51
|
Clerkin KJ, Restaino SW, Zorn E, Vasilescu ER, Marboe CC, Mancini DM. The effect of timing and graft dysfunction on survival and cardiac allograft vasculopathy in antibody-mediated rejection. J Heart Lung Transplant 2016; 35:1059-66. [PMID: 27423693 DOI: 10.1016/j.healun.2016.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/21/2016] [Accepted: 04/13/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Antibody-mediated rejection (AMR) has been associated with increased death and cardiac allograft vasculopathy (CAV). Early studies suggested that late AMR was rarely associated with graft dysfunction, whereas recent reports have demonstrated an association with increased mortality. We investigated the timing of AMR and its association with graft dysfunction, death, and CAV. METHODS This retrospective cohort study identified all adult orthotopic heart transplant (OHT) recipients (N = 689) at Columbia University Medical Center from 2004 to 2013. There were 68 primary cases of AMR, which were stratified by early (< 1 year post-OHT) or late (> 1 year post-OHT) AMR. Kaplan-Meier survival analysis and modeling was performed with multivariable logistic regression and Cox proportional hazards regression. RESULTS From January 1, 2004, through October 1, 2015, early AMR (median 23 days post-OHT) occurred in 43 patients and late AMR (median 1,084 days post-OHT) occurred in 25. Graft dysfunction was less common with early compared with late AMR (25.6% vs 56%, p = 0.01). Patients with late AMR had decreased post-AMR survival compared with early AMR (1 year: 80% vs 93%, 5 years: 51% vs 73%, p < 0.05). When stratified by graft dysfunction, only those with late AMR and graft dysfunction had worse survival (30 days: 79%, 1 year: 64%, 5 years: 36%; p < 0.006). The association remained irrespective of age, sex, donor-specific antibodies, left ventricular assist device use, reason for OHT, and recovery of graft function. Similarly, those with late AMR and graft dysfunction had accelerated development of de novo CAV (50% at 1 year; hazard ratio, 5.42; p = 0.009), whereas all other groups were all similar to the general transplant population. CONCLUSIONS Late AMR is frequently associated with graft dysfunction. When graft dysfunction is present in late AMR, there is an early and sustained increased risk of death and rapid development of de novo CAV despite aggressive treatment.
Collapse
Affiliation(s)
- Kevin J Clerkin
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Susan W Restaino
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Elena R Vasilescu
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Charles C Marboe
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donna M Mancini
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York.
| |
Collapse
|
52
|
Abstract
The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.
Collapse
|
53
|
ISHLT pathology antibody mediated rejection score correlates with increased risk of cardiovascular mortality: A retrospective validation analysis. J Heart Lung Transplant 2016; 35:320-325. [DOI: 10.1016/j.healun.2015.10.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 01/12/2023] Open
|
54
|
Muduma G, Odeyemi I, Smith-Palmer J, Pollock RF. Review of the Clinical and Economic Burden of Antibody-Mediated Rejection in Renal Transplant Recipients. Adv Ther 2016; 33:345-56. [PMID: 26905265 DOI: 10.1007/s12325-016-0292-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 01/29/2023]
Abstract
UNLABELLED Antibody-mediated rejection (AbMR) is a leading cause of late graft loss in kidney transplant recipients, accounting for up to 60% of late graft failures. AbMR manifests as two distinct phenotypes: the first occurs in the immediate post-transplant period in sensitized patients; the second occurs in the late post-transplant period and has been associated with non-adherence to immunosuppression. The present review summarizes the current treatment options for AbMR, its clinical and economic burden, and approaches for reducing the risk of AbMR. While AbMR is typically refractory to treatment with corticosteroids, there are numerous other approaches focused on removal, inhibition or neutralization of donor-specific antibodies, or inhibition of complement-mediated allograft damage. AbMR treatment is generally expensive with one US study reporting costs of USD 49,000-155,000 per episode. However, leaving AbMR untreated puts patients at high risk of capillaritis, microangiopathy, necrosis and graft failure, which may ultimately result in much greater costs associated with a return to dialysis. Given the barriers to treatment, which include the high cost and the fact that pharmacologic treatments are currently used off-label, prevention of AbMR is important, with improvement in patient adherence to immunosuppression a key strategic approach that may be worthy of further evaluation. FUNDING Astellas Pharma EMEA Limited.
Collapse
|
55
|
Levine DJ, Glanville AR, Aboyoun C, Belperio J, Benden C, Berry GJ, Hachem R, Hayes D, Neil D, Reinsmoen NL, Snyder LD, Sweet S, Tyan D, Verleden G, Westall G, Yusen RD, Zamora M, Zeevi A. Antibody-mediated rejection of the lung: A consensus report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2016; 35:397-406. [PMID: 27044531 DOI: 10.1016/j.healun.2016.01.1223] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 12/22/2022] Open
Abstract
Antibody-mediated rejection (AMR) is a recognized cause of allograft dysfunction in lung transplant recipients. Unlike AMR in other solid-organ transplant recipients, there are no standardized diagnostic criteria or an agreed-upon definition. Hence, a working group was created by the International Society for Heart and Lung Transplantation with the aim of determining criteria for pulmonary AMR and establishing a definition. Diagnostic criteria and a working consensus definition were established. Key diagnostic criteria include the presence of antibodies directed toward donor human leukocyte antigens and characteristic lung histology with or without evidence of complement 4d within the graft. Exclusion of other causes of allograft dysfunction increases confidence in the diagnosis but is not essential. Pulmonary AMR may be clinical (allograft dysfunction which can be asymptomatic) or sub-clinical (normal allograft function). This consensus definition will have clinical, therapeutic and research implications.
Collapse
Affiliation(s)
- Deborah J Levine
- Pulmonary Disease and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Allan R Glanville
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia.
| | - Christina Aboyoun
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - John Belperio
- Pulmonary Disease and Critical Care Medicine, University of California, Los Angeles, California, USA
| | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Gerald J Berry
- Division of Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey Hachem
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Don Hayes
- Department of Pulmonology, The Ohio State University, Columbus, Ohio, USA
| | - Desley Neil
- Department of Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Nancy L Reinsmoen
- Department of Immunology, Cedars-Sinai Hospital, Los Angeles, California, USA
| | - Laurie D Snyder
- Department of Pulmonology, Duke University, Durham, North Carolina, USA
| | - Stuart Sweet
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Dolly Tyan
- Division of Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Geert Verleden
- Department of Pulmonology, University Hospitals Leuven, Leuven, Belgium
| | - Glen Westall
- Department of Pulmonology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Roger D Yusen
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Martin Zamora
- Department of Pulmonology, University of Colorado, Denver, Colorado, USA
| | - Adriana Zeevi
- Department of Immunology, University of Pittsburgh, Pittsburgh, Pennyslvania, USA
| |
Collapse
|
56
|
Abstract
PURPOSE OF REVIEW Pulmonary antibody-mediated rejection (AMR) while contributing to acute and chronic allograft dysfunction remains a diagnostic and therapeutic challenge. The diagnostic tenets upon which AMR is defined will be reviewed in the light of recent studies. RECENT FINDINGS The introduction of solid phase assays such as the Luminex platform has provided a wealth of quantitative data on the presence of anti-human leukocyte antigen (HLA) donor-specific antibodies (DSA). Further studies are required to better define the relationship of circulating DSA and activation of proinflammatory immune pathways that result in allograft dysfunction. The limitations of C4d staining in defining AMR are highlighted from recent studies in lung transplantation and from the 2013 Banff meeting on renal transplantation. SUMMARY The current challenge to the lung transplant community is to agree on a working definition of pulmonary AMR. Only then can we better appreciate the epidemiology, clinical phenotypes, and treatment of AMR.
