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Caveolin-1 in Kidney Chronic Antibody-Mediated Rejection: An Integrated Immunohistochemical and Transcriptomic Analysis Based on the Banff Human Organ Transplant (B-HOT) Gene Panel. Biomedicines 2021; 9:biomedicines9101318. [PMID: 34680435 PMCID: PMC8533527 DOI: 10.3390/biomedicines9101318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023] Open
Abstract
Caveolin-1 overexpression has previously been reported as a marker of endothelial injury in kidney chronic antibody-mediated rejection (c-ABMR), but conclusive evidence supporting its use for daily diagnostic practice is missing. This study aims to evaluate if Caveolin-1 can be considered an immunohistochemical surrogate marker of c-ABMR. Caveolin-1 expression was analyzed in a selected series of 22 c-ABMR samples and 11 controls. Caveolin-1 immunohistochemistry proved positive in peritubular and glomerular capillaries of c-ABMR specimens, irrespective of C4d status whereas all controls were negative. Multiplex gene expression profiling in c-ABMR cases confirmed Caveolin-1 overexpression and identified additional genes (n = 220) and pathways, including MHC Class II antigen presentation and Type II interferon signaling. No differences in terms of gene expression (including Caveolin-1 gene) were observed according to C4d status. Conversely, immune cell signatures showed a NK-cell prevalence in C4d-negative samples compared with a B-cell predominance in C4d-positive cases, a finding confirmed by immunohistochemical assessment. Finally, differentially expressed genes were observed between c-ABMR and controls in pathways associated with Caveolin-1 functions (angiogenesis, cell metabolism and cell–ECM interaction). Based on our findings, Caveolin-1 resulted as a key player in c-ABMR, supporting its role as a marker of this condition irrespective of C4d status.
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Boix F, Feito J, Rodríguez-Campón A, Chillón MC, García-Sánchez S, Tabernero G, Fraile P, García-Sanz R. Management of mixed acute rejection driven by a de novo donor-specific complement-binding anti-DQB1*03:01 antibody and intraepithelial CD8 T-cells in a kidney recipient: a case report. Br J Biomed Sci 2021; 78:244-247. [PMID: 34105441 DOI: 10.1080/09674845.2021.1927308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Mixed acute rejection is a clinicopathological entity that is difficult to accurately diagnose, and so may be under-reported. Allografts are lost more often than in either humoral or cellular rejection. The diagnosis requires both histological and immunological studies on renal biopsy and blood specimens from the transplant recipient to provide the required rescue therapy to abolish the allogeneic response against the graft. We present a clinical case report of an active mixed acute rejection driven by a de novo donor-specific complement-binding anti-DQB1*03:01 antibody and intraepithelial CD8 T-cells in a patient with a kidney transplant. The patient was diagnosed, treated, and followed up as per the local institution's procedure with a full recovery of graft function. Our case emphasises the challenge of a mixed acute rejection and supports the need to improve the post-transplant outcome of recipients and their grafts.
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Affiliation(s)
- F Boix
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC, and Cancer Research Institute of Salamanca-IBMCC (CSIC-USAL University), Salamanca, Spain
| | - J Feito
- Department of Clinical Pathology, University Hospital of Salamanca (HUS-IBSAL), Salamanca, Spain
| | - A Rodríguez-Campón
- Department of Nephrology, University Hospital of Salamanca (HUS-IBSAL), Salamanca, Spain
| | - M C Chillón
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC, and Cancer Research Institute of Salamanca-IBMCC (CSIC-USAL University), Salamanca, Spain
| | - S García-Sánchez
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC, and Cancer Research Institute of Salamanca-IBMCC (CSIC-USAL University), Salamanca, Spain
| | - G Tabernero
- Department of Nephrology, University Hospital of Salamanca (HUS-IBSAL), Salamanca, Spain
| | - P Fraile
- Department of Nephrology, University Hospital of Salamanca (HUS-IBSAL), Salamanca, Spain
| | - R García-Sanz
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC, and Cancer Research Institute of Salamanca-IBMCC (CSIC-USAL University), Salamanca, Spain
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Hooper DK, Varnell CD, Rich K, Carle A, Huber J, Mostajabi F, Dahale D, Pai ALH, Goebel J, Modi AC. A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study. Am J Kidney Dis 2021; 79:335-346. [PMID: 34352285 DOI: 10.1053/j.ajkd.2021.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Adolescent and young adult kidney transplant recipients have high risk of rejection related to suboptimal adherence. Multi-component interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allograft rejection using evidence-based adherence promotion clinical strategies. STUDY DESIGN Interrupted time series. SETTING AND PARTICIPANTS Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥1 year post-transplant and taking ≥1 immunosuppressive medication from 2014 through 2017. QUALITY IMPROVEMENT ACTIVITIES The following interventions were implemented over 14 months: 1) adherence promotion training for clinical staff, 2) EHR-supported adherence risk screening, 3) systematic assessment of medication adherence barriers, 4) designation of specific staff to address adherence barriers, 5) shared decision-making with the patients to overcome adherence barriers, 6) follow-up to assess progress, 7) optional electronic medication monitoring. OUTCOMES Primary Outcome: Late acute rejection. Process measures: barriers assessments performed, barriers identified, number of interventions performed. Secondary outcomes/balancing measures: de novo DSA, biopsy rate, rejections per biopsy. ANALYTICAL APPROACH Time series analysis using statistical process control, evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed. RESULTS The monthly rejection rate fell from 1.61 rejections/100 patient-months in the 26-months pre-implementation to 0.88 rejections/100 patient-months in the 22-months post-implementation. In multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (IRR 0.50, 95% CI: 0.27-0.91, p=0.02). DSA and time since transplant were also associated with rejection incidence (IRR 2.27, p=0.02 and IRR 0.87, p=0.02, respectively) LIMITATIONS: A single center study. Potential confounding by unmeasured variables. CONCLUSIONS Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over two years.
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Affiliation(s)
- David K Hooper
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229.
| | - Charles D Varnell
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Kristin Rich
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Adam Carle
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; Univerisity of Cincinnati, Collage of Arts and Sciences, Department of Psychology, 155 B McMicken Hall Cincinnati, OH 45221
| | - John Huber
- Department of Information Services (MLC 9009), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Farida Mostajabi
- James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Devesh Dahale
- Southeast Alabama Medical Center, 1108 Ross Clark Circle, Dothan, AL 36301
| | - Ahna L H Pai
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Jens Goebel
- Section of Pediatric Nephrology, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503; Department of Pediatrics and Human Development, Michigan State University, Life Sciences Bldg. 1355 Bogue St., B240, East Lansing MI 48824
| | - Avani C Modi
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
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Preka E, Sekar T, Lopez Garcia SC, Shaw O, Kessaris N, Mamode N, Stojanovic J, Sebire NJ, Kim JJ, Marks SD. Outcomes of paediatric kidney transplant recipients using the updated 2013/2017 Banff histopathological classification for antibody-mediated rejection. Pediatr Nephrol 2021; 36:2575-2585. [PMID: 34143297 DOI: 10.1007/s00467-021-05103-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND After the major changes with regard to acute and chronic ABMR in the Banff classification initiated in 2013, there has been an improvement in diagnosing antibody-mediated rejection (ABMR) in adult studies but no data have been published in the paediatric population. METHODS We assessed 56 paediatric kidney transplant biopsies due to kidney dysfunction in patients with donor-specific antibodies (DSA) in a retrospective single-centre study between January 2006 and March 2012. The results were compared with 2003/2007 Banff classification noting the subsequent 2017 and 2019 modifications do not change the 2013 Banff classification with regard to acute antibody-mediated rejection (apart from the addition of gene transcripts/classifiers that do not affect our analysis). RESULTS Following the 2013 Banff classification, there were seven cases (12.5%) diagnosed with ABMR that would have been misclassified when applying the 2003/2007 classification. Evaluating the histological features of all ABMR-related cases, we report the importance of v- (intimal arteritis) and t- (tubulitis) lesions: absence of v- and t- lesions in the biopsy is related to significantly higher kidney allograft survival (OR 7.3, 95%CI 1.1-48.8, p = 0.03 and OR 5.3, 95%CI 1.2-25.5, p = 0.04 respectively). Moreover, absence of t- lesions was associated with significantly fewer rejection episodes the year after the initial biopsy (OR 5.1, 95%CI 1.4-19.8, p = 0.01). CONCLUSIONS Our study supports that the updated 2013 Banff classification shows superior clinicopathological correlation in identifying ABMR in paediatric kidney transplant recipients. Our results can be extrapolated to the recently updated 2019 Banff classification.
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Affiliation(s)
- Evgenia Preka
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
- Southampton University Children's Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - Thivya Sekar
- Department of Paediatric Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sergio C Lopez Garcia
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Olivia Shaw
- Viapath Clinical Transplantation Laboratory, Guy's Hospital, London, UK
| | - Nicos Kessaris
- Department of Transplantation, Guy's Hospital, London, UK
| | - Nizam Mamode
- Department of Transplantation, Guy's Hospital, London, UK
| | - Jelena Stojanovic
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Neil J Sebire
- Department of Paediatric Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Jon Jin Kim
- Department of Paediatric Nephrology, Nottingham University Hospital, Nottingham, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
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Change in Estimated GFR and Risk of Allograft Failure in Patients Diagnosed With Late Active Antibody-mediated Rejection Following Kidney Transplantation. Transplantation 2021; 105:648-659. [PMID: 33617203 DOI: 10.1097/tp.0000000000003274] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are challenges in designing adequate, well-controlled studies of patients with active antibody-mediated rejection (AMR) after kidney transplantation (KTx). METHODS We assessed the functional relationship between change in estimated glomerular filtration rate (eGFR) following the diagnosis of AMR and the risk of subsequent death-censored graft failure using the joint modeling framework. We included recipients of solitary KTx between 1995 and 2013 at 4 transplant centers diagnosed with biopsy-proven active AMR at least 1 year post-KTx, who had a minimum of 3-year follow-up. RESULTS A total of 91 patients across participating centers were included in the analysis. Of the 91 patients, n = 54 patients (59%) met the death-censored graft failure endpoint and n = 62 patients (68%) met the all-cause graft failure composite endpoint. Kaplan-Meier death-censored graft survival rates at 12, 36, and 60 months postdiagnosis of AMR pooled across centers were 88.9%, 58.9%, and 36.4%, respectively. Spaghetti plots indicated a linear trend in the change in eGFR, especially in the first 12 months postdiagnosis of active AMR. A significant change in eGFR was observed within the first 12 months postdiagnosis of active AMR, getting worse by a factor of -0.757 mL/min/1.73 m2 per month during the 12-month analysis period (a delta of -9.084 mL/min/1.73 m2 at 1 y). Notably, an extrapolated 30% improvement in the slope of eGFR in the first 12 months was associated with a 10% improvement in death-censored graft failure at 5 years. CONCLUSIONS If prospectively validated, this study may inform the design of pivotal clinical trials for therapies for late AMR.
