101
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Recommended Treatment for Antibody-mediated Rejection After Kidney Transplantation: The 2019 Expert Consensus From the Transplantion Society Working Group. Transplantation 2020; 104:911-922. [PMID: 31895348 PMCID: PMC7176344 DOI: 10.1097/tp.0000000000003095] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the development of modern solid-phase assays to detect anti-HLA antibodies and a more precise histological classification, the diagnosis of antibody-mediated rejection (AMR) has become more common and is a major cause of kidney graft loss. Currently, there are no approved therapies and treatment guidelines are based on low-level evidence. The number of prospective randomized trials for the treatment of AMR is small, and the lack of an accepted common standard for care has been an impediment to the development of new therapies. To help alleviate this, The Transplantation Society convened a meeting of international experts to develop a consensus as to what is appropriate treatment for active and chronic active AMR. The aim was to reach a consensus for standard of care treatment against which new therapies could be evaluated. At the meeting, the underlying biology of AMR, the criteria for diagnosis, the clinical phenotypes, and outcomes were discussed. The evidence for different treatments was reviewed, and a consensus for what is acceptable standard of care for the treatment of active and chronic active AMR was presented. While it was agreed that the aims of treatment are to preserve renal function, reduce histological injury, and reduce the titer of donor-specific antibody, there was no conclusive evidence to support any specific therapy. As a result, the treatment recommendations are largely based on expert opinion. It is acknowledged that properly conducted and powered clinical trials of biologically plausible agents are urgently needed to improve patient outcomes.
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102
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DSA Are Associated With More Graft Injury, More Fibrosis, and Upregulation of Rejection-associated Transcripts in Subclinical Rejection. Transplantation 2020; 104:551-561. [PMID: 31651790 DOI: 10.1097/tp.0000000000003034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Subclinical T cell-mediated rejection (subTCMR) is commonly found after liver transplantation and has a good short-term prognosis, even when it is left untreated. Donor-specific antibodies (DSA) are putatively associated with a worse prognosis for recipient and graft after liver transplantation. METHODS To assess the immune regulation in subTCMR grafts, gene expression of 93 transcripts for graft injury, tolerance, and immune regulation was analyzed in 77 biopsies with "no histologic rejection" (NHR; n = 25), "clinical TCMR" (cTMCR; n = 16), and subTCMR (n = 36). In addition, all available subTCMR biopsies (n = 71) were tested for DSA with bead assays. RESULTS SubTCMR showed heterogeneous and intermediate expression profiles of transcripts that were upregulated in cTCMR. Graft gene expression suggested a lower activation of effector lymphocytes and a higher activation of regulatory T cells in grafts with subTCMR compared to cTCMR. DSA positivity in subTCMR was associated with histological evidence of more severe graft inflammation and fibrosis. This more severe DSA+ associated graft injury in subTCMR was converged with an upregulation of cTCMR-associated transcripts. In nonsupervised analysis, DSA positive subTCMR mostly clustered together with cTCMR, while DSA negative subTCMR clustered together with NHR. CONCLUSIONS T cell-mediated rejection seems to form a continuum of alloimmune activation. Although subTCMR exhibited less expression of TCMR-associated transcript, DSA positivity in subTCMR was associated with an upregulation of rejection-associated transcripts. The identification of DSA positive subclinical rejection might help to define patients with more inflammation in the graft and development of fibrosis.
