am J Transplant 2021; 21:453-455. [PMID: 32717109 DOI: 10.1111/ajt.16221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Cesar Y Guerrero-Miranda
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
| | - Shelley A Hall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
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30
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Setia G, Nishihara K, Singer-Englar T, Zhang X, Patel J, Kobashigawa J. Crossing low/moderate-level donor-specific antibodies during heart transplantation. Clin Transplant 2020; 35:e14196. [PMID: 33338283 DOI: 10.1111/ctr.14196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/10/2020] [Accepted: 12/07/2020] [Indexed: 12/21/2022]
Abstract
Donor-specific antibodies (DSAs) in patients prior to heart transplantation are associated with increased risk of rejection and can lead to longer waitlist times, but it is not known whether patients with low/moderate-level DSA at transplant have acceptable post-transplant outcomes. We performed a single-center, retrospective review to examine outcomes associated with crossing pre-existing low/moderate-level DSA. We assessed 864 patients awaiting heart transplantation between 2010 and 2018, identified 67 patients with low/moderate-level DSA and compared them to patients who were sensitized without DSA at the time of heart transplantation, as well as a control group of non-sensitized patients. Outcomes included 3-year survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE), and 1-year freedom from rejection. In the first-year post-transplant, there was decreased freedom from antibody-mediated rejection (AMR) in the patients with pre-existing DSA compared with patients sensitized without DSA and non-sensitized patients. However, the DSA group experienced similar 3-year post-transplant survival, freedom from CAV, and freedom from NF-MACE compared with the other study groups. Our findings suggest that crossing low/moderate-level DSA does not lead to worse outcomes in heart transplantation and may offer a viable way to increase a sensitized patient's chance to obtain a suitable donor.
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Affiliation(s)
- Gayatri Setia
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Keith Nishihara
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Xiaohai Zhang
- HLA Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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31
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Khachatoorian Y, Khachadourian V, Chang E, Sernas ER, Reed EF, Deng M, Piening BD, Pereira AC, Keating B, Cadeiras M. Noninvasive biomarkers for prediction and diagnosis of heart transplantation rejection. Transplant Rev (Orlando) 2020; 35:100590. [PMID: 33401139 DOI: 10.1016/j.trre.2020.100590] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
For most patients with end-stage heart failure, heart transplantation is the treatment of choice. Allograft rejection is one of the major post-transplantation complications affecting graft outcome and survival. Recent advancements in science and technology offer an opportunity to integrate genomic and other omics-based biomarkers into clinical practice, facilitating noninvasive evaluation of allograft for diagnostic and prognostic purposes. Omics, including gene expression profiling (GEP) of blood immune cell components and donor-derived cell-free DNA (dd-cfDNA) are of special interest to researchers. Several studies have investigated levels of dd-cfDNA and miroRNAs in blood as potential markers for early detection of allograft rejection. One of the achievements in the field of transcriptomics is AlloMap, GEP of peripheral blood mononuclear cells (PBMC), which can identify 11 differentially expressed genes and help with detection of moderate and severe acute cellular rejection in stable heart transplant recipients. In recent years, the utilization of GEP of PBMC for identifying differentially expressed genes to diagnose acute antibody-mediated rejection and cardiac allograft vasculopathy has yielded promising results. Advancements in the field of metabolomics and proteomics as well as their potential implications have been further discussed in this paper.