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56
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Innate-like self-reactive B cells infiltrate human renal allografts during transplant rejection. Nat Commun 2021; 12:4372. [PMID: 34272370 PMCID: PMC8285506 DOI: 10.1038/s41467-021-24615-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/24/2021] [Indexed: 12/13/2022] Open
Abstract
Intrarenal B cells in human renal allografts indicate transplant recipients with a poor prognosis, but how these cells contribute to rejection is unclear. Here we show using single-cell RNA sequencing that intrarenal class-switched B cells have an innate cell transcriptional state resembling mouse peritoneal B1 or B-innate (Bin) cells. Antibodies generated by Bin cells do not bind donor-specific antigens nor are they enriched for reactivity to ubiquitously expressed self-antigens. Rather, Bin cells frequently express antibodies reactive with either renal-specific or inflammation-associated antigens. Furthermore, local antigens can drive Bin cell proliferation and differentiation into plasma cells expressing self-reactive antibodies. These data show a mechanism of human inflammation in which a breach in organ-restricted tolerance by infiltrating innate-like B cells drives local tissue destruction. Intrarenal B cells are indicative of poor prognosis in human renal allografts. Here the authors use single cell RNA sequencing to examine how intrarenal B cells contribute to renal rejection and find a population of innate B cells reactive to renal-specific or inflammation-associated antigens.
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57
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Miyairi S, Ueda D, Yagisawa T, Okada D, Keslar KS, Tanabe K, Dvorina N, Valujskikh A, Baldwin WM, Hazen SL, Fairchild RL. Recipient myeloperoxidase-producing cells regulate antibody-mediated acute versus chronic kidney allograft rejection. JCI Insight 2021; 6:148747. [PMID: 34081629 PMCID: PMC8410093 DOI: 10.1172/jci.insight.148747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
Antibody-mediated rejection (ABMR) continues to be a major problem undermining the success of kidney transplantation. Acute ABMR of kidney grafts is characterized by neutrophil and monocyte margination in the tubular capillaries and by graft transcripts indicating NK cell activation, but the myeloid cell mechanisms required for acute ABMR have remained unclear. Dysregulated donor-specific antibody (DSA) responses with high antibody titers are induced in B6.CCR5-/- mice transplanted with complete MHC-mismatched A/J kidneys and are required for rejection of the grafts. This study tested the role of recipient myeloid cell production of myeloperoxidase (MPO) in the cellular and molecular components of acute ABMR. Despite induction of equivalent DSA titers, B6.CCR5-/- recipients rejected A/J kidneys between days 18 and 25, with acute ABMR, whereas B6.CCR5-/-MPO-/- recipients rejected the grafts between days 46 and 54, with histopathological features of chronic graft injury. On day 15, myeloid cells infiltrating grafts from B6.CCR5-/- and B6.CCR5-/-MPO-/- recipients expressed marked phenotypic and functional transcript differences that correlated with the development of acute versus chronic allograft injury, respectively. Near the time of peak DSA titers, activation of NK cells to proliferate and express CD107a was decreased within allografts in B6.CCR5-/-MPO-/- recipients. Despite high titers of DSA, depletion of neutrophils reproduced the inhibition of NK cell activation and decreased macrophage infiltration but increased monocytes producing MPO. Overall, recipient myeloid cells producing MPO regulate graft-infiltrating monocyte/macrophage function and NK cell activation that are required for DSA-mediated acute kidney allograft injury, and their absence switches DSA-mediated acute pathology and graft outcomes to chronic ABMR.
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Affiliation(s)
- Satoshi Miyairi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Daisuke Ueda
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Takafumi Yagisawa
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Daigo Okada
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Karen S. Keslar
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Nina Dvorina
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William M. Baldwin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stanley L. Hazen
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert L. Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Crespo M, Llinàs-Mallol L, Redondo-Pachón D, Butler C, Gimeno J, Pérez-Sáez MJ, Burballa C, Buxeda A, Arias-Cabrales C, Folgueiras M, Sanz-Ureña S, Valenzuela NM, Reed EF, Pascual J. Non-HLA Antibodies and Epitope Mismatches in Kidney Transplant Recipients With Histological Antibody-Mediated Rejection. Front Immunol 2021; 12:703457. [PMID: 34305943 PMCID: PMC8300190 DOI: 10.3389/fimmu.2021.703457] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/15/2021] [Indexed: 01/03/2023] Open
Abstract
Background Correlation between antibody-mediated rejection (ABMR) and circulating HLA donor-specific antibodies (HLA-DSA) is strong but imperfect in kidney transplant (KT) recipients, raising the possibility of undetected HLA-DSA or non-HLA antibodies contributing to ABMR. Detailed evaluation of the degree of HLA matching together with the identification of non-HLA antibodies in KT may help to decipher the antibody involved. Methods We retrospectively assessed patients with transplant biopsies scored following Banff'15 classification. Pre- and post-transplant serum samples were checked for HLA and non-HLA antibodies [MICA-Ab, angiotensin-II type-1-receptor (AT1R)-Ab, endothelin-1 type-A-receptor (ETAR)-Ab and crossmatches with primary aortic endothelial cells (EC-XM)]. We also analyzed HLA epitope mismatches (HLA-EM) between donors and recipients to explore their role in ABMR histology (ABMRh) with and without HLA-DSA. Results One-hundred eighteen patients with normal histology (n = 19), ABMRh (n = 52) or IFTA (n = 47) were studied. ABMRh patients were HLA-DSApos (n = 38, 73%) or HLA-DSAneg (n = 14, 27%). Pre-transplant HLA-DSA and AT1R-Ab were more frequent in ABMRh compared with IFTA and normal histology cases (p = 0.006 and 0.003), without differences in other non-HLA antibodies. Only three ABMRhDSAneg cases showed non-HLA antibodies. ABMRhDSAneg and ABMRhDSApos cases showed similar biopsy changes and graft-survival. Both total class II and DRB1 HLA-EM were associated with ABMRhDSApos but not with ABMRhDSAneg. Multivariate analysis showed that pre-transplant HLA-DSA (OR: 3.69 [1.31-10.37], p = 0.013) and AT1R-Ab (OR: 5.47 [1.78-16.76], p = 0.003) were independent predictors of ABMRhDSApos. Conclusions In conclusion, pre-transplant AT1R-Ab is frequently found in ABMRhDSApos patients. However, AT1R-Ab, MICA-Ab, ETAR-Ab or EC-XM+ are rarely found among ABMRhDSAneg patients. Pre-transplant AT1R-Ab may act synergistically with preformed or de novo HLA-DSA to produce ABMRhDSApos but not ABMRhDSAneg. HLA epitope mismatch associates with ABMRhDSApos compared with ABMRhDSAneg, suggesting factors other than HLA are responsible for the damage.
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Affiliation(s)
- Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Dolores Redondo-Pachón
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carrie Butler
- UCLA Immunogenetics Center, University of California Los Angeles, Los Angeles, CA, United States
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Javier Gimeno
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carla Burballa
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carlos Arias-Cabrales
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Montserrat Folgueiras
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Sara Sanz-Ureña
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Nicole M. Valenzuela
- UCLA Immunogenetics Center, University of California Los Angeles, Los Angeles, CA, United States
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Elaine F. Reed
- UCLA Immunogenetics Center, University of California Los Angeles, Los Angeles, CA, United States
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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Yu SC, Chang KC, Wang H, Li MF, Yang TL, Chen CN, Chen CJ, Chen KC, Shen CY, Kuo PY, Lin LW, Lin YM, Lin WC. Distinguishing lupus lymphadenitis from Kikuchi disease based on clinicopathological features and C4d immunohistochemistry. Rheumatology (Oxford) 2021; 60:1543-1552. [PMID: 33169134 DOI: 10.1093/rheumatology/keaa524] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/18/2020] [Accepted: 07/07/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Distinguishing Kikuchi disease (KD) from lupus lymphadenitis (LL) histologically is nearly impossible. We applied C4d immunohistochemical (IHC) stain to develop diagnostic tools. METHODS We retrospectively investigated clinicopathological features and C4d IHC staining in an LL-enriched development cohort (19 LL and 81 KD specimens), proposed risk stratification criteria and trained machine learning models, and validated them in an external cohort (2 LL and 55 KD specimens). RESULTS Clinically, we observed that LL was associated with an older average age (33 vs 25 years; P=0.005), higher proportion of biopsy sites other than the neck [4/19 (21%) vs 1/81 (1%); P=0.004], and higher proportion of generalized lymphadenopathy compared with KD [9/16 (56%) vs 7/31 (23%); P=0.028]. Histologically, LL involved a larger tissue area than KD did (P=0.006). LL specimens exhibited more frequent interfollicular pattern [5/19 (26%) vs 3/81 (4%); P=0.001] and plasma cell infiltrates (P=0.002), and less frequent histiocytic infiltrates in the necrotic area (P=0.030). Xanthomatous infiltrates were noted in 6/19 (32%) LL specimens. Immunohistochemically, C4d endothelial staining in the necrotic area [11/17 (65%) vs 2/62 (3%); P<10-7], and capillaries/venules [5/19 (26%) vs 7/81 (9%); P=0.048] and trabecular/hilar vessels [11/18 (61%) vs 8/81 (10%); P<10-4] in the viable area was more common in LL. During validation, both the risk stratification criteria and machine learning models were superior to conventional histological criteria. CONCLUSIONS Integrating clinicopathological and C4d findings could distinguish LL from KD.
