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Serine Protease Inhibitor-6 Inhibits Granzyme B–Mediated Injury of Renal Tubular Cells and Promotes Renal Allograft Survival. Transplantation 2014; 98:402-10. [DOI: 10.1097/tp.0000000000000237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Glomerular inflammation correlates with endothelial injury and with IL-6 and IL-1β secretion in the peripheral blood. Transplantation 2014; 97:1034-42. [PMID: 24406453 DOI: 10.1097/01.tp.0000441096.22471.36] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Transplant glomerulitis is an active form of glomerular injury associated with suboptimal graft outcome, inadequate histologic reproducibility, and poorly understood pathogenesis. Using a modified pathologic schema where glomerular inflammation is defined by the presence of five or more leukocytes per glomerulus, we sought to assess the reproducibility of transplant glomerulitis and to prospectively investigate the pathogenesis of glomerular inflammation. METHODS Our cohort includes 59 kidney transplant recipients who underwent 60 "for cause" allograft biopsies. In addition to light microscopy, the majority of the biopsies were assessed using immunohistochemistry, immunofluorescence, and electron microscopy studies. Biopsies were classified as noninflamed (n=21), inflamed (borderline changes or above) without glomerulitis (n=21), and transplant glomerulitis (n=18). Peripheral blood was collected on the day of biopsy and cytokines secreted by peripheral blood mononuclear cells (PBMCs) were measured ex vivo. RESULTS Our modified schema had higher inter-observer agreement for detecting glomerulitis than that of the current Banff schema. Biopsies with glomerulitis showed ultrastructural signs of glomerular capillary wall remodeling. In contrast to other anatomic compartments, intraglomerular leukocytes in glomerulitis group consisted largely of monocytes. Patients with glomerulitis had high levels of IL-6 and IL-1β secreted by PBMCs. Furthermore, the percentage of inflamed glomeruli and the number of intraglomerular monocytes showed independent association with IL-6 and IL-1β levels, which tended to correlate with subsequent estimated glomerular filtration rate decline. CONCLUSIONS Inter-observer reproducibility of transplant glomerulitis can be improved by using more stringent histologic criteria. Glomerular inflammation correlates with endothelial injury, monocyte influx, and IL-6 and IL-β secretion by circulating immune cells.
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Sapir-Pichhadze R, Curran SP, John R, Tricco AC, Uleryk E, Laupacis A, Tinckam K, Sis B, Beyene J, Logan AG, Kim SJ. A systematic review of the role of C4d in the diagnosis of acute antibody-mediated rejection. Kidney Int 2014; 87:182-94. [PMID: 24827778 DOI: 10.1038/ki.2014.166] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/21/2014] [Accepted: 03/27/2014] [Indexed: 01/03/2023]
Abstract
In this study, we conducted a systematic review of the literature to re-evaluate the role of C4d in the diagnosis of acute antibody-mediated rejection of kidney allografts. Electronic databases were searched until September 2013. Eligible studies allowed derivation of diagnostic tables for the performance of C4d by immunofluorescence or immunohistochemistry with comparison to histopathological features of acute antibody-mediated rejection and/or donor-specific antibody (DSA) assays. Of 3492 unique abstracts, 29 studies encompassing 3485 indication and 868 surveillance biopsies were identified. Assessment of C4d by immunofluorescence and immunohistochemistry exhibited slight to moderate agreement with glomerulitis, peritubular capillaritis, solid-phase DSA assays, DSA with glomerulitis, and DSA with peritubular capillaritis. The sensitivity and specificity of C4d varied as a function of C4d and comparator test thresholds. Prognostically, the presence of C4d was associated with inferior allograft survival compared with DSA or histopathology alone. Thus, our findings support the presence of complement-dependent and -independent phenotypes of acute antibody-mediated rejection. Whether the presence of C4d in combination with histopathology or DSA should be considered for the diagnosis of acute antibody-mediated rejection warrants further study.
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Affiliation(s)
- Ruth Sapir-Pichhadze
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simon P Curran
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rohan John
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Andreas Laupacis
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Banu Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Beyene
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Population Health Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada [3] Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alexander G Logan
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada [4] Division of Nephrology and the Renal Transplant Program, St Michael's Hospital, Toronto, Ontario, Canada
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Bodonyi-Kovacs G, Strom TB, Putheti P. A20—A Biomarker of Allograft Outcome: A Showcase in Kidney Transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 809:103-16. [DOI: 10.1007/978-1-4939-0398-6_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Bröcker V, Hirzallah M, Gwinner W, Bockmeyer CL, Wittig J, Zell S, Agustian PA, Schwarz A, Ganzenmüller T, Zilian E, Immenschuh S, Becker JU. Histopathological and clinical findings in renal transplants with Banff type II and III acute cellular rejection without tubulointerstitial infiltrates. Virchows Arch 2013; 464:203-11. [PMID: 24374461 DOI: 10.1007/s00428-013-1487-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 08/20/2013] [Accepted: 09/17/2013] [Indexed: 12/21/2022]
Abstract
According to the Banff guidelines for renal transplants, pure endothelialitis without any tubulointerstitial infiltrates (with the Banff components v ≥ 1, i0, t0) has to be called acute cellular rejection (ACR). The pathophysiology of this rare lesion abbreviated as v_only is currently unclear, as well as its clinical, serological, and prognostic implications. Therefore, we conducted this retrospective comparative study. We compared all 23 biopsies with v_only from Hannover Medical School between 2003 and 2010 with 23 matched biopsies with the Banff components v ≥ 1, i ≥ 1, and t ≥ 1 (v_plus) and 23 biopsies with v0, i0, and t0 (v0i0t0). Serological (available in 10, 11, and 14 patients, respectively), histological, and clinical data were compared. Of all biopsies, 0.4 % had findings of v_only. v_only, v_plus, and v0i0t0 only showed minimal differences in the Banff components apart from the cohort-defining components. Endothelialitis in v_only more frequently involved the arcuate arteries than the smaller preglomerular vessels compared to v_plus and vice versa. Combining histopathological data and serological data, v_only more frequently showed criteria for acute humoral rejection than v0i0t0 (albeit not persistent after the Bonferroni-Holm correction in pairwise comparisons), while there was no difference between v_only and v_plus. No difference could be demonstrated regarding clinical presentation at biopsy or outcome. Our results show minimal differences regarding clinical presentation, outcome, and histological features between v_only and v_plus. Patients with v_only should be thoroughly investigated for evidence of acute humoral rejection.