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Affiliation(s)
- Yeraz Khachatoorian
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Vahe Khachadourian
- Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Eleanor Chang
- Division of Cardiology, David Geffen School of Medicine, Los Angeles, CA, United States of America
| | - Erick R Sernas
- Division of Cardiovascular Medicine, University of California Davis, Davis, CA, United States of America
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Mario Deng
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Brian D Piening
- Earle A Chiles Research Institute, Providence Health and Services, Portland, OR, United States of America
| | | | - Brendan Keating
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Martin Cadeiras
- Division of Cardiovascular Medicine, University of California Davis, Davis, CA, United States of America
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32
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Donor specific anti-HLA antibodies and cardiac allograft vasculopathy: A prospective study using highly automated 3-D optical coherence tomography analysis. Transpl Immunol 2020; 65:101340. [PMID: 33069814 DOI: 10.1016/j.trim.2020.101340] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Recent studies suggested potential positive correlations between HLA-specific antibodies and development of cardiac allograft vasculopathy (CAV). METHODS This prospective two-center study investigated early progression of CAV by coronary optical coherence tomography in 1 month and 12 months after heart transplantation (HTx) in 104 patients. Detection and characterization of donor specific (DSA) and MHC class-I polypeptide-related sequence A (MICA) antibodies were performed before, 1, 6 and 12 months after transplantation. RESULTS During the first post-HTx year, we observed a significant reduction in the mean coronary luminal area (P < .001), and progression in mean intimal thickness (IT) (P < .001). DSA and anti-MICA occurred in 17% of all patients, but no significant relationship was observed between presence of DSA/anti-MICA and IT progression within 12 months after HTx. In contrast, we observed significant association between presence of DSA (p=0.031), de-novo DSA (p=0.031), HLA Class II DSA (p=0.017) and media thickness (MT) progression. CONCLUSION Results of our study did not identify a direct association between presence of DSA/anti-MICA and intimal thickness progression in an early period after HTx. However, we found significant relationships between DSA and media thickness progression that may identify a newly recognized immune-pathological aspect of CAV.
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Wei X, Valenzuela NM, Rossetti M, Sosa RA, Nevarez-Mejia J, Fishbein GA, Mulder A, Dhar J, Keslar KS, Baldwin WM, Fairchild RL, Hou J, Reed EF. Antibody-induced vascular inflammation skews infiltrating macrophages to a novel remodeling phenotype in a model of transplant rejection. Am J Transplant 2020; 20:2686-2702. [PMID: 32320528 PMCID: PMC7529968 DOI: 10.1111/ajt.15934] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/15/2020] [Accepted: 04/07/2020] [Indexed: 01/25/2023]
Abstract
HLA donor-specific antibodies (DSAs) binding to vascular endothelial cells of the allograft trigger inflammation, vessel injury, and antibody-mediated rejection (AMR). Accumulation of intragraft-recipient macrophages is a histological characteristic of AMR, which portends worse outcome. HLA class I (HLA I) DSAs enhance monocyte recruitment by activating endothelial cells and engaging FcγRs, but the DSA-activated donor endothelial influence on macrophage differentiation is unknown. In this study, we explored the consequence of DSA-activated endothelium on infiltrating monocyte differentiation. Here we show that cardiac allografts from murine recipients treated with MHC I DSA upregulated genes related to monocyte transmigration and Fc receptor stimulation. Human monocytes co-cultured with HLA I IgG-stimulated primary human endothelium promoted monocyte differentiation into CD68+ CD206+ CD163+ macrophages (M(HLA I IgG)), whereas HLA I F(ab')2 stimulated endothelium solely induced higher CD206 (M(HLA I F(ab')2 )). Both macrophage subtypes exhibited significant changes in discrete cytokines/chemokines and unique gene expression profiles. Cross-comparison of gene transcripts between murine DSA-treated cardiac allografts and human co-cultured macrophages identified overlapping genes. These findings uncover the role of HLA I DSA-activated endothelium in monocyte differentiation, and point to a novel, remodeling phenotype of infiltrating macrophages that may contribute to vascular injury.