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Affiliation(s)
- Shan-Chi Yu
- Department of Pathology and Graduate Institute of Pathology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Microbiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kung-Chao Chang
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan Wang
- Department of Pathology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Meng-Fang Li
- Department of Pathology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Tsung-Lin Yang
- Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Nan Chen
- Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chih-Jung Chen
- Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ko-Chin Chen
- Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chieh-Yu Shen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Yen Kuo
- Department of Pathology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Long-Wei Lin
- Department of Pathology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Yueh-Min Lin
- Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
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60
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Slepicka PF, Yazdanifar M, Bertaina A. Harnessing Mechanisms of Immune Tolerance to Improve Outcomes in Solid Organ Transplantation: A Review. Front Immunol 2021; 12:688460. [PMID: 34177941 PMCID: PMC8222735 DOI: 10.3389/fimmu.2021.688460] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/24/2021] [Indexed: 12/15/2022] Open
Abstract
Survival after solid organ transplantation (SOT) is limited by chronic rejection as well as the need for lifelong immunosuppression and its associated toxicities. Several preclinical and clinical studies have tested methods designed to induce transplantation tolerance without lifelong immune suppression. The limited success of these strategies has led to the development of clinical protocols that combine SOT with other approaches, such as allogeneic hematopoietic stem cell transplantation (HSCT). HSCT prior to SOT facilitates engraftment of donor cells that can drive immune tolerance. Recent innovations in graft manipulation strategies and post-HSCT immune therapy provide further advances in promoting tolerance and improving clinical outcomes. In this review, we discuss conventional and unconventional immunological mechanisms underlying the development of immune tolerance in SOT recipients and how they can inform clinical advances. Specifically, we review the most recent mechanistic studies elucidating which immune regulatory cells dampen cytotoxic immune reactivity while fostering a tolerogenic environment. We further discuss how this understanding of regulatory cells can shape graft engineering and other therapeutic strategies to improve long-term outcomes for patients receiving HSCT and SOT.
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Affiliation(s)
- Priscila Ferreira Slepicka
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mahboubeh Yazdanifar
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Alice Bertaina
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
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61
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Santiago JL, Sánchez-Pérez L, Pérez-Flores I, de la Higuera MAM, Romero NC, Querol-García J, Urcelay E, Sánchez-Fructuoso AI. Association of Polymorphisms in T-Cell Activation Costimulatory/Inhibitory Signal Genes With Allograft Kidney Rejection Risk. Front Immunol 2021; 12:650979. [PMID: 34149691 PMCID: PMC8206554 DOI: 10.3389/fimmu.2021.650979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/18/2021] [Indexed: 12/31/2022] Open
Abstract
The genes CD28, CD86 and CTLA-4 conform the costimulatory (CD28-CD86) or inhibitory (CTLA-4-CD86) signal in T-cell activation. T-cell immune response has a critical role in allograft rejection, and single nucleotide polymorphisms (SNPs) located in these genes have been widely analyzed with controversial results. We analyzed a group of SNPs located in the three genes: CD28: rs3116496; CD86: rs1129055; and CTLA-4: rs231775 and rs3087243 in a cohort of 632 consecutively recruited kidney transplanted subjects. All polymorphisms were genotyped by TaqMan chemistry and the diagnosis of rejection was confirmed by biopsy and categorized according to the Banff classification. The analyses showed a statistically significant protective effect to T cell-mediated rejection (TCMR) in carriers of the CTLA-4 rs3087243*G allele, especially in patients with TCMR Banff ≥2 in the overall cohort and in patients without thymoglobulin induction therapy. Both associations were corroborated as independent factors in the multivariate analysis. Interestingly, associations with rejection were not found for any SNP in patients with thymoglobulin induction therapy. As expected, considering the major role of these genes in T-cell activation, no effect was observed for antibody-mediated rejection (ABMR). In conclusion, the SNP rs3087243 located in the CTLA-4 gene may be considered a useful independent biomarker for TCMR risk especially for severe TCMR in patients who did no received thymoglobulin induction therapy.
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Affiliation(s)
- Jose Luis Santiago
- Lab. Genetics and Molecular Basis of Complex Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Immunology Department, Hospital Fundación Jiménez-Díaz, Madrid, Spain
| | - Luis Sánchez-Pérez
- Lab. Genetics and Molecular Basis of Complex Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Isabel Pérez-Flores
- Nephrology Department Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, IdISSC, Madrid, Spain
| | | | - Natividad Calvo Romero
- Nephrology Department Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, IdISSC, Madrid, Spain
| | - Javier Querol-García
- Lab. Genetics and Molecular Basis of Complex Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Elena Urcelay
- Lab. Genetics and Molecular Basis of Complex Diseases, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Ana Isabel Sánchez-Fructuoso
- Nephrology Department Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, IdISSC, Madrid, Spain
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62
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Donor-derived Cell-free DNA Kinetics Post-kidney Transplant Biopsy. Transplant Direct 2021; 7:e703. [PMID: 34056078 PMCID: PMC8154469 DOI: 10.1097/txd.0000000000001149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/26/2022] Open
Abstract
Background. Donor-derived cell-free DNA (dd-cfDNA) has generated interest as a biomarker for kidney injury including transplant (KT) rejection. It is possible that the KT biopsy procedure can cause the release of dd-cfDNA, therefore affecting the reliability of this assay in the postbiopsy period. We evaluated the effect of KT biopsy on the kinetics of dd-cfDNA. Methods. We conducted a single-arm prospective study. Samples were collected from 16 adult KT recipients undergoing KT biopsy. All participants had samples drawn within 8 h before the biopsy (prebiopsy), within 20 min (hour 0), 2 h (hour 2), and 24–48 h (hours 24–48) after the biopsy. We evaluated the change in dd-cfDNA from the prebiopsy time point to the following 3 time points after the biopsy. Results. At hour 0 and hour 2, there was a significantly larger log dd-cfDNA mean score compared with the prebiopsy score (least square mean estimate 0.4 [0.17-0.63] and 0.39 [0.09-0.68], respectively). By 24–28 h postbiopsy, there was no significant difference in log dd-cfDNA mean score compared with the prebiopsy score (least square mean estimate −0.21 [−0.6 to 0.19]). Conclusions. Mechanical injury from a KT biopsy can transiently increase circulating dd-cfDNA. The increase resolves by 24–48 h after the biopsy. Providers should wait 48 h postbiopsy to obtain dd-cfDNA levels to establish the correct baseline to be used for monitoring.
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63
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Halverson LP, Hachem RR. Antibody-Mediated Rejection and Lung Transplantation. Semin Respir Crit Care Med 2021; 42:428-435. [PMID: 34030204 DOI: 10.1055/s-0041-1728796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antibody-mediated rejection (AMR) is now a widely recognized form of lung allograft rejection, with mounting evidence for AMR as an important risk factor for the development of chronic lung allograft dysfunction and markedly decreased long-term survival. Despite the recent development of the consensus diagnostic criteria, it remains a challenging diagnosis of exclusion. Furthermore, even after diagnosis, treatment directed at pulmonary AMR has been nearly exclusively derived from practices with other solid-organ transplants and other areas of medicine, such that there is a significant lack of data regarding the efficacy for these in pulmonary AMR. Lastly, outcomes after AMR remain quite poor despite aggressive treatment. In this review, we revisit the history of AMR in lung transplantation, describe our current understanding of its pathophysiology, discuss the use and limitations of the consensus diagnostic criteria, review current treatment strategies, and summarize long-term outcomes. We conclude with a synopsis of our most pressing gaps in knowledge, introduce recommendations for future directions, and highlight promising areas of active research.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
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Challenges of Diagnosing Antibody-Mediated Rejection: The Role of Invasive and Non-Invasive Biomarkers. ACTA ACUST UNITED AC 2021; 57:medicina57050439. [PMID: 34063583 PMCID: PMC8147623 DOI: 10.3390/medicina57050439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 12/22/2022]
Abstract
Kidney transplantation is the best treatment modality for end-stage kidney disease, leading to improvement in a patient’s quality and quantity of life. With significant improvements in short-term outcomes, prolonging long-term allograft and patient survival remain ongoing challenges. The ability to monitor allograft function, immune tolerance and predict rejection accurately would enable personalization and better prognostication during post-transplant care. Though kidney biopsy remains the backbone of transplant diagnostics, emerging biomarkers can help detecting kidney allograft injury early enough to prevent permanent damage and detect injury before it is clinically apparent. In this review, we summarize the recent biomarkers that have shown promise in the prediction of acute rejection with a focus on antibody-mediated rejection in kidney transplantation.
