101
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Daly KP, Chandler SF, Almond CS, Singh TP, Mah H, Milford E, Matte GS, Bastardi HJ, Mayer JE, Fynn-Thompson F, Blume ED. Antibody depletion for the treatment of crossmatch-positive pediatric heart transplant recipients. Pediatr Transplant 2013; 17:661-9. [PMID: 23919762 PMCID: PMC3843490 DOI: 10.1111/petr.12131] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
Abstract
Sensitization to HLA is a risk factor for adverse outcomes after heart transplantation. Requiring a negative prospective CM results in longer waiting times and increased waitlist mortality. We report outcomes in a cohort of sensitized children who underwent transplant despite a positive CDC CM+ using a protocol of antibody depletion at time of transplant, followed by serial IVIG administration. All patients <21 yrs old who underwent heart transplantation at Boston Children's Hospital from 1/1998 to 1/2011 were included. We compared freedom from allograft loss, allograft rejection, and serious infection between CM+ and CM- recipients. Of 134 patients in the cohort, 33 (25%) were sensitized prior to transplantation and 12 (9%) received a CM+ heart transplant. Serious infection in the first post-transplant year was more prevalent in the CM+ patients compared with CM- patients (50% vs. 16%; p = 0.005), as was HD-AMR (50% vs. 2%; p < 0.001). There was no difference in freedom from allograft loss or any rejection. At our center, children transplanted despite a positive CM had acceptable allograft survival and risk of any rejection, but a higher risk of HD-AMR and serious infection.
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Affiliation(s)
- Kevin P. Daly
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, 02115
| | | | | | - Tajinder P. Singh
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, 02115
| | - Helen Mah
- Tissue Typing Laboratory, Brigham & Women's Hospital, Boston, MA, 02115
| | - Edgar Milford
- Tissue Typing Laboratory, Brigham & Women's Hospital, Boston, MA, 02115
| | - Gregory S. Matte
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, 02115
| | | | - John E. Mayer
- Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, 02115
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102
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Fedrigo M, Feltrin G, Poli F, Frigo AC, Benazzi E, Gambino A, Tona F, Caforio ALP, Castellani C, Toscano G, Gerosa G, Thiene G, Angelini A. Intravascular macrophages in cardiac allograft biopsies for diagnosis of early and late antibody-mediated rejection. J Heart Lung Transplant 2013; 32:404-9. [PMID: 23498161 DOI: 10.1016/j.healun.2012.12.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 11/13/2012] [Accepted: 12/13/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of our study was to evaluate the role of intravascular macrophages in the diagnosis of early and late antibody-mediated rejection (AMR) on endomyocardial biopsies (EMBs). METHODS We reviewed 1,420 consecutive EMBs from 131 patients and selected 75 C4d+ EMBs. The C4d+ group was compared with a control group (66 patients) matched for age, gender, date of transplantation, follow-up, immunosuppressive regimen and primary heart disease. A total of 141 EMBs were evaluated. Immunoperoxidase staining for C4d and CD68 were performed. Post-transplant IgG anti-HLA reactivity was investigated by Luminex technology. Clinical data were also collected. Fourteen EMBs were available from 11 symptomatic AMR patients. RESULTS Of the 141 EMBs evaluated, 53 were positive for intravascular macrophages (CD68); among them, 32 were also positive for C4d (32 of 53, 60.4%). Of the 88 CD68- EMBs, 43 were also C4d+ (43 of 88, 48.9%). Of the 53 CD68+ EMBs, 30 EMBs were within the first year since transplantation (30 of 53, 57.8%), and among these 21 were also positive for C4d (21 of 30, 70.0%). In the late period, among the 23 CD68+ EMBs (23 of 53, 42.2%) 11 were also positive for C4d (11 of 23, 47.8%). In the early period, intravascular macrophages were more common in symptomatic (3 of 3, 100%) than asymptomatic (3 of 11, 27.3%) patients. Sensitivity and specificity of intravascular macrophages in predicting donor-specific antibodies (DSA) within the first year were 50.0% and 100.0%, respectively. CONCLUSIONS Intravascular macrophages predict C4d, DSA and symptoms early after transplantation; however, in the late period, they are unable to identify patients with circulating DSA, C4d and/or symptoms.
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Affiliation(s)
- Marny Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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103
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Frank R, Molina MR, Wald JW, Goldberg LR, Kamoun M, Lal P. Correlation of circulating donor-specific anti-HLA antibodies and presence of C4d in endomyocardial biopsy with heart allograft outcomes: a single-center, retrospective study. J Heart Lung Transplant 2013; 32:410-7. [PMID: 23498162 DOI: 10.1016/j.healun.2012.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 12/06/2012] [Accepted: 12/18/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Donor-specific antibodies (DSA) are associated with increased cardiac graft loss and cardiac vasculopathy (CAV). Detection of antibody-mediated rejection (AMR) relies on graft dysfunction, C4d immunofluorescence (IF) and DSA. METHODS We retrospectively studied the relationship of DSA, endomyocardial biopsy (EMB) and C4d IF to cardiac transplant outcomes. DSA were evaluated against HLA class I and II specificities, both pre- and post-transplant, using microbead-based assays. RESULTS Of 626 cardiac transplant patients, 109 with concurrent EMBs and C4d IF and DSA measurement were included in this study. In patients with and without DSA, CAV occurred in 31% and 13% and acute cellular rejection (ACR) in 100% and 84%, respectively. One hundred ten of 170 EMBs procured during episodes of graft dysfunction had concurrent DSA. In these patients, C4d IF correlated better with DSA to class I or both class I and II and less so in patients with DSA to class II. Graft failure (GF) rates of 40%, 29% and 58% with average times to GF of 33, 77 and 48 months were seen in patients with DSA to class I, II or both, respectively. CONCLUSIONS Patients with DSA to class I or to both class I and II showed a correlation with C4d IF and had higher GF rates compared to patients with DSA to only class II or no DSA; patients with DSA to class II remained at risk for CAV. Episodes of ACR and CAV, but not AMR, appeared to be more frequently associated with graft dysfunction in patients with circulating DSA.
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Affiliation(s)
- Renee Frank
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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104
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Gulleroglu K, Baskin E, Bayrakci US, Turan M, Ozdemir BH, Moray G, Karakayali H, Haberal M. Antibody-Mediated Rejection and Treatment in Pediatric Patients: One Center’s Experience. EXP CLIN TRANSPLANT 2013; 11:404-7. [DOI: 10.6002/ect.2012.0242] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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105
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Late and chronic antibody-mediated rejection: main barrier to long term graft survival. Clin Dev Immunol 2013; 2013:859761. [PMID: 24222777 PMCID: PMC3816029 DOI: 10.1155/2013/859761] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/03/2013] [Indexed: 12/02/2022]
Abstract
Antibody-mediated rejection (AMR) is an important cause of graft loss after organ transplantation. It is caused by anti-donor-specific antibodies especially anti-HLA antibodies. C4d had been regarded as a diagnosis marker for AMR. Although most early AMR episodes can be successfully controlled or reversed, late and chronic AMR remains the leading cause of late graft loss. The strategies which work in early AMR have limited effect on late/chronic episodes. Here, we reviewed the lines of evidence that late/chronic AMR is the leading cause of late graft loss, characteristics of late AMR, and current strategies in managing late/chronic AMR. More effort should be put on the management of late/chronic AMR to make a better long term graft survival.
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106
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Abstract
PURPOSE OF REVIEW To review the recent publications on pediatric heart failure and pediatric transplantation. RECENT FINDINGS Little progress has been made in the chronic medical management of pediatric heart failure. Basic science studies demonstrating disparate regulation of β2-adrenergic receptors and microRNA between pediatric and adult heart failure may give clues to the lack of improvement in pediatric outcomes. Pediatric ventricular assist devices have significantly improved survival of bridge-to-transplant, but currently have too many limitations for destination therapy for children. Several areas of pediatric heart transplant have had significant developments over the last few years: the role of antibodies in mediating graft dysfunction after transplantation, ABO-incompatible transplant, extending the pediatric limits on acceptable pulmonary vascular resistance, and risk prediction of pediatric transplant outcomes. Failed single-ventricle palliation is a growing indication for heart transplantation with its own unique challenges. SUMMARY Pediatric heart transplantation can have excellent outcomes with survival beyond 20 years after transplant common, especially in the infant. However, the growing population of children and young adults being referred for heart transplantation after failed congenital heart surgery, especially after failed single-ventricle palliation, is presenting new obstacles that may start reducing the survival rates for pediatric heart transplantation. This may in part be ameliorated by earlier referral for transplant evaluation.