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Affiliation(s)
- Verena Bröcker
- Institute of Pathology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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The reproducibility and predictive value on outcome of renal biopsies from expanded criteria donors. Kidney Int 2013; 85:1161-8. [PMID: 24284518 DOI: 10.1038/ki.2013.461] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 08/29/2013] [Accepted: 09/05/2013] [Indexed: 11/08/2022]
Abstract
Reproducibility and predictive value on outcome are the main criteria to evaluate the utility of histological scores. Here we analyze the reproducibility of donor biopsy assessment by different on-call pathologists and the retrospective evaluation by a single renal pathologist blinded to clinical outcomes. We also evaluate the predictive value on graft outcome of both evaluations. A biopsy was performed in donors with any of the following: age≥55 years, hypertension, diabetes, creatinine>1.5 mg/dl, or stroke. Glomerulosclerosis, interstitial fibrosis, tubular atrophy, intimal thickening, and arteriolar hyalinosis evaluated according to the Banff criteria were added to obtain a chronic score. Biopsies were classified as mild (≥3), intermediate (4-5), or advanced (6-7) damage, and unacceptable (≥8) for transplantation of 127 kidneys biopsied. Weighted κ value between both readings was 0.41 (95% CI: 0.28-0.54). Evaluation of biopsies by the renal pathologist was significantly and independently associated with estimated 12-month glomerular filtration rate and a significant composite outcome variable, including death-censored graft survival and time to reach an estimated glomerular filtration rate<30 ml/min per 1.73 m2. Thus, there was no association between readings of on-call pathologists and outcome. The lack of association between histological scores obtained by the on-call pathologists and graft outcome suggests that a specific training on renal pathology is recommended to optimize the use of kidneys retrieved from expanded criteria donors.
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Distinct expression of interleukin 17, tumor necrosis factor α, transforming growth factor β, and forkhead box P3 in acute rejection after kidney transplantation. Ann Diagn Pathol 2013; 17:75-9. [DOI: 10.1016/j.anndiagpath.2012.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/03/2012] [Indexed: 11/15/2022]
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Discovery and validation of a molecular signature for the noninvasive diagnosis of human renal allograft fibrosis. Transplantation 2012; 93:1136-46. [PMID: 22592886 DOI: 10.1097/tp.0b013e31824ef181] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tubulointerstitial fibrosis (fibrosis), a histologic feature associated with a failing kidney allograft, is diagnosed using the invasive allograft biopsy. A noninvasive diagnostic test for fibrosis may help improve allograft outcome. METHODS We obtained 114 urine specimens from 114 renal allograft recipients: 48 from 48 recipients with fibrosis in their biopsy results and 66 from 66 recipients with normal biopsy results. Levels of messenger RNAs (mRNAs) in urinary cells were measured using kinetic, quantitative polymerase chain reaction assays, and the levels were related to allograft diagnosis. A discovery set of 76 recipients (32 with allograft fibrosis and 44 with normal biopsy results) was used to develop a diagnostic signature, and an independent validation set of 38 recipients (16 with allograft fibrosis and 22 with normal biopsy results) was used to validate the signature. RESULTS In the discovery set, urinary cell levels of the following mRNAs were significantly associated with the presence of allograft fibrosis: vimentin (P<0.0001, logistic regression model), hepatocyte growth factor (P<0.0001), α-smooth muscle actin (P<0.0001), fibronectin 1 (P<0.0001), perforin (P=0.0002), plasminogen activator inhibitor 1 (P=0.0002), transforming growth factor β1 (P=0.0004), tissue inhibitor of metalloproteinase 1 (P=0.0009), granzyme B (P=0.0009), fibroblast-specific protein 1 (P=0.006), CD103 (P=0.02), and collagen 1A1 (P=0.04). A four-gene model composed of the levels of mRNA for vimentin, NKCC2, and E-cadherin and of 18S ribosomal RNA provided the most accurate, parsimonious diagnostic model of allograft fibrosis with a sensitivity of 93.8% and a specificity of 84.1% (P<0.0001). In the independent validation set, this same model predicted the presence of allograft fibrosis with a sensitivity of 77.3% and a specificity of 87.5% (P<0.0001). CONCLUSIONS Measurement of mRNAs in urinary cells may offer a noninvasive means of diagnosing fibrosis in human renal allografts.
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Shang Y, Ju W, Kong Y, Schroder PM, Liang W, Ling X, Guo Z, He X. Performance of polymerase chain reaction techniques detecting perforin in the diagnosis of acute renal rejection: a meta-analysis. PLoS One 2012; 7:e39610. [PMID: 22768097 PMCID: PMC3387236 DOI: 10.1371/journal.pone.0039610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 05/23/2012] [Indexed: 11/18/2022] Open
Abstract
Background Studies in the past have shown that perforin expression is up-regulated during acute renal rejection, which provided hopes for a non-invasive and reliable diagnostic method to identify acute rejection. However, a systematic assessment of the value of perforin as a diagnostic marker of acute renal rejection has not been performed. We conducted this meta-analysis to document the diagnostic performance of perforin mRNA detection and to identify potential variables that may affect the performance. Methodology/Principal Findings Relevant materials that reported the diagnostic performance of perforin mRNA detection in acute renal rejection patients were extracted from electronic databases. After careful evaluation of the studies included in this analysis, the numbers of true positive, true negative, false positive and false negative cases of acute renal rejection identified by perforin mRNA detection were gathered from each data set. The publication year, sample origin, mRNA quantification method and housekeeping gene were also extracted as potential confounding variables. Fourteen studies with a total of 501 renal transplant subjects were included in this meta-analysis. The overall performance of perforin mRNA detection was: pooled sensitivity, 0.83 (95% confidence interval: 0.78 to 0.88); pooled specificity, 0.86 (95% confidence interval: 0.82 to 0.90); diagnostic odds ratio, 28.79 (95% confidence interval: 16.26 to 50.97); and area under the summary receiver operating characteristic curves value, 0.9107±0.0174. The univariate analysis of potential variables showed some changes in the diagnostic performance, but none of the differences reached statistical significance. Conclusions/Significance Despite inter-study variability, the test performance of perforin mRNA detected by polymerase chain reaction was consistent under circumstances of methodological changes and demonstrated both sensitivity and specificity in detecting acute renal rejection. These results suggest a great diagnostic potential for perforin mRNA detection as a reliable marker of acute rejection in renal allograft recipients.
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Affiliation(s)
- Yushu Shang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weiqiang Ju
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuan Kong
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Paul M. Schroder
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine, Toledo, Ohio, United States of America
| | - Wenhua Liang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoting Ling
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (ZG); (XH)
| | - Xiaoshun He
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (ZG); (XH)
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Buob D, Grimbert P, Glowacki F, Labalette M, Dufossé F, Nochy D, Copin MC, Boleslawski E, Noël C, Hazzan M. Three-year outcome of isolated glomerulitis on 3-month protocol biopsies of donor HLA antibody negative patients. Transpl Int 2012; 25:663-70. [DOI: 10.1111/j.1432-2277.2012.01473.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sequential monitoring of TIM-3 gene expression in peripheral blood for diagnostic and prognostic evaluation of acute rejection in renal graft recipients. Transplant Proc 2012; 43:3669-74. [PMID: 22172823 DOI: 10.1016/j.transproceed.2011.08.106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 02/07/2011] [Accepted: 08/19/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND TIM-3 is expressed on primary T effector cells, including th1, ctl, and Th17, which play essential roles in acute allograft rejection (AR). In this study we monitored sequential changes of TIM-3 gene expression among peripheral blood leukocytes (PBL) from renal transplant recipients. METHODS The study consisted of an AR group (n=24), a no AR group (n=20), and a stable group (n=18). Prospective serial blood samples were collected after allotransplantation and during AR episodes. The mRNA encoding for TIM-3 was quantified using real-time reverse-transcription polymerase chain reaction (RT-PCR). Statistical analyses were performed to correlate gene transcript measurements with clinical events. RESULTS TIM-3 mRNA in PBL showed significantly higher expression in the AR compared with the no AR and stable groups: 286.72±86.28 vs 126.10±28.31 vs 96.91±17.88, respectively (P=.00). The receiver operating characteristic curve showed a specificity of 100% and a sensitivity of 87.5% for the utility of TIM-3 for rejection diagnosis. Antirejection therapy decreased TIM-3 mRNA expression in all AR patients. There was a positive correlation between TIM-3 mRNA expression and serum creatinine (r2=0.716; P=.00). CONCLUSIONS TIM-3 mRNA quantification by RT-PCR in PBL may be a promising tool for a noninvasive diagnosis of AR. But the utility for predicting the prognosis of AR after antirejection treatment was limited, owing to the great variations of TIM-3 mRNA expression during AR episodes.