Collapse
|
57
|
Donor Specific Anti-HLA Antibody and Risk of Graft Failure in Haploidentical Stem Cell Transplantation. Adv Hematol 2016; 2016:4025073. [PMID: 26904122 PMCID: PMC4745275 DOI: 10.1155/2016/4025073] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/22/2015] [Indexed: 01/09/2023] Open
Abstract
Outcomes of allogeneic hematopoietic stem cell transplantation (AHSCT) using HLA-half matched related donors (haploidentical) have recently improved due to better control of alloreactive reactions in both graft-versus-host and host-versus-graft directions. The recognition of the role of humoral rejection in the development of primary graft failure in this setting has broadened our understanding about causes of engraftment failure in these patients, helped us better select donors for patients in need of AHSCT, and developed rational therapeutic measures for HLA sensitized patients to prevent this unfortunate event, which is usually associated with a very high mortality rate. With these recent advances the rate of graft failure in haploidentical transplantation has decreased to less than 5%.
Collapse
|
58
|
Ho MH, Wu SY, Ou KW, Su TF, Hsieh CB. Retransplant as Rescue Treatment for ABO-Compatible Living-Donor Liver Transplant Related Antibody-Mediated Rejection: A Case Report. EXP CLIN TRANSPLANT 2016; 16:222-226. [PMID: 26742858 DOI: 10.6002/ect.2015.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antibody-mediated rejection after liver transplant, especially when the donor is not a direct relative; it is associated with additional inconvenience for patients. We encountered a case in which antibody-mediated rejection because of de novo donor specific antibodies against donor human leukocyte antigen developed 6 months after ABO-compatible living-donor liver transplant and was treated with retransplant. A 38-year-old man with hepatitis B virus-related hepatocellular carcinoma underwent living-donor liver transplant with a graft from his wife. Six months later, he experienced fatigue and jaundice. Liver biopsy revealed C4d deposits, and histologic examination showed an antibody-mediated rejection pattern. We re-evaluated recipient-donor human leukocyte antigen matching and tested the patient's blood for antihuman leukocyte antigen donor-specific antibodies against donor human leukocyte antigen. De novo auto-antibodies against human leukocyte antigen-DQ6 were identified by Luminex single antigen beads.Because exhausting all treatment options, a rescue second living-donor liver transplant was planned with the patient's stepdaughter as the donor. Pretransplant human leukocyte antigen matching was performed, and the patient was discharged without event. Two months later, hyperbilirubinemia was noted, and a residual common bile duct from the first donor with chronic fibrosis and stricture was strongly suspected. Redo hepaticojejunostomy was successfully performed, with no problems during 1-years' follow-up. Thus, liver retransplant could be a rescue treatment for antibody-mediated rejection complicated with hepatic failure.
Collapse
Affiliation(s)
- Meng-Hsing Ho
- From the Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
59
|
Tran A, Fixler D, Huang R, Meza T, Lacelle C, Das BB. Donor-specific HLA alloantibodies: Impact on cardiac allograft vasculopathy, rejection, and survival after pediatric heart transplantation. J Heart Lung Transplant 2016; 35:87-91. [DOI: 10.1016/j.healun.2015.08.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/03/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022] Open
|
60
|
Tan C, Halushka M, Rodriguez E. Pathology of Cardiac Transplantation. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
61
|
Wallace WD, Li N, Andersen CB, Arrossi AV, Askar M, Berry GJ, DeNicola MM, Neil DA, Pavlisko EN, Reed EF, Remmelink M, Weigt SS, Weynand B, Zhang JQ, Budev MM, Farver CF. Banff study of pathologic changes in lung allograft biopsy specimens with donor-specific antibodies. J Heart Lung Transplant 2016; 35:40-48. [DOI: 10.1016/j.healun.2015.08.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/19/2015] [Accepted: 08/31/2015] [Indexed: 12/16/2022] Open
|
62
|
Surendra M, Raju SB, Raju N, Chandragiri S, Mukku KK, Uppin MS. Rituximab in the treatment of refractory late acute antibody-mediated rejection: Our initial experience. Indian J Nephrol 2016; 26:317-321. [PMID: 27795623 PMCID: PMC5015507 DOI: 10.4103/0971-4065.177207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Antibody-mediated rejection (AMR) is not uncommon after renal transplantation and is harder to handle compared to cell-mediated rejection. When refractory to conventional therapies, rituximab is an attractive option. This study aims to examine the effectiveness of rituximab in refractory late acute AMR. This is a retrospective study involving nine renal transplant recipients. Four doses of rituximab were administered at weekly interval for 4 weeks, at a dose of 375 mg/m2. The mean age of patients was 35.3 ± 7.38 years. The median period between transplantation and graft dysfunction was 30 ± 20 months. Mean serum creatinine at the time of discharge after transplantation and at the time of acute AMR diagnosis was 1.14 ± 0.19 mg/dl and 2.26 ± 0.57 mg/dl, respectively. After standard therapy, it was 2.68 ± 0.62 mg/dl. One patient died of Pseudomonas sepsis and three patients progressed to end-stage renal disease (ESRD). Four biopsies showed significant plasma cell infiltrations. Mean serum creatinine among non-ESRD patients at the end of 1 year progressed from 2.3 ± 0.4 to 3.8 ± 1.2 mg/dl (P value 0.04). eGFR prior to therapy and at the end of 1 year were 34.4 ± 6.18 and 20.8 ± 7.69 ml/min (P value 0.04), respectively. Only one patient showed improvement in graft function in whom donor-specific antibody (DSA) titers showed significant improvement. Rituximab may not be effective in late acute AMR unlike in early acute AMR. Monitoring of DSA has a prognostic role in these patients and plasma cell rich rejection is associated with poor prognosis.
Collapse
Affiliation(s)
- M Surendra
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S B Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S Chandragiri
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - K K Mukku
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
63
|
Frank R, Lal P, Kearns J, Molina MR, Wald JW, Goldberg LR, Kamoun M. Correlation of Circulating Complement-Fixing Donor-Specific Antibodies Identified by the C1q Assay and Presence of C4d in Endomyocardial Biopsy Specimens. Am J Clin Pathol 2016; 145:62-8. [PMID: 26712872 DOI: 10.1093/ajcp/aqv016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Donor-specific antibodies (DSAs) are associated with increased cardiac graft loss. We applied a C1q solid-phase assay in parallel with the standard immunoglobulin G (IgG) single antigen bead (SAB) assay to examine the correlation of circulating complement-fixing donor-specific antibodies and the presence of C4d in endomyocardial biopsy (EMB) specimens. METHODS We retrospectively studied the relationship of C1q+ DSAs and C4d immunofluorescence (IF) in 49 EMB specimens from 44 heart transplant recipients who had concurrent EMB, C4d IF, and DSA measurements. We applied a C1q SAB in parallel with the standard IgG SAB assay to examine the DSA profiles in heart transplant patients posttransplant. RESULTS A better concordance is observed between C1q+ DSAs with C4d IF+ compared with IgG DSAs with C4d IF + (40% vs 24%, P = .02). However, the correlation of C1q DSAs with C4d IF is not statistically significant (P = .24). Importantly, C1q+ DSAs were observed in 16 of 17 cases with C4d IF+; 24 cases had circulating C1q+ DSAs without detectable C4d staining, suggesting that that the presence of C1q+ DSAs may precede the detection of C4d deposition in EMB specimens and/or the development of antibody-mediated rejection. CONCLUSIONS In this cohort of 44 patients, no significant correlation was observed between circulating C1q DSAs and C4d IF in EMB specimens. Additional studies are needed to further evaluate the association of C1q DSAs with EMB specimens and C4d staining.