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107
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Snyder LD, Wang Z, Chen DF, Reinsmoen NL, Finlen-Copeland CA, Davis WA, Zaas DW, Palmer SM. Implications for human leukocyte antigen antibodies after lung transplantation: a 10-year experience in 441 patients. Chest 2013; 144:226-233. [PMID: 23328795 DOI: 10.1378/chest.12-0587] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Long-term survival after lung transplant is limited by the development of chronic and progressive airflow obstruction, a condition known as bronchiolitis obliterans syndrome (BOS). While prior studies strongly implicate cellular rejection as a strong risk factor for BOS, less is known about the clinical significance of human leukocyte antigen (HLA) antibodies and donor HLA-specific antibodies in long-term outcomes. METHODS A single-center cohort of 441 lung transplant recipients, spanning a 10-year period, was prospectively screened for HLA antibodies after transplant using flow cytometry-based methods. The prevalence of and predictors for HLA antibodies were determined. The impact of HLA antibodies on survival after transplant and the development of BOS were determined using Cox models. RESULTS Of the 441 recipients, 139 (32%) had detectable antibodies to HLA. Of these 139, 54 (39%) developed antibodies specific to donor HLA. The detection of posttransplant HLA antibodies was associated with BOS (HR, 1.54; P=.04) and death (HR, 1.53; P=.02) in multivariable models. The detection of donor-specific HLA antibodies was associated with death (HR, 2.42; P<.0001). The detection of posttransplant HLA antibodies was associated with pretransplant HLA-antibody detection, platelet transfusions, and the development of BOS and cytomegalovirus pneumonitis. CONCLUSIONS Approximately one-third of lung transplant recipients have detectable HLA antibodies, which are associated with a worse prognosis regarding graft function and patient survival.
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Affiliation(s)
| | - Ziwei Wang
- Department of Medicine, Duke University, Durham, NC
| | | | - Nancy L Reinsmoen
- Department of Pediatrics and Medical Genetics Research Institute, Cedars-Sinai Health Systems, Los Angeles, CA
| | | | | | - David W Zaas
- Department of Medicine, Duke University, Durham, NC
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108
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Sadaka B, Alloway RR, Woodle ES. Management of antibody-mediated rejection in transplantation. Surg Clin North Am 2013; 93:1451-66. [PMID: 24206861 DOI: 10.1016/j.suc.2013.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite intensive traditional immunosuppressive therapy, rates of graft loss have approximated 15% to 20% at 1 year following antibody-mediated rejection (AMR) in solid organ transplant recipients. Therefore, the development of antihumoral therapies that provide prompt elimination of donor-specific anti-HLA antibodies and improve allograft survival is an important goal. Traditional treatment modalities for AMR deplete B-cell populations but not the cell at the source of antibody production, the mature plasma cell. Plasma cell-targeted therapies using proteasome inhibition is a novel approach to treating AMR. This review discusses current and emerging treatment modalities used for AMR.
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Affiliation(s)
- Basma Sadaka
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 558, Cincinnati, OH 45267-0558, USA
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109
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Nixon JN, Biyyam DR, Stanescu L, Phillips GS, Finn LS, Parisi MT. Imaging of Pediatric Renal Transplants and Their Complications: A Pictorial Review. Radiographics 2013; 33:1227-51. [DOI: 10.1148/rg.335125150] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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110
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Witt CA, Gaut JP, Yusen RD, Byers DE, Iuppa JA, Bennett Bain K, Alexander Patterson G, Mohanakumar T, Trulock EP, Hachem RR. Acute antibody-mediated rejection after lung transplantation. J Heart Lung Transplant 2013; 32:1034-40. [PMID: 23953920 DOI: 10.1016/j.healun.2013.07.004] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Antibody-mediated rejection (AMR) after lung transplantation remains enigmatic, and there is no consensus on the characteristic clinical, immunologic and histologic features. METHODS We performed a retrospective, single-center cohort study and identified cases of acute AMR based on the presence of circulating donor-specific human leukocyte antigen (HLA) antibodies (DSA), histologic evidence of acute lung injury, C4d deposition and clinical allograft dysfunction. RESULTS We identified 21 recipients with acute AMR based on the aforementioned criteria. AMR occurred a median 258 days after transplantation; 7 recipients developed AMR within 45 days of transplantation. All patients had clinical allograft dysfunction, DSA, histology of acute lung injury and capillary endothelial C4d deposition. Fifteen recipients improved clinically and survived to hospital discharge, but 6 died of refractory AMR. One survivor had bronchiolitis obliterans syndrome at the time of AMR diagnosis; 13 of the 14 remaining survivors developed chronic lung allograft dysfunction (CLAD) during follow-up. Overall, 15 recipients died during the study period, and the median survival after the diagnosis of AMR was 593 days. CONCLUSIONS Acute AMR can be a fulminant form of lung rejection, and survivors are at increased risk of developing CLAD. The constellation of acute lung injury, DSA and capillary endothelial C4d deposition is compelling for acute AMR in recipients with allograft dysfunction. This clinicopathologic definition requires validation in a multicenter cohort, but may serve as a foundation for future studies to further characterize AMR.
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Affiliation(s)
- Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri.
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111
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Lee J, Romero R, Xu Y, Miranda J, Yoo W, Chaemsaithong P, Kusanovic JP, Chaiworapongsa T, Tarca AL, Korzeniewski SJ, Hassan SS, Than NG, Yoon BH, Kim CJ. Detection of anti-HLA antibodies in maternal blood in the second trimester to identify patients at risk of antibody-mediated maternal anti-fetal rejection and spontaneous preterm delivery. Am J Reprod Immunol 2013; 70:162-75. [PMID: 23841577 PMCID: PMC4154511 DOI: 10.1111/aji.12141] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 04/30/2013] [Indexed: 02/04/2023] Open
Abstract
PROBLEM Maternal anti-fetal rejection is a mechanism of disease in spontaneous preterm labor. The objective of this study was to determine whether the presence of human leukocyte antigen (HLA) panel-reactive antibodies (PRA) during the second trimester increases the risk of spontaneous preterm delivery. METHODS OF STUDY This longitudinal case-control study included pregnant women with spontaneous preterm deliveries (n = 310) and control patients with normal term pregnancies (n = 620), matched for maternal age and gravidity. Maternal plasma samples obtained at 14-16, 16-20, 20-24, and 24-28 weeks of gestation were analyzed for HLA class I and class II PRA positivity using flow cytometry. The fetal HLA genotype and maternal HLA alloantibody epitope were determined for a subset of patients with positive HLA PRA. RESULTS (i) Patients with spontaneous preterm delivery were more likely to exhibit HLA class I (adjusted OR = 2.54, P < 0.0001) and class II (adjusted OR = 1.98, P = 0.002) PRA positivity than those delivering at term; (ii) HLA class I PRA positivity for patients with spontaneous preterm delivery between 28 and 34 weeks (adjusted OR = 2.88; P = 0.001) and after 34 weeks of gestation (adjusted OR = 2.53; P < 0.0001) was higher than for those delivering at term; (iii) HLA class II PRA positivity for patients with spontaneous preterm delivery after 34 weeks of gestation was higher than for those delivering at term (adjusted OR = 2.04; P = 0.002); (iv) multiparous women were at a higher risk for HLA class I PRA positivity than nulliparous women (adjusted OR = 0.097, P < 0.0001 for nulliparity); (v) nulliparous women had a higher rate of HLA class I PRA positivity with advancing gestational age (P = 0.001); and (vi) 78% of women whose fetuses were genotyped had alloantibodies specific against fetal HLA class I antigens. CONCLUSION Pregnant women with positive HLA class I or class II PRA during the second trimester are at an increased risk of spontaneous preterm delivery due to antibody-mediated maternal anti-fetal rejection.