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Randhawa P. The "borderline" renal allograft biopsy in the era of molecular diagnostics: a sampling conundrum? Am J Transplant 2012; 12:11-2. [PMID: 21992442 DOI: 10.1111/j.1600-6143.2011.03781.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Attempted depletion of passenger leukocytes by irradiation in pigs. J Transplant 2011; 2011:928759. [PMID: 22220268 PMCID: PMC3246790 DOI: 10.1155/2011/928759] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/01/2011] [Accepted: 09/18/2011] [Indexed: 11/18/2022] Open
Abstract
Allograft/xenograft rejection is associated with “passenger leukocyte” migration from the organ into recipient lymph nodes. In Study 1, we attempted to deplete leukocytes from potential kidney “donor” pigs, using two regimens of total body irradiation. A dose of 700 cGy was administered, followed by either 800 cGy (“low-dose”) or 1,300 cGy (“high dose”) with the kidneys shielded. Neither regimen was entirely successful in depleting all leukocytes, although remaining T and 8 cell numbers were negligible. Study 2 was aimed at providing an indication of whether near-complete depletion of leukocytes had any major impact on kidney allograft survival. In non-immunosuppressed recipient pigs, survival of a kidney from a donor that received high-dose irradiation was compared with that of a kidney taken from a non-irradiated donor. Kidney graft survival was 9 and 7 days, respectively, suggesting that depletion had little impact on graft survival. The lack of effect may have been related to (i) inadequate depletion of passenger leukocytes, thus not preventing a direct T cell response, (ii) the presence of dead or dying leukocytes (antigens), thus not preventing an indirect T cell response, or (iii) constitutive expression of MHC class II and B7 molecules on the porcine vascular endothelium, activating recipient T cells.
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Nadazdin O, Boskovic S, Murakami T, Tocco G, Smith RN, Colvin RB, Sachs DH, Allan J, Madsen JC, Kawai T, Cosimi AB, Benichou G. Host alloreactive memory T cells influence tolerance to kidney allografts in nonhuman primates. Sci Transl Med 2011; 3:86ra51. [PMID: 21653831 PMCID: PMC3261229 DOI: 10.1126/scitranslmed.3002093] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transplant tolerance, defined as indefinite allograft survival without immunosuppression, has been regularly achieved in laboratory mice but not in nonhuman primates or humans. In contrast to laboratory mice, primates regularly have high frequencies of alloreactive memory T cells (TMEMs) before transplantation. These TMEMs are poorly sensitive to conventional immunosuppression and costimulation blockade, and the presence of donor-reactive TMEMs in primates may account for their resistance to transplant tolerance protocols that have proven consistently effective in mice. We measured the frequencies of anti-donor TMEMs before and after transplantation in a series of rejecting and tolerant monkeys that underwent nonmyeloablative conditioning, short-term immunosuppression, and combined allogeneic kidney/cell transplantation. Transplants were acutely rejected in all the monkeys with high numbers of donor-specific TMEMs before transplantation. In contrast, long-term survival was observed in the recipients harboring lower frequencies of anti-donor TMEMs before transplantation. Similar amounts of TMEM homeostatic expansion were recorded in all transplanted monkeys upon hematopoietic reconstitution; however, only the tolerant monkeys had no expansion or activation of donor-reactive TMEMs after transplantation. These results indicate that the presence of high frequencies of host donor-reactive TMEMs before transplantation impairs tolerance induction to kidney allografts in this nonhuman primate model. Indeed, recipients harboring a low anamnestic reactivity to their donor before transplantation were successfully rendered tolerant via infusion of donor cells and short-term immunosuppression. This suggests that selection of allogeneic donors with low memory responses in recipients may be essential to successful transplant tolerance induction in patients.
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Affiliation(s)
- Ognjenka Nadazdin
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Svjetlan Boskovic
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Toru Murakami
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Georges Tocco
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Rex-Neal Smith
- Pathology Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Robert B. Colvin
- Pathology Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - David H. Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Boston, MA 02129, USA
| | - James Allan
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Joren C. Madsen
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Tatsuo Kawai
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - A. Benedict Cosimi
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Gilles Benichou
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Baker R, Jardine A, Andrews P. Renal Association Clinical Practice Guideline on post-operative care of the kidney transplant recipient. Nephron Clin Pract 2011; 118 Suppl 1:c311-47. [PMID: 21555902 DOI: 10.1159/000328074] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 02/05/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- R Baker
- Renal Unit, Lincoln Wing, St. James's University Hospital, Beckett Street, Leeds.
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Sellarés J, de Freitas DG, Mengel M, Sis B, Hidalgo LG, Matas AJ, Kaplan B, Halloran PF. Inflammation lesions in kidney transplant biopsies: association with survival is due to the underlying diseases. Am J Transplant 2011; 11:489-99. [PMID: 21342447 DOI: 10.1111/j.1600-6143.2010.03415.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Assessment of kidney transplant biopsies relies on nonspecific inflammatory lesions: Interstitial infiltrates (i), tubulitis (t) and intimal arteritis (v). We studied the relationship between inflammation and prognosis in biopsies for clinical indications from 314 patients (median follow-up 25 months). We used a modified Banff classification, separately assessing inflammation (i-) in nonscarred (i-Banff), scarred (i-IFTA) and whole cortex (i-total), plus tubulitis and intimal arteritis. In early biopsies (<1 year), i- and t-lesions had no association with graft survival. In late (>1 year) biopsies, all i-scores correlated with progression to failure, due to the association of these infiltrates with progressive diseases: antibody-mediated rejection (ABMR) and glomerulonephritis. Tubulitis in nonscarred areas had no impact on survival. Severe tubulitis including scarred areas (tis3) was associated with worse survival, but reflected polyoma virus nephropathy or ABMR, not T-cell-mediated rejection. Intimal arteritis (v-lesions) had no association with allograft loss in early or late biopsies. In multivariate analysis, outcome was better predicted by the presence of progressive disease than by inflammation. Thus inflammation in late kidney transplants has no inherent prognostic impact, but predicts reduced survival because inflammation indicates actively progressing diseases. The most important predictor of outcome is the diagnosis of a progressive disease.