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65
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Degner KR, Parajuli S, Aziz F, Garg N, Mohamed M, Mandelbrot DA, Panzer SE, Wilson NA, Reese SR, Van Hyfte K, Zhong W, Hidalgo LG, Nickerson P, Djamali A. Modest Improvements in Refractory Antibody-Mediated Rejection After Prolonged Treatment. Kidney Int Rep 2021; 6:1397-1401. [PMID: 34013117 PMCID: PMC8116765 DOI: 10.1016/j.ekir.2021.02.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/15/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Kenna R. Degner
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha Mohamed
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A. Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sarah E. Panzer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nancy A. Wilson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Shannon R. Reese
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristin Van Hyfte
- The Office of Clinical Trials, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Weixiong Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Luis G. Hidalgo
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter Nickerson
- Department of Internal Medicine and Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arjang Djamali
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Gaitonde S, Hassan M, Mehta V, Benedetti E, Tzvetanov I, Lichvar A, Pirzada S, Setty S. Histopathology of Human Donor Spleen Utilized as a Desensitization Tool Before Intestinal Transplantation. Am J Clin Pathol 2021; 155:621-626. [PMID: 33219820 DOI: 10.1093/ajcp/aqaa175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To describe the histopathologic and immunophenotypic features of a temporary splenic allograft exposed to massive donor-specific antibody (DSA) insult. METHODS A human cadaveric donor splenic allograft was temporarily transplanted in a highly sensitized patient with the intention of removing DSA before intestinal transplantation from the same donor. Before splenic transplant, the patient had several preformed cytotoxic DSAs that resulted in positive flow cytometric and complement-dependent cytotoxicity crossmatch. The splenic allograft was removed before intestinal transplantation and evaluated by H&E and immunohistochemical stains. RESULTS Explanted donor splenic allograft showed several histopathologic changes: expanded red pulp secondary to congestion and marked neutrophilic and macrophage infiltration in the sinusoids, numerous neutrophilic microabscesses, and focal capillaritis. The C4d and IgG immunohistochemical stains were diffusely positive in the endothelial lining of the capillaries and sinusoidal lining, indicating diffuse IgG deposition and complement activation. CONCLUSIONS We propose that the noted changes are features of splenic acute antibody-mediated rejection (AMR). Additional cases are required to determine all the features of splenic AMR. To our knowledge, this is the first report of histopathologic changes in donor spleen after exposure to DSA for a short duration.
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Affiliation(s)
- Sujata Gaitonde
- Department of Pathology, University of Illinois Hospital & Health Sciences System, Chicago
| | - Mohamed Hassan
- Department of Pathology, University of Illinois Hospital & Health Sciences System, Chicago
| | - Vikas Mehta
- Department of Pathology, University of Illinois Hospital & Health Sciences System, Chicago
| | - Enrico Benedetti
- Department of Surgery, University of Illinois Hospital & Health Sciences System, Chicago
| | - Ivo Tzvetanov
- Department of Surgery, University of Illinois Hospital & Health Sciences System, Chicago
| | - Alicia Lichvar
- Department of Pharmacology, University of Illinois Hospital & Health Sciences System, Chicago
| | | | - Suman Setty
- Department of Pathology, University of Illinois Hospital & Health Sciences System, Chicago
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Kobayashi H, Konno M, Utsugisawa T, Tanabe K, Kanno H. Preoperative autologous blood donation for kidney transplant and end-stage renal disease patients: A single-center study. Transfus Apher Sci 2021; 60:103149. [PMID: 34148766 DOI: 10.1016/j.transci.2021.103149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
Although preoperative autologous blood donation (PABD) has many advantages, there has been a decrease in the performance due to a decrease in the residual risk of allogeneic blood transfusion. In allogeneic blood transfusion, anti HLA antibodies and donor-specific antibodies mediate antibody-mediated rejection, which results in graft failure. PABD for anemic patients such as those with end-stage renal disease (ESRD) and a kidney transplant is relatively contraindicated. In this study, we aimed to investigate the characteristics of patients who underwent PABD and elucidate the safety and feasibility of PABD. We performed PABD safely in ten ESRD patients and nine kidney transplant patients and retrospectively analyzed medical records of the hospital. All kidney transplant patients avoided allogeneic blood transfusion, but 4 out of 10 ESRD patients had allogeneic blood transfusion, even if their blood donation volume was larger than those of the kidney transplant patients. It depends on the type of operation; cardiovascular surgery was more common in ESRD patients, and orthopedic surgery was more common in kidney transplant patients. There was profuse bleeding in cardiovascular surgery compared to orthopedic surgery because of longer operation time of the former. Completely avoiding allogeneic blood transfusion in major surgery was rather difficult even if PABD was performed. To prevent the formation of anti- HLA antibodies, PABD would be considered for ESRD patients undergoing kidney transplantation and kidney transplant patients that are potential candidates for secondary kidney transplantation.
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Affiliation(s)
- Hirohito Kobayashi
- Division of Transfusion and Cell Therapy, Tokyo Women's Medical University Medical Center East, Tokyo, Japan; Department of Urology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Mayumi Konno
- Department of Transfusion Medicine and Cell Processing, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Taiju Utsugisawa
- Department of Transfusion Medicine and Cell Processing, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Hitoshi Kanno
- Department of Transfusion Medicine and Cell Processing, Tokyo Women's Medical University Hospital, Tokyo, Japan
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68
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Tomita Y, Ishida H, Uehara S, Takiguchi S, Sato T, Nakamura M. CD45RA -CD25 highCD127 -CD4 + activated regulatory T cells are correlated with de novo donor-specific anti-HLA antibody formation after kidney transplantation in standard immunosuppression. Int Immunopharmacol 2021; 97:107661. [PMID: 33887579 DOI: 10.1016/j.intimp.2021.107661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/22/2021] [Accepted: 04/05/2021] [Indexed: 12/16/2022]
Abstract
Although de novo donor-specific anti-HLA antibodies (dnDSA) remain a barrier for human kidney transplantation (KTx), the role of regulatory T (Treg) cells in dnDSA formation remains unknown. To address this question, we evaluated Treg cell subsets in peripheral blood mononuclear cells in 15 healthy volunteers and 59 KTx recipients using flow cytometric analysis. The post-transplant CD25highCD127-CD4+ Treg cells in KTx recipients were down-regulated compared with those of healthy volunteers (P < .001). Among them, 11 KTx recipients showed dnDSA formation, which was associated with lower frequencies of CD25highCD127-CD4+ Treg cells (P = .040). Furthermore, of the total Treg cell population, CD45RA-CD25highCD127-CD4+ activated Treg (aTreg) cells were significantly dominant in patients with dnDSA (P = .038), but not CD45RA+CD25highCD127-CD4+ resting Treg cells (P = .961). In contrast, non-donor-specific anti-HLA antibody formation was not associated with CD45RA- aTreg cells (P = .772). Multivariate logistic regression analyses revealed that CD45RA- aTreg cells were independently associated with dnDSA formation (Odds ratio = 6.69, P = .040). These findings indicate that CD45RA- aTreg cells are strongly associated with dnDSA formation in KTx recipients and might be an important risk factor of antibody-mediated rejection before clinical diagnosis.
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Affiliation(s)
- Yusuke Tomita
- Department of Transplant Surgery, Tokai University School of Medicine, Kanagawa, Japan.
| | - Hiroaki Ishida
- Department of Transplant Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Saeko Uehara
- Department of Transplant Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Shinya Takiguchi
- Department of Transplant Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Takehito Sato
- Department of Immunology, Tokai University School of Medicine, Kanagawa, Japan
| | - Michio Nakamura
- Department of Transplant Surgery, Tokai University School of Medicine, Kanagawa, Japan
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Yang Z, Han F, Liao T, Zheng H, Luo Z, Ma M, He J, Li L, Ye Y, Zhang R, Huang Z, Zhang Y, Sun Q. Artemisinin Attenuates Transplant Rejection by Inhibiting Multiple Lymphocytes and Prolongs Cardiac Allograft Survival. Front Immunol 2021; 12:634368. [PMID: 33717174 PMCID: PMC7943449 DOI: 10.3389/fimmu.2021.634368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/07/2021] [Indexed: 01/06/2023] Open
Abstract
Immunological rejection is an important factor resulting in allograft dysfunction, and more valid therapeutic methods need to be explored to improve allograft outcomes. Many researches have indicated that artemisinin and its derivative exhibits immunosuppressive functions, apart from serving as a traditional anti-malarial drug. In this assay, we further explored the therapeutic effects of artemisinin for transplant rejection in a rat cardiac transplantation model. We found that it markedly attenuated allograft rejection and histological injury and significantly prolonged the survival of allograft. Upon further exploring the mechanism, we demonstrated that artemisinin not only attenuated T cell-mediated rejection (TCMR) by reducing effector T cell infiltration and inflammatory cytokine secretion and increasing regulatory T cell infiltration and immunoregulatory cytokine levels, but also attenuated antibody-mediated rejection (ABMR) through inhibition of B cells activation and antibody production. Furthermore, artemisinin also reduced macrophage infiltration in allografts, which was determined to be important for TCMR and ABMR. Moreover, we demonstrated that artemisinin significantly inhibited the function of pure T cells, B cells, and macrophages in vitro. All in all, this study provide evidence that artemisinin significantly attenuates TCMR and ABMR by targeting multiple effectors. Therefore, this agent might have potential for use in clinical settings to protect against transplant rejection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Zhengyu Huang
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yannan Zhang
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiquan Sun
- Research Institute of Organ Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Reducing Donor-specific Antibody During Acute Rejection Diminishes Long-term Renal Allograft Loss: Comparison of Early and Late Rejection. Transplantation 2021; 104:2403-2414. [PMID: 32000256 DOI: 10.1097/tp.0000000000003145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reduction in donor-specific antibody (DSA) has been associated with improved renal allograft survival after antibody-mediated rejection (AMR). These observations have not been separately analyzed for early and late AMR and mixed acute rejection (MAR). The purpose of this study was to evaluate long-term responses to proteasome inhibitor-based therapy for 4 rejection phenotypes and to determine factors that predict allograft survival. METHODS Retrospective cohort study evaluating renal transplant recipients with first AMR episodes treated with proteasome inhibitor-based therapy from January 2005 to July 2015. RESULTS A total of 108 patients were included in the analysis. Immunodominant DSA reduction at 14 days differed significantly (early AMR 79.6%, early MAR 54.7%, late AMR 23.4%, late MAR 21.1%, P < 0.001). Death-censored graft survival (DCGS) differed at 3 years postrejection (early AMR 88.3% versus early MAR 77.8% versus late AMR 56.7% versus late MAR 54.9%, P = 0.02). Multivariate analysis revealed that immunodominant DSA reduction > 50% at 14 days was associated with improved DCGS (odds ratio, 0.12, 95% CI, 0.02-0.52, P = 0.01). CONCLUSIONS In summary, significant differences exist across rejection phenotypes with respect to histological and DSA responses. The data suggest that DSA reduction may be associated with improved DCGS in both early and late AMR.