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Affiliation(s)
- JoonHo Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Yi Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Jezid Miranda
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Wonsuk Yoo
- Biostatistics and Epidemiology Division, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Sótero del Río Hospital, Santiago, Chile
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Adi L. Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Computer Science, Wayne State University, Detroit, Michigan, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nandor Gabor Than
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Chong Jai Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pathology, Wayne State University School of Medicine, Hutzel Women's Hospital, Detroit, Michigan, USA
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112
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The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol 2013; 2013:678180. [PMID: 23935649 PMCID: PMC3722852 DOI: 10.1155/2013/678180] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/15/2013] [Accepted: 06/23/2013] [Indexed: 12/11/2022]
Abstract
Antibody-mediated rejection (AMR) is highly detrimental to the prolonged survival of transplanted kidneys. C4d has been regarded as a footprint of AMR tissue damage, and the introduction of C4d staining in daily clinical practice aroused an ever-increasing interest in the role of antibody-mediated mechanisms in allograft rejection. Despite the general acceptance of the usefulness of C4d in the identification of acute AMR, the data for C4d staining in chronic AMR is variable. The presence of C4d in the majority of the biopsies with features of chronic antibody-mediated rejection is reported, but this rejection without C4d staining is observed as well, suggesting that C4d is specific but not sensitive. Further studies on AMR with positive C4d staining in biopsy specimens are really important, as well as the study of novel routine markers that may participate in the pathogenesis of this process.
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113
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Siskind E, Bhaskaran M, Boctor F, Shah K, Molmenti E. Treatment of Late Class II Antibody-Mediated Rejection Status Postkidney Transplantation: Two Case Reports. Int J Angiol 2013; 21:107-10. [PMID: 23730140 DOI: 10.1055/s-0032-1315622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We are describing the successful treatment of two cases of late Class II antibody mediated rejection status postkidney transplantation. The first patient was treated with a combination of plasmapheresis, intravenous immunoglobulin (IVIG), and stenting of the transplanted renal artery. The second was treated with IVIG and pulse steroids.
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Affiliation(s)
- Eric Siskind
- North Shore Long Island Jewish Health System Transplantation Center, Manhasset, New York
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114
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Lobo LJ, Aris RM, Schmitz J, Neuringer IP. Donor-specific antibodies are associated with antibody-mediated rejection, acute cellular rejection, bronchiolitis obliterans syndrome, and cystic fibrosis after lung transplantation. J Heart Lung Transplant 2013; 32:70-7. [PMID: 23260706 DOI: 10.1016/j.healun.2012.10.007] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 09/26/2012] [Accepted: 10/17/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Lung transplantation is limited by chronic lung allograft dysfunction. Acute cellular rejection (ACR) is a risk factor for allograft dysfunction; however, the role of antibody-mediated rejection (AMR) is not well characterized. METHODS This was a retrospective review from 2007 to 2011 of lung transplant recipients with human leukocyte antigen (HLA) antibody testing using Luminex (Luminex Corp, Austin, TX) single-antigen beads. Statistics included Fisher's exact test for significance. RESULTS Donor-specific antibodies (DSA) developed in 13 of 44 patients. Of the 13 with DSA, 12 had cystic fibrosis compared with 18 of 31 in the non-DSA group (p = 0.035). Of those with DSAs, 23.1% occurred within the first year, and 69.2% occurred between 1 and 3 years. Twelve of 13 DSA patients had anti-HLA DQ specificity compared with 2 of 31 non-DSA patients (p = 0.0007). AMR developed in 10 of the 13 DSA patients compared with 1 of 31 non-DSA patients (p = 0.0001). The DSA group experienced 2.6 episodes/patient of cellular rejection vs 1.7 episodes/patient in the non-DSA group (p = 0.059). Bronchiolitis obliterans syndrome developed in 11 of 13 in the DSA group vs 10 of 31 in the non-DSA group (p = 0.0024). In the DSA group, 11.5% HLAs matched compared with 20.4% in the non-DSA group (p = 0.093). AMR developed in 11 of 22 patients in the non-DSA HLA group compared with 0 of 22 in the group without non-DSA HLA antibodies (p = 0.002). Survival at 1 and 3 years was 92% and 36% in the DSA group, respectively, and 97% and 65% in the non-DSA group. CONCLUSIONS DSAs and non-DSAs occur frequently after lung transplantation. DSAs are prevalent in the cystic fibrosis population and are associated with AMR, bronchiolitis obliterans syndrome, and possibly, ACR.
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Affiliation(s)
- Leonard J Lobo
- University of North Carolina, Division of Pulmonary and Critical Care Medicine, 130 Mason Farm Rd, Campus Box 7020, Chapel Hill, NC 27599, USA.
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115
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Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
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Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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116
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Beaty CA, Yang A, George TJ, Illei PB, Shah AS. Unilateral humoral rejection after reoperative single-lung transplant. Ann Thorac Surg 2013; 95:e79-81. [PMID: 23522237 DOI: 10.1016/j.athoracsur.2012.09.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 09/18/2012] [Accepted: 09/28/2012] [Indexed: 11/30/2022]
Abstract
The role of antibody-mediated rejection in acute and chronic rejection after lung transplantation is poorly understood. We report the case of a prior single-lung transplant recipient undergoing an acute antibody-mediated rejection isolated to her new, contralateral single-lung transplant. A 44-year-old woman 6 years after undergoing a single-lung transplant for idiopathic pulmonary fibrosis underwent a second single-lung transplant for bronchiolitis obliterans syndrome. Despite a negative crossmatch, she subsequently exhibited severe antibody-mediated rejection to her new allograft within 6 days of transplantation. The process of allograft sensitization is dynamic, and further study is warranted to better understand this process.
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Affiliation(s)
- Claude A Beaty
- Division of Cardiac Surgery, Department of Surgical Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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Abstract
PURPOSE OF REVIEW There is increasing evidence to suggest that antibody-mediated mechanisms play a role in the pathogenesis of liver allograft rejection. This article will review the pathology of antibody-mediated rejection (AMR) focusing on recent studies which have improved our understanding of the clinicopathological features and diagnostic approaches. RECENT FINDINGS Recent studies have investigated the patterns of immunohistochemical staining for C4d as a tissue marker of AMR in posttransplant biopsies, and have correlated these findings with other histopathological changes and with the presence of donor-specific antibodies (DSAs). These studies have highlighted the diagnostic applications and limitations of C4d immunostaining. They have also emphasized the importance of using strict criteria for defining 'pure' AMR in the liver allograft - that is, graft dysfunction associated with compatible histological findings (typically resembling biliary obstruction), the presence of DSAs and diffusely positive staining for C4d. SUMMARY Pure AMR is relatively uncommon in ABO-compatible grafts - it should be diagnosed on the basis of strict criteria and requires treatment with antibody-depleting immunosuppression. C4d immunostaining in isolation has limited diagnostic value. However, the presence of diffuse C4d immunostaining (involving endothelium or stroma in >50% of portal tracts or sinusoids) suggests a significant component of antibody-mediated graft damage. In a person with suggestive histological features, this finding should prompt testing for DSAs. Even in the absence of typical histological features of AMR, the combined presence of DSAs and diffuse C4d positivity is associated with more frequent or severe acute and chronic rejection, which may also warrant treatment with antibody-depleting immunosuppression.
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118
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High frequency of rejections in HIV-positive recipients of kidney transplantation: a single center prospective trial. Transplantation 2013; 94:1020-4. [PMID: 23169224 DOI: 10.1097/tp.0b013e31826c3947] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND This is a single institution report of the incidence of combined acute antibody-mediated rejection (ABMR) + acute cellular rejection (ACR) [mixed rejection] in HIV (+) kidney transplant recipients. METHODS We prospectively enrolled 92 HIV (+) patients who received a kidney transplant between 2001 and 2009. There were three cohorts: no rejection [n=26], ACR [n=53], and mixed rejections (ABMR and ACR) [n=13]. Immunosuppression comprised of basiliximab, cyclosporine, sirolimus, and steroid minimization. Fisher exact tests for categorical variables, t test for continuous variables, and Kaplan-Meier estimates were used to describe events. RESULTS Mixed rejections were seen in all 13 HIV (+) kidney transplant recipients (14%) with a median time to ABMR of 48 days. Acute cellular rejection occurred in 28% at 1 month and 55% at 12 months. eGFR was lower for recipients who experienced ABMR versus those experiencing ACR and those never experiencing rejection up to 3 years (14 ± 9.4 vs 19 ± 3.3 vs 29 ± 7.3 mL/min, respectively). Kaplan-Meier showed that graft survival up to 9 years was worse in recipients experiencing mixed rejection. Suboptimal donors with terminal creatinine greater than 2.5 mg/dL was associated with increased incidence of mixed rejections versus cellular rejections and no rejection (42% vs 17% vs. 8%, respectively). CONCLUSIONS Our single center study showed a relatively higher incidence of mixed rejection compared with that reported for non-HIV transplant recipients. A donor terminal serum creatinine greater than 2.5 mg/dL predicted mixed rejection, which was associated with poor outcomes. Donor selection and optimization of immunosuppression may be critical in these patients.
