51
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Berry GJ, Angelini A, Burke MM, Bruneval P, Fishbein MC, Hammond E, Miller D, Neil D, Revelo MP, Rodriguez ER, Stewart S, Tan CD, Winters GL, Kobashigawa J, Mehra MR. The ISHLT working formulation for pathologic diagnosis of antibody-mediated rejection in heart transplantation: evolution and current status (2005-2011). J Heart Lung Transplant 2011; 30:601-11. [PMID: 21555100 DOI: 10.1016/j.healun.2011.02.015] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 02/15/2011] [Indexed: 10/18/2022] Open
Affiliation(s)
- Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA.
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52
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Positive virtual crossmatch with negative flow crossmatch results in two cases. Transpl Immunol 2011; 25:77-81. [DOI: 10.1016/j.trim.2011.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/13/2011] [Accepted: 05/16/2011] [Indexed: 11/20/2022]
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53
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Loupy A, Cazes A, Guillemain R, Amrein C, Hedjoudje A, Tible M, Pezzella V, Fabiani JN, Suberbielle C, Nochy D, Hill GS, Empana JP, Jouven X, Bruneval P, Duong Van Huyen JP. Very late heart transplant rejection is associated with microvascular injury, complement deposition and progression to cardiac allograft vasculopathy. Am J Transplant 2011; 11:1478-87. [PMID: 21668629 DOI: 10.1111/j.1600-6143.2011.03563.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In heart transplants, the significance of very late rejection (after 7 years post-transplant, VLR) detected by routine endomyocardial biopsies (EMB) remains uncertain. Here, we assessed the prevalence, histopathological and immunological phenotype, and outcome of VLR in clinically stable patients. Between 1985 and 2009, 10 662 protocol EMB were performed at our institution in 398 consecutive heart transplants recipients. Among the 196 patients with >7-year follow-up, 20 (10.2%) presented subclinical ≥3A/2R-ISHLT rejection. The VLR group was compared to a matched control group of patients without rejection. All biopsies were stained for C4d/C3d/CD68 with sera screened for the presence of donor-specific antibodies (DSAs). In addition to cellular infiltrates with myocyte damage, 60% of VLR patients had evidence of intravascular macrophages. C4d and/or C3d-capillary deposition was found in 55% VLR EMB. All cases of VLR associated with microcirculation injury had DSAs (mean DSA(max) -MFI = 1751 ± 583). This entity was absent from the control group (p < 0.0001). Finally, after a similar follow-up postreference EMB of 6.4 ± 1 years, the mean of CAV grade was 0.76 ± 0.18 in the control group compared to 2.06 ± 0.26 in the VLR group respectively, p = 0.001). There was no difference in patient survival between study and control groups. In conclusion, VLR is frequently associated with complement-cascade activation, microvascular injury and DSA, suggesting an antibody-mediated process. VLR is associated with a dramatic progression to severe CAV in long-term follow-up.
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Affiliation(s)
- A Loupy
- Service de Transplantation Rénale et de Soins Intensifs, Hôpital Necker, APHP, Paris, F-75015, France
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54
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Kobashigawa J, Crespo-Leiro MG, Ensminger SM, Reichenspurner H, Angelini A, Berry G, Burke M, Czer L, Hiemann N, Kfoury AG, Mancini D, Mohacsi P, Patel J, Pereira N, Platt JL, Reed EF, Reinsmoen N, Rodriguez ER, Rose ML, Russell SD, Starling R, Suciu-Foca N, Tallaj J, Taylor DO, Van Bakel A, West L, Zeevi A, Zuckermann A. Report from a consensus conference on antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2011; 30:252-69. [PMID: 21300295 DOI: 10.1016/j.healun.2010.11.003] [Citation(s) in RCA: 225] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 11/03/2010] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The problem of AMR remains unsolved because standardized schemes for diagnosis and treatment remains contentious. Therefore, a consensus conference was organized to discuss the current status of antibody-mediated rejection (AMR) in heart transplantation. METHODS The conference included 83 participants (transplant cardiologists, surgeons, immunologists and pathologists) representing 67 heart transplant centers from North America, Europe, and Asia who all participated in smaller break-out sessions to discuss the various topics of AMR and attempt to achieve consensus. RESULTS A tentative pathology diagnosis of AMR was established, however, the pathologist felt that further discussion was needed prior to a formal recommendation for AMR diagnosis. One of the most important outcomes of this conference was that a clinical definition for AMR (cardiac dysfunction and/or circulating donor-specific antibody) was no longer believed to be required due to recent publications demonstrating that asymptomatic (no cardiac dysfunction) biopsy-proven AMR is associated with subsequent greater mortality and greater development of cardiac allograft vasculopathy. It was also noted that donor-specific antibody is not always detected during AMR episodes as the antibody may be adhered to the donor heart. Finally, recommendations were made for the timing for specific staining of endomyocardial biopsy specimens and the frequency by which circulating antibodies should be assessed. Recommendations for management and future clinical trials were also provided. CONCLUSIONS The AMR Consensus Conference brought together clinicians, pathologists and immunologists to further the understanding of AMR. Progress was made toward a pathology AMR grading scale and consensus was accomplished regarding several clinical issues.