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71
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Abuzeineh M, Kyeso Y, Philogene MC, Alachkar N, Alasfar S. Presentation and Outcomes of Antibody-Mediated Rejection Associated With Angiotensin II Receptor 1 Antibodies Among Kidney Transplant Recipients. Transplant Proc 2021; 53:1501-1508. [PMID: 33573814 DOI: 10.1016/j.transproceed.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/30/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND It remains challenging to manage antibody-mediated rejection (ABMR) associated with angiotensin II type 1 receptor antibodies (AT1R-Abs) in kidney transplant recipients and the outcomes are not well defined. We describe the presentation, clinical course, and outcomes of this condition. METHODS This retrospective study included kidney transplant recipients with AT1R-Ab levels ≥10 units/mL and biopsy-proven ABMR in the absence of significant HLA-donor-specific antibodies at the time of rejection. RESULTS We identified 13 recipients. Median creatinine (Cr) at rejection was significantly higher (2.05 mg/dL) compared with baseline (1.2 mg/dL), P = .006. After ABMR management, the difference in median Cr was not significant (1.5 mg/dL), P = .152. Median AT1R-Ab level was higher in the pretransplant sample (34.5 units/mL) compared with the level at rejection (19 units/mL) and after rejection treatment (13 units/mL); however, these differences were not significant, P = .129. Eight of the 13 recipients received antibody reduction therapy with plasmapheresis and intravenous immunoglobulin, and 5 of the 13 recipients had other therapies. After rejection management, 6 of the 13 recipients had improvement in Cr to baseline and 7 of the 13 recipients had > 50% reduction in proteinuria. CONCLUSIONS AT1R-Ab-associated ABMR management and outcomes depend on the clinical presentation and may include antibody-reducing therapies among other therapies. Further prospective cohorts will improve recognizing and managing this condition.
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Affiliation(s)
- Mohammad Abuzeineh
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yousuf Kyeso
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Nada Alachkar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sami Alasfar
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Molecular Analysis of Renal Allograft Biopsies: Where Do We Stand and Where Are We Going? Transplantation 2021; 104:2478-2486. [PMID: 32150035 DOI: 10.1097/tp.0000000000003220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A renal core biopsy for histological evaluation is the gold standard for diagnosing renal transplant pathology. However, renal biopsy interpretation is subjective and can render insufficient precision, making it difficult to apply a targeted therapeutic regimen for the individual patient. This warrants a need for additional methods assessing disease state in the renal transplant. Significant research activity has been focused on the role of molecular analysis in the diagnosis of renal allograft rejection. The identification of specific molecular expression patterns in allograft biopsies related to different types of allograft injury could provide valuable information about the processes underlying renal transplant dysfunction and can be used for the development of molecular classifier scores, which could improve our diagnostic and prognostic ability and could guide treatment. Molecular profiling has the potential to be more precise and objective than histological evaluation and may identify injury even before it becomes visible on histology, making it possible to start treatment at the earliest time possible. Combining conventional diagnostics (histology, serology, and clinical data) and molecular evaluation will most likely offer the best diagnostic approach. We believe that the use of state-of-the-art molecular analysis will have a significant impact in diagnostics after renal transplantation. In this review, we elaborate on the molecular phenotype of both acute and chronic T cell-mediated rejection and antibody-mediated rejection and discuss the additive value of molecular profiling in the setting of diagnosing renal allograft rejection and how this will improve transplant patient care.
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Miyairi S, Baldwin WM, Valujskikh A, Fairchild RL. Natural Killer Cells: Critical Effectors During Antibody-mediated Rejection of Solid Organ Allografts. Transplantation 2021; 105:284-290. [PMID: 32384380 DOI: 10.1097/tp.0000000000003298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Antibody-mediated rejection (AMR) is an important cause of graft loss and continues to present a formidable obstacle to successful transplantation. Unresolved problems continue to be the absence of effective strategies to ablate the donor-specific antibody (DSA) response as well as to attenuate the antibody-mediated graft tissue injury. While the properties of DSA that cause greater graft tissue injury and the characteristic microvascular pathology of the graft injury are well documented, the mechanisms underlying the injury mediated by the antibodies remains unclear. Recent transcriptome interrogation of kidney and heart biopsies procured during ongoing AMR has indicated the expression of genes associated with natural killer (NK) cell activation that is absent during T cell-mediated rejection. The expression of NK cell transcripts during AMR correlates with the presence of CD56+ cells in the microcirculation inflammation observed during AMR. Several mouse models have recently demonstrated the role of NK cells in antibody-mediated chronic vasculopathy in heart allografts and the requirement for NK cell activation during acute AMR of kidney allografts. In the latter model, NK cell activation within kidney allografts is regulated by the activation of myeloid cells producing myeloperoxidase. Overall, the studies to date indicate that AMR constitutes a complex series of DSA-induced interactions with components of the innate immune response. The innate immune participants and their expressed effector functions resulting in the rejection are beginning to be identified. The identification of these components should uncover novel targets that can be used to attenuate acute graft tissue injury in the presence of DSA.
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Affiliation(s)
- Satoshi Miyairi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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74
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Yao T, Zha D, Gao P, Wu X. Silencing circ-USP1 protects the renal tubular from kidney injury induced by hypoxia via modulating miR-194-5p/DNMT3A axis in acute renal allografts. J Cell Mol Med 2021; 25:5940-5948. [PMID: 33484504 PMCID: PMC8256350 DOI: 10.1111/jcmm.16286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/22/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Recent studies indicate that circular RNAs are involved in dysregulation of kidney injury. Nevertheless, the underlying mechanisms remain largely unclear. Therefore, this study sought to investigate the role of circ-USP1 in the pathogenesis of early renal allografts. Thirty-two male C57BL/6J mice aged between 6 and 8 weeks were divided into the sham and allograft groups. Thereafter, the association between miR-194-5p, circ-USP1 and DNMT3A was confirmed using a combination of bioinformatics and the luciferase reporter gene assay. Additionally, the expression of circ-USP1, miR-194-5p and DNMT3A mRNA was detected through qPCR. Afterwards, the Western blot assay was performed to examine the expression of DNMT3A protein. Finally, the TUNEL assay was conducted to determine the rate of apoptosis in DNMT3A cells. The expression of circ-USP1 increased, while that of miR-194-5p decreased in renal allografts. Additionally, silencing circ-USP1 reduced kidney injuries caused by renal allografts in mice. Moreover, miR-194-5p was a target for circ-USP1, and DNMT3A was a target of miR-194-5p. Finally, it was shown that silencing circ-USP1 reduced DNMT3A expression in the kidney of mice that received renal allografts. Circ-USP1 functions as a competing endogenous RNA for miR-194-5p. This occurs in order to regulate DNMT3A expression in kidney injury induced by hypoxia in acute renal allografts.
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Affiliation(s)
- Tao Yao
- Department of NephrologyZhongnan Hospital of Wuhan UniversityWuhanChina
| | - Dongqing Zha
- Department of NephrologyZhongnan Hospital of Wuhan UniversityWuhanChina
| | - Ping Gao
- Department of NephrologyZhongnan Hospital of Wuhan UniversityWuhanChina
| | - Xiaoyan Wu
- Department of NephrologyZhongnan Hospital of Wuhan UniversityWuhanChina
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Wu Z, Qiu L, Wang C, Liu X, Li Q, Yu S, Yue Y, Li J, Chen W, Lai J, Chen L, Wang C, Chen G. Clinical and Pathologic Feature of Patients With Early Versus Late Active Antibody-Mediated Rejection After Kidney Transplantation: A Single-Center Experience. Transplant Proc 2021; 53:1025-1031. [PMID: 33419576 DOI: 10.1016/j.transproceed.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/26/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Active antibody-mediated rejection (aABMR), particularly late aABMR, remains a major challenge for long-term renal allograft survival. This single-center retrospective study aimed to compare clinical features between early vs late aABMR and to identify risk factors for allograft failure among patients with aABMR. METHOD Forty-one patients diagnosed with aABMR at our hospital were included and were divided into 2 groups: early aABMR (≤6 months; n = 10) vs late aABMR (>6 months; n = 31) based on the time from transplant to diagnosis. Their clinical and pathologic data were compared. This study was performed in compliance with the Helsinki Congress and the Declaration of Istanbul. RESULTS Of 10 patients with early aABMR, none had allograft failure, whereas 8 of 31 patients with late aABMR had developed allograft failure at the time of follow-up (25.8%). At the time of biopsy, patients with early aABMR had higher positive grade in urine occult blood test than patients with late aABMR (P = .01); however, the late aABMR group displayed more intensive interstitial fibrosis and tubular atrophy (P = .03) and more frequent HLA-DQ-type donor-specific antibodies. Interestingly, donor-specific antibody conversion from positive to negative was not associated with C4d grade but was correlated with time from transplant to biopsy. Multivariate Cox regression analysis indicated that high levels of serum creatinine or proteinuria and concomitant T-cell-mediated rejection were independent risk factors for allograft failure in patients with aABMR. CONCLUSION These data not only confirm that early aABMR has better clinical outcomes than late aABMR but highlight the importance of early diagnostic biopsy and early therapeutic interventions in ABMR, particularly in patients with high levels of serum creatinine or proteinuria in the early posttransplant phase.
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Affiliation(s)
- Zixuan Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Longhui Qiu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Chang Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaomian Liu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Qihao Li
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Shuangjin Yu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yuan Yue
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Jie Li
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Wutao Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jiajian Lai
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Lizhong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.
| | - Guodong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.