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119
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Jackups R, Canter C, Sweet SC, Mohanakumar T, Morris GP. Measurement of donor-specific HLA antibodies following plasma exchange therapy predicts clinical outcome in pediatric heart and lung transplant recipients with antibody-mediated rejection. J Clin Apher 2013; 28:301-8. [DOI: 10.1002/jca.21270] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 01/13/2013] [Accepted: 01/16/2013] [Indexed: 12/18/2022]
Affiliation(s)
- Ronald Jackups
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis; Missouri
| | - Charles Canter
- Department of Pediatrics; Washington University School of Medicine; St. Louis; Missouri
| | - Stuart C. Sweet
- Department of Pediatrics; Washington University School of Medicine; St. Louis; Missouri
| | | | - Gerald P Morris
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis; Missouri
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120
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Verhelst XPD, Troisi RI, Colle I, Geerts A, van Vlierberghe H. Biomarkers for the diagnosis of acute cellular rejection in liver transplant recipients: A review. Hepatol Res 2013. [PMID: 23186289 DOI: 10.1111/hepr.12012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The gold standard for the diagnosis of acute cellular rejection (ACR) is a liver biopsy. The quest for an alternative non-invasive biomarkers has been long and is ongoing. However, an efficient and useful biomarker has not been developed yet. In this manuscript, we review all possible candidate biomarkers that have been studied in recent years, starting with cytokines and ending with an overview of different newly discovered "omics". Promising paths are being explored but a valid non-invasive biomarker has not been discovered yet.
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Affiliation(s)
- Xavier P D Verhelst
- Department of Hepatology and Gastroenterology, Ghent University Hospital, Ghent, Belgium
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121
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Lefaucheur C, Loupy A, Vernerey D, Duong-Van-Huyen JP, Suberbielle C, Anglicheau D, Vérine J, Beuscart T, Nochy D, Bruneval P, Charron D, Delahousse M, Empana JP, Hill GS, Glotz D, Legendre C, Jouven X. Antibody-mediated vascular rejection of kidney allografts: a population-based study. Lancet 2013. [PMID: 23182298 DOI: 10.1016/s0140-6736(12)61265-3] [Citation(s) in RCA: 253] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Rejection of allografts has always been the major obstacle to transplantation success. We aimed to improve characterisation of different kidney-allograft rejection phenotypes, identify how each one is associated with anti-HLA antibodies, and investigate their distinct prognoses. METHODS Patients who underwent ABO-compatible kidney transplantations in Necker Hospital and Saint-Louis Hospital (Paris, France) between Jan 1, 1998, and Dec 31, 2008, were included in our population-based study. We assessed patients who provided biopsy samples for acute allograft rejection, which was defined as the association of deterioration in function and histopathological lesions. The main outcome was kidney allograft loss-ie, return to dialysis. To investigate distinct rejection patterns, we retrospectively assessed rejection episodes with review of graft histology, C4d in allograft biopsies, and donor-specific anti-HLA antibodies. FINDINGS 2079 patients were included in the main analyses, of whom 302 (15%) had acute biopsy-proven rejection. We identified four distinct patterns of kidney allograft rejection: T cell-mediated vascular rejection (26 patients [9%]), antibody-mediated vascular rejection (64 [21%]), T cell-mediated rejection without vasculitis (139 [46%]), and antibody-mediated rejection without vasculitis (73 [24%]). Risk of graft loss was 9·07 times (95 CI 3·62-19·7) higher in antibody-mediated vascular rejection than in T cell-mediated rejection without vasculitis (p<0·0001), compared with an increase of 2·93 times (1·1-7·9; P=0·0237) in antibody-mediated rejection without vasculitis and no significant rise in T cell-mediated vascular rejection (hazard ratio [HR] 1·5, 95% CI 0·33-7·6; p=0·60). INTERPRETATION We have identified a type of kidney rejection not presently included in classifications: antibody-mediated vascular rejection. Recognition of this distinct phenotype could lead to the development of new treatment strategies that could salvage many kidney allografts. FUNDING None.
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Affiliation(s)
- Carmen Lefaucheur
- Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, INSERM U940, Paris, France
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122
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Singh N, Sun Q, Nadasdy T, Adams P, Dipaola NR, Pesavento T, Winters H, Satoskar A, Yu Z, Henry M, Hadley GA, Pelletier RP. The pathogenesis of acute allograft dysfunction in desensitized renal transplant recipients. Clin Transplant 2013; 26:E402-11. [PMID: 22882695 DOI: 10.1111/j.1399-0012.2012.01684.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute allograft rejection after HLA desensitization is common early post-transplant but the sequence of histopathologic changes leading to graft dysfunction has not been well defined. METHODS We evaluated the early pathogenesis and sequence of antibody-mediated graft damage of 35 desensitized living donor kidney recipients by studying the course of biopsies taken in the very early post-transplant period (<1 month). RESULTS A total of 14 of the 35 patients met criteria for acute antibody-mediated rejection (AMR). In these patients, the chronologic sequence of pathologic changes was C4d peritubular capillary deposition, acute tubular injury, and peritubular capillaritis, followed by glomerulitis and interstitial inflammation. Classic AMR lesions occurred early, followed by mononuclear cellular infiltration, which comprised CD4 and CD8 T cells and monocytes. Development of graft dysfunction in most patients occurred concurrently with the emergence of graft cellular infiltration, rather than at the earlier time of antibody deposition as detected via C4d deposition. CONCLUSION These data provide novel insight into the sequence of pathologic changes in patients with AMR post-transplant after HLA desensitization.
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Affiliation(s)
- N Singh
- Department of Medicine, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA
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123
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Therapeutic apheresis in transplantation medicine, experience with cardiac and lung transplantation in Jena. ATHEROSCLEROSIS SUPP 2013; 14:33-8. [DOI: 10.1016/j.atherosclerosissup.2012.10.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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124
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Xie A, Buras ED, Xia J, Chen W. The Emerging Role of Interleukin-21 in Transplantation. ACTA ACUST UNITED AC 2013; Suppl 9:1-7. [PMID: 23828737 DOI: 10.4172/2155-9899.s9-002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Since its discovery in 2000, IL-21 has been shown to play critical roles in the regulation of both innate and adaptive immune responses. IL-21 is produced predominantly by multiple effector CD4+ T-cell types [T helper 17 (Th17), follicular helper T (TFH), and other activated CD4+ cells] and NKT cells. In addition to T cell receptor (TCR) signals, the production of IL-21 by activated CD4+ T cells is intricately regulated by various extrinsic factors and intrinsic molecules, such as IL-6, IL-21, ICOS, Stat3, IRF4, and Batf. Because IL-21 receptor (IL-21R) is broadly expressed on T, B, NK, and dentritic cells (DCs), IL-21 signaling via Jak-Stat and other pathways has direct pleiotropic effects on their proliferation, differentiation, and effector function. For instance, while Th17 and TFH cells produce IL-21, IL-21 also facilitates the development of these cells. IL-21-producing TFH cells are important for the generation and maintenance of germinal centers, and control the differentiation of germinal center B cells and immunoglobulin production. Thus, IL-21R deficiency or IL-21 neutralization with IL-21R-Fc fusion protein prevents B cell-mediated autoimmunity in lupus-prone BXSB.B6-Yaa+ or MRL-Faslpr mouse models, respectively. IL-21 also enhances expansion and cytotoxicity of CD8+ effector T cells. During chronic lymphocytic choriomeningitis viral infection, chronic IL-21 production by antigen-specific CD4+ T cells is needed to sustain CD8+ T cell function for viral control. IL-21 is also required for the development of T cell-mediated type 1 diabetes in NOD mice, possibly through sustaining effector T cell function in a similar manner. Recently, two papers have shown that IL-21R-Fc prevents both auto- and allo-immune responses after islet transplantation. A timely discussion is thus needed to address the immune actions of IL-21 as well as the therapeutic potential of targeting IL-21 in transplantation.