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Affiliation(s)
- Xuedong Wei
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California,Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Nicole M. Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Rebecca A. Sosa
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jessica Nevarez-Mejia
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Gregory A. Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Arend Mulder
- Department of Immunohaematology and Bloodtransfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Jayeeta Dhar
- Lerner Research Institute and Transplant Center, Cleveland Clinic, Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Karen S. Keslar
- Lerner Research Institute and Transplant Center, Cleveland Clinic, Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - William M. Baldwin
- Lerner Research Institute and Transplant Center, Cleveland Clinic, Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert L. Fairchild
- Lerner Research Institute and Transplant Center, Cleveland Clinic, Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jianquan Hou
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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Patel JK. Blood-based immunological monitoring after heart transplant. Current status and future prospects. Indian J Thorac Cardiovasc Surg 2020; 36:194-199. [DOI: 10.1007/s12055-020-00928-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 10/24/2022] Open
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Abstract
PURPOSE OF REVIEW Despite significant improvement in pancreas allograft survival, rejection continues to be a major clinical problem. This review will focus on emerging literature related to the impact of pretransplant and de-novo DSA (dnDSA) in pancreas transplant recipients, and the diagnosis and treatment of T-cell-medicated rejection (TCMR) and antibody-mediated rejection (ABMR) in this complex group of patients. RECENT FINDINGS Recent data suggest that pretransplant DSA and the emergence of dnDSA in pancreas transplant recipients are both associated with increased risk of ABMR. The pancreas allograft biopsy is essential for the specific diagnosis of TCMR and/or ABMR, distinguish rejection from other causes of graft dysfunction, and to guide-targeted therapy. This distinction is important especially in the setting of solitary pancreas transplants but also in simultaneous pancreas-kidney transplants where solid evidence has now emerged demonstrating discordant biopsy findings. Treatment of rejection in a functioning pancreas can prolong allograft survival. SUMMARY The accurate and timely diagnosis of active alloimmune destruction in pancreas transplant recipients is paramount to preserving graft function in the long term. This review will discuss new, rapidly evolving information that is valuable for the physician caring for these patients to achieve optimal immunological outcomes.
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Spitaleri G, Farrero Torres M, Sabatino M, Potena L. The pharmaceutical management of cardiac allograft vasculopathy after heart transplantation. Expert Opin Pharmacother 2020; 21:1367-1376. [PMID: 32401066 DOI: 10.1080/14656566.2020.1753698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Cardiac allograft vasculopathy (CAV) is a major limitation to long-term survival after heart transplantation. Its peculiar pathophysiology involves multifactorial pathways including immune-mediated and metabolic risk factors, which are associated with the development of specific pathological lesions. The often diffuse and chronic nature of the disease reduces the effectiveness of revascularization procedures, and pharmacological prevention of the disease is the sole therapeutic approach with some proven efficacy. AREAS COVERED In this article, after briefly outlining the risk factors for CAV, the authors revise the potential pharmacological approaches that may reduce the burden of CAV. While several therapies have shown convincing efficacy in terms of CAV prevention diagnosed by coronary imaging, very few have been reported to improve prognosis with any meaningful level of evidence. EXPERT OPINION The authors believe that a customizable approach is necessary for clinical practice given the currently available evidence. Furthermore, it is important, in the future, to address the glaring therapeutic gap of an effective treatment against donor-specific antibodies, whose effect on endothelial injury is currently one of the major mechanisms of CAV development and for which no pharmacological treatment is currently available.
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Affiliation(s)
- Giosafat Spitaleri
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Marta Farrero Torres
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic , Barcelona, Spain
| | - Mario Sabatino
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Bologna Academic Hospital , Bologna, Italy
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Dandel M, Hetzer R. Impact of rejection-related immune responses on the initiation and progression of cardiac allograft vasculopathy. Am Heart J 2020; 222:46-63. [PMID: 32018202 DOI: 10.1016/j.ahj.2019.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/22/2019] [Indexed: 12/17/2022]
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Abstract
Purpose of review Since the discovery of human leukocyte antigen (HLA) in the 1950s, there has been great interest in the role of antibodies in posttransplant rejection. The development of the lymphocyte toxicity test by Terasaki et al. in the 1960s was the first step toward understanding the role of antibodies in posttransplant rejection. Recent findings Subsequently, various organs have been transplanted and improving posttransplant outcomes have become a focus of research. In particular, methods to measure antibodies that affect posttransplant outcomes, including anti-HLA antibodies, and methods to desensitize patients from specific antibodies have been explored. One recent method for measuring antibodies is called the solid-phase assay, which uses purified HLA fixed to microbeads. This assay does not use donor lymphocytes and allows clinicians to test the reactivity of patient serum against a panel of antibodies. It has also enabled the identification of specific anti-HLA antibodies using a single HLA. Summary In addition to advances in methods to measure and analyze anti-HLA antibodies, the clinical impact of non-HLA antibodies has also received much attention recently.