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76
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Kuan K, Schwartz D. Educational Case: Kidney Transplant Rejection. Acad Pathol 2021; 8:23742895211006832. [PMID: 33889718 PMCID: PMC8040549 DOI: 10.1177/23742895211006832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 12/30/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.
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Affiliation(s)
- Kevin Kuan
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Schwartz
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
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La Muraglia GM, Zeng S, Crichton ES, Wagener ME, Ford ML, Badell IR. Superior inhibition of alloantibody responses with selective CD28 blockade is CTLA-4 dependent and T follicular helper cell specific. Am J Transplant 2021; 21:73-86. [PMID: 32406182 PMCID: PMC7665991 DOI: 10.1111/ajt.16004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/15/2020] [Accepted: 05/07/2020] [Indexed: 01/25/2023]
Abstract
Anti-donor antibodies cause immunologic injury in transplantation. CD28 blockade with CTLA-4-Ig has the ability to reduce the incidence of these donor-specific antibodies (DSA), but its mechanism is suboptimal for the inhibition of alloimmunity in that CTLA-4-Ig blocks both CD28 costimulation and CTLA-4 coinhibition. Thus selective CD28 blockade that spares CTLA-4 has potential to result in improved inhibition of humoral alloimmunity. To test this possibility, we utilized a full allogeneic mismatch murine transplant model and T follicular helper (Tfh):B cell co-culture system. We observed that selective blockade with an anti-CD28 domain antibody (dAb) compared to CTLA-4-Ig led to superior inhibition of Tfh cell, germinal center, and DSA responses in vivo and better control of B cell responses in vitro. CTLA-4 blockade enhanced the humoral alloresponse and, in combination with anti-CD28 dAb, abrogated the effects of selective blockade. This CTLA-4-dependent inhibition was Tfh cell specific in that CTLA-4 expression by Tfh cells was necessary and sufficient for the improved humoral inhibition observed with selective CD28 blockade. As CD28 blockade attracts interest for control of alloantibodies in the clinic, these data support selective CD28 blockade as a superior strategy to address DSA via the sparing of CTLA-4 and more potent targeting of Tfh cells.
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Affiliation(s)
| | - Susan Zeng
- Emory Transplant Center, Atlanta, GA, USA
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78
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Hiramitsu T, Tomosugi T, Futamura K, Okada M, Nishihira M, Goto N, Ichimori T, Narumi S, Kobayashi T, Uchida K, Watarai Y. Optimal blood levels of (extended-release) tacrolimus in living donor kidney transplantation to prevent de novo donor-specific antibody production: A retrospective cohort study. Int Immunopharmacol 2020; 91:107038. [PMID: 33388731 DOI: 10.1016/j.intimp.2020.107038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 01/25/2023]
Abstract
Chronic antibody-mediated rejection, caused by de novo donor-specific antibody (dnDSA) production, results in poor graft survival. To prevent dnDSA production, optimal blood levels of immunosuppressive drugs in living donor kidney transplant recipients were determined. A total of 772 recipients underwent living donor kidney transplantation between January 2008 and December 2017. Graft survival and risk factors for dnDSA production were investigated in 647 recipients. Optimal blood levels of tacrolimus (TAC) and extended-release TAC (TACER) were measured in recipients receiving steroids and mycophenolate mofetil, combined with TAC (n = 53) or TACER (n = 135). Receiver operating characteristic (ROC) curve analysis and comparisons between dnDSA-negative and dnDSA-positive recipients were carried out. The Kaplan-Meier method revealed significantly poor graft survival in dnDSA-positive recipients (P < 0.001). Cox regression models indicated calcineurin inhibitor withdrawal as a significant risk for dnDSA production (P < 0.001; hazard ratio 6.637; 95% confidence interval 2.667-6.517). Average trough levels of TAC and TACER in dnDSA-negative recipients were significantly higher than those in dnDSA-positive recipients (4.88 vs 3.69 ng TAC/ml, P = 0.023, and 4.60 vs 3.85 ng TACER/ml, P = 0.001). ROC curve analysis indicated 4.325 and 3.990 ng/ml as the best trough levels under TAC- and TACER-based regimens, respectively, to prevent dnDSA production (areas under the curve: 0.788 and 0.813, respectively). Maintenance of the trough levels of TAC > 4.325 ng/ml and TACER > 3.990 ng/ml may prevent dnDSA production.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan.
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Morikuni Nishihira
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, 453-8566 35-28 Takehashi-cho, Nakamura-ku, Nagoya, Aichi, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, 480-1195 1-1 Yazakokarimata, Nagakute, Aichi, Japan
| | - Kazuharu Uchida
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan; Department of Renal Transplant Surgery, Masuko Memorial Hospital, 453-8566 35-28 Takehashi-cho, Nakamura-ku, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
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79
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Senev A, Emonds M, Van Sandt V, Lerut E, Coemans M, Sprangers B, Kuypers D, Naesens M. Clinical importance of extended second field high-resolution HLA genotyping for kidney transplantation. Am J Transplant 2020; 20:3367-3378. [PMID: 32337773 PMCID: PMC7754319 DOI: 10.1111/ajt.15938] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 01/25/2023]
Abstract
The need for extended second field high-resolution (2F-HR) HLA genotyping in kidney transplantation is debated. In a cohort of 1000 kidney transplants, we evaluated the impact of different HLA genotyping levels on the assignment of donor-specific anti-HLA antibodies (DSA) and investigated whether inference of 2F-HR genotypes from low-resolution (LR) genotypes could be used to correctly assign DSA. Based on LR genotypes, 224 pretransplant DSAs were present in 140 patients and absent in 860 patients (DSAneg group). With extended 2F-HR HLA genotyping, we confirmed 173 DSA (77.2%) in 108 (77.1%) patients (2F-HRpos LRpos DSA group) and excluded DSA in 32 patients (22.9%) (2F-HRneg LRpos DSA group). Kaplan-Meier curves showed that 10-year graft survival rates were similar between the DSAneg and 2F-HRneg LRpos DSA groups (82.4% vs 93.8%; P = .27) and confirmed that DSA determined using LR typing but not confirmed using 2F-HR typing were indeed misclassified. By inferring 2F-HR genotypes using HaploStats, DSA still could not be correctly assigned in 23.3% of cases. We conclude that extended 2F-HR typing of the donor-recipient pairs is relevant for the correct assessment of DSA. Although inference of 2F-HR genotypes may improve the assessment of DSA in some cases, significant misclassification occurs, and warrants caution in using inferred HLA results for clinical and research purposes.
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Affiliation(s)
- Aleksandar Senev
- Histocompatibility and Immunogenetics LaboratoryBelgian Red Cross‐FlandersMechelenBelgium,Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Marie‐Paule Emonds
- Histocompatibility and Immunogenetics LaboratoryBelgian Red Cross‐FlandersMechelenBelgium,Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics LaboratoryBelgian Red Cross‐FlandersMechelenBelgium
| | - Evelyne Lerut
- Department of Imaging & PathologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of Nephrology and Renal TransplantationUniversity Hospitals LeuvenLeuvenBelgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of Nephrology and Renal TransplantationUniversity Hospitals LeuvenLeuvenBelgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of Nephrology and Renal TransplantationUniversity Hospitals LeuvenLeuvenBelgium
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80
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Grazioli A, Athale J, Tanaka K, Madathil R, Rabin J, Kaczorowski D, Mazzeffi M. Perioperative Applications of Therapeutic Plasma Exchange in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:3429-3443. [DOI: 10.1053/j.jvca.2020.01.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 12/17/2022]
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81
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Donor-specific antibodies in liver transplantation: challenges in diagnosis and determining clinical impact. Curr Opin Organ Transplant 2020; 25:549-554. [PMID: 33105198 DOI: 10.1097/mot.0000000000000825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Our understanding of the clinical impact of donor-specific antibodies in liver transplant recipients has evolved in recent years as outcomes for liver allografts have improved and advances in diagnostic testing have made recognition of antibody mediated rejection in transplant patients more sensitive. RECENT FINDINGS Two main types of donor-specific antibodies - preformed and de novo - have been reported in the literature to have a negative impact on graft survival, and researchers have been able to further identify subclasses of class II donor-specific antibodies as being the most clinically impactful. Furthermore, there is evidence that donor-specific antibody formation can augment cellular rejection in liver grafts and lead to worsened clinical outcomes. Recent data have shown a higher prevalence of donor-specific antibody formation than previously reported. SUMMARY This review explores the most recent literature regarding the clinical impact of both preformed and de-novo donor-specific antibodies and potential management guidelines for patients undergoing liver transplantation. The best practice guidelines for undergoing monitoring for donor-specific antibody formation and protocol biopsies in sensitized patients will depend on further multiinstitutional studies.
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82
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Alfano G, Giaroni F, Fontana F, Neri L, Mosconi G, Mussini C, Guaraldi G, Cappelli G. Rituximab in people living with HIV affected by immune-mediated renal diseases: a case-series. Int J STD AIDS 2020; 31:1426-1431. [PMID: 33104497 DOI: 10.1177/0956462420946662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Over the last two decades, rituximab (RTX) has played an important role in the treatment of some lymphoproliferative malignancies and immune-mediated diseases. RTX administration is generally safe and well-tolerated, but side effects including late-onset neutropenia, hypogammaglobulinemia, hepatitis B reactivation and rare cases of progressive multifocal leukoencephalopathy have been observed after its administration. Although there are no absolute contraindications regarding its use in people living with HIV (PLWH), the prescription of this drug has been principally limited in patients with oncohematological diseases. In this report, we described the outcome of four PLWH who underwent RTX therapy after the diagnosis of immune-mediated renal disease. The main RTX-associated adverse effects were leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts. In addition, two of the four patients experienced pneumonia requiring hospitalization within six months from the last RTX infusion. We suggest that RTX should be used with caution in PLWH until further evidence emerges on its safety profile in this vulnerable population.