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Affiliation(s)
- J Sellarés
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
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Fogo AB, Alpers CE. Navigating the Challenges of Fibrosis Assessment: Land in Sight? J Am Soc Nephrol 2010; 22:11-3. [DOI: 10.1681/asn.2010111132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Batal I, Lunz JG, Aggarwal N, Zeevi A, Sasatomi E, Basu A, Tan H, Shapiro R, Randhawa P. A critical appraisal of methods to grade transplant glomerulitis in renal allograft biopsies. Am J Transplant 2010; 10:2442-52. [PMID: 20977635 DOI: 10.1111/j.1600-6143.2010.03261.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transplant glomerulitis is an increasingly recognized lesion in renal transplant biopsies. To develop a refined grading system, we defined glomerulitis by the presence of ≥5 leukocytes/glomerulus and evaluated 111 biopsies using three different grading systems: (i) percentage of glomerular involvement, (ii) peak inflammation in the most severely affected glomerulus and (iii) presence/absence of endocapillary occlusion by inflammatory cells. Endocapillary occlusion had no impact on graft survival, but was associated with increased serum creatinine, proteinuria and subsequent transplant glomerulopathy. Grading based on either percent or peak glomerular involvement correlated with graft failure and peritubular capillaritis. However, the percent glomerular involvement method had the additional advantage of displaying associations with: concurrent proteinuria, focal or diffuse immunoperoxidase peritubular capillary C4d staining, 1-year postbiopsy serum creatinine, subsequent detection of donor-specific antibody and development of transplant glomerulopathy. Patients with >75% glomerular involvement also revealed persistent high-grade glomerulitis on follow-up biopsies despite antirejection treatment. In conclusion, grading of glomerulitis is a meaningful exercise, and a quantification system based on percentage of glomerular involvement shows the most robust associations with clinical parameters and prognosis.
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Affiliation(s)
- I Batal
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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70
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Abstract
Infant recipients have better survival after solid organ transplantation than older children and adults possibly due to immune tolerance. Over the past two decades, postsurgical complications have markedly decreased, and multidrug immunosuppressive regimens have become effective in preventing and treating rejection. Immunocompromised for life, these patients are susceptible to both the usual bacterial as well as opportunistic infections that often involve the lung. Post-transplant lymphoproliferative disease seems to be decreasing even further in frequency. This article focuses on the findings seen on biopsy, usually of the transplanted organ, and also of other sites affected by post-transplant complications.
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Affiliation(s)
- Aliya N Husain
- Department of Pathology, MC6101, Room S627, University of Chicago Medical Center, Chicago, IL 60637, USA.
| | - Anthony Chang
- Department of Pathology, MC6101, Room S628, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Sarangarajan Ranganathan
- Department of Pathology, Room B258, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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71
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Pancreas Allograft Rejection: Analysis of Concurrent Renal Allograft Biopsies and Posttherapy Follow-Up Biopsies. Transplantation 2010; 90:75-84. [DOI: 10.1097/tp.0b013e3181dda17e] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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72
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Einecke G, Reeve J, Sis B, Mengel M, Hidalgo L, Famulski KS, Matas A, Kasiske B, Kaplan B, Halloran PF. A molecular classifier for predicting future graft loss in late kidney transplant biopsies. J Clin Invest 2010; 120:1862-72. [PMID: 20501945 DOI: 10.1172/jci41789] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 04/26/2010] [Indexed: 01/05/2023] Open
Abstract
Kidney transplant recipients that develop signs of renal dysfunction or proteinuria one or more years after transplantation are at considerable risk for progression to renal failure. To assess the kidney at this time, a "for-cause" biopsy is performed, but this provides little indication as to which recipients will go on to organ failure. In an attempt to identify molecules that could provide this information, we used microarrays to analyze gene expression in 105 for-cause biopsies taken between 1 and 31 years after transplantation. Using supervised principal components analysis, we derived a molecular classifier to predict graft loss. The genes associated with graft failure were related to tissue injury, epithelial dedifferentiation, matrix remodeling, and TGF-beta effects and showed little overlap with rejection-associated genes. We assigned a prognostic molecular risk score to each patient, identifying those at high or low risk for graft loss. The molecular risk score was correlated with interstitial fibrosis, tubular atrophy, tubulitis, interstitial inflammation, proteinuria, and glomerular filtration rate. In multivariate analysis, molecular risk score, peritubular capillary basement membrane multilayering, arteriolar hyalinosis, and proteinuria were independent predictors of graft loss. In an independent validation set, the molecular risk score was the only predictor of graft loss. Thus, the molecular risk score reflects active injury and is superior to either scarring or function in predicting graft failure.
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Affiliation(s)
- Gunilla Einecke
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
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73
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74
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Yang H, Mao Y, Yu J, Chen J, He Q, Shou Z, Wu J, Chen Y, Zheng S. Diagnosis of C4d+ Renal Allograft Acute Humoral Rejection by Urine Protein Fingerprint Analysis. J Int Med Res 2010; 38:176-86. [PMID: 20233527 DOI: 10.1177/147323001003800120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aimed to develop urine protein fingerprint models for the diagnosis of acute rejection (AR) and complement split product positive (C4d+) acute humoral rejection (AHR) following renal allograft transplantation. Urine samples from 101 renal transplant recipients were analysed by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry combined with bioinformatics. The patients comprised 36 with stable allograft function (stable group), 10 with acute tubular necrosis (ATN) and 55 with AR (20 with C4d- acute cellular rejection [ACR] and 15 with C4d+ AHR). The ATN group was differentiated from the stable group with a sensitivity and specificity of 100% (pattern 1). The stable group was differentiated from the AR group with a specificity of 86.4% and a sensitivity of 85.4% (pattern 2). The C4d- ACR subgroup was differentiated from the C4d+ AHR subgroup with a specificity and sensitivity of 95% and 80%, respectively (pattern 3). It is concluded that urine protein fingerprint analysis can provide a noninvasive tool to diagnose AR and C4d+ AHR.
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Affiliation(s)
- H Yang
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Y Mao
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - J Yu
- Cancer Institute, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - J Chen
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multiorgan Transplantation, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Q He
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Z Shou
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - J Wu
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Y Chen
- The Kidney Disease Centre, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - S Zheng
- Cancer Institute, Ministry of Public Health, The First Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, China
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75
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Functional genomic analysis of peripheral blood during early acute renal allograft rejection. Transplantation 2010; 88:942-51. [PMID: 19935467 DOI: 10.1097/tp.0b013e3181b7ccc6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Acute graft rejection is an important clinical problem in renal transplantation and an adverse predictor for long-term graft survival. Peripheral blood biomarkers that provide evidence of early graft rejection may offer an important option for posttransplant monitoring, optimize the utility of graft biopsy, and permit timely and effective therapeutic intervention to minimize the graft damage. METHODS In this feasibility study (n=58), we have used gene expression profiling in a case-control design to compare whole blood samples between normal subjects (n=20) and patients with (n=11) or without (n=22) biopsy-confirmed acute rejection (BCAR) or borderline changes (n=5). RESULTS A total of 183 probe sets representing 160 genes were differentially expressed (false discovery rate [FDR] <0.01) between subjects with or without BCAR, from which linear discriminant analysis and cross-validation identified an initial gene signature of 24 probe sets, and a more refined set of 11 probe sets found to classify subject samples correctly. Cross-validation suggested an out-of-sample sensitivity of 73% and specificity of 91% for identification of samples with or without BCAR. An increase in classifier gene expression correlated closely with acute rejection during the first 3 months posttransplant. Biological evaluation indicated that the differentially expressed genes encompassed processes related to immune response, signal transduction, and cytoskeletal reorganization. CONCLUSION Preliminary evidence indicates that gene expression in the peripheral blood may yield a relevant measure for the occurrence of BCAR and offer a potential tool for immunologic monitoring. These results now require confirmation in a larger cohort.
