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Rabant M, Amrouche L, Lebreton X, Aulagnon F, Benon A, Sauvaget V, Bonifay R, Morin L, Scemla A, Delville M, Martinez F, Timsit MO, Duong Van Huyen JP, Legendre C, Terzi F, Anglicheau D. Urinary C-X-C Motif Chemokine 10 Independently Improves the Noninvasive Diagnosis of Antibody-Mediated Kidney Allograft Rejection. J Am Soc Nephrol 2015; 26:2840-51. [PMID: 25948873 DOI: 10.1681/asn.2014080797] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 12/22/2014] [Indexed: 01/08/2023] Open
Abstract
Urinary levels of C-X-C motif chemokine 9 (CXCL9) and CXCL10 can noninvasively diagnose T cell-mediated rejection (TCMR) of renal allografts. However, performance of these molecules as diagnostic/prognostic markers of antibody-mediated rejection (ABMR) is unknown. We investigated urinary CXCL9 and CXCL10 levels in a highly sensitized cohort of 244 renal allograft recipients (67 with preformed donor-specific antibodies [DSAs]) with 281 indication biopsy samples. We assessed the benefit of adding these biomarkers to conventional models for diagnosing/prognosing ABMR. Urinary CXCL9 and CXCL10 levels, normalized to urine creatinine (Cr) levels (CXCL9:Cr and CXCL10:Cr) or not, correlated with the extent of tubulointerstitial (i+t score; all P<0.001) and microvascular (g+ptc score; all P<0.001) inflammation. CXCL10:Cr diagnosed TCMR (area under the curve [AUC]=0.80; 95% confidence interval [95% CI], 0.68 to 0.92; P<0.001) and ABMR (AUC=0.76; 95% CI, 0.69 to 0.82; P<0.001) with high accuracy, even in the absence of tubulointerstitial inflammation (AUC=0.70; 95% CI, 0.61 to 0.79; P<0.001). Although mean fluorescence intensity of the immunodominant DSA diagnosed ABMR (AUC=0.75; 95% CI, 0.68 to 0.82; P<0.001), combining urinary CXCL10:Cr with immunodominant DSA levels improved the diagnosis of ABMR (AUC=0.83; 95% CI, 0.77 to 0.89; P<0.001). At the time of ABMR, urinary CXCL10:Cr ratio was independently associated with an increased risk of graft loss. In conclusion, urinary CXCL10:Cr ratio associates with tubulointerstitial and microvascular inflammation of the renal allograft. Combining the urinary CXCL10:Cr ratio with DSA monitoring significantly improves the noninvasive diagnosis of ABMR and the stratification of patients at high risk for graft loss.
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Affiliation(s)
- Marion Rabant
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France; Paris Descartes, Sorbonne Paris Cité University, Paris, France; Pathology Department and
| | - Lucile Amrouche
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Xavier Lebreton
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France
| | - Florence Aulagnon
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and
| | - Aurélien Benon
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Virginia Sauvaget
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Raja Bonifay
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Lise Morin
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and
| | - Anne Scemla
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and
| | - Marianne Delville
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and
| | - Frank Martinez
- Department of Nephrology and Kidney Transplantation, Necker Hospital, and
| | - Marc Olivier Timsit
- Paris Descartes, Sorbonne Paris Cité University, Paris, France; Department of Urology, Georges Pompidou European Hospital-Necker, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | | | - Christophe Legendre
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France; Paris Descartes, Sorbonne Paris Cité University, Paris, France; Department of Nephrology and Kidney Transplantation, Necker Hospital, and Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France
| | - Fabiola Terzi
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France
| | - Dany Anglicheau
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, Paris, France; Paris Descartes, Sorbonne Paris Cité University, Paris, France; Department of Nephrology and Kidney Transplantation, Necker Hospital, and Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France
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102
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Loupy A, Viglietti D, Mengel M. Complement inhibition in HLA-incompatible kidney transplants: persisting antibody-mediated injury despite marked decrease of clinical ABMR. Am J Transplant 2015; 15:1139-40. [PMID: 25731892 DOI: 10.1111/ajt.13172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/11/2014] [Accepted: 12/14/2014] [Indexed: 01/25/2023]