Collapse
Affiliation(s)
- Renee Frank
- From the Department of Pathology and Laboratory Medicine
| | - Priti Lal
- From the Department of Pathology and Laboratory Medicine
| | - Jane Kearns
- From the Department of Pathology and Laboratory Medicine
| | - Maria R Molina
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joyce W Wald
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee R Goldberg
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- From the Department of Pathology and Laboratory Medicine
| |
Collapse
|
64
|
Kulkarni HS, Bemiss BC, Hachem RR. Antibody-mediated Rejection in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2015; 2:316-323. [PMID: 27896040 PMCID: PMC5123809 DOI: 10.1007/s40472-015-0074-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There has been increasing awareness of antibody-mediated rejection (AMR) as an important cause of graft failure after lung transplantation in recent years. However, the diagnostic criteria for pulmonary AMR are not well defined. All four tenets of AMR in kidney and heart transplantation, graft dysfunction, complement component deposition, circulating donor-specific antibodies (DSA), and histopathologic changes consistent with AMR, are infrequently present in lung transplantation. Nonetheless, the lung transplant community has made important progress recognizing cases of AMR and developing a definition. However, AMR is often refractory to therapy resulting in graft failure and death. In this review, we discuss the progress and challenges in the diagnosis and therapeutic options for pulmonary AMR. In addition, we briefly examine emerging paradigms of C4d-negative AMR and chronic AMR, and conclude that significant progress is needed to mitigate the effects of humoral immune responses after lung transplantation.
Collapse
Affiliation(s)
- Hrishikesh S. Kulkarni
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Bradford C. Bemiss
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8766, Fax: (314) 454-7956
| |
Collapse
|
65
|
Blatter J, Sweet S. Lung Transplantation in Cystic Fibrosis: Trends and Controversies. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:237-243. [PMID: 26697265 DOI: 10.1089/ped.2015.0564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article is not an overview of all facets of lung transplantation in cystic fibrosis (CF), but rather it is intended as a review of current allocation controversies, as well as of trends in diagnostics and management in lung transplant recipients and in patients with end-stage lung disease. Despite changes in donor and recipient selection, long-term survival in pediatric lung transplant has continued to be limited by chronic lung allograft dysfunction (CLAD). Due to, in part, this short survival benefit, transplant continues to be an appropriate option for only a subset of pediatric patients with CF. The feasibility of transplant as a therapeutic option is also affected by the limited pediatric organ supply, which has moreover contributed to controversy over lung allocation. Debates over the allocation of this scarce resource, however, may also help to drive innovation in the field of lung transplant. Longer pretransplant survival-as aided by new lung bypass technologies, for example-could help to alleviate organ shortages, as well as facilitate the transport of organs to suitable pediatric recipients. Improved diagnosis and treatment for CLAD and for antibody-mediated rejection have the potential to extend survival in pediatric lung transplant. Regardless, the relative rarity of transplant could pose future challenges for pediatric lung transplant programs, which require adequate numbers of patients to maintain proper expertise.
Collapse
Affiliation(s)
- Joshua Blatter
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| | - Stuart Sweet
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine , St. Louis, Missouri
| |
Collapse
|
66
|
Cuadrado A, San Segundo D, López-Hoyos M, Crespo J, Fábrega E. Clinical significance of donor-specific human leukocyte antigen antibodies in liver transplantation. World J Gastroenterol 2015; 21:11016-11026. [PMID: 26494958 PMCID: PMC4607901 DOI: 10.3748/wjg.v21.i39.11016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/29/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Antibody-mediated rejection (AMR) caused by donor-specific anti-human leukocyte antigen antibodies (DSA) is widely accepted to be a risk factor for decreased graft survival after kidney transplantation. This entity also plays a pathogenic role in other solid organ transplants as it appears to be an increasingly common cause of heart graft dysfunction and an emerging issue in lung transplantation. In contrast, the liver appears relatively resistant to DSA-mediated injury. This “immune-tolerance” liver property has been sustained by a low rate of liver graft loss in patients with preformed DSA and by the intrinsic liver characteristics that favor the absorption and elimination of DSA; however, alloantibody-mediated adverse consequences are increasingly being recognized, and several cases of acute AMR after ABO-compatible liver transplant (LT) have been reported. Furthermore, the availability of new solid-phase assays, allowing the detection of low titers of DSA and the refinement of objective diagnostic criteria for AMR in solid organ transplants and particularly in LT, have improved the recognition and management of this entity. A cost-effective strategy of DSA monitoring, avoidance of class II human leukocyte antigen mismatching, judicious immunosuppression attached to a higher level of clinical suspicion of AMR, particularly in cases unresponsive to conventional anti-rejection therapy, can allow a rational approach to this threat.
Collapse
|
67
|
Liver inclusion improves outcomes of intestinal retransplantation in adults. [Corrected]. Transplantation 2015; 99:1265-72. [PMID: 25427167 DOI: 10.1097/tp.0000000000000488] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Retransplantation is a viable treatment option for patients with primary intestinal graft loss. METHODS We analyzed outcomes of retransplantations (n = 23) in adults from May 2000 to May 2010 at our center and compared patients who received liver-free retransplantations (n = 13) with those who received liver-inclusive retransplantations (n = 10). RESULTS The overall survival rates at 1, 3, and 5 years in retransplantations were 90.9%, 67.1%, and 59.7% (patient) and 82.2%, 58.6%, and 51.3% (graft), respectively, which were similar to the rates in primary transplants. The patient survival rates at 1, 3, and 5 years were 91.7%, 55.6%, and 41.7%, respectively, in liver-free retransplantations, as compared to rates of 90.0%, 80.0%, and 80.0% in liver-inclusive retransplantations. The graft survival rates at 1, 3, and 5 years in liver-free retransplantations were 76.2%, 40.6%, and 27.1%, respectively, which were significantly worse than those in liver-inclusive retransplantations (P = 0.03). Within an average follow-up of 32.3 months, 8 of 13 (61.5%) of liver-free retransplantations underwent enterectomy because of severe acute cellular rejection (n = 3) or chronic rejection (n = 5). Six of 13 (46.2%) recipients succumbed to rejection-related complications. Compared to liver-free retransplantations, the rate and severity of acute rejection were markedly de creased in liver-inclusive retransplantations, and no chronic rejection was seen. Within an average follow-up of 44.5 months, two of 10 (20%) died due to graft-versus-host disease and infection, respectively. CONCLUSION A liver-inclusive retransplantation offers a better long-term patient and graft survival, suggesting that including the liver as part of an intestinal graft should be considered in adult recipients when retransplantation is necessary.
Collapse
|
68
|
Hayes D, Auletta JJ, Whitson BA, Black SM, Kirkby S, Tobias JD, Mansour HM. Human leukocyte antigen mismatching and survival after lung transplantation in adult and pediatric patients with cystic fibrosis. J Thorac Cardiovasc Surg 2015; 151:549-57.e1. [PMID: 26414151 DOI: 10.1016/j.jtcvs.2015.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The influence of human leukocyte antigen (HLA) mismatching on survival in adult and pediatric patients with cystic fibrosis (CF) after lung transplantation (LTx) is unknown. METHODS The United Network for Organ Sharing database was queried from 1987 to 2013 to determine the influence of HLA mismatching on survival in adult and pediatric CF LTx recipients by assessing the association of HLA mismatching with survival in first-time adult (aged ≥ 18 years) and pediatric (aged <18 years) recipients. RESULTS Of 3149 adult and 489 pediatric patients with CF, 3145 and 489 were used for univariate Cox analysis, 2687 and 363 for Kaplan-Meier survival analysis, and 2073 and 257 for multivariate Cox analysis, respectively. Univariate analyses in adult and pediatric patients with CF demonstrated conflicting associations between HLA mismatching and survival (adult hazard ratio [HR], 1.0; 95% confidence interval [CI], 0.97-1.1; P = .45 vs pediatric HR, 0.87; 95% CI, 0.77-0.99; P = .032). Multivariate Cox models including both pediatric and adult patients confirmed that HLA mismatching had an initially protective effect at young ages (HR, 0.85; 95% CI, 0.73-0.99; P = .044) and that this protective effect diminished at older ages and was no longer associated with survival at P < .05 beyond age 10 years. CONCLUSIONS HLA mismatching has significantly different implications for survival after LTx in adult compared with pediatric patients with CF.