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C4d Analysis in Endomyocardial Biopsies of Heart Transplant Patients: Is There a Correlation with Hemodynamic Data? Transplant Proc 2011; 43:1168-70. [DOI: 10.1016/j.transproceed.2011.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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56
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Kucirka LM, Maleszewski JJ, Segev DL, Halushka MK. Survey of North American pathologist practices regarding antibody-mediated rejection in cardiac transplant biopsies. Cardiovasc Pathol 2011; 20:132-8. [DOI: 10.1016/j.carpath.2010.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 03/05/2010] [Accepted: 03/15/2010] [Indexed: 11/30/2022] Open
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57
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Amico P, Hirt-Minkowski P, Hönger G, Gürke L, Mihatsch MJ, Steiger J, Hopfer H, Schaub S. Risk stratification by the virtual crossmatch: a prospective study in 233 renal transplantations. Transpl Int 2011; 24:560-9. [PMID: 21332582 DOI: 10.1111/j.1432-2277.2011.01235.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The virtual crossmatch (virtual-XM) has been proposed for accurate identification of donor-specific HLA-antibodies, but large prospective studies assessing its value for pretransplant risk stratification are lacking. A total of 233 consecutive renal allograft recipients were prospectively stratified according to the virtual-XM. In patients with a negative virtual-XM (n=190, 82%), prospective cytotoxicity crossmatches (CDC-XM) were omitted, and they received standard immunosuppression. Virtual-XM positive patients were only transplanted if CDC-XM were negative. They received additional induction with anti-T-lymphocyte-globulin and intravenous immunoglobulins (n=43, 18%). The cumulative incidence of clinical/subclinical antibody-mediated rejection (AMR) at 1 year was lower in the negative virtual-XM than in the positive virtual-XM group [15/190 (8%) vs. 18/43 (42%); P<0.0001]. After a median follow-up of 2.6 years, allograft loss because of AMR occurred less often in the negative virtual-XM group (1% vs. 7%; P=0.04) and death-censored allograft survival at 2 years was higher (98% vs. 91%; P=0.02). Serum creatinine was not different at the last follow-up (129 μm vs. 130 μm; P=0.58). We conclude that a negative virtual-XM defines patients at low risk for AMR and early allograft loss, while a positive virtual-XM represents a significant risk for AMR despite enhanced induction therapy. This supports the utility of the virtual-XM for risk stratification and treatment allocation.
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Affiliation(s)
- Patrizia Amico
- Transplantation Immunology and Nephrology, University Hospital Basel, Petersgraben 4, Basel, Switzerland
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58
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Wehner JR, Baldwin WM. Cardiac allograft vasculopathy: do adipocytes bridge alloimmune and metabolic risk factors? Curr Opin Organ Transplant 2011; 15:639-44. [PMID: 20689436 DOI: 10.1097/mot.0b013e32833deaee] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Cardiac allograft vasculopathy (CAV) is still a major cause of chronic graft failure. CAV develops in the coronary arteries as a diffuse, concentric expansion of the intima in conjunction with inflammation and fibrosis of the adventitia. We review recent publications that could link metabolic and immunologic risk factors for CAV.A concept is offered that periarterial adipocytes may provide proinflammatory cytokines that augment immune injury of the coronary arteries. RECENT FINDINGS Clinical and experimental evidence indicate that some alloantibodies and autoantibodies are associated with CAV. Limited data are available on the expression of target antigens on coronary arteries at different times after transplantation. Perivascular adipose tissue is an abundant source of IL-6, IL-8 and MCP-1. Adding to the inflammatory bias, perivascular adipocytes secrete less of the anti-inflammatory adiponectin in comparison to other types of fat. Adiponectin modulates expression of adhesion molecules on the vascular endothelium. It also decreases neointimal formation in arteries following mechanical endovascular injury. SUMMARY Alterations in the balance between proinflammatory and anti-inflammatory cytokines secreted by perivascular fat have been implicated in atherosclerosis and restenosis. This imbalance may also augment the immune responses in the coronary arteries of transplanted hearts.