Affiliation(s)
- A Loupy
- Department of Kidney Transplantation, Necker Hospital Assitance Publique -, Hoà pitaux de Paris, Paris, France; Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
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103
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Salazar IDR, Merino López M, Chang J, Halloran PF. Reassessing the Significance of Intimal Arteritis in Kidney Transplant Biopsy Specimens. J Am Soc Nephrol 2015; 26:3190-8. [PMID: 25918035 DOI: 10.1681/asn.2014111064] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/10/2015] [Indexed: 12/23/2022] Open
Abstract
Intimal arteritis (the presence of v-lesions) in kidney transplant biopsy specimens is believed to have major prognostic and diagnostic significance. We assessed the relationship of v-lesions to prognosis in 703 indication biopsy specimens and used microarray-based molecular tests to re-examine the relationship of v-lesions to rejection. v-Lesions were noted in 49 specimens (7%) and were usually mild (v1). The presence of v-lesions had no effect on graft survival compared with the absence of v-lesions. Pathologists using current conventions almost always interpreted v-lesions as reflecting T cell-mediated rejection (TCMR), either pure or mixed with antibody-mediated rejection (ABMR). The molecular scores questioned the conventional diagnoses in 29 of 49 specimens (59%), including ten that were conventional TCMR with no molecular rejection and nine that were conventional TCMR mixed with pure ABMR molecularly. The presence of tubulointerstitial inflammation (i-t) meeting TCMR criteria allowed subclassification of v-lesion specimens into 21 i-t-v-lesion specimens and 28 isolated v-lesion specimens. Molecular TCMR scores were positive in 95% of i-t-v-lesion specimens but only 21% of isolated v-lesion specimens. Molecular ABMR scores were often positive in isolated v-lesion biopsies (46%). Time of biopsy after transplantation was critical for understanding isolated v-lesions: most early isolated v-lesion specimens had no molecular rejection and were DSA negative, whereas most isolated >1 year after transplantation had positive DSA and ABMR scores. Therefore, v-lesions in indication biopsy specimens do not affect prognosis and can reflect TCMR, ABMR, or no rejection. Time after transplantation, DSA, and accompanying inflammation provide probabilistic basis for interpreting v-lesions.
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Affiliation(s)
- Israel D R Salazar
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada; Department of Medicine, Viedma Hospital, Cochabamba, Bolivia; Caja National Health Hospital, Cochabamba, Bolivia; and
| | | | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada; Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
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104
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Boor P, Floege J. Renal allograft fibrosis: biology and therapeutic targets. Am J Transplant 2015; 15:863-86. [PMID: 25691290 DOI: 10.1111/ajt.13180] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/30/2014] [Accepted: 12/19/2014] [Indexed: 01/25/2023]
Abstract
Renal tubulointerstitial fibrosis is the final common pathway of progressive renal diseases. In allografts, it is assessed with tubular atrophy as interstitial fibrosis/tubular atrophy (IF/TA). IF/TA occurs in about 40% of kidney allografts at 3-6 months after transplantation, increasing to 65% at 2 years. The origin of renal fibrosis in the allograft is complex and includes donor-related factors, in particular in case of expanded criteria donors, ischemia-reperfusion injury, immune-mediated damage, recurrence of underlying diseases, hypertensive damage, nephrotoxicity of immunosuppressants, recurrent graft infections, postrenal obstruction, etc. Based largely on studies in the non-transplant setting, there is a large body of literature on the role of different cell types, be it intrinsic to the kidney or bone marrow derived, in mediating renal fibrosis, and the number of mediator systems contributing to fibrotic changes is growing steadily. Here we review the most important cellular processes and mediators involved in the progress of renal fibrosis, with a focus on the allograft situation, and discuss some of the challenges in translating experimental insights into clinical trials, in particular fibrosis biomarkers or imaging modalities.