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The clinical impact of donor-specific antibodies on antibody-mediated rejection and long-term prognosis after heart transplantation. Curr Opin Organ Transplant 2020; 24:245-251. [PMID: 31090631 DOI: 10.1097/mot.0000000000000636] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Outcomes after cardiac transplantation have improved over past decades, but long-term graft survival remains limited in part because of uncertainty regarding clinical implications of donor-specific antibodies (DSAs). The purpose of this review is to consolidate recent advances in knowledge on the topic of DSA and their potential to impact long-term prognosis after heart transplantation. RECENT FINDINGS The presence of persistent DSA increases the risk of poor outcome after heart transplantation, including development of antibody-mediated rejection (AMR), graft failure, cardiac allograft vasculopathy, and mortality. Importantly, different DSA vary in clinical significance. DSA capable of activating the complement cascade portend a higher risk of developing AMR. human leukocyte antigen class I and class II antigens are expressed differently within the heart, and so, clinical manifestations of class I and class II DSA vary accordingly. Further, compared with class I, class II DSA carry an increased risk of graft loss and mortality. When comparing preexisting DSA with formation of de-novo DSA, de-novo DSA are associated with worse outcome. SUMMARY DSAs are generally associated worse long-term prognosis after heart transplantation but vary in their clinical significance. Recognition of specific risk profiles is essential for guiding posttransplant antibody management.
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Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) is a major contributor of impaired long-term survival after heart transplantation (HTx). The presence of circulating donor-specific antihuman leukocyte antigen (HLA) antibodies (DSAs) is considered as a mandatory criterion for AMR after HTx. DSA are known prognostic biomarkers of outcome, for example, recipients with de-novo DSA have a three-fold increased risk of mortality. RECENT FINDINGS Although the awareness of the impact and prognosis of DSA on the survival has been increased in the HTx community over the last decade, the management of DSA pre and posttransplant varies among centers and is mainly based on the experience of transplant physicians. Thus, firm consensus strategies for each HTx recipient should be established by a center advisory board of experts in the field of HLA genetics, transplantation immunology, and HTx to evaluate the immunological risk preoperatively and also continuously during the posttransplant course. Consequently, the recent advances of invasive and noninvasive diagnostic tools should be applied, according to the risk, laboratory findings, and clinical events of the recipient. Such individual strategy will result in tailored therapeutic options. SUMMARY Novel standards for the management of DSA in HTx recipients on the basis of an interdisciplinary approach of experts will improve diagnostics for personalized medicine.