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Affiliation(s)
- Jennifer R Wehner
- Department of Immunology NB30, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio, USA
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59
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Abstract
PURPOSE OF REVIEW The proportion of heart transplant candidates who are allosensitized has increased over time. Advances in tissue typing and immunosuppression have improved the rate of successful transplant in this challenging population. Recently published data regarding contemporary approaches to desensitization prior to and immunosuppression following transplant are summarized. RECENT FINDINGS Continued progress in measurement and characterization of antibodies and strategies to abrogate antibody production both prior to and following heart transplant have been encouraging. Updates on the role of non-human leukocyte antigen antibodies and the impact of mechanical circulatory support on allosensitization are provided. Data on current desensitization strategies, including the increasing use of monoclonal antibodies, are provided and the potential role of complement inhibitors will be reviewed. Increasing experience with potent novel agents is likely to provide the opportunity to improve transplant outcomes for highly sensitized patients. SUMMARY Although allosensitized heart transplant candidates remain a management challenge, excellent outcomes can be achieved with contemporary approaches. Advances in the understanding of B-cell biology are anticipated to further broaden options and improve outcomes.
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60
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Diagnosis of antibody-mediated rejection in cardiac transplantation: a call for standardization. Curr Opin Organ Transplant 2010; 15:769-73. [DOI: 10.1097/mot.0b013e32834016e4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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61
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Can C4d Immunostaining on Endomyocardial Biopsies Be Considered a Prognostic Biomarker in Heart Transplant Recipients? Transplantation 2010; 90:791-8. [DOI: 10.1097/tp.0b013e3181efd059] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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62
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Xu S, Chen J, Wang F, Kang X, Lan T, Wang F, Li Z, Qi Z, Xing J. Arsenic trioxide combined with co-stimulatory molecule blockade prolongs survival of cardiac allografts in alloantigen-primed mice. Transpl Immunol 2010; 24:57-63. [DOI: 10.1016/j.trim.2010.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 07/23/2010] [Accepted: 07/25/2010] [Indexed: 01/08/2023]
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63
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Abstract
PURPOSE OF REVIEW The aim of this review is to bring to attention the most recent advances made in understanding the role of complement components in both innate and adaptive immune responses in solid organ transplantation with emphasis on the kidney. RECENT FINDINGS Alongside recent findings related to the role of anaphylatoxins in modulating adaptive immune responses, there has been a genomic study to assess the expression of inflammatory markers in kidney transplantation, showing significant involvement of some complement molecules in predicting graft function. Modulators of complement pathway activity such as decay accelerating factor (CD55) and CD59 have also been shown to have a role in graft rejection. Potential new therapeutic targets related to complement proteins are being investigated. SUMMARY The mechanism of rejection in solid organ transplantation is influenced by the initial inflammatory response and subsequent adaptive allo-immune response, both of which have been shown to be affected by various complement components. Due to limitations of existing treatments, new approaches are needed to better control these responses to improve graft survival. Built on an expanding knowledge of complement involvement, targeted blocking of the effector complement molecules and modulating the expression of complement inhibitors has suggested potentially useful approaches for reducing the effect of inflammatory damage from cold ischaemia as well as reducing the activation of the adaptive immune system related to complement.
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Affiliation(s)
- Elham Asgari
- MRC Centre for Transplantation, King's College London, Guy's Hospital, Great Maze Pond, London, UK
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64
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Baldwin WM, Valujskikh A, Fairchild RL. Antibody-mediated rejection: emergence of animal models to answer clinical questions. Am J Transplant 2010; 10:1135-42. [PMID: 20346069 PMCID: PMC2975939 DOI: 10.1111/j.1600-6143.2010.03065.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Decades of experiments in small animals had tipped the balance of opinion away from antibodies as a cause of transplant rejection. However, clinical experience, especially with sensitized patients, has convinced basic immunologists of the need to develop models to investigate mechanisms underlying antibody-mediated rejection (AMR). This resurgent interest has resulted in several new rodent models to investigate antibody-mediated mechanisms of heart and renal allograft injury, but satisfactory models of chronic AMR remain more elusive. Nevertheless, these new studies have begun to reveal many insights into the molecular and pathological sequelae of antibody binding to the allograft endothelium. In addition, complement-independent and complement-dependent effects of antibodies on endothelial cells have been identified in vitro. As small animal models become better defined, it is anticipated that they will be more widely used to answer further questions concerning mechanisms of antibody-mediated tissue injury as well as to design therapeutic interventions.