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Affiliation(s)
- P Boor
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany; Department of Pathology, RWTH University of Aachen, Aachen, Germany; Institute of Molecular Biomedicine, Bratislava, Slovakia
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105
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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106
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107
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Affiliation(s)
- Bruce A Molitoris
- Nephrology Division, Department of Medicine, Indiana University School of Medicine, Roudebush Veterans Affairs Medical Center, and the Indiana Center for Biological Microscopy, Indianapolis, Indiana
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108
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Higgins RM, Daga S, Mitchell DA. Antibody-incompatible kidney transplantation in 2015 and beyond. Nephrol Dial Transplant 2014; 30:1972-8. [PMID: 25500804 DOI: 10.1093/ndt/gfu375] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/11/2014] [Indexed: 01/18/2023] Open
Abstract
Rejection caused by donor-specific antibodies (principally ABO and HLA antibodies) has become one of the major barriers to successful long-term transplantation. This review focuses on clinical outcomes in antibody-incompatible transplantation, the current state of the science underpinning clinical observations, and how these may be translated into further novel therapies. The clinical outcomes for allografts facing donor-specific antibodies are at present determined largely by the use of agents developed in the 20th century for the treatment of T-lymphocyte-mediated cellular rejection, such as interleukin-2 agents and anti-thymocyte globulin. These treatments are partially effective, because acute antibody-mediated rejection is mediated to a considerable extent by T lymphocytes. However these treatments are essentially ineffective in chronic antibody-mediated rejection. Future therapies for the prevention and treatment of antibody-mediated rejection are likely to fall into the categories of those that reduce antibody production, extracorporeal antibody removal and disruption of the effector arms of antibody-mediated tissue damage.
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Affiliation(s)
- Rob M Higgins
- Renal Unit, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Sunil Daga
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dan A Mitchell
- Warwick Medical School, University of Warwick, Coventry, UK
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109
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Broecker V, Mengel M. The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 2014; 28:136-43. [PMID: 25205033 DOI: 10.1111/tri.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 01/20/2023]
Abstract
In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
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Affiliation(s)
- Verena Broecker
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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110
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Stegall MD, Gaston RS, Cosio FG, Matas A. Through a glass darkly: seeking clarity in preventing late kidney transplant failure. J Am Soc Nephrol 2014; 26:20-9. [PMID: 25097209 DOI: 10.1681/asn.2014040378] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A common lament is that long-term kidney transplant outcomes remain the same despite improvements in early graft survival. To be fair, progress has been made-in both our understanding of chronic injury and modestly, graft survival. However, we are still a long way from actually solving this important and difficult problem. In this review, we outline recent data supporting the existence of several causes of renal allograft loss, the incidences of which peak at different time points after transplantation. On the basis of this broadened concept of chronic renal allograft injury, we examine the challenges of clinical trial design in long-term studies, including the use of surrogate end points and biomarkers. Finally, we suggest a path forward that, ultimately, may improve long-term renal allograft survival.
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Affiliation(s)
- Mark D Stegall
- Division of Transplant Surgery, Departments of Surgery and Immunology, von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota;
| | - Robert S Gaston
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fernando G Cosio
- Division of Nephrology and Hypertension, Department of Medicine, von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota; and
| | - Arthur Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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111
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Morath C, Zeier M. Transplantation: Molecular diagnosis of kidney transplant rejection. Nat Rev Nephrol 2014; 10:429-30. [PMID: 24935708 DOI: 10.1038/nrneph.2014.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christian Morath
- University of Heidelberg, Department of Nephrology, Im Neuenheimer Feld 162, Heidelberg 69120, Germany
| | - Martin Zeier
- University of Heidelberg, Department of Nephrology, Im Neuenheimer Feld 162, Heidelberg 69120, Germany
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