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103
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Stites E, Kumar D, Olaitan O, John Swanson S, Leca N, Weir M, Bromberg J, Melancon J, Agha I, Fattah H, Alhamad T, Qazi Y, Wiseman A, Gupta G. High levels of dd-cfDNA identify patients with TCMR 1A and borderline allograft rejection at elevated risk of graft injury. Am J Transplant 2020; 20:2491-2498. [PMID: 32056331 PMCID: PMC7496411 DOI: 10.1111/ajt.15822] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 01/25/2023]
Abstract
The clinical importance of subclinical, early T cell-mediated rejection (Banff TCMR 1A and borderline lesions) remains unclear, due, in part to the fact that histologic lesions used to characterize early TCMR can be nonspecific. Donor-derived cell-free DNA (dd-cfDNA) is an important molecular marker of active graft injury. Over a study period from June 2017 to May 2019, we assessed clinical outcomes in 79 patients diagnosed with TCMR 1A/borderline rejection across 11 US centers with a simultaneous measurement of dd-cfDNA. Forty-two patients had elevated dd-cfDNA (≥0.5%) and 37 patients had low levels (<0.5%). Elevated levels of dd-cfDNA predicted adverse clinical outcomes: among patients with elevated cfDNA, estimated glomerular filtration rate declined by 8.5% (interquartile rate [IQR] -16.22% to -1.39%) (-3.50 mL/min/1.73 m2 IQR -8.00 to -1.00) vs 0% (-4.92%, 4.76%) in low dd-cfDNA patients (P = .004), de novo donor-specific antibody formation was seen in 40% (17/42) vs 2.7% (P < .0001), and future or persistent rejection occurred in 9 of 42 patients (21.4%) vs 0% (P = .003). The use of dd-cfDNA may complement the Banff classification and to risk stratify patients with borderline/TCMR 1A identified on biopsy.
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Affiliation(s)
| | - Dhiren Kumar
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | | | | | - Nicolae Leca
- Division of NephrologyDepartment of MedicineUniversity of Washington Medical CenterSeattleWashingtonUSA
| | - Matthew Weir
- Division of NephrologyUniversity of MarylandBaltimoreMarylandUSA
| | | | - Joseph Melancon
- SurgeryGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Irfan Agha
- Medical City Dallas HospitalDallasTexasUSA
| | - Hasan Fattah
- University of Kentucky Medical CenterLexingtonKentuckyUSA
| | - Tarek Alhamad
- Washington University in Saint LouisSaint LouisMissouriUSA
| | - Yasir Qazi
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Internal MedicineDivision of NephrologyLos AngelesCaliforniaUSA
| | | | - Gaurav Gupta
- Medicine/NephrologyVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
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104
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Monitoring of Donor-specific Anti-HLA Antibodies and Management of Immunosuppression in Kidney Transplant Recipients: An Evidence-based Expert Paper. Transplantation 2020; 104:S1-S12. [DOI: 10.1097/tp.0000000000003270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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105
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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106
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Okada M, Tomosugi T, Futamura K, Hiramitsu T, Goto N, Narumi S, Takeda A, Watarai Y. Mid-Term Outcomes After Treatment for Antibody-Mediated Rejection by De Novo Donor-Specific HLA Antibody in Renal Transplant Recipients: Does Early Treatment Lead to Better Outcomes? Transplant Proc 2020; 52:3051-3057. [PMID: 32694058 DOI: 10.1016/j.transproceed.2020.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/15/2020] [Accepted: 06/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND De novo donor-specific HLA antibody (DSA) and antibody-mediated rejection (ABMR) are strongly associated with late allograft loss in renal transplant recipients. However, the impact of therapeutic intervention with the current treatment options for ABMR remains unclear. This study aimed to elucidate the efficacy of treatment for ABMR. METHODS Sixty-seven patients who had de novo DSAs underwent diagnostic biopsy for ABMR, and these patients were classified into 3 groups: ABMR-free group (n = 40), clinical ABMR group (n = 15), and subclinical ABMR group (n = 12). The ABMR-positive groups were treated mainly with double-filtration plasmapheresis followed by rituximab and corticosteroid pulse. The patient characteristics and graft outcomes were compared between groups. RESULTS The clinical and subclinical ABMR groups were younger and had a higher number and mean fluorescence intensity (MFI) of de novo DSAs than the ABMR-free group. The graft survival in the clinical ABMR group was significantly lower than that in the ABMR-free group, but the subclinical ABMR group had a surprisingly good graft survival rate compared to the ABMR-free group (43.3% vs 100% vs 94.2% 5 years after diagnostic biopsy in the clinical ABMR, subclinical ABMR, and ABMR-free groups, respectively, P < .001). CONCLUSIONS Our findings indicated that early therapeutic intervention for patients with de novo DSAs may improve graft survival.