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Affiliation(s)
- Aini Xie
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA ; Department of Cardiovascular Surgery, Union Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
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125
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Daoud AHS, Betensley AD. Diagnosis and treatment of antibody mediated rejection in lung transplantation: A retrospective case series. Transpl Immunol 2013; 28:1-5. [DOI: 10.1016/j.trim.2012.11.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 11/23/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
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126
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Berger M, Zeevi A, Farmer DG, Abu-Elmagd KM. Immunologic challenges in small bowel transplantation. Am J Transplant 2012; 12 Suppl 4:S2-8. [PMID: 23181675 DOI: 10.1111/j.1600-6143.2012.04332.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Since the introduction of tacrolimus, small-bowel and multivisceral transplantion has increased to 100-200/year in the United States. The intestine carries more passenger lymphocytes than other organs, and bidirectional trafficking of lymphocytes and other immunocytes begins as soon as the vascular clamp is released. Because of ischemia-reperfusion injury and exposure to ligands for Toll-like receptors from the lumen, the innate immune system of the graft is activated, causing inflammation which must be brought under control by regulatory cells. Inclusion of the liver in the allograft favors graft acceptance, but the mechanism of this effect has not been determined. Anti-HLA and other anti-donor antibodies clearly play a major role in determining the long-term fate of the graft, as reflected in 5-year graft survival. Development of new (de novo) HLA antibodies and/or increases in their titers or function-especially the ability to bind C1q and activate complement increase the risk of graft loss. Monitoring antidonor antibody production and the use of new therapies including complement inhibitors will contribute to increasing success of SBT.
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Affiliation(s)
- M Berger
- Immunology R&D, CSL Behring, LLC, King of Prussia, PA, USA.
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127
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Miyagawa-Hayashino A, Yoshizawa A, Uchida Y, Egawa H, Yurugi K, Masuda S, Minamiguchi S, Maekawa T, Uemoto S, Haga H. Progressive graft fibrosis and donor-specific human leukocyte antigen antibodies in pediatric late liver allografts. Liver Transpl 2012; 18:1333-42. [PMID: 22888064 DOI: 10.1002/lt.23534] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The role of donor-specific anti-human leukocyte antigen antibodies (DSAs) that develop late after living donor liver transplantation is unknown. Seventy-nine pediatric recipients who had good graft function and underwent protocol liver biopsy more than 5 years after transplantation (median = 11 years, range = 5-20 years) were reviewed. DSAs were determined with the Luminex single-antigen bead assay at the time of the last biopsy, and complement component 4d (C4d) immunostaining was assessed at the times of the last biopsy and the previous biopsy. The donor specificity of antibodies could be identified in 67 patients: DSAs were detected in 32 patients (48%), and they were usually against human leukocyte antigen class II (30 cases) but were rarely against class I (2 cases). These patients had a higher frequency of bridging fibrosis or cirrhosis (28/32 or 88%) than DSA-negative patients (6/35 or 17%, P < 0.001). Fibrosis was likely to be centrilobular-based. DSA-positive patients, in comparison with DSA-negative patients, had higher frequencies of diffuse/focal endothelial C4d staining (P < 0.001) and mild/indeterminate acute rejection [15/32 (47%) versus 5/35 (14%), P = 0.004]. Four DSA-negative patients were off immunosuppression, whereas no patients in the DSA-positive group were (P = 0.048). In conclusion, the high prevalence of graft fibrosis and anti-class II DSAs in late protocol biopsy samples suggests that humoral alloreactivity may contribute to the process of unexplained graft fibrosis late after liver transplantation.
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128
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Abu-Elmagd KM, Wu G, Costa G, Lunz J, Martin L, Koritsky DA, Murase N, Irish W, Zeevi A. Preformed and de novo donor specific antibodies in visceral transplantation: long-term outcome with special reference to the liver. Am J Transplant 2012; 12:3047-60. [PMID: 22947059 DOI: 10.1111/j.1600-6143.2012.04237.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite improvement in early outcome, rejection particularly chronic allograft enteropathy continues to be a major barrier to long-term visceral engraftment. The potential role of donor specific antibodies (DSA) was examined in 194 primary adult recipients. All underwent complement-dependent lymphocytotoxic crossmatch (CDC-XM) with pre- and posttransplant solid phase HLA-DSA assay in 156 (80%). Grafts were ABO-identical with random HLA-match. Liver was included in 71 (37%) allografts. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 150 (77%). CDC-XM was positive in 55 (28%). HLA-DSA was detectable before transplant in 49 (31%) recipients with 19 continuing to have circulating antibodies. Another 19 (18%) developed de novo DSA. Ninety percent of patients with preformed DSA harbored HLA Class-I whereas 74% of recipients with de novo antibodies had Class-II. Gender, age, ABO blood-type, cold ischemia, splenectomy and allograft type were significant DSA predictors. Preformed DSA significantly (p < 0.05) increased risk of acute rejection. Persistent and de novo HLA-DSA significantly (p < 0.001) increased risk of chronic rejection and associated graft loss. Inclusion of the liver was a significant predictor of better outcome (p = 0.004, HR = 0.347) with significant clearance of preformed antibodies (p = 0.04, OR = 56) and lower induction of de novo DSA (p = 0.07, OR = 24). Innovative multifaceted anti-DSA strategies are required to further improve long-term survival particularly of liver-free allografts.
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Affiliation(s)
- K M Abu-Elmagd
- Department of Surgery Department of Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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129
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Ectonucleotidases in solid organ and allogeneic hematopoietic cell transplantation. J Biomed Biotechnol 2012; 2012:208204. [PMID: 23125523 PMCID: PMC3482062 DOI: 10.1155/2012/208204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 07/10/2012] [Indexed: 01/27/2023] Open
Abstract
Extracellular nucleotides are ubiquitous signalling molecules which modulate distinct physiological and pathological processes. Nucleotide concentrations in the extracellular space are strictly regulated by cell surface enzymes, called ectonucleotidases, which hydrolyze nucleotides to the respective nucleosides. Recent studies suggest that ectonucleotidases play a significant role in inflammation by adjusting the balance between ATP, a widely distributed proinflammatory danger signal, and the anti-inflammatory mediator adenosine. There is increasing evidence for a central role of adenosine in alloantigen-mediated diseases such as solid organ graft rejection and acute graft-versus-host disease (GvHD). Solid organ and hematopoietic cell transplantation are established treatment modalities for a broad spectrum of benign and malignant diseases. Immunological complications based on the recognition of nonself-antigens between donor and recipient like transplant rejection and GvHD are still major challenges which limit the long-term success of transplantation. Studies in the past two decades indicate that purinergic signalling influences the severity of alloimmune responses. This paper focuses on the impact of ectonucleotidases, in particular, NTPDase1/CD39 and ecto-5'-nucleotidase/CD73, on allograft rejection, acute GvHD, and graft-versus-leukemia effect, and on possible clinical implications for the modulation of purinergic signalling after transplantation.
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130
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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131
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Paterno F, Shiller M, Tillery G, O’Leary JG, Susskind B, Trotter J, Klintmalm GB. Bortezomib for acute antibody-mediated rejection in liver transplantation. Am J Transplant 2012; 12:2526-31. [PMID: 22681986 PMCID: PMC4410023 DOI: 10.1111/j.1600-6143.2012.04126.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) is an uncommon, but challenging type of rejection after solid organ transplantation. We review three cases of AMR in ABO-compatible liver transplant recipients. These cases were characterized by severe acute rejection resistant to steroids and antithymocyte globulin, histologic evidence of plasma cell infiltrates, C4d positivity and high serum anti-HLA donor-specific antibodies. All three patients were treated with bortezomib, a proteasome inhibitor effective in depleting plasma cells. After treatment, all patients had improved or normal liver function tests, resolution of C4d deposition and significant decline in their HLA donor-specific antibodies.