Collapse
Affiliation(s)
- Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio.
| | - Jeffery J Auletta
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio; Section of Hematology/Oncology and Bone Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Section of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sylvester M Black
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Stephen Kirkby
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Heidi M Mansour
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, Ariz
| |
Collapse
|
69
|
Abstract
Cardiothoracic transplantation has significantly impacted the lives of pediatric patients with advanced cardiopulmonary failure. The current state of lung transplantation in children as well as its ongoing and future challenges are discussed.
Collapse
|
70
|
Hayes D, Whitson BA, Ghadiali SN, Tobias JD, Mansour HM, Black SM. Influence of HLA Mismatching on Survival in Lung Transplantation. Lung 2015. [DOI: 10.1007/s00408-015-9768-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
71
|
Kauke T, Kneidinger N, Martin B, Dick A, Schneider C, Schramm R, Meimarakis G, Preissler G, Eickelberg O, von Dossow V, Behr J, Hatz R, Neurohr C, Winter H. Bronchiolitis obliterans syndrome due to donor-specific HLA-antibodies. ACTA ACUST UNITED AC 2015. [PMID: 26204790 DOI: 10.1111/tan.12626] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) is a limiting factor for long-term survival in lung transplant recipients. Donor-specific human leukocyte antigen (HLA)-antibodies (DSA) have been suggested as potential risk factors for CLAD. However, their impact on clinical outcome following lung transplantation remains controversial. We performed a single-center study of 120 lung transplant recipients transplanted between 2006 and 2011. Patient sera were investigated before and after transplantation. The sera were screened by means of Luminex(®) technology (Luminex Inc., Austin, TX, USA) for IgG-HLA-class I and class II antibodies (ab). Using single antigen beads, DSA were identified and correlated retrospectively with clinical parameters. After transplantation 39 out of 120 patients (32.5%) were positive for HLA-ab. The incidence of de novo DSA formation was 27 of 120 patients (22.5%). Eleven of 27 (41%) of de novo DSA-positive patients developed BOS compared to 13 of 93 (14%) DSA-negative patients (p = 0.002). Furthermore, the generation of de novo DSA was independently associated with the development of BOS in multivariable analysis [hazard ration (HR) 2.5, 95% confidence interval (CI) 1.0-6.08; p = 0.046). Our results indicate that de novo DSA are associated with the development of BOS after lung transplantation. Monitoring of HLA-ab after transplantation is useful for identifying high-risk patients and offers an opportunity for early therapeutic intervention.
Collapse
Affiliation(s)
- T Kauke
- Laboratory for Immunogenetics, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany.,Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - N Kneidinger
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - B Martin
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - A Dick
- Laboratory for Immunogenetics, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - C Schneider
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - R Schramm
- Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - G Meimarakis
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - G Preissler
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - O Eickelberg
- Comprehensive Pneumology Center Munich (CPC-M), Institute of Lung Biology and Disease, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - V von Dossow
- Department of Anaesthesiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich Lung Transplant Group (MLTP), Munich, Germany
| | - J Behr
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - R Hatz
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - C Neurohr
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - H Winter
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| |
Collapse
|
72
|
Mehrotra S, Rishishwar P, Sharma R. Evaluation of immunological barriers in transplantation: Role of transplant immunology lab. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
73
|
Time-dependent specificity of immunopathologic (C4d-CD68) and histologic criteria of antibody-mediated rejection for donor-specific antibodies and allograft dysfunction in heart transplantation. Transplantation 2015; 99:586-93. [PMID: 24983305 DOI: 10.1097/tp.0000000000000246] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In heart transplantation, antibody-mediated rejection (AMR) is diagnosed and graded on the basis of immunopathologic (C4d-CD68) and histopathologic criteria found on endomyocardial biopsies (EMB). Because some pathologic AMR (pAMR) grades may be associated with clinical AMR, and because humoral responses may be affected by the intensity of immunosuppression during the first posttransplantation year, we investigated the incidence and positive predictive values (PPV) of C4d-CD68 and pAMR grades for clinical AMR as a function of time. METHODS All 564 EMB from 40 adult heart recipients were graded for pAMR during the first posttransplantation year. Clinical AMR was diagnosed by simultaneous occurrence of pAMR on EMB, donor specific antibodies and allograft dysfunction. RESULTS One patient demonstrated clinical AMR at postoperative day 7 and one at 6 months (1-year incidence 5%). C4d-CD68 was found on 4,7% EMB with a "decrescendo" pattern over time (7% during the first 4 months vs. 1.2% during the last 8 months; P < 0.05). Histopathologic criteria of AMR occurred on 10.3% EMB with no particular time pattern. Only the infrequent (1.4%) pAMR2 grade (simultaneous histopathologic and immunopathologic markers) was predictive for clinical AMR, particularly after the initial postoperative period (first 4 months and last 8 months PPV = 33%-100%; P < 0.05). CONCLUSION In the first posttransplantation year, AMR immunopathologic and histopathologic markers were relatively frequent, but only their simultaneous occurrence (pAMR2) was predictive of clinical AMR. Furthermore, posttransplantation time may modulate the occurrence of C4d-CD68 on EMB and thus the incidence of pAMR2 and its relevance to the diagnosis of clinical AMR.
Collapse
|
74
|
Abe T, Ishii D, Gorbacheva V, Kohei N, Tsuda H, Tanaka T, Dvorina N, Nonomura N, Takahara S, Valujskikh A, Baldwin WM, Fairchild RL. Anti-huCD20 antibody therapy for antibody-mediated rejection of renal allografts in a mouse model. Am J Transplant 2015; 15:1192-204. [PMID: 25731734 PMCID: PMC5021301 DOI: 10.1111/ajt.13150] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Indexed: 01/25/2023]
Abstract
We have reported that B6.CCR5(-/-) mice reject renal allografts with high serum donor-specific antibody (DSA) titers and marked C4d deposition in grafts, features consistent with antibody-mediated rejection (AMR). B6.huCD20/CCR5(-/-) mice, where human CD20 expression is restricted to B cells, rejected A/J renal allografts by day 26 posttransplant with DSA first detected in serum on day 5 posttransplant and increased thereafter. Recipient treatment with anti-huCD20 mAb prior to the transplant and weekly up to 7 weeks posttransplant promoted long-term allograft survival (>100 days) with low DSA titers. To investigate the effect of B cell depletion at the time serum DSA was first detected, recipients were treated with anti-huCD20 mAb on days 5, 8, and 12 posttransplant. This regimen significantly reduced DSA titers and graft inflammation on day 15 posttransplant and prolonged allograft survival >60 days. However, DSA returned to the titers observed in control treated recipients by day 30 posttransplant and histological analyses on day 60 posttransplant indicated severe interstitial fibrosis. These results indicate that anti-huCD20 mAb had the greatest effect as a prophylactic treatment and that the distinct kinetics of DSA responses accounts for acute renal allograft failure versus the development of fibrosis.