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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107
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Urinary Protein Biomarker Panel for the Diagnosis of Antibody-Mediated Rejection in Kidney Transplant Recipients. Kidney Int Rep 2020; 5:1448-1458. [PMID: 32954069 PMCID: PMC7486186 DOI: 10.1016/j.ekir.2020.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Antibody-mediated rejection (ABMR) impacts kidney allograft outcome. The diagnosis is made based on findings from invasive kidney transplant biopsy specimens. The aim of this study was to identify a noninvasive urinary protein biomarker for ABMR after kidney transplantation. Methods We performed a multicenter case-control study to identify a urinary biomarker for ABMR (training cohort, n = 249) and an independent, prospective multicenter cohort study for validation (n = 391). We used concomitant biopsies to classify the samples according to the Banff classification. After untargeted protein identification and quantification, we used a support vector machine to train the model in the training cohort. The primary endpoint was the diagnostic accuracy of the urinary biomarker for ABMR in the validation cohort. Results We identified a set of 10 urinary proteins that accurately discriminated patients with (n = 60) and without (n = 189) ABMR in the training cohort with an area under the curve (AUC) of 0.98 (95% confidence interval [CI], 0.96–1.00). The diagnostic accuracy was maintained in the validation cohort (AUC, 0.88; 95% CI, 0.8–0.93) for discriminating the presence (n = 43) from the absence (n = 348) of ABMR. The negative predictive value of the 10-protein marker set for exclusion of ABMR was 0.99, and the positive predictive value was 0.33. The diagnostic accuracy was independent of the reason for performing the biopsy, time after transplantation, and better than the accuracy of gross proteinuria (AUC, 0.76). Conclusions We identified and validated a urinary protein biomarker set that can be used to exclude ABMR.
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108
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Lee DM, Abecassis MM, Friedewald JJ, Rose S, First MR. Kidney Graft Surveillance Biopsy Utilization and Trends: Results From a Survey of High-Volume Transplant Centers. Transplant Proc 2020; 52:3085-3089. [PMID: 32576474 DOI: 10.1016/j.transproceed.2020.04.1816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/13/2020] [Accepted: 04/25/2020] [Indexed: 12/22/2022]
Abstract
An e-mail-based market research survey focused on high-volume US adult transplant centers was developed and implemented to assess surveillance based on United Network for Organ Sharing/Scientific Registry of Transplant Recipients data: 51 to 100 transplants, 101 to 200 transplants, and more than 200 transplants. Eighty-three centers responded to the survey. Respondent centers represented 13,837/21,167 (65%) of the total kidney transplants in 2018. In total, 38/83 (46%) centers reported the use of surveillance biopsies-20 centers in all patients and 18 in select patients. Surveillance biopsies were performed in 37% (7/19) of centers performing 51 to 100 transplants annually, in 44% (15/34) doing 101 to 200 transplants, and in 53% (16/30) of centers doing more than 200 transplants. Of the 20 centers doing surveillance biopsies in all patients, 17/20 (85%) perform more than 100 annual transplants, and 3/20 (15%) perform less than 100 annual transplants. Of the 45 centers not currently doing surveillance biopsies, 13 (29%) used surveillance biopsies in the past; discontinuation was primarily due to patient inconvenience, adverse events, and cost. Using survey percentages, it is estimated that surveillance biopsies are performed in approximately 34% of kidney transplant recipients and that 74% of all surveillance biopsies occur in centers performing more than 100 kidney transplants per year.