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Affiliation(s)
- F. Paterno
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, TX
| | - M. Shiller
- Department of Pathology, Baylor University Medical Center at Dallas, Baylor University Medical Center at Dallas, TX
| | - G. Tillery
- Department of Pathology, Baylor University Medical Center at Dallas, Baylor University Medical Center at Dallas, TX
| | - J. G. O’Leary
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, TX
| | - B. Susskind
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, TX
| | - J. Trotter
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, TX
| | - G. B. Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center at Dallas, TX,Corresponding author: Goran B. Klintmalm,
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132
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Billing H, Rieger S, Süsal C, Waldherr R, Opelz G, Wühl E, Tönshoff B. IVIG and rituximab for treatment of chronic antibody-mediated rejection: a prospective study in paediatric renal transplantation with a 2-year follow-up. Transpl Int 2012; 25:1165-73. [PMID: 22897111 DOI: 10.1111/j.1432-2277.2012.01544.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Chronic antibody-mediated rejection (AMR) is the major cause of late renal allograft loss. There is, however, no established treatment for this condition. We report the results of a prospective pilot study on an antihumoral therapy (AHT) consisting of high-dose intravenous immunoglobulin G (IVIG) and rituximab in 20 paediatric renal transplant recipients. Donor-specific HLA antibodies (HLA DSA) were quantified by Luminex-based bead array technology. Loss of eGFR decreased significantly from 7.6 ml/min/1.73 m² during 6 months prior to AHT to 2.1 ml/min/1.73 m² (P = 0.0013) during 6 months after AHT. Fourteen patients (70%) responded: nine of nine patients (100%) without and five of 11 (45%) with transplant glomerulopathy (P = 0.014). C4d positivity in PTC decreased from 40 ± 18.5% in the index biopsy to 11.6 ± 12.2% (P = 0.002) in the follow-up biopsy. In four of nine biopsies (44%) C4d staining turned negative. During 2 years of follow-up, the median loss of eGFR in each of the four 6-month periods remained significantly lower compared with prior to AHT. Class I DSA declined in response to AHT by 61% (p = 0.044), class II DSA by 63% (p = 0.033) 12 months after intervention. AHT with IVIG and rituximab significantly reduces or stabilizes the progressive loss of transplant function in paediatric patients with chronic AMR over an observation period of 2 years, apparently by lowering circulating DSA and reducing intrarenal complement activation.
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Affiliation(s)
- Heiko Billing
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
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133
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Pathologic features of antibody-mediated rejection in renal allografts: an expanding spectrum. Curr Opin Nephrol Hypertens 2012; 21:264-71. [PMID: 22388553 DOI: 10.1097/mnh.0b013e3283520efa] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW This review discusses recent findings that are changing and expanding the spectrum of pathologic changes associated with antibodies directed against renal allografts. RECENT FINDINGS This review focuses on four lesions: subclinical antibody-mediated rejection (AMR), C4d-negative AMR, intimal arteritis, and arterial intimal fibrosis. A number of studies have identified morphologic lesions of AMR in protocol biopsies of normally functioning renal allografts, particularly in sensitized recipients, that correlate with subsequent development of chronic changes in the graft, including transplant glomerulopathy. These same studies as well as molecular studies of indication biopsies of conventional renal allografts have noted evidence of microvascular injury, which, in the presence of donor-specific antibodies (DSAs) but the absence of C4d deposition in peritubular capillaries, is associated with development of transplant glomerulopathy and graft loss. Finally, recent studies suggest that intimal arteritis, previously felt to represent a lesion of cell-mediated rejection, and bland arterial intimal fibrosis, resembling arteriosclerosis, may in some cases be manifestations of DSA-induced graft injury. SUMMARY Incorporation of these newly recognized lesions of AMR into a working diagnostic schema with sufficient sensitivity and specificity to minimize undertreatment and overtreatment of patients is an important challenge currently faced by renal pathologists and transplant clinicians.
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134
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Hattori Y, Bucy RP, Kubota Y, Baldwin WM, Fairchild RL. Antibody-mediated rejection of single class I MHC-disparate cardiac allografts. Am J Transplant 2012; 12:2017-28. [PMID: 22578247 PMCID: PMC3409335 DOI: 10.1111/j.1600-6143.2012.04073.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Murine CCR5(-/-) recipients produce high titers of antibody to complete MHC-mismatched heart and renal allografts. To study mechanisms of class I MHC antibody-mediated allograft injury, we tested the rejection of heart allografts transgenically expressing a single class I MHC disparity in wild-type C57BL/6 (H-2(b)) and B6.CCR5(-/-) recipients. Donor-specific antibody titers in CCR5(-/-) recipients were 30-fold higher than in wild-type recipients. B6.K(d) allografts survived longer than 60 days in wild-type recipients whereas CCR5(-/-) recipients rejected all allografts within 14 days. Rejection was accompanied by infiltration of CD8 T cells, neutrophils and macrophages, and C4d deposition in the graft capillaries. B6.K(d) allografts were rejected by CD8(-/-)/CCR5(-/-), but not μMT(-/-)/CCR5(-/-), recipients indicating the need for antibody but not CD8 T cells. Grafts recovered at day 10 from CCR5(-/-) and CD8(-/-)/CCR5(-/-) recipients and from RAG-1(-/-) allograft recipients injected with anti-K(d) antibodies expressed high levels of perforin, myeloperoxidase and CCL5 mRNA. These studies indicate that the continual production of antidonor class I MHC antibody can mediate allograft rejection, that donor-reactive CD8 T cells synergize with the antibody to contribute to rejection, and that expression of three biomarkers during rejection can occur in the absence of this CD8 T cell activity.
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Affiliation(s)
- Yusuke Hattori
- Glickman Urological and Kidney Institute Cleveland Clinic, Cleveland, OH 44195
- Department of Immunology, Cleveland Clinic, Cleveland, OH 44195
- Department of Urology, Yokohama City University, Kanagawa, Japan
| | - R. Pat Bucy
- Department of Pathology, University of Alabama-Birmingham, Birmingham, AL
| | - Yoshinobu Kubota
- Department of Urology, Yokohama City University, Kanagawa, Japan
| | - William M. Baldwin
- Glickman Urological and Kidney Institute Cleveland Clinic, Cleveland, OH 44195
- Department of Immunology, Cleveland Clinic, Cleveland, OH 44195
| | - Robert L. Fairchild
- Glickman Urological and Kidney Institute Cleveland Clinic, Cleveland, OH 44195
- Department of Immunology, Cleveland Clinic, Cleveland, OH 44195
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106
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135
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Akiyoshi T, Hirohashi T, Alessandrini A, Chase CM, Farkash EA, Neal Smith R, Madsen JC, Russell PS, Colvin RB. Role of complement and NK cells in antibody mediated rejection. Hum Immunol 2012; 73:1226-32. [PMID: 22850181 DOI: 10.1016/j.humimm.2012.07.330] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 07/07/2012] [Accepted: 07/19/2012] [Indexed: 01/26/2023]
Abstract
Despite extensive research on T cells and potent immunosuppressive regimens that target cellular mediated rejection, few regimens have been proved to be effective on antibody-mediated rejection (AMR), particularly in the chronic setting. C4d deposition in the graft has been proved to be a useful marker for AMR; however, there is an imperfect association between C4d and AMR. While complement has been considered as the main player in acute AMR, the effector mechanisms in chronic AMR are still debated. Recent studies support the role of NK cells and direct effects of antibody on endothelium cells in a mechanism suggesting the presence of a complement-independent pathway. Here, we review the history, currently available systems and progress in experimental animal research. Although there are consistent findings from human and animal research, transposing the experimental results from rodent to human has been hampered by the differences in endothelial functions between species. We briefly describe the findings from patients and compare them with results from animals, to propose a combined perspective.