Collapse
Affiliation(s)
- Toyofumi Abe
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Specific Organ Regulation (Urology), Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Daisuke Ishii
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Urology, Kitasato University, Sagamihara, Kanagawa 228-8555, Japan
| | | | - Naoki Kohei
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - Hidetoshi Tsuda
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - Toshiaki Tanaka
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - Nina Dvorina
- Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - Norio Nonomura
- Department of Specific Organ Regulation (Urology), Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shiro Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Anna Valujskikh
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - William M. Baldwin
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
| | - Robert L. Fairchild
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
| |
Collapse
|
75
|
Luk A, Alba AC, Butany J, Tinckam K, Delgado D, Ross HJ. C4d immunostaining is an independent predictor of cardiac allograft vasculopathy and death in heart transplant recipients. Transpl Int 2015; 28:857-63. [DOI: 10.1111/tri.12560] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/07/2015] [Accepted: 02/27/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Adriana Luk
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Ana Carolina Alba
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Jagdish Butany
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Kathryn Tinckam
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
- Division of Nephrology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Diego Delgado
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Heather J. Ross
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| |
Collapse
|
76
|
Acute and chronic antibody-mediated rejection in pediatric kidney transplantation. Pediatr Nephrol 2015; 30:417-24. [PMID: 24865478 DOI: 10.1007/s00467-014-2851-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/28/2014] [Accepted: 05/08/2014] [Indexed: 01/05/2023]
Abstract
Acute antibody-mediated rejection is a diagnostic challenge in renal transplantation medicine. However, it is an important diagnosis to make, since chronic antibody-mediated rejection (CAMR) is the main cause of long-term graft loss. Antibody-mediated rejection is diagnosed by detecting donor-specific antibodies (DSAs) in the blood in combination with observing typical histomorphological signs in kidney biopsy, as described in the Banff classification. Therapy is based on the removal of DSAs by administering intravenous immunoglobulins (IVIGs), plasmapheresis, or immunoadsorption. Reoccurrence of antibodies is diminished by the use of rituximab, increased immunosuppression, and in some cases additional experimental substances. A combination of these techniques has been shown to be successful in the majority of cases of acute and chronic antibody-mediated rejection. Routine DSA monitoring is warranted for early detection of antibody-mediated rejection.
Collapse
|
77
|
Antibody-Mediated Rejection in Reconstructive Transplantation. THE SCIENCE OF RECONSTRUCTIVE TRANSPLANTATION 2015. [DOI: 10.1007/978-1-4939-2071-6_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
78
|
Mehrotra S, Sharma R, Mayya M, Gupta A, Prasad N, Kaul A, Bhadauria D. Pre transplant PRA (penal reactive antibody) and DSA (donor specific antibody) screening status and outcome after renal transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
79
|
Ejaz NS, Alloway RR, Halleck F, Dürr M, Budde K, Woodle ES. Review of bortezomib treatment of antibody-mediated rejection in renal transplantation. Antioxid Redox Signal 2014; 21:2401-18. [PMID: 24635140 DOI: 10.1089/ars.2014.5892] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
SIGNIFICANCE Development of donor-specific antibodies (DSA) after kidney transplantation is associated with reduced allograft survival. A few strategies have been tested in controlled clinical trials for the treatment of antibody-mediated rejection (AMR), and no therapies are approved by regulatory authorities. Thus development of antihumoral therapies that provide prompt elimination of DSA and improve allograft survival is an important goal. RECENT ADVANCES Proteasome inhibitor (PI)-based regimens provide a promising new approach for treating AMR. To date, experiences have been limited to off-label bortezomib use in AMR. Key findings with PI-based therapy are that they provide effective primary and rescue therapy for AMR by prompt reduction in immunodominant DSA and improvements in histologic and renal function. Early and late AMR differ immunologically and in response to PI therapy. Bortezomib-related toxicities in renal transplant recipients are similar to those observed in the multiple myeloma population. CRITICAL ISSUES Although preliminary evidence with PI therapy for AMR is encouraging, the evidence is limited. Larger, prospective, randomized controlled trials with long-term follow up are needed. Advancement in endpoints of clinical trial designs and rigorous clinical trials with more standardized adjunct therapies are also required to explore the risks and benefits of AMR treatment modalities. FUTURE DIRECTIONS In the next few years, new PIs are likely to be introduced and new approaches would be developed for achieving synergy with PIs. The ultimate goal will be to develop a regimen that delivers reliable, rapid, complete, and durable elimination of DSA with an acceptable safety profile.
Collapse
Affiliation(s)
- Nicole S Ejaz
- 1 Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | | | | | | | | | | |
Collapse
|
80
|
|
81
|
Masterson R, Hughes P, Walker RG, Hogan C, Haeusler M, Robertson AR, Millar R, Suh N, Cohney SJ. ABO incompatible renal transplantation without antibody removal using conventional immunosuppression alone. Am J Transplant 2014; 14:2807-13. [PMID: 25389083 DOI: 10.1111/ajt.12920] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/23/2014] [Accepted: 06/25/2014] [Indexed: 01/25/2023]
Abstract
ABO incompatible living donor renal transplantation (ABOi) can achieve outcomes comparable to ABO compatible transplantation (ABOc). However, with the exception of blood group A2 kidneys transplanted into recipients with low titer anti-A antibody, regimens generally include antibody removal, intensified immunosuppression and splenectomy or rituximab. We now report a series of 20 successful renal transplants across a range of blood group incompatibilities using conventional immunosuppression alone in recipients with low baseline anti-blood group antibody (ABGAb) titers. Incompatibilities were A1 to O (3), A1 to B (2), A2 to O (2), AB to A (2), AB to B (1), B to A1 (9), B to O (1); titers 1:1 to 1:16 by Ortho. At 36 months, patient and graft survival are 100%. Antibody-mediated rejection (AbMR) occurred in one patient with thrombophilia and low level donor-specific anti-HLA antibody. Four patients experienced cellular rejection (two subclinical), which responded to oral prednisolone. This series demonstrates that selected patients with low titer ABGAb can undergo ABOi with standard immunosuppression alone, suggesting baseline titer as a reliable predictor of AbMR. This reduces morbidity and cost of ABOi for patients with low titer ABGAb and increases the possibility of ABOi from deceased donors.
Collapse
Affiliation(s)
- R Masterson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
82
|
Frank R, Molina MR, Goldberg LR, Wald JW, Kamoun M, Lal P. Circulating donor-specific anti-human leukocyte antigen antibodies and complement C4d deposition are associated with the development of cardiac allograft vasculopathy. Am J Clin Pathol 2014; 142:809-15. [PMID: 25389335 DOI: 10.1309/ajcptlbeu5bq8shn] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) continues to be a limiting factor in long-term survival of heart transplant recipients (HTRs). Pathophysiologic and immunologic factors affecting CAV are complex, and criteria for early diagnosis remain elusive. METHODS We performed a retrospective analysis of the relationship between donor-specific antibody (DSA), C4d immunofluorescence, and the development of CAV. RESULTS We evaluated 330 endomyocardial biopsy (EMB) specimens from 112 cardiac grafts. Twenty-four (21%) of 112 grafts developed CAV, and 18 (75%) of 24 were positive for C4d. Patients with DSA (n = 51) against human leukocyte antigen class I (n = 5), II (n = 26), or both (n = 20) developed CAV at a rate of 40%, 38%, and 20% and a mean time to CAV of 89, 47, and 25 months, respectively. Of 61 grafts without DSA, only 13% developed CAV, with a mean time to CAV of 116 months. CONCLUSIONS Compared with the general HTR population, patients with graft dysfunction and DSA or positive C4d on EMB show a statistically significant increased incidence of CAV and allograft failure, suggesting an antibody-mediated injury. The presence of pre- and posttransplant DSA, even in the absence of positive C4d immunofluorescence, may identify a group of HTRs at increased risk of developing CAV.