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76
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Nierentransplantation. PRAXIS DER NEPHROLOGIE 2010. [PMCID: PMC7123704 DOI: 10.1007/978-3-642-10213-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Die Nierentransplantation ist die effektivste Behandlungsmethode der chronischen terminalen Niereninsuffizienz. Seit den 1960er Jahren entwickelte sie sich zu einer Standardtherapie. Wichtige Voraussetzungen waren die Entdeckung des HLASystems, die Entwicklung der Immunsuppressiva sowie die technische Perfektionierung des Organerhaltes außerhalb eines lebenden Körpers. Die 5- Jahres-Überlebensrate für Allotransplantate beträgt etwa 65%, diejenige von Lebendspenden 79%. Die Einrichtung von zentralen Erfassungsstellen, wie z. B. Eurotransplant (Deutschland, Benelux- Staaten, Österreich, Slowenien), ist für die Organisation des zeitgebundenen Ablaufes von großer Bedeutung. Bei diesen Institutionen sind alle potentiellen Nierenempfänger registriert. Dort werden auch alle potentiellen Spenderorgane gemeldet und dem passenden Empfänger zugeordnet.
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77
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Bhowmik DM, Dinda AK, Mahanta P, Agarwal SK. The evolution of the Banff classification schema for diagnosing renal allograft rejection and its implications for clinicians. Indian J Nephrol 2010; 20:2-8. [PMID: 20535263 PMCID: PMC2878403 DOI: 10.4103/0971-4065.62086] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Till the early 1990s there was no standardized international classification of renal allograft biopsies resulting in considerable heterogeneity in reporting among the various centers. A group of dedicated renal pathologists, nephrologists, and transplant surgeons developed a schema in Banff, Canada in 1991. Subsequently there have been updates at regular intervals. The following review presents the evolution of the Banff classification and its utility for clinicians.
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Affiliation(s)
- D. M. Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - A. K. Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - P. Mahanta
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - S. K. Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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78
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Kozakowski N, Regele H. Biopsy diagnostics in renal allograft rejection: from histomorphology to biological function. Transpl Int 2009; 22:945-53. [DOI: 10.1111/j.1432-2277.2009.00885.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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79
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Reeve J, Einecke G, Mengel M, Sis B, Kayser N, Kaplan B, Halloran PF. Diagnosing rejection in renal transplants: a comparison of molecular- and histopathology-based approaches. Am J Transplant 2009; 9:1802-10. [PMID: 19519809 DOI: 10.1111/j.1600-6143.2009.02694.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The transcriptome has considerable potential for improving biopsy diagnoses. However, to realize this potential the relationship between the molecular phenotype of disease and histopathology must be established. We assessed 186 consecutive clinically indicated kidney transplant biopsies using microarrays, and built a classifier to distinguish rejection from nonrejection using predictive analysis of microarrays (PAM). Most genes selected by PAM were interferon-gamma-inducible or cytotoxic T-cell associated, for example, CXCL9, CXCL11, GBP1 and INDO. We then compared the PAM diagnoses to those from histopathology, which are based on the Banff diagnostic criteria. Disagreement occurred in approximately 20% of diagnoses, principally because of idiosyncratic limitations in the histopathology scoring system. The problematic diagnosis of 'borderline rejection' was resolved by PAM into two distinct classes, rejection and nonrejection. The diagnostic discrepancies between Banff and PAM in these cases were largely due to the Banff system's requirement for a tubulitis threshold in defining rejection. By examining the discrepancies between gene expression and histopathology, we provide external validation of the main features of the histopathology diagnostic criteria (the Banff consensus system), recommend improvements and outline a pathway for introducing molecular measurements.
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Affiliation(s)
- J Reeve
- Department of Laboratory Medicine and Pathology, Arizona Health Science Centre, University of Arizona, Tucson, AZ, USA
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80
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Legendre C. [New faces of acute rejection in 2008]. Nephrol Ther 2009; 5 Suppl 4:S297-300. [PMID: 19596353 DOI: 10.1016/s1769-7255(09)74563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Along the time, the definition of acute rejection has been modified according to the successive Banff classifications, the use of C4d and the identification of anti- HLA antibodies. Both cellular and humoral acute rejection are nowadays considered to be different with regard to definition, pathogenesis and hence treatment. The Banffclassification remains a very useful tool to improve the precision of these definitions. The new technologies such as microarrays should help to identify new aspects of acute rejection.
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Affiliation(s)
- C Legendre
- Université Paris Descartes & Service de Transplantation Rénale Adulte, Hôpital Necker, 149 rue de Sèvres, 75743 Paris cedex 15.
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81
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Noninvasive Tim-3 messenger RNA evaluation in renal transplant recipients with graft dysfunction. Transplantation 2009; 86:1869-74. [PMID: 19104436 DOI: 10.1097/tp.0b013e3181914246] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Renal biopsies are usually needed to elucidate graft dysfunction. In this study, T-cell immunoglobulin domain, mucin domain mRNA expression in the peripheral blood leukocytes (PBL) and urinary cells (UC) were studied as a noninvasive method for the diagnosis of acute rejection (AR) of kidney transplant patients with dysfunction. METHODS One hundred sixty biopsies were obtained from 115 patients. Blood and urine samples were collected immediately before the biopsies. Histopathologic diagnoses were acute tubular necrosis with superimposed AR or acute tubular necrosis in patients with delayed graft function (DGF), and (AR), or calcineurin inhibitor nephrotoxicity (CIN), or interstitial fibrosis and tubular atrophy in patients with acute graft dysfunction (AGD). Fifteen protocol biopsies of stable grafts were used as controls. mRNA relative quantification was performed by real-time polymerase chain reaction. RESULTS Gene expression in tissue, PBL, and UC was always higher in patients with AR than in patients with the other causes of graft dysfunction (P<0.001). Significant correlations of gene expression in different compartments were observed (P<0.001). The obtained diagnostic parameters were 100% accurate in the DGF group and, respectively, for blood and urine: sensitivity (87% and 84%); specificity (95% and 96%); positive predictive value (87% and 89%); negative predictive value (93% and 94%); and accuracy (91% and 93%) for the group of patients with AGD. CONCLUSION T-cell immunoglobulin domain, mucin domain mRNA quantification by real-time polymerase chain reaction in PBL and UC of renal transplant patients undergoing DGF or AGD may become a useful tool for an accurate noninvasive diagnosis of AR.
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83
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Abstract
In organ transplantation, blood borne cells and macromolecules (e.g., antibodies) of the host immune system are brought into direct contact with the endothelial cell lining of graft vessels. In this location, graft endothelial cells play several roles in allograft rejection, including the initiation of rejection responses by presentation of alloantigen to circulating T cells; the development of inflammation and thrombosis; and as targets of injury and agents of repair.
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84
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Abstract
In organ transplantation, blood borne cells and macromolecules (e.g., antibodies) of the host immune system are brought into direct contact with the endothelial cell lining of graft vessels. In this location, graft endothelial cells play several roles in allograft rejection, including the initiation of rejection responses by presentation of alloantigen to circulating T cells; the development of inflammation and thrombosis; and as targets of injury and agents of repair.