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Affiliation(s)
- Takurin Akiyoshi
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
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136
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Rummler S, Barz D. Plasma Exchange and Immunoadsorption of Patients with Thoracic Organ Transplantation. ACTA ACUST UNITED AC 2012; 39:234-240. [PMID: 22969692 DOI: 10.1159/000341676] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/06/2012] [Indexed: 11/19/2022]
Abstract
Primary organ failure after transplantation (TX) remains a serious complication and leads to a high percentage of lethality. It is known, however, that the speed of rejection and tissue destruction depends on 3 main factors: antibody titer, the ability of the tissue to repair itself, and immunosuppressive measures. Especially with evidence for antibodies against human leukocyte antigen (HLA-ab), the immunological risk of persistent and acute episodes of rejection increases. The role of non-HLA-ab in rejection episodes is often underestimated and should be studied further. Antibody-mediated rejection (AMR) is still an unsolved problem in thoracic organ TX. An essential pillar of antihumoral therapy are the extracorporeal procedures like plasmapheresis (PP), therapeutic plasma exchange (TPE), and immunoadsorption (IA), because only they have the ability to remove preformed or de novo developed antibodies quickly and effectively. The quick removal of antibodies and other plasma factors through TPE or IA remains an effective and supportive method for treating AMR and allows the TX despite preformed antibodies. The pertinent literature does not disclose, however, how often and for how long treatment should be administered. It is known, that repeated treatment cycles with adequately processed plasma volume must be used to overcome redistribution of pathological antibodies. Based on our experience in heart transplant recipients with compromised graft function due to non-HLA-ab and HLA-ab, IA seems to be more effective.
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Affiliation(s)
- Silke Rummler
- Institute of Transfusion Medicine, University Hospital Jena
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137
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Seifert M, Stolk M, Polenz D, Volk HD. Detrimental effects of rat mesenchymal stromal cell pre-treatment in a model of acute kidney rejection. Front Immunol 2012; 3:202. [PMID: 22826709 PMCID: PMC3398550 DOI: 10.3389/fimmu.2012.00202] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/28/2012] [Indexed: 12/21/2022] Open
Abstract
Mesenchymal stromal cells (MSC) have shown immunomodulatory and tissue repair potential including partial tolerance induction by pre-treatment of donor-specific cells in a rat heart transplantation model. Very recently, we could show that autologous MSC attenuated ischemia reperfusion injury in a highly mismatched donor–recipient rat kidney transplant model. Therefore, we investigated donor-specific MSC pre-treatment in this rat kidney transplantation model to study whether graft function could be improved, or if tolerance could be induced. Donor- and recipient-type MSC or phosphate buffered saline (PBS) as a control was injected i.v. 4 days before kidney transplantation. Mycophenolate mofetil immunosuppression (20mg/kg body weight) was applied for 7 days. Kidney grafts and spleens were harvested between days 8 and 10 and analyzed by quantitative RT-PCR and immunohistology. In addition, creatinine levels in the blood were measured and serum was screened for the presence of donor-specific antibodies. Surprisingly, application of both donor- and recipient-specific MSC resulted in enhanced humoral immune responses verified by intragraft B cell infiltration and complement factor C4d deposits. Moreover, signs of inflammation and rejection were generally enhanced in both MSC-treated groups relative to PBS control group. Additionally, pre-treatment with donor-specific MSC significantly enhanced the level of donor-specific antibody formation when compared with PBS- or recipient MSC-treated groups. Pre-treatment with both MSC types resulted in a higher degree of kidney cortex tissue damage and elevated creatinine levels at the time point of rejection. Thus, MSC pre-sensitization in this model impairs the allograft outcome. Our data from this pre-clinical kidney transplantation model indicate that pre-operative MSC administration may not be optimal in kidney transplantation and caution must be exerted before moving forward with clinical studies in order to avoid adverse effects.
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Affiliation(s)
- Martina Seifert
- Berlin-Brandenburg Center for Regenerative Therapies, Charité Universitätsmedizin Berlin , Berlin, Germany
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138
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Budd SJ, Aris RM, Medaiyese AA, Tilley SL, Neuringer IP. Increased plasma mannose binding lectin levels are associated with bronchiolitis obliterans after lung transplantation. Respir Res 2012; 13:56. [PMID: 22762710 PMCID: PMC3441326 DOI: 10.1186/1465-9921-13-56] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 04/09/2012] [Indexed: 11/11/2022] Open
Abstract
Background Long-term lung allograft survival is limited by bronchiolitis obliterans syndrome (BOS). Mannose binding lectin (MBL) belongs to the innate immune system, participates in complement activation, and may predispose to graft rejection. We investigated mannose binding (MBL) during cold ischemia and in tissue samples from explanted lungs with BOS, and assessed MBL and complement proteins in plasma post-lung transplantation relative to BOS staging. Methods MBL was detected by immunohistochemistry lung tissue at the time of cold ischemia and in samples with BOS. MBL was assayed in the peripheral blood of 66 lung transplant patients transplanted between 1990–2007. Results MBL localized to vasculature and basement membrane during cold ischemia and BOS. Patients further out post-lung transplant > 5 years (n = 33), had significantly lower levels of MBL in the blood compared to lung transplant patients < 5 years with BOS Op-3 (n = 17), 1738 ± 250 ng/ml vs 3198 ± 370 ng/ml, p = 0.027, and similar levels to lung transplant patients < 5 years with BOS 0 (n = 16), 1738 ± 250 ng/ml vs 1808 ± 345 ng/ml. MBL levels in all BOS 0 (n = 30) vs. all BOS Op-3 (n = 36) were 1378 ± 275 ng/ml vs. 2578 ± 390 ng/ml, p = 0.001, respectively. C3 plasma levels in BOS 0 (n = 30) vs. BOS Op-3 (n = 36) were 101 ± 19.8 mg/ml vs. 114 ± 25.2 mg/ml, p = 0.024, respectively. Conclusions MBL localizes within the lung during graft ischemia and BOS, higher levels of plasma MBL are associated with BOS Op-3 and < 5 years post-transplant, and higher level of plasma complement protein C3 was associated with BOS Op-3 clinical status. MBL may serve as a biomarker for poorer outcome post-lung transplantation.
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139
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Patel JK, Kobashigawa JA. Improving survival during heart transplantation: diagnosis of antibody-mediated rejection and techniques for the prevention of graft injury. Future Cardiol 2012; 8:623-35. [DOI: 10.2217/fca.12.27] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The diagnosis of antibody-mediated rejection (AMR) has presented a challenge due to the pleiomorphic immunologic responses that represent the condition. A consensus with regard to its pathological diagnosis continues to evolve. Due to an increasing number of sensitized patients undergoing heart transplantation, its incidence appears to be on the rise and the condition is associated with worse outcomes than acute cellular rejection. Treatment of AMR is also more difficult and response to increases in conventional immunosuppression is often limited. Risk factors for AMR include the use of ventricular assist devices, prior exposure to blood products, allografts and multiparity. Detection of alloantibodies with a high specificity and sensitivity allows risk stratification of recipients at potential risk of AMR. Desensitization and AMR treatment strategies are focused on several therapeutic targets, including suppression of T and B cells and elimination or inhibition of circulating antibodies.
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Affiliation(s)
- Jignesh K Patel
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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140
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Sicard A, Phares TW, Yu H, Fan R, Baldwin WM, Fairchild RL, Valujskikh A. The spleen is the major source of antidonor antibody-secreting cells in murine heart allograft recipients. Am J Transplant 2012; 12:1708-19. [PMID: 22420367 PMCID: PMC3381891 DOI: 10.1111/j.1600-6143.2012.04009.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody-mediated allograft rejection is an increasingly recognized problem in clinical transplantation. However, the primary location of donor-specific alloantibody (DSA)-producing cells after transplantation have not been identified. The purpose of this study was to test the contribution of allospecific antibody-secreting cells (ASCs) from different anatomical compartments in a mouse transplantation model. Fully MHC-mismatched heart allografts were transplanted into three groups of recipients: nonsensitized wild type, alloantigen-sensitized wild-type and CCR5(-/-) mice that have exaggerated alloantibody responses. We found that previous sensitization to donor alloantigens resulted in the development of antidonor alloantibody (alloAb) with accelerated kinetics. Nevertheless, the numbers of alloantibody-secreting cells and the serum titers of antidonor IgG alloantibody were equivalent in sensitized and nonsensitized recipients 6 weeks after transplantation. Regardless of recipient sensitization status, the spleen contained higher numbers of donor-reactive ASCs than bone marrow at days 7-21 after transplantation. Furthermore, individual spleen ASCs produced more antidonor IgG alloantibody than bone marrow ASCs. Taken together, our results indicate that the spleen rather than bone marrow is the major source of donor-reactive alloAb early after transplantation in both sensitized and nonsensitized recipients.