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Affiliation(s)
- William M. Baldwin
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH 44195, USA
| | - Anna Valujskikh
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH 44195, USA
| | - Robert L. Fairchild
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH 44195, USA
,Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA
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Bächler K, Amico P, Hönger G, Bielmann D, Hopfer H, Mihatsch MJ, Steiger J, Schaub S. Efficacy of induction therapy with ATG and intravenous immunoglobulins in patients with low-level donor-specific HLA-antibodies. Am J Transplant 2010; 10:1254-62. [PMID: 20353473 DOI: 10.1111/j.1600-6143.2010.03093.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Low-level donor-specific HLA-antibodies (HLA-DSA) (i.e. detectable by single-antigen flow beads, but negative by complement-dependent cytotoxicity crossmatch) represent a risk factor for early allograft rejection. The short-term efficacy of an induction regimen consisting of polyclonal anti-T-lymphocyte globulin (ATG) and intravenous immunoglobulins (IvIg) in patients with low-level HLA-DSA is unknown. In this study, we compared 67 patients with low-level HLA-DSA not having received ATG/IvIg induction (historic control) with 37 patients, who received ATG/IvIg induction. The two groups were equal regarding retransplants, HLA-matches, number and class of HLA-DSA. The overall incidence of clinical/subclinical antibody-mediated rejection (AMR) was lower in the ATG/IvIg than in the historic control group (38% vs. 55%; p = 0.03). This was driven by a significantly lower rate of clinical AMR (11% vs. 46%; p = 0.0002). Clinical T-cell-mediated rejection (TCR) was significantly lower in the ATG/IvIg than in the historic control group (0% vs. 50%; p < 0.0001). Within the first year, allograft loss due to AMR occurred in 7.5% in the historic control and in 0% in the ATG/IvIg group. We conclude that in patients with low-level HLA-DSA, ATG/IvIg induction significantly reduces TCR and the severity of AMR, but the high rate of subclinical AMR suggests an insufficient control of the humoral immune response.
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Affiliation(s)
- K Bächler
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
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66
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Controversies in defining cardiac antibody-mediated rejection: Need for updated criteria. J Heart Lung Transplant 2010; 29:389-94. [DOI: 10.1016/j.healun.2009.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 10/27/2009] [Accepted: 10/27/2009] [Indexed: 11/19/2022] Open
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67
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Sis B, Mengel M, Haas M, Colvin RB, Halloran PF, Racusen LC, Solez K, Baldwin WM, Bracamonte ER, Broecker V, Cosio F, Demetris AJ, Drachenberg C, Einecke G, Gloor J, Glotz D, Kraus E, Legendre C, Liapis H, Mannon RB, Nankivell BJ, Nickeleit V, Papadimitriou JC, Randhawa P, Regele H, Renaudin K, Rodriguez ER, Seron D, Seshan S, Suthanthiran M, Wasowska BA, Zachary A, Zeevi A. Banff '09 meeting report: antibody mediated graft deterioration and implementation of Banff working groups. Am J Transplant 2010; 10:464-71. [PMID: 20121738 DOI: 10.1111/j.1600-6143.2009.02987.x] [Citation(s) in RCA: 590] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The 10th Banff Conference on Allograft Pathology was held in Banff, Canada from August 9 to 14, 2009. A total of 263 transplant clinicians, pathologists, surgeons, immunologists and researchers discussed several aspects of solid organ transplants with a special focus on antibody mediated graft injury. The willingness of the Banff process to adapt continuously in response to new research and improve potential weaknesses, led to the implementation of six working groups on the following areas: isolated v-lesion, fibrosis scoring, glomerular lesions, molecular pathology, polyomavirus nephropathy and quality assurance. Banff working groups will conduct multicenter trials to evaluate the clinical relevance, practical feasibility and reproducibility of potential changes to the Banff classification. There were also sessions on quality improvement in biopsy reading and utilization of virtual microscopy for maintaining competence in transplant biopsy interpretation. In addition, compelling molecular research data led to the discussion of incorporation of omics-technologies and discovery of new tissue markers with the goal of combining histopathology and molecular parameters within the Banff working classification in the near future.
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Affiliation(s)
- B Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
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Wehner JR, Morrell CN, Rodriguez ER, Fairchild RL, Baldwin WM. Immunological challenges of cardiac transplantation: the need for better animal models to answer current clinical questions. J Clin Immunol 2010; 29:722-9. [PMID: 19802689 DOI: 10.1007/s10875-009-9334-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 09/11/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In the last decade, two advances have shifted attention from cellular rejection to antibody-mediated rejection (AMR) of cardiac transplants. First, more sensitive diagnostic tests for detection of AMR have been developed. Second, improvements in immunosuppression have made severe acute cellular rejection uncommon, but have had less effect on AMR. DISCUSSION Antibodies can contribute to graft rejection by activation of complement, by activation of vascular endothelial and smooth muscle cells, and by activation of neutrophils, macrophages or natural killer cells. Because acute rejection is a risk factor for chronic rejection in all types of organ transplants, it is has been proposed that AMR can cause chronic rejection. CONCLUSION Small animal models need to be developed to gain further insights into AMR and the role of antibodies in chronic graft arteriopathy. This article reviews the current clinical data and existing mouse models for AMR.
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Affiliation(s)
- Jennifer R Wehner
- Department of Pathology, Johns Hopkins Medical Institutes, Baltimore, MD, USA
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