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Affiliation(s)
- G Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - F Giaroni
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - F Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - L Neri
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy
| | - G Mosconi
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy.,Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - C Mussini
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Guaraldi
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
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83
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Donor-specific antibodies in kidney transplantation: the University of Wisconsin experience. Curr Opin Organ Transplant 2020; 25:543-548. [PMID: 33044350 DOI: 10.1097/mot.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (ABMR) is the leading cause of allograft failure in kidney transplant recipients. This article provides a summary of the clinical research relating to donor-specific antibodies (DSA) and ABMR in kidney transplant recipients at the University of Wisconsin-Madison Transplant Center. RECENT FINDINGS Over 40% of the kidney transplant candidates on the UNOS waitlist are sensitized, and both preformed and de novo DSA are associated with increased risk of rejection and graft loss. We have developed graded induction-desensitization treatment and monitoring protocols based on the degree of immunologic risk. We have also implemented standard treatment and surveillance strategies for patients with ABMR. Additional important observations from our studies include high rates of ABMR in patients with positive C4d staining in postreperfusion biopsies and rise in DSA at 1 week after transplant, and increased risk of kidney allograft failure in patients with de novo DSA and ABMR, as well as in patients with HLA-DSA undetectable ABMR. We also found worse outcomes with de novo DSA following simultaneous pancreas--kidney and liver--kidney transplantation. Notably, favorable long-term graft outcomes were observed in patients with DSA who do not present the classic histopathological findings of ABMR. SUMMARY In order to improve long-term outcomes for kidney transplant recipients, further research focusing on the pathogenic mechanisms elicited by HLA and non-HLA DSA, and novel therapies targeting these pathways is needed.
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84
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Sorohan BM, Ismail G, Leca N, Tacu D, Obrișcă B, Constantinescu I, Baston C, Sinescu I. Angiotensin II type 1 receptor antibodies in kidney transplantation: An evidence-based comprehensive review. Transplant Rev (Orlando) 2020; 34:100573. [DOI: 10.1016/j.trre.2020.100573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
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85
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van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev 2020; 29:190132. [PMID: 32699023 PMCID: PMC9489139 DOI: 10.1183/16000617.0132-2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade.
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Affiliation(s)
- Sophie C van der Mark
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Authors contributed equally
| | - Rogier A S Hoek
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Authors contributed equally
| | - Merel E Hellemons
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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86
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Immunological follow-up of patients with renal transplants: A proposal for clinical practice in Colombia. ACTA ACUST UNITED AC 2020; 40:479-486. [PMID: 33030826 PMCID: PMC7666855 DOI: 10.7705/biomedica.5092] [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: 06/05/2019] [Indexed: 11/21/2022]
Abstract
Graft damage is a process that starts at the moment of transplantation, due to comorbidities of receptor, donor status, ischemia time, ischemia-reperfusion phenomenon, among others, those induce metabolic and immune factors that ultimately trigger clinical manifestations of graft dysfunction. However, the preclinical progression between the time of transplantation and the appearance of signs and symptoms of graft damage can take weeks to years.
Therefore, the implementation of rational monitoring approaches during the post-transplantation period is critical and should include not only the clinical follow-up but also anticipate immunological graft damage. In the present essay, we propose an immunological monitoring algorithm for the post-renal transplantation period.
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87
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Monitoring of Donor-specific Anti-HLA Antibodies and Management of Immunosuppression in Kidney Transplant Recipients: An Evidence-based Expert Paper. Transplantation 2020; 104:S1-S12. [DOI: 10.1097/tp.0000000000003270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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88
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Karava V, Gakiopoulou H, Zampetoglou A, Marinaki S, Havaki S, Bitsori M, Stefanidis CJ, Mitsioni A. Antibody-mediated rejection with the presence of glomerular crescents in a pediatric kidney transplant recipient: A case report. Pediatr Transplant 2020; 24:e13722. [PMID: 32437064 DOI: 10.1111/petr.13722] [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: 09/15/2018] [Revised: 05/18/2019] [Accepted: 04/05/2020] [Indexed: 12/01/2022]
Abstract
Glomerular crescents in kidney transplantation are indicative of severe glomerular injury and constitute a hallmark of RPGN. Their concurrence with ABMR has been rarely described only in adult patients. We report a case of 10-year-old boy with compound heterozygous Fin-major Finnish-type congenital nephrotic syndrome, who had received a deceased-donor kidney transplant 5 years before onset of acute kidney injury and nephrotic range proteinuria without hematuria. Kidney allograft biopsy illustrated 6 glomeruli with global sclerosis and 6 with remarkable circumferential or segmental cellular crescents. Negative glomerular immunofluorescence for immune-complex deposits and the absence of serum ANCA eliminated the presence of immune-mediated and ANCA-positive pauci-immune crescentic glomerulonephritis. Diagnosis of ABMR was based on the high levels of HLA class II DSA and the histological evidence of glomerulitis, peritubular capillaritis, and acute tubular injury with positive linear peritubular capillary C4d staining. The patient despite plasmapheresis and enhanced immunosuppressive treatment progressed to end-stage renal disease. We conclude that glomerular crescents may represent a finding of AMBR and possibly a marker of poor allograft prognosis in pediatric patients.
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Affiliation(s)
- Vasiliki Karava
- Pediatric Nephrology Department, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Hara Gakiopoulou
- 1st Department of Pathology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Argyroula Zampetoglou
- Pediatric Nephrology Department, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Smaragdi Marinaki
- Nephrology Department and Renal Transplantation Unit, Laiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Sofia Havaki
- Division of Histology - Embryology, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Bitsori
- Department of Paediatrics, Heraklion University Hospital, Heraklion, Greece
| | | | - Andromach Mitsioni
- Pediatric Nephrology Department, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
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89
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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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90
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Abstract
Antibody-mediated rejection continues to hinder long-term survival of solid organ allografts. Natural antibodies (Nabs) with polyreactive and autoreactive properties have recently emerged as potential contributors to antibody-mediated graft rejection. This review discusses Nabs, their functions in health and disease, their significance in rejection following kidney, heart, and lung transplantation, and their implication in serum reactivity to key antigens associated with rejection. Finally, potential effector mechanisms of Nabs in the context of transplantation are explored.
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91
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Franzin R, Stasi A, Fiorentino M, Stallone G, Cantaluppi V, Gesualdo L, Castellano G. Inflammaging and Complement System: A Link Between Acute Kidney Injury and Chronic Graft Damage. Front Immunol 2020; 11:734. [PMID: 32457738 PMCID: PMC7221190 DOI: 10.3389/fimmu.2020.00734] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
The aberrant activation of complement system in several kidney diseases suggests that this pillar of innate immunity has a critical role in the pathophysiology of renal damage of different etiologies. A growing body of experimental evidence indicates that complement activation contributes to the pathogenesis of acute kidney injury (AKI) such as delayed graft function (DGF) in transplant patients. AKI is characterized by the rapid loss of the kidney's excretory function and is a complex syndrome currently lacking a specific medical treatment to arrest or attenuate progression in chronic kidney disease (CKD). Recent evidence suggests that independently from the initial trigger (i.e., sepsis or ischemia/reperfusions injury), an episode of AKI is strongly associated with an increased risk of subsequent CKD. The AKI-to-CKD transition may involve a wide range of mechanisms including scar-forming myofibroblasts generated from different sources, microvascular rarefaction, mitochondrial dysfunction, or cell cycle arrest by the involvement of epigenetic, gene, and protein alterations leading to common final signaling pathways [i.e., transforming growth factor beta (TGF-β), p16 ink4a , Wnt/β-catenin pathway] involved in renal aging. Research in recent years has revealed that several stressors or complications such as rejection after renal transplantation can lead to accelerated renal aging with detrimental effects with the establishment of chronic proinflammatory cellular phenotypes within the kidney. Despite a greater understanding of these mechanisms, the role of complement system in the context of the AKI-to-CKD transition and renal inflammaging is still poorly explored. The purpose of this review is to summarize recent findings describing the role of complement in AKI-to-CKD transition. We will also address how and when complement inhibitors might be used to prevent AKI and CKD progression, therefore improving graft function.
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Affiliation(s)
- Rossana Franzin
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
- Department Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Alessandra Stasi
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Vincenzo Cantaluppi
- Department Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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92
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Maenaka A, Kenta I, Ota A, Miwa Y, Ohashi W, Horimi K, Matsuoka Y, Ohnishi M, Uchida K, Kobayashi T. Interferon-γ-induced HLA Class II expression on endothelial cells is decreased by inhibition of mTOR and HMG-CoA reductase. FEBS Open Bio 2020; 10:927-936. [PMID: 32237049 PMCID: PMC7193171 DOI: 10.1002/2211-5463.12854] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/10/2020] [Accepted: 03/26/2020] [Indexed: 12/15/2022] Open
Abstract
In organ transplantation, donor‐specific HLA antibody (DSA) is considered a major cause of graft rejection. Because DSA targets primarily donor‐specific human leukocyte antigen (HLA) expressed on graft endothelial cells, the prevention of its expression is a possible strategy for avoiding or salvaging DSA‐mediated graft rejection. We examined the effect of various clinically used drugs on HLA class II expression on endothelial cells. Interferon‐γ (IFN‐γ)‐induced HLA class II DR (HLA‐DR) was downregulated by everolimus (EVR, 49.1% ± 0.8%; P < 0.01) and fluvastatin (FLU, 33.8% ± 0.6%; P < 0.01). Moreover, the combination of EVR and FLU showed a greater suppressive effect on HLA‐DR expression. In contrast, cyclosporine, tacrolimus, mycophenolic acid, and prednisolone did not exhibit any significant suppressive effect. FLU, but not EVR, suppressed mRNA of HLA‐DR. Imaging analysis revealed that HLA‐DR expressed in cytosol or on the cell surface was repressed by EVR (cytosol: 58.6% ± 4.9%, P < 0.01; cell surface: 80.9% ± 4.0%, P < 0.01) and FLU (cytosol: 19.0% ± 3.4%, P < 0.01; cell surface: 48.3% ± 4.8%, P < 0.01). These data indicated that FLU and EVR suppressed IFN‐γ‐induced HLA‐DR expression at the transcriptional and post‐translational level, respectively, suggesting a potential approach for alleviating DSA‐related issues in organ transplantation.