Collapse
Affiliation(s)
- Renee Frank
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Maria R. Molina
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Lee R. Goldberg
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Joyce W. Wald
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Priti Lal
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| |
Collapse
|
83
|
|
84
|
Li F, Wei J, Valenzuela NM, Lai C, Zhang Q, Gjertson D, Fishbein MC, Kobashigawa JA, Deng M, Reed EF. Phosphorylated S6 kinase and S6 ribosomal protein are diagnostic markers of antibody-mediated rejection in heart allografts. J Heart Lung Transplant 2014; 34:580-587. [PMID: 25511749 DOI: 10.1016/j.healun.2014.09.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 08/22/2014] [Accepted: 09/30/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Anti-MHC Class I alloantibodies have been implicated in the processes of acute and chronic rejection. These antibodies (Ab) bind to endothelial cells (EC) and transduce signals leading to the activation of cell survival and proliferation pathways, including Src, FAK and mTOR, as well as downstream targets ERK, S6 kinase (S6K) and S6 ribosomal protein (S6RP). We tested the hypothesis that phosphorylation of S6K, S6RP and ERK in capillary endothelium may serve as an adjunct diagnostic tool for antibody-mediated rejection (AMR) in heart allografts. METHODS Diagnosis of AMR was based on histology or immunoperoxidase staining of paraffin-embedded tissue, consistent with 2013 ISHLT criteria. Diagnosis of acute cellular rejection (ACR) was based on ISHLT criteria. Endomyocardial biopsies from 67 heart transplant recipients diagnosed with acute rejection [33 with pAMR, 18 with ACR (15 with Grade 1R, 3 with Grade ≥2R), 16 with pAMR and ACR (13 with 1R and 3 with ≥2R)] and 40 age- and gender-matched recipients without rejection were tested for the presence of phosphorylated forms of ERK, S6RP and S6K by immunohistochemistry. RESULTS Immunostaining of endomyocardial biopsies with evidence of pAMR showed a significant increase in expression of p-S6K and p-S6RP in capillary EC compared with controls. A weaker association was observed between pAMR and p-ERK. CONCLUSIONS Biopsies diagnosed with pAMR often showed phosphorylation of S6K and S6RP, indicating that staining for p-S6K and p-S6RP is useful for the diagnosis of AMR. Our findings support a role for antibody-mediated HLA signaling in the process of graft injury.
Collapse
Affiliation(s)
- Fang Li
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Jennifer Wei
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Nicole M Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Chi Lai
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - David Gjertson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| | - Jon A Kobashigawa
- Heart Transplant Program, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd, Third Floor Cardiology A3107, los Angeles, CA 90048
| | - Mario Deng
- UCLA Cardiovascular Center, Ronald Reagan UCLA Medical Center, UCLA Medical Center, Los Angeles, CA 90095, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095
| |
Collapse
|
85
|
Berry GJ, Burke MM, Andersen C, Bruneval P, Fedrigo M, Fishbein MC, Goddard M, Hammond EH, Leone O, Marboe C, Miller D, Neil D, Rassl D, Revelo MP, Rice A, Rene Rodriguez E, Stewart S, Tan CD, Winters GL, West L, Mehra MR, Angelini A. The 2013 International Society for Heart and Lung Transplantation Working Formulation for the standardization of nomenclature in the pathologic diagnosis of antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2014; 32:1147-62. [PMID: 24263017 DOI: 10.1016/j.healun.2013.08.011] [Citation(s) in RCA: 361] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/12/2013] [Indexed: 11/30/2022] Open
Abstract
During the last 25 years, antibody-mediated rejection of the cardiac allograft has evolved from a relatively obscure concept to a recognized clinical complication in the management of heart transplant patients. Herein we report the consensus findings from a series of meetings held between 2010-2012 to develop a Working Formulation for the pathologic diagnosis, grading, and reporting of cardiac antibody-mediated rejection. The diagnostic criteria for its morphologic and immunopathologic components are enumerated, illustrated, and described in detail. Numerous challenges and unresolved clinical, immunologic, and pathologic questions remain to which a Working Formulation may facilitate answers.
Collapse
Affiliation(s)
- Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Ius F, Sommer W, Tudorache I, Kühn C, Avsar M, Siemeni T, Salman J, Hallensleben M, Kieneke D, Greer M, Gottlieb J, Kielstein JT, Boethig D, Welte T, Haverich A, Warnecke G. Preemptive treatment with therapeutic plasma exchange and rituximab for early donor-specific antibodies after lung transplantation. J Heart Lung Transplant 2014; 34:50-58. [PMID: 25447575 DOI: 10.1016/j.healun.2014.09.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 08/07/2014] [Accepted: 09/19/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE De novo donor-specific anti-human leukocyte antigen antibodies develop in a high proportion of lung transplant recipients early after lung transplantation. We recently showed that de novo donor-specific antibodies (DSA) occurrence is associated with significantly increased mortality. Here, we studied the efficacy of a preemptive treatment protocol. METHODS A retrospective observational study was conducted on all lung transplantations at Hanover Medical School between January 2009 and May 2013. RESULTS Among the 500 transplant recipients, early DSA developed in 86 (17%). Of these, 56 patients (65%; Group A) received therapeutic plasma exchange, and 30 patients (35%; Group B) did not. Among Group A patients, 51 also received rituximab. Between groups, there was no statistically significant difference in mortality, incidence of pulsed steroid therapies, rejections diagnosed by biopsy specimen, incidence of bronchitis obliterans syndrome (BOS), or infections requiring hospitalization at 1 year and 3 years. Also, there were no statistically significant differences after matching 21 Group A with 21 Group B patients through propensity score analysis. Significantly more Group A patients (65%) than Group B patients (34%) cleared DSA at hospital discharge (p = 0.01). At the last control after transplantation (median, 14 months; interquartile range, 5-24 months), 11 Group A (22%) and 9 Group B patients (33%) still showed DSA (p = 0.28). CONCLUSIONS Preemptive treatment with therapeutic plasma exchange and rituximab led to improved elimination of DSA early after lung transplantation (p = 0.01). However, spontaneous elimination in untreated Group B patients also occurred frequently. This treatment protocol was not associated with significantly improved outcome.
Collapse
Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | | | - Daniela Kieneke
- Department of Transfusion Medicine, Hanover Medical School, Hanover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany
| | - Jan T Kielstein
- Department of Hypertension and Nephrology, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Paediatric Cardiology, Hanover Medical School, Hanover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany.
| |
Collapse
|
87
|
Bossini N, Sandrini S, Casari S, Tardanico R, Maffeis R, Setti G, Valerio F, Forleo MA, Nodari F, Cancarini G. Kidney transplantation in HIV-positive patients treated with a steroid-free immunosuppressive regimen. Transpl Int 2014; 27:1050-9. [DOI: 10.1111/tri.12377] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 03/25/2014] [Accepted: 06/17/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Nicola Bossini
- Operative Unit of Nephrology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Silvio Sandrini
- Operative Unit of Nephrology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Salvatore Casari
- Second Operative Unit of Infectious Diseases; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Regina Tardanico
- Department of Pathology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Roberto Maffeis
- Department of Surgery; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Gisella Setti
- Operative Unit of Nephrology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Francesca Valerio
- Operative Unit of Nephrology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Maria A. Forleo
- Second Operative Unit of Infectious Diseases; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Franco Nodari
- Department of Surgery; A.O. Spedali Civili and University of Brescia; Brescia Italy
| | - Giovanni Cancarini
- Operative Unit of Nephrology; A.O. Spedali Civili and University of Brescia; Brescia Italy
| |
Collapse
|
88
|
Evolving experience of treating antibody-mediated rejection following lung transplantation. Transpl Immunol 2014; 31:75-80. [DOI: 10.1016/j.trim.2014.06.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 06/12/2014] [Accepted: 06/12/2014] [Indexed: 11/21/2022]
|
89
|
Abe T, Su CA, Iida S, Baldwin WM, Nonomura N, Takahara S, Fairchild RL. Graft-derived CCL2 increases graft injury during antibody-mediated rejection of cardiac allografts. Am J Transplant 2014; 14:1753-64. [PMID: 25040187 PMCID: PMC4464804 DOI: 10.1111/ajt.12780] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/14/2014] [Accepted: 04/01/2014] [Indexed: 01/25/2023]
Abstract
The pathogenic role of macrophages in antibody-mediated rejection (AMR) remains unclear. Monocyte chemoattractant protein-1 (MCP-1/CCL2) is a potent chemotactic factor for monocytes and macrophages. The current studies used a murine model of AMR to investigate the role of graft-derived CCL2 in AMR and how macrophages may participate in antibody-mediated allograft injury. B6.CCR5−/−/CD8−/− recipients rejected MHC-mismatched WT A/J allografts with high donor-reactive antibody titers and diffuse C4d deposition in the large vessels and myocardial capillaries, features consistent with AMR. In contrast, A/J.CCL2−/− allografts induced low donor-reactive antibody titers and C4d deposition at Day 7 posttransplant. Decreased donor-reactive CD4 T cells producing interferon gamma were induced in response to A/J.CCL2−/− versus WT allografts. Consequently, A/J.CCL2−/− allograft survival was modestly but significantly longer than A/J allografts. Macrophages purified from WT allografts expressed high levels of IL-1β and IL-12p40 and this expression and the numbers of classically activated macrophages were markedly reduced in CCL2-deficient allografts on Day 7. The results indicate that allograft-derived CCL2 plays an important role in directing classically activated macrophages into allografts during AMR and that macrophages are important contributors to the inflammatory environment mediating graft tissue injury in this pathology, suggesting CCL2 as a therapeutic target for AMR.