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Affiliation(s)
- Antoine Sicard
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
- Université Paris V, Service de Transplantation Rénale, Hôpital Necker, Paris, France
| | | | - Hong Yu
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
| | - Ran Fan
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
| | - William M. Baldwin
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
| | - Robert L. Fairchild
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
| | - Anna Valujskikh
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH
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141
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Gheith O, Al-Otaibi T, Nampoory N, Halim M, Nair P, Saied T, Al-Waheeb S, Muzeirei I, Ibraheim M. Effective therapy for acute antibody-mediated rejection with mild chronic changes: case report and review of the literature. EXP CLIN TRANSPLANT 2012; 10:406-9. [PMID: 22746156 DOI: 10.6002/ect.2011.0153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
To reduce the long-term toxicities of immunosuppressant drugs, corticosteroid-sparing and calcineurin-inhibitor-sparing immunosuppression protocols have become increasingly popular in managing kidney transplant recipients. The most vexing clinical condition caused by antibodies in organ transplants is antibody-mediated rejection. Limitations of the current antibody-mediated rejection therapies include (1) antibody-mediated rejection reversal tends to be gradual rather than prompt, (2) expense, (3) rejection reversal rates below 80%, (4) common appearance of chronic rejection after antibody-mediated rejection treatment, and (5) long-term persistence of donor specific antibodies after therapy. Because these limitations may be due to a lack of effects on mature plasma cells, the effects of bortezomib on mature plasma cells may represent a quantum advance in antihumoral therapy. Our experiences represent the first clinical use of bortezomib as an antihumoral agent in renal allograft recipients in Kuwait. We present 2 cases with resistant-acute antibody-mediated rejection to the standard therapies that were managed successfully with bortezomib.
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Affiliation(s)
- Osama Gheith
- Department of Nephrology, Hamed Al-Essa Organ Transplant Center, Kuwait.
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142
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Abstract
Antibody-mediated rejection after lung transplantation remains enigmatic. However, emerging evidence over the past several years suggests that humoral immunity plays an important role in allograft rejection. Indeed, the development of donor-specific antibodies after transplantation has been identified as an independent risk factor for acute cellular rejection and bronchiolitis obliterans syndrome. Furthermore, cases of acute antibody-mediated rejection resulting in severe allograft dysfunction have been reported, and these demonstrate that antibodies can directly injure the allograft. However, the incidence and toll of antibody-mediated rejection are unknown because there is no widely accepted definition and some cases may be unrecognized. Clearly, humoral immunity has become an important area for research and clinical investigation.
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Affiliation(s)
- Ramsey Hachem
- Washington University School of Medicine, Division of Pulmonary & Critical Care Medicine, 660 S. Euclid Ave., Campus Box 8052, St. Louis, MO 63110, USA,
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143
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Wilkes DS. Autoantibody formation in human and rat studies of chronic rejection and primary graft dysfunction. Semin Immunol 2012; 24:131-5. [PMID: 21925897 PMCID: PMC3873136 DOI: 10.1016/j.smim.2011.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 08/24/2011] [Indexed: 01/02/2023]
Abstract
Lung transplantation is considered a definitive treatment for many lung diseases. However, rejection and other pathologic entities are major causes of morbidity and mortality for lung transplant recipients. Primary graft dysfunction (PGD) and obliterative bronchiolitis (OB) are the leading causes of early and late mortality, respectively. While the immune basis of PGD has not been clearly defined, evidence is emerging about roles for autoantibodies in this process. Similarly, the pathogenesis of OB has been linked recently to autoimmunity. This review will highlight the current understanding of autoantibodies in PGD and OB post lung transplantation.
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Affiliation(s)
- David S Wilkes
- Center for Immunobiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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144
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Biomarkers of heart transplant rejection: the good, the bad, and the ugly! Transl Res 2012; 159:238-51. [PMID: 22424428 DOI: 10.1016/j.trsl.2012.01.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/19/2012] [Accepted: 01/19/2012] [Indexed: 12/24/2022]
Abstract
Acute cellular rejection (ACR), antibody-mediated rejection (AMR), and cardiac allograft vasculopathy (CAV) are important limitations for the long-term survival of heart transplant recipients. Although much progress has been made in reducing ACR with modern immunosuppressive treatments and continuous biopsy surveillance, there is still a long way to go to better understand and treat AMR, to enable early detection of patients at risk of CAV, and to reduce the development and sustained progression of this irreversible disease that permanently compromises graft function. This review considers the advances made in ACR detection and treatment allowing a more prolonged survival and the risk factors leading to endothelial injury, dysfunction, inflammation, and subsequent CAV, as well as new treatment modalities for CAV. The review also evaluates the controversies around the definition, pathogenesis, and treatment of AMR. To date, much progress is still needed to significantly reduce post-transplant complications and increase graft and patient survival.
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145
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Kwon GY. The Diagnosis of Acute Antibody-Mediated Rejection in ABO-Incompatible Liver Transplants. KOREAN JOURNAL OF TRANSPLANTATION 2012. [DOI: 10.4285/jkstn.2012.26.1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ghee Young Kwon
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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146
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Campo-Cañaveral de la Cruz JL, Naranjo JM, Salas C, Varela de Ugarte A. Fulminant hyperacute rejection after unilateral lung transplantation. Eur J Cardiothorac Surg 2012; 42:373-5. [PMID: 22422930 DOI: 10.1093/ejcts/ezs066] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hyperacute rejection (HAR) is a well-known complication in renal and cardiac transplantation, but rare in lung recipients. We present a case of HAR of the lung graft with a fatal outcome of a male patient with preformed class II anti-HLA antibodies.
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147
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148
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Shindoh J, Sugawara Y, Akamatsu N, Kaneko J, Tamura S, Yamashiki N, Aoki T, Sakamoto Y, Hasegawa K, Kokudo N. Thrombotic microangiopathy after living-donor liver transplantation. Am J Transplant 2012; 12:728-36. [PMID: 22070669 DOI: 10.1111/j.1600-6143.2011.03841.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Thrombotic microangiopathy (TMA) is an infrequent but severe life-threatening disorder in solid organ transplant recipients. Few studies of TMA in living donor liver transplant (LDLT) recipients, however, have been reported. We investigated the clinical characteristics and prognostic factors of TMA after LDLT. Among 393 adult LDLT recipients, 30 patients (7.6%) were identified to have TMA. The 1-, 3- and 5-year survival rates of these patients were lower (60.6%, 52.5% and 47.7%, respectively) than those of patients without TMA (93.0%, 89.0% and 87.3%, respectively). Multivariate analysis confirmed that reduced administration of fresh frozen plasma and sensitization against HLA are closely related with TMA (odds ratio [OR]: 2.6 and 16.1, respectively). However, a review of the cases revealed that individual responses to treatment varied considerably and the main etiologies were difficult to determine. A comparison of the clinical factors suggested that late onset (>30 days), poor response to treatment and delayed diagnosis and/or treatment are associated with a poor outcome. Because the prevention of TMA in LDLT patients is difficult, early diagnosis and initiation of intensive therapies may be crucial to improve the prognosis.
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Affiliation(s)
- J Shindoh
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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149
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Antibody-mediated rejection of a unilateral donor lung in bilateral living-donor lobar lung transplantation: report of a case. Surg Today 2012; 42:808-11. [DOI: 10.1007/s00595-012-0151-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/18/2011] [Indexed: 10/28/2022]
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150
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Current status of pediatric intestinal failure, rehabilitation, and transplantation: summary of a colloquium. Transplantation 2012; 92:1173-80. [PMID: 22067308 DOI: 10.1097/tp.0b013e318234c325] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
An international symposium convened September 9-11, 2010, in Chicago to present the state of the art and science of the multidisciplinary care of intestinal failure in children. Medical and surgical management of the child with intestinal failure was presented with a focus on the importance of multidisciplinary intestinal failure management. Issues of timing of referral and benefit risk analysis for intestine "rehabilitation" and transplant were presented. Areas of opportunity such as increased donor recovery, improvement of long-term transplant outcomes, optimization of immune monitoring, and quality-of-life outcomes were reviewed.
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