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Sgambat K, Clauss S, Moudgil A. Circulating de novo Donor Specific Antibodies and Carotid Intima-media Thickness in Pediatric Kidney Transplant Recipients, A Pilot Study. Front Pediatr 2020; 8:17. [PMID: 32083044 PMCID: PMC7006029 DOI: 10.3389/fped.2020.00017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background: The presence of circulating de novo donor specific anti-HLA antibodies (dnDSA) has been implicated in an immune-mediated form of accelerated systemic arteriosclerosis in adult heart and kidney transplant recipients, however this has not been previously investigated in pediatric kidney transplant recipients. Carotid intima-media thickness (CIMT) is a reliable method for detection of arteriosclerosis. We hypothesized that children who develop dnDSA after kidney transplant would have increased CIMT compared with those who remain dnDSA negative. Methods: A prospective, controlled pilot cohort study of 38 transplant patients and 20 healthy controls was conducted to investigate the association between CIMT and development of dnDSA after kidney transplant. CIMT, anthropometrics, blood pressure and lipid panel were measured at 1, 18, and 30 months post-transplant. DSA was checked at 6, 12, 18, 24 and 30 months post-transplant. CIMT of DSA positive transplant recipients was compared to DSA negative and controls. Results: Of the 38 transplant recipients, 7 patients developed dnDSA by 18-30 months post-transplant. Among 5 dnDSA positive patients who did not receive treatment for DSA prior to CIMT measurement (n=6 observations), the median CIMT was 0.505 mm (95% CI 0.454-0.560 mm) at 18-30 months post-transplant, compared to 0.455 mm (95% CI 0.440-0.470) in DSA negative transplant recipients (n = 54 observations of 30 patients) and 0.450 mm (95% CI 0.436-0.460) in the healthy controls (20 observations of 20 patients). Presence of dnDSA was independently associated with a 7.8% increase in CIMT compared to those without dnDSA (p=0.006), after adjusting for race, hypertension, dyslipidemia, and abdominal obesity. Conclusions: Development of dnDSA was associated with increased CIMT, an indicator of arteriosclerosis, in a cohort of dnDSA positive pediatric kidney transplant recipients. The association between dnDSA and CIMT was independent of traditional CV risk factors, including hypertension, dyslipidemia, and abdominal obesity.
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Affiliation(s)
- Kristen Sgambat
- Department of Nephrology, Children's National Hospital, Washington, DC, United States
| | - Sarah Clauss
- Department of Cardiology, Children's National Hospital, Washington, DC, United States
| | - Asha Moudgil
- Department of Nephrology, Children's National Hospital, Washington, DC, United States
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Abstract
Despite advancements in transplant immunosuppression and techniques for managing critically ill patients awaiting heart transplantation, children who are immunologically sensitized to human leukocyte antigen remain at increased risk for morbidity and mortality, both while awaiting and after heart transplant. In this review we will discuss the epidemiology of sensitization, review the immunologic basis and methods of human leukocyte antigen antibody detection, describe outcomes for sensitized pediatric transplant candidates, and consider both pre- and post-transplant management options for sensitized patients.
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Affiliation(s)
- Erik L Frandsen
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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Jahnukainen T, Lauronen J, Raissadati A, Pihkala JI, Ylinen E, Puntila JT, Salminen JT, Pätilä T, Mattila IP, Jalanko HJ. Development of Human Leukocyte Antigen (HLA) Antibodies Against Vascular Homograft Donor in Pediatric Heart Transplant Recipients. Ann Transplant 2019; 24:454-460. [PMID: 31383839 PMCID: PMC6698089 DOI: 10.12659/aot.917232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The appearance of human leukocyte antigen (HLA) antibodies after solid organ transplantation predisposes recipients to graft dysfunction. In theory, vascular homografts, which are widely used in children with congenital heart defects, may cause allosensitization. Material/Methods In this single-center retrospective study, the presence of pre-existing HLA antibodies in pediatric heart transplant (HTx) recipients with a vascular homograft was evaluated in a cohort of 12 patients. HLA antibodies were screened before and after HTx and positive screening results were confirmed and identified using the Luminex® single antigen bead method. Endomyocardial biopsies (EMB) and coronary angiography studies were re-evaluated to assess the prevalence of acute rejections and coronary artery change in these patients. Results At the time of HTx, 8 patients (67%) had HLA antibodies detected by the Luminex assay, none of which were heart donor specific (DSA). All patients had negative leukocyte crossmatch. One patient developed DSAs against homograft donor prior to HTx. After the HTx, 5 patients (42%) developed DSAs against the heart donor and 4 patients (40%) against the homograft donor. In 2 patients (17%), the antibodies were against both heart and homograft donors. The rejection rate or prevalence of coronary artery vasculopathy did not differ significantly between the homograft cohort and our historical controls. Conclusions Our results suggest that the prevalence of DSAs against homograft donor prior to HTx is relatively rare. However, almost half of the patients developed DSAs against homograft post-HTx. The clinical importance of these antibodies warrants further studies.