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Piovesan A, Lucon A, David D, Nahas W, Antonopoulos I, Srougi M. Multifocal Renal Allograft Biopsy: Impact on Therapeutic Decisions. Transplant Proc 2008; 40:3397-400. [DOI: 10.1016/j.transproceed.2008.09.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 06/09/2008] [Accepted: 09/03/2008] [Indexed: 10/21/2022]
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Raffetseder U, Rauen T, Djudjaj S, Kretzler M, En-Nia A, Tacke F, Zimmermann HW, Nelson PJ, Frye BC, Floege J, Stefanidis I, Weber C, Mertens PR. Differential regulation of chemokine CCL5 expression in monocytes/macrophages and renal cells by Y-box protein-1. Kidney Int 2008; 75:185-96. [PMID: 18800033 DOI: 10.1038/ki.2008.457] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Y-box protein-1 (YB-1) belongs to the family of cold shock proteins that have pleiotropic functions such as gene transcription, RNA splicing, and mRNA translation. YB-1 has a critical role in atherogenesis due to its regulatory effects on chemokine CCL5 (RANTES) gene transcription in vascular smooth muscle cells. Since CCL5 is a key mediator of kidney transplant rejection, we determined whether YB-1 is involved in allograft rejection by manipulating its expression. In human kidney biopsies, YB-1 transcripts were amplified 17-fold in acute and 21-fold in chronic allograft rejection with a close correlation between CCL5 and YB-1 mRNA expression in both conditions. Among three possible YB-1 binding sites in the CCL5 promoter, a critical element was mapped at -28/-10 bps. This site allowed up-regulation of CCL5 transcription in monocytic THP-1 and HUT78 T-cells and in human primary monocytes; however, it repressed transcription in differentiated macrophages. Conversely, YB-1 knockdown led to decreased CCL5 transcription and secretion in monocytic cells. We show that YB-1 is a cell-type specific regulator of CCL5 expression in infiltrating T-cells and monocytes/macrophages and acts as an adaptive controller of inflammation during kidney allograft rejection.
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Affiliation(s)
- Ute Raffetseder
- Department of Nephrology and Clinical Immunology, University Hospital RWTH-Aachen, Aachen, Germany
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Gewaltig J, Kummer M, Koella C, Cathomas G, Biedermann BC. Requirements for CD8 T-cell migration into the human arterial wall. Hum Pathol 2008; 39:1756-62. [PMID: 18706675 DOI: 10.1016/j.humpath.2008.04.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 04/12/2008] [Accepted: 04/23/2008] [Indexed: 01/11/2023]
Abstract
Atherosclerotic lesions develop in the arterial intima. Among the leukocytes that accumulate in advanced atherosclerotic plaques, CD8 T cells play a quantitatively important role. They may be involved in disease progression and plaque destabilization, leading to plaque rupture or erosion. These events finally precipitate cardiovascular events. Therefore, we wished to determine the accessibility of the human arterial wall, particularly the arterial intima, for CD8-positive, cytotoxic T lymphocytes. We quantified the number of CD8-positive T cells in the arterial wall using human arterial tissue microarrays. The conditions for efficient cytotoxic T-lymphocyte migration into the arterial wall were determined in an in vitro tissue invasion assay. The invasion pattern of resting or activated cytotoxic T-lymphocyte clones was morphometrically analyzed by confocal microscopy. CD8 T cells represented up to 50% of the lymphocytes in advanced atherosclerotic lesions. Resting CD8-positive cytotoxic T lymphocytes were able to migrate into the arterial intima when it was affected by advanced lesions but not at the earliest stages of the disease. After T-cell receptor and/or proinflammatory cytokine activation, cytotoxic T lymphocytes migrated efficiently into the arterial intima, even in the healthy or mildly affected sites. This in vitro tissue invasion assay mimics conditions under which effector cytotoxic T lymphocytes migrate into the arterial wall to reach similar cell densities as observed in arterial tissue sections from autopsies. Interference with T-cell activation may be important to inhibit cytotoxic T-lymphocyte invasion into the unaffected, healthy artery but may not prevent cytotoxic T-lymphocyte invasion into arteries that are severely affected by atherosclerotic lesions.
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Affiliation(s)
- Jan Gewaltig
- University Department of Medicine, Bruderholzspital, 4101 Bruderholz, Switzerland; Department of Biomedicine, University Hospital, 4031 Basel, Switzerland
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89
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Smith RN, Kawai T, Boskovic S, Nadazdin O, Sachs DH, Cosimi AB, Colvin RB. Four stages and lack of stable accommodation in chronic alloantibody-mediated renal allograft rejection in Cynomolgus monkeys. Am J Transplant 2008; 8:1662-72. [PMID: 18557724 PMCID: PMC2796366 DOI: 10.1111/j.1600-6143.2008.02303.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The etiology of immunologically mediated chronic renal allograft failure is unclear. One cause is thought to be alloantibodies. Previously in Cynomolgus monkeys, we observed a relationship among donor-specific alloantibodies (DSA), C4d staining, allograft glomerulopathy, allograft arteriopathy and progressive renal failure. To define the natural history of chronic antibody-mediated rejection and its effect on renal allograft survival, we now extend this report to include 417 specimens from 143 Cynomolgus monkeys with renal allografts. A subset of animals with long-term renal allografts made DSA (48%), were C4d positive (29%), developed transplant glomerulopathy (TG) (22%) and chronic allograft arteriopathy (CAA) (19%). These four features were highly correlated and associated with statistically significant shortened allograft survival. Acute cellular rejection, either Banff type 1 or 2, did not correlate with alloantibodies, C4d deposition or TG. However, endarteritis (Banff type 2) correlated with later CAA. Sequential analysis identified four progressive stages of chronic antibody-mediated rejection: (1) DSA, (2) deposition of C4d, (3) TG and (4) rising creatinine/renal failure. These new findings provide strong evidence that chronic antibody-mediated rejection develops without enduring stable accommodation, progresses through four defined clinical pathological stages and shortens renal allograft survival.
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90
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The art of classifying renal allograft pathology. ACTA ACUST UNITED AC 2008; 4:420-1. [PMID: 18594502 DOI: 10.1038/ncpneph0859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 05/08/2008] [Indexed: 11/08/2022]
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Blasco V, Leone M, Bouvenot J, Geissler A, Albanèse J, Martin C. Impact of intensive care on renal function before graft harvest: results of a monocentric study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R103. [PMID: 17868450 PMCID: PMC2556746 DOI: 10.1186/cc6120] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2007] [Revised: 08/30/2007] [Accepted: 09/14/2007] [Indexed: 12/01/2022]
Abstract
Background The aim of life-support measures in brain-dead donors is to preserve the functional value of their organs. In renal transplantation, serum creatinine level is one of the criteria for graft harvest. The aim of this study was to assess the impact of intensive care on donor renal function through two criteria: preharvesting serum creatinine level above 120 μmol/L and the elevation of serum creatinine level above 20% between intensive care unit (ICU) admission and graft harvest. Methods Between 1 January 1999 and 31 December 2005, we performed an observational study on 143 brain-dead donors. ICU chronology, hemodynamic, hematosis, and treatment data were collected for each patient from ICU admission to kidney removal. Results Twenty-two percent of the 143 patients had a serum creatinine level above 120 μmol/L before graft harvest. The independent factors revealed by multivariate analysis were the administration of epinephrine (odds ratio [OR]: 4.36, 95% confidence interval [CI]: 1.33 to 14.32; p = 0.015), oliguria (OR: 3.73, 95% CI: 1.22 to 11.36; p = 0.021), acidosis (OR: 3.26, 95% CI: 1.07 to 9.95; p = 0.038), the occurrence of disseminated intravascular coagulation (OR: 3.97, 95% CI: 1.05 to 15.02; p = 0.042), female gender (OR: 0.13, 95% CI: 0.03 to 0.50; p = 0.003), and the administration of desmopressin (OR: 0.12, 95% CI: 0.03 to 0.44; p = 0.002). The incidence of elevated serum creatinine level above 20% between admission and graft harvest was 41%. The independent risk factors were the duration of brain death greater than 24 hours (OR: 2.64, 95% CI: 1.25 to 5.59; p = 0.011) and the volume of mannitol (OR: 2.08, 95% CI: 1.03 to 4.21; p = 0.041). Conclusion This study shows that the resuscitation of brain-dead donors impacts on their renal function. The uses of epinephrine and mannitol are associated with impairment of kidney function. It seems that graft harvest should be performed less than 24 hours after brain death diagnosis.