Collapse
Affiliation(s)
- Toyofumi Abe
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Specific Organ Regulation (Urology), Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Charles A. Su
- Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
| | - Shoichi Iida
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195
| | - William M. Baldwin
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
| | - Norio Nonomura
- Department of Specific Organ Regulation (Urology), Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shiro Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Robert L. Fairchild
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Immunology, Cleveland Clinic Foundation, Cleveland, OH 44195,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
| |
Collapse
|
90
|
Histologic Evaluation of Post-implantation Immediate C4d Deposition in 13 Intestinal Grafts: Correlation With Cell-based Crossmatching, Cold Ischemia Time, and Preservation Injury. Transplant Proc 2014; 46:2099-101. [DOI: 10.1016/j.transproceed.2014.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
91
|
Donor-specific human leukocyte antigen antibodies in intestinal transplantation. Curr Opin Organ Transplant 2014; 19:261-6. [PMID: 24811437 DOI: 10.1097/mot.0000000000000078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Early outcomes following intestinal transplantation (ITx) have markedly improved in recent years. However, there has been a lack of improvement in long-term outcomes. Increasing amounts of data suggest the humoral immune system is a major contributor to rejection and late allograft loss. This review will summarize the available data on donor-specific human leukocyte antigen antibodies (DSAs) in ITx, with a focus on the clinical significance of DSAs, diagnosis of antibody-mediated rejection (AMR), and available treatment modalities. Areas requiring further investigation will also be identified. RECENT FINDINGS Mounting evidence shows that pre- and/or posttransplant DSAs are associated with rejection and allograft loss following ITx. Preformed DSAs are present in nearly one-third of ITx recipients, and de-novo DSAs develop in up to 40% of patients. Diagnosis and treatment of AMR remains challenging, but reports indicate that when optimal induction and maintenance immunosuppressive agents are used, the impact of DSAs may be negligible. SUMMARY Although data are limited due to center differences with regard to patient population, induction and maintenance immunosuppression protocols, and monitoring strategies, DSAs are associated with poor outcomes following ITx. A consensus to define AMR and optimal treatment strategies is needed.
Collapse
|
92
|
Wallace WD, Weigt SS, Farver CF. Update on pathology of antibody-mediated rejection in the lung allograft. Curr Opin Organ Transplant 2014; 19:303-8. [DOI: 10.1097/mot.0000000000000079] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
93
|
Antibody-mediated rejection in ABO compatible husband to wife living donor liver transplant and review of the literature. Hum Immunol 2014; 75:578-83. [DOI: 10.1016/j.humimm.2014.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/03/2014] [Accepted: 02/04/2014] [Indexed: 01/25/2023]
|
94
|
Muthukumar T, Lee JR, Dadhania DM, Ding R, Sharma VK, Schwartz JE, Suthanthiran M. Allograft rejection and tubulointerstitial fibrosis in human kidney allografts: interrogation by urinary cell mRNA profiling. Transplant Rev (Orlando) 2014; 28:145-54. [PMID: 24929703 DOI: 10.1016/j.trre.2014.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/26/2014] [Accepted: 05/22/2014] [Indexed: 01/07/2023]
Abstract
Because the kidney allograft has the potential to function as an in-vivo flow cytometer and facilitate the access of immune cells and kidney parenchymal cells in to the urinary space, we hypothesized that mRNA profiling of urinary cells offers a noninvasive means of assessing the kidney allograft status. We overcame the inherent challenges of urinary cell mRNA profiling by developing pre-amplification protocols to compensate for low RNA yield from urinary cells and by developing robust protocols for absolute quantification mRNAs using RT-PCR assays. Armed with these tools, we undertook first single-center studies urinary cell mRNA profiling and then embarked on the multicenter Clinical Trials in Organ Transplantation-04 study of kidney transplant recipients. We report here our discovery and validation of diagnostic and prognostic biomarkers of acute cellular rejection and of interstitial fibrosis and tubular atrophy (IF/TA). Our urinary cell mRNA profiling studies, in addition to demonstrating the feasibility of accurate diagnosis of acute cellular rejection and IF/TA in the kidney allograft, advance mechanistic and potentially targetable biomarkers. Interventional trials, guided by urinary cell mRNA profiles, may lead to personalized immunosuppression in recipients of kidney allografts.
Collapse
Affiliation(s)
- Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY.
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Vijay K Sharma
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Joseph E Schwartz
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Psychiatry and Behavioral Science, Stony Brook School of Medicine, Stony Brook, NY
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
| |
Collapse
|
95
|
Taner T, Stegall MD, Heimbach JK. Antibody-mediated rejection in liver transplantation: current controversies and future directions. Liver Transpl 2014; 20:514-27. [PMID: 24470340 DOI: 10.1002/lt.23826] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 01/10/2014] [Indexed: 12/12/2022]
Abstract
Interest in the role of donor-specific human leukocyte antibodies in liver transplantation has been rekindled recently. Emerging evidence suggests that these antibodies may cause injury to the liver allograft. Here we review the clinical literature, highlight controversial results, and propose a path forward for the definition and better understanding of antibody-mediated injury to the liver.
Collapse
Affiliation(s)
- Timucin Taner
- William J. von Liebig Transplantation Center, Mayo Clinic, Rochester, MN
| | | | | |
Collapse
|
96
|
Kim M, Martin ST, Townsend KR, Gabardi S. Antibody-mediated rejection in kidney transplantation: a review of pathophysiology, diagnosis, and treatment options. Pharmacotherapy 2014; 34:733-44. [PMID: 24753207 DOI: 10.1002/phar.1426] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antibody-mediated rejection (AMR), also known as B-cell-mediated or humoral rejection, is a significant complication after kidney transplantation that carries a poor prognosis. Although fewer than 10% of kidney transplant patients experience AMR, as many as 30% of these patients experience graft loss as a consequence. Although AMR is mediated by antibodies against an allograft and results in histologic changes in allograft vasculature that differ from cellular rejection, it has not been recognized as a separate disease process until recently. With an improved understanding about the importance of the development of antibodies against allografts as well as complement activation, significant advances have occurred in the treatment of AMR. The standard of care for AMR includes plasmapheresis and intravenous immunoglobulin that remove and neutralize antibodies, respectively. Agents targeting B cells (rituximab and alemtuzumab), plasma cells (bortezomib), and the complement system (eculizumab) have also been used successfully to treat AMR in kidney transplant recipients. However, the high cost of these medications, their use for unlabeled indications, and a lack of prospective studies evaluating their efficacy and safety limit the routine use of these agents in the treatment of AMR in kidney transplant recipients.