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Affiliation(s)
- Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Alireza Raissadati
- Department of Pediatric Cardiology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jaana I Pihkala
- Department of Pediatric Cardiology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Tapani Puntila
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jukka T Salminen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tommi Pätilä
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka P Mattila
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannu Jaakko Jalanko
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Understanding the Correlation Between DSA, Complement Activation, and Antibody-Mediated Rejection in Heart Transplant Recipients. Transplantation 2019; 102:e431-e438. [PMID: 29916988 DOI: 10.1097/tp.0000000000002333] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Donor-specific HLA antibodies (DSA) are associated with increased rates of rejection and of graft failure in cardiac transplantation. The goal of this study was to determine the association of preformed and posttransplant development of newly detected DSA (ndDSA) with antibody-mediated rejection (AMR) and characterize the clinical relevance of complement-activating DSA in heart allograft recipients. METHODS The study included 128 adult and 48 pediatric heart transplant patients transplanted between 2010 and 2013. Routine posttransplant HLA antibody testing was performed by IgG single-antigen bead test. The C3d single-antigen bead assay was used to identify complement-activating antibodies. Rejection was diagnosed using International Society for Heart and Lung Transplantation criteria. RESULTS In this study, 22 patients were transplanted with preexisting DSA, and 43 patients developed ndDSA posttransplant. Pretransplant (P < 0.05) and posttransplant (P < 0.001) ndDSA were associated with higher incidence of AMR. Patients with C3d + DSA had significantly higher incidence of AMR compared with patients with no DSA (P < 0.001) or patients with C3d-DSA (P = 0.02). Nine (36%) of 25 patients with AMR developed transplant coronary artery disease compared with 17 (15.9%) of 107 patients without AMR (P < 0.05). Among the 47 patients who received ventricular assistant device (VAD), 7 of 9 VAD+ patients with preformed DSA experienced AMR compared with 7 of 38 VAD+ patients without preformed DSA, indicating presensitization to donor HLA significantly increased the risk of AMR (P < 0.01). CONCLUSIONS Preformed and posttransplant ndDSA were associated with AMR. C3d + DSA correlates with complement deposition on the graft and higher risk of AMR which may permit the application of personalized immunotherapy targeting the complement pathway.
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Chen CY, Warner P, Albers EL, Kemna MS, Delaney M, Hong BJ, Law YM. Donor-specific anti-HLA antibody production following pediatric ABO-incompatible heart transplantation. Pediatr Transplant 2019; 23:e13332. [PMID: 30515928 DOI: 10.1111/petr.13332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
ABO-i heart transplantation can be performed in infants with end-stage heart failure to increase organ availability. The development of newly detected DSAs is associated with decreased cardiac graft survival, and the effect of ABO-i transplantation on DSA production is unknown. We examined DSA production and rejection frequency in infant recipients of ABO-i and ABO-c heart transplants via a retrospective cohort study of infant heart transplant recipients transplanted at a single pediatric center between January 2004 and November 2014. Patients were included if they were less than 1 year of age at transplant and had a minimum of 6 months follow-up. DSA positivity was examined under two categories, either the lowest level detectable (MFI > 500) or a level presumed to have clinical relevance in our immunogenetics laboratory (MFI > 5000). Of 52 patients, 36 received ABO-c transplants and 16 received ABO-i transplants. Compared to ABO-c recipients, the ABO-i group showed a consistent but statistically non-significant finding of less frequent ndDSA positivity (69.4% ABO-c vs 43.8% ABO-i with MFI >500, P = 0.122; 41.7% ABO-c vs 25% ABO-i with MFI >5000, P = 0.353). Additionally, ABO-i patients were less likely to have any form of rejection (12.5% vs 47.2%, P = 0.027) or acute cellular rejection (6.3% vs 38.9%, P = 0.021). Our data suggest that infants receiving ABO-i heart transplants may be less likely to develop ndDSAs or have rejection compared to same age ABO-c recipients. Larger multicenter studies are needed to confirm results from this single center study.