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Affiliation(s)
- Valéry Blasco
- Département d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille cedex 20, Université de la Méditerranée, Faculté de Médecine, 13005 Marseille, France
| | - Marc Leone
- Département d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille cedex 20, Université de la Méditerranée, Faculté de Médecine, 13005 Marseille, France
| | - Julien Bouvenot
- Service de Biostatistique, Faculté de Médecine, Université de la Méditerranée, Bd Jean Moulin, 13005 Marseille, France
| | - Alain Geissler
- Département d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille cedex 20, Université de la Méditerranée, Faculté de Médecine, 13005 Marseille, France
| | - Jacques Albanèse
- Département d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille cedex 20, Université de la Méditerranée, Faculté de Médecine, 13005 Marseille, France
| | - Claude Martin
- Département d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille cedex 20, Université de la Méditerranée, Faculté de Médecine, 13005 Marseille, France
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Liu G, Changsirikulchai S, Hudkins KL, Banas MC, Kowalewska J, Yang X, Wietecha TA, Volpone J, Gilbertson DG, Alpers CE. Identification of platelet-derived growth factor D in human chronic allograft nephropathy. Hum Pathol 2008; 39:393-402. [PMID: 18187181 DOI: 10.1016/j.humpath.2007.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Revised: 07/11/2007] [Accepted: 07/18/2007] [Indexed: 01/24/2023]
Abstract
Chronic allograft nephropathy (CAN), a descriptive term denoting chronic scarring injury of the renal parenchyma and vasculature in allograft kidneys arising from various etiologies including chronic rejection, is the most common cause of late allograft failure, but mediators of this progressive injury largely remain unknown. We hypothesized that platelet-derived growth factor D (PDGF-D) and its specific receptor PDGF-Rbeta may be an important mediator in the pathogenesis of CAN and, hence, sought to identify its expression in this setting. Allograft nephrectomies demonstrating CAN, obtained from patients with irreversible transplant kidney failure (n = 15), were compared with renal tissues without prominent histopathological abnormalities (n = 18) and a series of renal allograft biopsies demonstrating acute vascular rejection (AVR) (n = 12). Antibodies to PDGF-D and PDGF-Rbeta were used for immunohistochemistry. Double and triple immunohistochemistry was used to identify cell types expressing PDGF-D. PDGF-D was widely expressed in most neointimas in arteries exhibiting the chronic arteriopathy of CAN and only weakly expressed in a small proportion of sclerotic arteries in the other 2 groups. Double and triple immunolabeling demonstrated that the neointimal cells expressing PDGF-D were alpha-smooth muscle actin-expressing cells, but not infiltrating macrophages or endothelial cells. PDGF-Rbeta expression evaluated in serial sections was localized to the same sites where neointimal PDGF-D was expressed. PDGF-Rbeta was expressed in interstitial cells more abundantly in the CAN group compared with the normal and AVR groups, without demonstrable colocalization of PDGF-D. PDGF-D is present in the neointima of the arteriopathy of CAN, where it can engage PDGF-Rbeta to promote mesenchymal cell migration, proliferation, and neointima formation. PDGF-D may engage the PDGF-Rbeta to promote interstitial injury in chronic allograft injury, but its sources within the interstitium were unidentified.
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Affiliation(s)
- Gang Liu
- Institute of Nephrology, Peking University, First Hospital, 100034 Beijing, China
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93
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Mueller TF, Einecke G, Reeve J, Sis B, Mengel M, Jhangri GS, Bunnag S, Cruz J, Wishart D, Meng C, Broderick G, Kaplan B, Halloran PF. Microarray analysis of rejection in human kidney transplants using pathogenesis-based transcript sets. Am J Transplant 2007; 7:2712-22. [PMID: 17941957 DOI: 10.1111/j.1600-6143.2007.02005.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Microarrays offer potential for objective diagnosis and insights into pathogenesis of allograft rejection. We used mouse transplants to annotate pathogenesis-based transcript sets (PBTs) that reflect major biologic events in allograft rejection-cytotoxic T-cell infiltration, interferon-gamma effects and parenchymal deterioration. We examined the relationship between PBT expression, histopathologic lesions and clinical diagnoses in 143 consecutive human kidney transplant biopsies for cause. PBTs correlated strongly with one another, indicating that transcriptome disturbances in renal transplants have a stereotyped internal structure. This disturbance was continuous, not dichotomous, across rejection and nonrejection. PBTs correlated with histopathologic lesions and were the highest in biopsies with clinically apparent rejection episodes. Surprisingly, antibody-mediated rejection had changes similar to T-cell mediated rejection. Biopsies lacking PBT disturbances did not have rejection. PBTs suggested that some current Banff histopathology criteria are unreliable, particularly at the cut-off between borderline and rejection. Results were validated in 51 additional biopsies. Thus many transcriptome changes previously described in rejection are features of a large-scale disturbance characteristic of rejection but occurring at lower levels in many forms of injury. PBTs represent a quantitative measure of the inflammatory disturbances in organ transplants, and a new window on the mechanisms of these changes.
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Affiliation(s)
- T F Mueller
- Department of Medicine, Division of Nephrology and Immunology, University of Alberta, Edmonton, AB, Canada
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94
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Mengel M, Sis B, Halloran PF. SWOT analysis of Banff: strengths, weaknesses, opportunities and threats of the international Banff consensus process and classification system for renal allograft pathology. Am J Transplant 2007; 7:2221-6. [PMID: 17848174 DOI: 10.1111/j.1600-6143.2007.01924.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Banff process defined the diagnostic histologic lesions for renal allograft rejection and created a standardized classification system where none had existed. By correcting this deficit the process had universal impact on clinical practice and clinical and basic research. All trials of new drugs since the early 1990s benefited, because the Banff classification of lesions permitted the end point of biopsy-proven rejection. The Banff process has strengths, weaknesses, opportunities and threats (SWOT). The strength is its self-organizing group structure to create consensus. Consensus does not mean correctness: defining consensus is essential if a widely held view is to be proved wrong. The weaknesses of the Banff process are the absence of an independent external standard to test the classification; and its almost exclusive reliance on histopathology, which has inherent limitations in intra- and interobserver reproducibility, particularly at the interface between borderline and rejection, is exactly where clinicians demand precision. The opportunity lies in the new technology such as transcriptomics, which can form an external standard and can be incorporated into a new classification combining the elegance of histopathology and the objectivity of transcriptomics. The threat is the degree to which the renal transplant community will participate in and support this process.