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Affiliation(s)
- Akihiro Maenaka
- Department of Pharmacy, Aichi Medical University School of Medicine, Nagakute, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Iwasaki Kenta
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Akinobu Ota
- Department of Biochemistry, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yuko Miwa
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kosei Horimi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yutaka Matsuoka
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Masafumi Ohnishi
- Department of Pharmacy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kazuharu Uchida
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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93
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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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94
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Efficacy and Safety of Tocilizumab in the Treatment of Acute Active Antibody-mediated Rejection in Kidney Transplant Recipients. Transplant Direct 2020; 6:e543. [PMID: 32309629 PMCID: PMC7145000 DOI: 10.1097/txd.0000000000000988] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/07/2020] [Indexed: 11/26/2022] Open
Abstract
Antibody-mediated rejection (AMR) continues to have a deleterious impact on kidney allograft survival. Recent evidence supports use of tocilizumab for treatment of chronic active AMR, but it has not been assessed for treatment of acute active AMR.
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95
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Kakuta Y, Okumi M, Kanzawa T, Unagami K, Iizuka J, Takagi T, Ishida H, Tanabe K. Impact of donor‐related arteriosclerosis in pretransplant biopsy on long‐term outcome of living‐kidney transplantation: A propensity score‐matched cohort study. Int J Urol 2020; 27:423-430. [DOI: 10.1111/iju.14212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/02/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Yoichi Kakuta
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
| | - Taichi Kanzawa
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine Tokyo Women’s Medical University Tokyo Japan
| | - Junpei Iizuka
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
| | - Toshio Takagi
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine Tokyo Women’s Medical University Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology Tokyo Women’s Medical University Tokyo Japan
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96
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Bery AI, Hachem RR. Antibody-mediated rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:411. [PMID: 32355855 PMCID: PMC7186640 DOI: 10.21037/atm.2019.11.86] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibody-mediated rejection (AMR) has been identified as a significant form of acute allograft dysfunction in lung transplantation. The development of consensus diagnostic criteria has created a uniform definition of AMR; however, significant limitations of these criteria have been identified. Treatment modalities for AMR have been adapted from other areas of medicine and data on the effectiveness of these therapies in AMR are limited. AMR is often refractory to these therapies, and graft failure and death are common. AMR is associated with increased rates of chronic lung allograft dysfunction (CLAD) and poor long-term survival. In this review, we discuss the history of AMR and describe known mechanisms, application of the consensus diagnostic criteria, data for current treatment strategies, and long-term outcomes. In addition, we highlight current gaps in knowledge, ongoing research, and future directions to address these gaps. Promising diagnostic techniques are actively being investigated that may allow for early detection and treatment of AMR. We conclude that further investigation is required to identify and define chronic and subclinical AMR, and head-to-head comparisons of currently used treatment protocols are necessary to identify an optimal treatment approach. Gaps in knowledge regarding the epidemiology, mechanisms, diagnosis, and treatment of AMR continue to exist and future research should focus on these aspects.
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Affiliation(s)
- Amit I Bery
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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97
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One-year Outcome of Everolimus With Standard-dose Tacrolimus Immunosuppression in De Novo ABO-incompatible Living Donor Kidney Transplantation: A Retrospective, Single-center, Propensity Score Matching Comparison With Mycophenolate in 42 Transplants. Transplant Direct 2020; 6:e514. [PMID: 32047842 PMCID: PMC6964930 DOI: 10.1097/txd.0000000000000962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/09/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background. Despite improvement in immunosuppressive therapy, long-term kidney allograft survival remains a major challenge. The outcomes of therapy with everolimus (EVR) and standard-dose tacrolimus (Tac) have not been compared with those of mycophenolate mofetil (MMF) and standard-dose Tac in recipients of de novo ABO-incompatible (ABOi) living donor kidney transplantation (LDKT). Methods. This retrospective, observational, single-center, propensity score matching (PSM) study compared the outcomes of EVR and standard-dose Tac with those of MMF and standard-dose Tac following de novo ABOi LDKT. In total, 153 recipients of ABOi LDKT between January 2008 and March 2018 were screened for inclusion in the study. The variables considered for PSM were: recipient age/sex, duration of dialysis, cytomegalovirus mismatch (seronegative recipient and seropositive donor), cause of kidney disease, donor age/sex, and numbers of mismatches (HLA-A, HLA-B, and HLA-DR). After PSM, there were 21 patients in each group (n = 42 overall). Results. Four patients in the EVR group and 1 patient in the MMF group were withdrawn because of adverse effects. There were no significant differences between the 2 groups in 1-year outcomes regarding patient death, graft loss, delayed graft function, biopsy-proven acute rejection, infection requiring hospital admission, or estimated glomerular filtration rate. The 1-year protocol biopsy showed that the severity of interstitial fibrosis/tubular atrophy was significantly milder in the EVR group than in the MMF group. Conclusions. The findings suggest that the renal efficacy and safety of EVR and standard-dose Tac in recipients of de novo ABOi LDKT are comparable with those of MMF and standard-dose Tac.
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98
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Yalcintas A, Sayin B, Turgut D, Atay G, Colak T, Haberal M. Risk Factors of Antibody-Mediated Rejection and Predictors of Outcome in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2020; 18:29-31. [PMID: 32008489 DOI: 10.6002/ect.tond-tdtd2019.o1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Kidney transplant is the treatment of choice for patients with end-stage renal disease. Antibody-mediated rejection is associated with higher rates of graft loss in kidney transplant recipients. Determining the risk factors of antibody-mediated rejection is vital for its prevention, early diagnosis, and appropriate treatment, as these factors may be important in maintaining long-term graft survival in transplant recipients. In our study, we analyzed the risk factors of antibody-mediated rejection in kidney transplant recipients and the negative impact of antibody-mediated rejection on graft function. MATERIALS AND METHODS We analyzed demographic and clinical data of 124 kidney transplant recipients (37 female [30%] and 87 male [70%] patients) who were diagnosed with antibody-mediated rejection at transplant biopsy. We compared graft outcomes of this patient cohort versus 75 kidney transplant recipients (24 female [32%] and 51 male [68%] patients) who were not diagnosed with antibody-mediated rejection. RESULTS Mean ages of patients with and without antibody-mediated rejection were 38.2 ± 13.6 and 34.4 ± 13.0 years, respectively. Mean ages of donors for patients with antibody-mediated rejection was significantly higher (48.0 ± 13.2 y) than for donors of patients without antibody-mediated rejection (47.1 ± 11.4 y; P < .05). Rate of graft loss was 15.3% in patients with antibody-mediated rejection; patients without antibody-mediated rejection had no graft loss (P < .05). Positive panel reactive antibody levels and blood transfusion before transplant were found to be risk factors of antibody-mediated rejection in kidney transplant recipients. However, recipients who received tacrolimus had less antibody-mediated rejection episodes than recipients who received sirolimus or cyclophosphamide. CONCLUSIONS Antibody-mediated rejection is associated with high rates of graft loss in kidney transplant recipients. Avoiding blood transfusion, lowering panel reactive antibody levels, choosing younger donors, and using tacrolimus in high-risk kidney transplant recipients may reduce antibody-mediated rejection rates and provide better graft survival.
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Affiliation(s)
- Aysenur Yalcintas
- From the Department of Internal Medicine, Baskent University Faculty of Medicine, Ankara, Turkey
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99
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La Muraglia GM, Wagener ME, Ford ML, Badell IR. Circulating T follicular helper cells are a biomarker of humoral alloreactivity and predict donor-specific antibody formation after transplantation. Am J Transplant 2020; 20:75-87. [PMID: 31250973 PMCID: PMC7193899 DOI: 10.1111/ajt.15517] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/15/2019] [Accepted: 06/16/2019] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSAs) contribute to renal allograft loss. However, biomarkers to guide clinical management of DSA posttransplant or detect humoral alloimmune responses before alloantibodies develop are not available. Circulating T follicular helper (cTfh) cells are CD4+ CXCR5+ Tfh-like cells in the blood that have been associated with alloantibodies in transplant recipients, but whether they precede antibody formation for their evaluation as a predictive biomarker in transplant is unknown. To evaluate the ability of cTfh cells to predict DSA, we used murine transplant models to determine the temporal relationship between cTfh cells, germinal center formation, and DSA development. We observed that donor-reactive CD4+ CXCR5+ cTfh cells expand after allotransplant. These cTfh cells were equivalent to graft-draining lymph node-derived Tfh cells in their ability to provide B cell help for antibody production. cTfh cell expansion and differentiation into ICOS+ PD-1+ cells temporally correlated with germinal center alloreactivity and preceded the generation of DSAs in instances of modified and unmodified alloantibody formation. Importantly, delayed costimulation blockade initiated after the detection of ICOS+ PD-1+ cTfh cells prevented DSAs. These findings suggest that cTfh cells could serve as a biomarker for humoral alloreactivity before the detection of alloantibodies and inform therapeutic approaches to prevent DSAs.
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Affiliation(s)
| | | | | | - I. Raul Badell
- Emory Transplant Center, Atlanta, GA, USA,Corresponding Author: I. Raul Badell,
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100
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Singh R, Gupta A, Bhargava V, Gupta A, Tiwari V, Malik M, Bhalla AK, Rana DS, Jain M. Effect of De novo donor-specific antibodies on graft function in renal allograft recipients. INDIAN JOURNAL OF TRANSPLANTATION 2020. [DOI: 10.4103/ijot.ijot_6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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