Collapse
Affiliation(s)
- Miae Kim
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | |
Collapse
|
97
|
Salvadori M, Bertoni E. Impact of donor-specific antibodies on the outcomes of kidney graft: Pathophysiology, clinical, therapy. World J Transplant 2014; 4:1-17. [PMID: 24669363 PMCID: PMC3964192 DOI: 10.5500/wjt.v4.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
Allo-antibodies, particularly when donor specific, are one of the most important factors that cause both early and late graft dysfunction. The authors review the current state of the art concerning this important issue in renal transplantation. Many antibodies have been recognized as mediators of renal injury. In particular donor-specific-Human Leukocyte Antigens antibodies appear to play a major role. New techniques, such as solid phase techniques and Luminex, have revealed these antibodies from patient sera. Other new techniques have uncovered alloantibodies and signs of complement activation in renal biopsy specimens. It has been acknowledged that the old concept of chronic renal injury caused by calcineurine inhibitors toxicity should be replaced in many cases by alloantibodies acting against the graft. In addition, the number of patients on waiting lists with preformed anti-human leukocyte antigens (HLA) antibodies is increasing, primarily from patients with a history of renal transplant failure already been sensitized. We should distinguish early and late acute antibody-mediated rejection from chronic antibody-mediated rejection. The latter often manifets late during the course of the post-transplant period and may be difficult to recognize if specific techniques are not applied. Different therapeutic strategies are used to control antibody-induced damage. These strategies may be applied prior to transplantation or, in the case of acute antibody-mediated rejection, after transplantation. Many new drugs are appearing at the horizon; however, these drugs are far from the clinic because they are in phase I-II of clinical trials. Thus the pipeline for the near future appears almost empty.
Collapse
|
98
|
Salah A, Fujimoto M, Yoshizawa A, Yurugi K, Miyagawa-Hayashino A, Sumiyoshi S, Minamiguchi S, Uemoto S, Maekawa T, Haga H. Application of complement component 4d immunohistochemistry to ABO-compatible and ABO-incompatible liver transplantation. Liver Transpl 2014; 20:200-9. [PMID: 24470446 DOI: 10.1002/lt.23789] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/15/2013] [Accepted: 10/15/2013] [Indexed: 12/12/2022]
Abstract
Antibody-mediated rejection (AMR) is difficult to diagnose after ABO-compatible or ABO-identical (ABO-C) liver transplantation. To determine whether complement component 4d (C4d) immunostaining would be useful for diagnosing AMR, we compared the results of C4d immunohistochemistry for allograft biopsy samples with assays for anti-donor antibodies performed at the time of biopsy. One hundred fourteen patients with ABO-C grafts and 29 patients with ABO-incompatible (ABO-I) grafts were included. Linear C4d endothelial staining (identifiable with a 4× objective lens) or staining seen in 50% or more of the portal tracts was considered positive. Five of the 114 patients (4%) with ABO-C grafts and 15 of the 29 patients (52%) with ABO-I grafts showed C4d positivity. In the ABO-C cases, C4d positivity in late biopsy samples (≥30 days after transplantation) was associated with stage 2 or higher fibrosis (METAVIR score; P = 0.01) and with the presence of donor-specific anti-human leukocyte antigen DR antibodies (HLA-DR DSAs) with a mean fluorescence intensity > 5000 according to the Luminex single-antigen bead assay (P = 0.04). Conversely, the presence of HLA-DR DSAs was associated with the presence of stage 2 or higher fibrosis, acute cellular rejection, and C4d positivity. During the 2-year follow-up, neither C4d positivity nor HLA-DR DSAs were related to graft loss. Among ABO-I patients, C4d positivity was not associated with allograft dysfunction or fibrosis. Only 3 of the 15 C4d-positive patients (20%) showed periportal hemorrhagic edema, which could be a histological sign of AMR in ABO-I grafts, and they were the only cases associated with elevations in anti-donor A/B antibody titers. In conclusion, C4d endothelial positivity among ABO-C patients is an uncommon event that could be associated with chronic graft damage with or without clinical AMR. C4d positivity is common among ABO-I patients and may not be associated with allograft dysfunction if alloantibody titers are not elevated.
Collapse
Affiliation(s)
- Adeeb Salah
- Departments of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
99
|
Lipshultz SE, Chandar JJ, Rusconi PG, Fornoni A, Abitbol CL, Burke GW, Zilleruelo GE, Pham SM, Perez EE, Karnik R, Hunter JA, Dauphin DD, Wilkinson JD. Issues in solid-organ transplantation in children: translational research from bench to bedside. Clinics (Sao Paulo) 2014; 69 Suppl 1:55-72. [PMID: 24860861 PMCID: PMC3884162 DOI: 10.6061/clinics/2014(sup01)11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In this review, we identify important challenges facing physicians responsible for renal and cardiac transplantation in children based on a review of the contemporary medical literature. Regarding pediatric renal transplantation, we discuss the challenge of antibody-mediated rejection, focusing on both acute and chronic antibody-mediated rejection. We review new diagnostic approaches to antibody-mediated rejection, such as panel-reactive antibodies, donor-specific cross-matching, antibody assays, risk assessment and diagnosis of antibody-mediated rejection, the pathology of antibody-mediated rejection, the issue of ABO incompatibility in renal transplantation, new therapies for antibody-mediated rejection, inhibiting of residual antibodies, the suppression or depletion of B-cells, genetic approaches to treating acute antibody-mediated rejection, and identifying future translational research directions in kidney transplantation in children. Regarding pediatric cardiac transplantation, we discuss the mechanisms of cardiac transplant rejection, including the role of endomyocardial biopsy in detecting graft rejection and the role of biomarkers in detecting cardiac graft rejection, including biomarkers of inflammation, cardiomyocyte injury, or stress. We review cardiac allograft vasculopathy. We also address the role of genetic analyses, including genome-wide association studies, gene expression profiling using entities such as AlloMap®, and adenosine triphosphate release as a measure of immune function using the Cylex® ImmuKnow™ cell function assay. Finally, we identify future translational research directions in heart transplantation in children.
Collapse
Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, United States
| | - Jayanthi J Chandar
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Paolo G Rusconi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alessia Fornoni
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - George W Burke
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaston E Zilleruelo
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Si M Pham
- Artificial Heart Programs, Transplant Institute, Jackson Memorial Division of Heart/Lung Transplant, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Elena E Perez
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ruchika Karnik
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Juanita A Hunter
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Danielle D Dauphin
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - James D Wilkinson
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| |
Collapse
|
100
|
The diagnostic value of transcription factors T-bet/GATA3 ratio in predicting antibody-mediated rejection. Clin Dev Immunol 2013; 2013:460316. [PMID: 24235972 PMCID: PMC3819890 DOI: 10.1155/2013/460316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 09/19/2013] [Accepted: 09/19/2013] [Indexed: 01/27/2023]
Abstract
Background. Previous data showed that the predominance of intraglomerular T-bet or GATA3 is correlated with different mechanisms of rejection, suggesting that the ratio of T-bet/GATA3 might be used to distinguish antibody-mediated rejection (ABMR) and T-cell-mediated rejection (TCMR). Methods. We compared the intraglomerular T-bet/GATA3 ratio in ABMR and TCMR. The intragraft expression of T-bet and GATA3 was studied via immunohistochemistry. The correlation of the diagnosis of AMR with the ratio of T-bet/GATA3 was examined. Results. Both intraglomerular T-bet- and GATA3-expressing cells were increased during acute rejection. T-bet/GATA3>1 was strongly correlated with ABMR (93.3% versus 18.2%). The incidence of positive HLA-I/II antibodies and glomerulitis is significantly higher in T-bet/GATA3>1 group (P < 0.001, 0.013, resp.). The scores of peritubular capillary inflammation and glomerulitis were also higher in T-bet/GATA3>1 group (P = 0.052, P < 0.001, resp.). Nevertheless, T-bet/GATA3>1 is also correlated with C4d-negative ABMR and resistance to steroid treatment. Compared with C4d deposition, T-bet/GATA3>1 had a slight lower (90% versus 100%) specificity but a much higher (87.5% versus 68.8%) sensitivity. Conclusion. Our data suggested that intraglomerular predominance of T-bet over GATA3 might be used as diagnosis maker of ABMR in addition to C4d, especially in C4d-negative cases.
Collapse
|