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Affiliation(s)
| | | | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - M Roy First
- Transplant Genomics, Inc., Mansfield, MA; Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
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109
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Navarrete M, Korkmaz B, Guarino C, Lesner A, Lao Y, Ho J, Nickerson P, Wilkins JA. Activity-based protein profiling guided identification of urine proteinase 3 activity in subclinical rejection after renal transplantation. Clin Proteomics 2020; 17:23. [PMID: 32549867 PMCID: PMC7296916 DOI: 10.1186/s12014-020-09284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/19/2020] [Indexed: 03/04/2023] Open
Abstract
Background The pathophysiology of subclinical versus clinical rejection remains incompletely understood given their equivalent histological severity but discordant graft function. The goal was to evaluate serine hydrolase enzyme activities to explore if there were any underlying differences in activities during subclinical versus clinical rejection. Methods Serine hydrolase activity-based protein profiling (ABPP) was performed on the urines of a case control cohort of patients with biopsy confirmed subclinical or clinical transplant rejection. In-gel analysis and affinity purification with mass spectrometry were used to demonstrate and identify active serine hydrolase activity. An assay for proteinase 3 (PR3/PRTN3) was adapted for the quantitation of activity in urine. Results In-gel ABPP profiles suggested increased intensity and diversity of serine hydrolase activities in urine from patients undergoing subclinical versus clinical rejection. Serine hydrolases (n = 30) were identified by mass spectrometry in subclinical and clinical rejection patients with 4 non-overlapping candidates between the two groups (i.e. ABHD14B, LTF, PR3/PRTN3 and PRSS12). Western blot and the use of a specific inhibitor confirmed the presence of active PR3/PRTN3 in samples from patients undergoing subclinical rejection. Analysis of samples from normal donors or from several serial post-transplant urines indicated that although PR3/PRTN3 activity may be highly associated with low-grade subclinical inflammation, the enzyme activity was not restricted to this patient group. Conclusions There appear to be limited qualitative and quantitative differences in serine hydrolase activity in patients with subclinical versus clinical renal transplant rejection. The majority of enzymes identified were present in samples from both groups implying that in-gel quantitative differences may largely relate to the activity status of shared enzymes. However qualitative compositional differences were also observed indicating differential activities. The PR3/PRTN3 analyses indicate that the activity status of urine in transplant patients is dynamic possibly reflecting changes in the underlying processes in the transplant. These data suggest that differential serine hydrolase pathways may be active in subclinical versus clinical rejection which requires further exploration in larger patient cohorts. Although this study focused on PR3/PRTN3, this does not preclude the possibility that other enzymes may play critical roles in the rejection process.
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Affiliation(s)
- Mario Navarrete
- Manitoba Centre for Proteomics and Systems Biology, 799 John Buhler Research Centre, 715 McDermot Ave., Winnipeg, MB R3E3P4 Canada
| | - Brice Korkmaz
- INSERM, UMR 1100, "Centre d'Etude des Pathologies Respiratoires", Université de Tours, 37032 Tours, France
| | - Carla Guarino
- INSERM, UMR 1100, "Centre d'Etude des Pathologies Respiratoires", Université de Tours, 37032 Tours, France
| | - Adam Lesner
- Faculty of Chemistry, University of Gdansk, 80-308 Gdansk, Poland
| | - Ying Lao
- Manitoba Centre for Proteomics and Systems Biology, 799 John Buhler Research Centre, 715 McDermot Ave., Winnipeg, MB R3E3P4 Canada
| | - Julie Ho
- Manitoba Centre for Proteomics and Systems Biology, 799 John Buhler Research Centre, 715 McDermot Ave., Winnipeg, MB R3E3P4 Canada.,Section Biomedical Proteomics, Dept. Internal Medicine, University of Manitoba, Winnipeg, MB Canada.,Section of Nephrology, Dept. Internal Medicine, University of Manitoba, Winnipeg, MB Canada.,Dept. Immunology, University of Manitoba, Winnipeg, MB Canada
| | - Peter Nickerson