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Affiliation(s)
- M Mengel
- Department of Medicine, Division of Nephrology & Immunology, Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Canada.
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95
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Serón D, Moreso F. Protocol biopsies in renal transplantation: prognostic value of structural monitoring. Kidney Int 2007; 72:690-7. [PMID: 17597702 DOI: 10.1038/sj.ki.5002396] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The natural history of renal allograft damage has been characterized in serial protocol biopsies. The prevalence of subclinical rejection (SCR) is maximal during the first months and it is associated with the progression of interstitial fibrosis/tubular atrophy (IF/TA) and a decreased graft survival. IF/TA rapidly progress during the first months and constitutes an independent predictor of graft survival. IF/TA associated with transplant vasculopathy, SCR, or transplant glomerulopathy implies a poorer prognosis than IF/TA without additional lesions. These observations suggest that protocol biopsies could be considered a surrogate of graft survival. Preliminary data suggest that the predictive value of protocol biopsies is not inferior to acute rejection or renal function. Additionally, protocol biopsies have been employed as a secondary efficacy variable in clinical trials. This strategy has been useful to demonstrate a decrease in the progression of IF/TA in some calcineurin-free regimens. Quantification of renal damage is associated with graft survival suggesting that quantitative parameters might improve the predictive value of protocol biopsies. Validation of protocol biopsies as a surrogate of graft survival is actively pursued, as the utility of classical surrogates of graft outcome such as acute rejection has become less useful because of its decreased prevalence with actual immunosuppression.
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Affiliation(s)
- D Serón
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain.
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96
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Vogler C, Wang Y, Brink DS, Wood E, Belsha C, Walker PD. Renal pathology in the pediatric transplant patient. Adv Anat Pathol 2007; 14:202-16. [PMID: 17452817 DOI: 10.1097/pap.0b013e3180504927] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Renal transplantation is a therapeutic goal for children with advanced chronic kidney disease. There are many causes of renal dysfunction in children with allografts--the transplanted kidney can develop a variety of morphologic alterations leading to dysfunction. Evaluation of the kidney biopsy is one of the best methods of determining the cause of graft dysfunction. Rejection is a major cause of renal allograft failure in children. The morphologic hallmarks of acute antibody-mediated and cell-mediated rejection and chronic allograft nephropathy have been codified in classification strategies that are useful in adults and children. Viral infection and Epstein-Barr virus-driven posttransplant lymphoproliferative disease also occur in the pediatric transplanted kidney. Drug toxicity from immunosuppressive agents also causes characteristic morphologic alterations in the renal allograft. As the survival of pediatric heart and liver transplant patients improves, the incidence of immunosuppression therapy-related disease in the native kidney in these patients will likely become more important clinically. In addition to renal lesions related to the allograft state, glomerular disease can recur or occur de novo in renal allografts. Here, we describe the pathology of the more common morphologic lesions in kidneys of children with a renal allograft.
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Affiliation(s)
- Carole Vogler
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
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97
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Hernández D, Rufino M, González-Posada JM, Torres A, Pascual J. Surrogate end points for graft failure and mortality in kidney transplantation. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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98
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Mengel M, Gwinner W, Schwarz A, Bajeski R, Franz I, Bröcker V, Becker T, Neipp M, Klempnauer J, Haller H, Kreipe H. Infiltrates in protocol biopsies from renal allografts. Am J Transplant 2007; 7:356-65. [PMID: 17283485 DOI: 10.1111/j.1600-6143.2006.01635.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In renal transplantation, clinical decisions are based primarily on the Banff classification of biopsies. However, the incorporation of 'minor or nonspecific' cellular infiltrates into the Banff classification and their interpretation is uncertain. We analyzed 833 protocol and 306 indicated biopsies to test whether such infiltrates are harmless or whether they have a bearing on outcomes. We characterized morphology, localization and cellular composition of infiltrates, and correlated these findings to the Banff classification and allograft outcome. We found that protocol biopsies had the same prevalence of infiltrates as indication biopsies (87% vs. 87%). Diffuse cortical infiltrates, the hallmark of cellular rejection were more common in indication biopsies and related to tubulitis and a rise in serum creatinine. However, in biopsies with cellular rejection according to Banff criteria, we observed an increase in all infiltrate types (specific and nonspecific) and all cell types (T cells, B cells, histiocytes). The only predictor of allograft function outcome was persistent inflammation in sequential biopsies, irrespective of type, localization and composition of the cellular infiltrates. As detected by sequential biopsies, persistence of any inflammation including those infiltrates currently not considered by the Banff classification should be regarded as a morphological correlate of ongoing allograft damage.
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Affiliation(s)
- M Mengel
- Institut fuer Pathologie, Medizinische Hochschule Hannover, Germany.
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99
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Nierentransplantation. PRAXIS DER NEPHROLOGIE 2007. [PMCID: PMC7121448 DOI: 10.1007/978-3-540-48556-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Die Nierentransplantation ist die effektivste Behandlungsmethode der chronischen terminalen Niereninsuffizienz. Seit den 1960er Jahren entwickelte sie sich zu einer Standardtherapie. Wichtige Voraussetzungen waren die Entdeckung des HLA-Systems, die Entwicklung der Immunsuppressiva sowie die technische Perfektionierung des Organerhaltes außerhalb eines lebenden Körpers. Die 5-Jahres-Überlebensrate für Allotransplantate beträgt etwa 65%, diejenige von Lebendspenden 79%.
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100
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Vargha R, Mueller T, Arbeiter K, Regele H, Exner M, Csaicsich D, Aufricht C. C4d in pediatric renal allograft biopsies: a marker for negative outcome in steroid-resistant rejection. Pediatr Transplant 2006; 10:449-53. [PMID: 16712602 DOI: 10.1111/j.1399-3046.2006.00492.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Recently, deposition of C4d, reflecting complement activation via the classical pathway, has been established as marker of antibody-mediated rejection. As C4d can be detected in paraffin sections, it allows for retrospective analysis in populations with low case loads, such as in pediatric transplantation. In this study we re-evaluated consecutive renal transplant biopsies obtained since 1990 in 36 children (18 boys, 18 girls) who had received their allograft (nine living, 27 cadaveric) at an age of 10.12+/-4.4 yr. Clinical indications for biopsy were 16 acute steroid resistant rejections (ASRs), 11 chronic rejections and nine other diagnoses. Overall, C4d deposition was found in nine cases (25%), eight of them with diagnosed ASR. Six out of these eight allografts were lost during 36 months of clinical follow-up, a significantly higher rate than in C4d-negative biopsies (p<0.05). C4d status therefore turned out to be an excellent predictor for inferior graft survival following ASR. None of the other histopathologic markers were sensitive for humoral rejections. In conclusion, the high prevalence of C4d-positive staining in ASR demonstrates the importance of the humoral part of the immune system in pediatric transplantation. The worse outcome of C4d-positive rejections despite massive immunosuppressive therapy clearly indicates the need for innovative therapies in this high-risk population.
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Affiliation(s)
- Regina Vargha
- Department of Paediatrics, AKH, Medical University of Vienna, Vienna, Austria
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