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Affiliation(s)
- Chiu-Yu Chen
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Paul Warner
- Immunogenetics/HLA Laboratory, Bloodworks Northwest, Seattle, Washington
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Children's National Health System, Washington, D.C.,Departments of Pathology and Pediatrics, George Washington University, Washington, D.C
| | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, Washington
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Padet L, Dieudé M, Karakeussian‐Rimbaud A, Yang B, Turgeon J, Cailhier J, Cardinal H, Hébert M. New insights into immune mechanisms of antiperlecan/LG3 antibody production: Importance of T cells and innate B1 cells. Am J Transplant 2019; 19:699-712. [PMID: 30129231 PMCID: PMC6519043 DOI: 10.1111/ajt.15082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/25/2018] [Accepted: 07/29/2018] [Indexed: 01/25/2023]
Abstract
Autoantibodies against perlecan/LG3 (anti-LG3) have been associated with increased risks of delayed graft function, acute rejection, and reduced long-term survival. High titers of anti-LG3 antibodies have been found in de novo renal transplants recipients in the absence of allosensitizing or autoimmune conditions. Here, we seek to understand the pathways controlling anti-LG3 production prior to transplantation. Mice immunized with recombinant LG3 produce concomitantly IgM and IgG anti-LG3 antibodies suggesting a memory response. ELISpot confirmed the presence of LG3-specific memory B cells in nonimmunized mice. Purification of B1 and B2 subtypes identified peritoneal B1 cells as the major source of memory B cells reactive to LG3. Although nonimmunized CD4-deficient mice were found to express LG3-specific memory B cells, depletion of CD4+ T cells in wild type mice during immunization significantly decreased anti-LG3 production. These results demonstrate that B cell memory to LG3 is T cell independent but that production of anti-LG3 antibodies requires T cell help. Further supporting an important role for T cells in controlling anti-LG3 levels, we found that human renal transplant recipients show a significant decrease in anti-LG3 titers upon the initiation of CNI-based immunosuppression. Collectively, these results identify T cell targeting interventions as a means of reducing anti-LG3 levels in renal transplant patients.
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Affiliation(s)
- Lauriane Padet
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada,Université de MontréalMontrealQuebecCanada
| | - Mélanie Dieudé
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada
| | - Annie Karakeussian‐Rimbaud
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada
| | - Bing Yang
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada,Université de MontréalMontrealQuebecCanada
| | - Julie Turgeon
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada
| | - Jean‐François Cailhier
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada
| | - Héloïse Cardinal
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada
| | - Marie‐Josée Hébert
- Research CentreCentre Hospitalier de l'Université de Montréal (CRCHUM)MontrealQuebecCanada,Canadian National Transplant Research ProgramEdmontonAlbertaCanada,Université de MontréalMontrealQuebecCanada
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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48
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Bagley J, Williams L, Hyde M, Birriel CR, Iacomini J. Hyperlipidemia and Allograft Rejection. CURRENT TRANSPLANTATION REPORTS 2019; 6:90-98. [PMID: 31934529 DOI: 10.1007/s40472-019-0232-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose of review Advances in the development of immunosuppressive drug regimens have led to impressive survival rates in the year following organ transplantation. However rates of long-term graft dysfunction remain undesirably high. Recently it has been shown that co-morbidities in the patient population may affect graft survival. In mouse models, hyperlipidemia, a co-morbidity present in the majority of cardiac transplant patients, can significantly alter T cell responses to cardiac and skin allografts, and accelerate graft rejection. Here we review recent advances in our understanding of how alterations in lipids affect immune function and graft survival. Recent Findings Recent work in humans has highlighted the importance of controlling low density lipoprotein (LDL) levels in transplant recipients to reduce the development of chronic allograft vasculopathy (CAV). High serum levels of cholesterol containing particles leads to extensive immune system changes to T cell proliferation, differentiation and suppression. Changes in B cell subsets, and the ability of antigen presenting cells to stimulate T cells in hyperlipidemic animals may also contribute to increased organ allograft rejection. Summary Cholesterol metabolism is a critical cellular pathway for proper control of immune cell homeostasis and activation. Increasing evidence in both human, and in mouse models shows that elevated levels of serum cholesterol can have profound impact on the immune system. Hyperlipidemia has been shown to increase T cell activation, alter the development of T helper subsets, increase the inflammatory capacity of antigen presenting cells (APC) and significantly accelerate graft rejection in several models.
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Affiliation(s)
- Jessamyn Bagley
- Tufts University School of Medicine, Department of Immunology, Sackler School of Biomedical Sciences Programs in Immunology and Genetics, Boston, MA 02111 USA
| | - Linus Williams
- Tufts University School of Medicine, Department of Immunology, Sackler School of Biomedical Sciences Programs in Immunology and Genetics, Boston, MA 02111 USA
| | - Michael Hyde
- Tufts University School of Medicine, Department of Immunology, Sackler School of Biomedical Sciences Programs in Immunology and Genetics, Boston, MA 02111 USA
| | - Christian Rosa Birriel
- Tufts University School of Medicine, Department of Immunology, Sackler School of Biomedical Sciences Programs in Immunology and Genetics, Boston, MA 02111 USA
| | - John Iacomini
- Tufts University School of Medicine, Department of Immunology, Sackler School of Biomedical Sciences Programs in Immunology and Genetics, Boston, MA 02111 USA
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50
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McCaughan JA, Battle RK, Singh SKS, Tikkanen JM, Moayedi Y, Ross HJ, Singer LG, Keshavjee S, Tinckam KJ. Identification of risk epitope mismatches associated with de novo donor-specific HLA antibody development in cardiothoracic transplantation. Am J Transplant 2018; 18:2924-2933. [PMID: 29847022 DOI: 10.1111/ajt.14951] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 05/22/2018] [Indexed: 01/25/2023]
Abstract
The development of de novo donor-specific HLA antibodies (dnDSA) after transplantation is associated with graft failure, mortality, and cost. There is no effective therapeutic intervention to prevent dnDSA or ameliorate associated injury. The aims of this study were to identify specific HLA factors associated with dnDSA development and to propose primary prevention strategies that could reduce the incidence of dnDSA without prohibitively limiting access to transplant. The investigation cohort included heart transplant recipients from 2008 to 2015 (n = 265). HLA typing was performed and HLA antibody testing was undertaken before and after transplantation. HLAMatchmaker analysis was performed for persistent dnDSA to identify potentially more immunogenic eplet differences. Validation was performed in recipients of lung transplants from 2008 to 2013 (n = 433). The majority of recipients with dnDSA had antibodies to identical eplet positions on DQ2 and DQ7. A high-risk epitope mismatch (found in DQA1*05 + DQB1*02/DQB1*03:01(7)) was associated with a 4.2- and 4.9-fold increased risk of dnDSA in heart and lung recipients respectively. HLA electrostatic potential modeling provided a plausible explanation for this observed immunogenicity. A theoretical allocation algorithm avoiding high-risk epitope mismatches was generated and predicted to reduce dnDSA by up to 72% without additional testing, eplet analysis, or cost.
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Affiliation(s)
- J A McCaughan
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - R K Battle
- Histocompatibility & Immunogenetics Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S K S Singh
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
| | - J M Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Y Moayedi
- Toronto Heart Transplant Program, University Health Network, Toronto, Canada
| | - H J Ross
- Toronto Heart Transplant Program, University Health Network, Toronto, Canada
| | - L G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - S Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - K J Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Canada.,Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
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