- Manitoba Centre for Proteomics and Systems Biology, 799 John Buhler Research Centre, 715 McDermot Ave., Winnipeg, MB R3E3P4 Canada.,Section Biomedical Proteomics, Dept. Internal Medicine, University of Manitoba, Winnipeg, MB Canada.,Section of Nephrology, Dept. Internal Medicine, University of Manitoba, Winnipeg, MB Canada.,Dept. Immunology, University of Manitoba, Winnipeg, MB Canada
| | - John A Wilkins
- Manitoba Centre for Proteomics and Systems Biology, 799 John Buhler Research Centre, 715 McDermot Ave., Winnipeg, MB R3E3P4 Canada.,Section Biomedical Proteomics, Dept. Internal Medicine, University of Manitoba, Winnipeg, MB Canada
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110
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Analysis of 75 Candidate SNPs Associated With Acute Rejection in Kidney Transplant Recipients: Validation of rs2910164 in MicroRNA MIR146A. Transplantation 2020; 103:1591-1602. [PMID: 30801535 PMCID: PMC6913779 DOI: 10.1097/tp.0000000000002659] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Identifying kidney allograft recipients who are predisposed to acute rejection (AR) could allow for optimization of clinical treatment to avoid rejection and prolong graft survival. It has been hypothesized that a part of this predisposition is caused by the inheritance of specific genetic variants. There are many publications reporting a statistically significant association between a genetic variant, usually in the form of a single-nucleotide polymorphism (SNP), and AR. However, there are additional publications reporting a lack of this association when a different cohort of recipients is analyzed for the same single-nucleotide polymorphism. METHODS In this report, we attempted to validate 75 common genetic variants, which have been previously reported to be associated with AR, using a large kidney allograft recipient cohort of 2390 European Americans and 482 African Americans. RESULTS Of those variants tested, only 1 variant, rs2910164, which alters the expression of the microRNA MIR146A, was found to exhibit a significant association within the African American cohort. Suggestive variants were found in the genes CTLA and TLR4. CONCLUSIONS Our results show that most variants previously reported to be associated with AR were not validated in our cohort. This shows the importance of validation when reporting the associations with complex clinical outcomes such as AR. Additional work will need to be done to understand the role of MIR146A in the risk of AR in kidney allograft recipients.
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111
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Nickerson PW. What have we learned about how to prevent and treat antibody-mediated rejection in kidney transplantation? Am J Transplant 2020; 20 Suppl 4:12-22. [PMID: 32538535 DOI: 10.1111/ajt.15859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023]
Abstract
Antibody-mediated rejection (ABMR) in kidney transplantation is a major cause of late graft loss, and despite all efforts to date the "standard of care" remains plasmapheresis, IVIg, and steroids, which itself is based on low quality evidence. This review focuses on the risk factors leading to memory and de novo donor-specific antibody (DSA)-associated ABMR, the optimal prevention strategies for ABMR, and advances in adjunctive and emerging therapies for ABMR. Because new agents require regulatory approval via a Phase 3 randomized control trial (RCT), an overview of progress in innovative trial design for ABMR is provided. Finally, based on the insights gained in the biology of ABMR, current knowledge gaps are identified for future research that could significantly affect our understanding of how to optimally treat ABMR.
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Affiliation(s)
- Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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112
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The Impact of Early Clinical and Subclinical T Cell-mediated Rejection After Kidney Transplantation. Transplantation 2020; 103:1457-1467. [PMID: 30747837 DOI: 10.1097/tp.0000000000002560] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated the effect of clinical and subclinical T cell-mediated rejection (C-TCMR and SC-TCMR) on allograft histology, function, and progression. METHODS Adult kidney recipients with 2 protocol biopsies were divided into No-TCMR on biopsies (n = 104), SC-TCMR (n = 56), and C-TCMR (n = 32) in at least 1 biopsy. Chronicity (ci + ct + cg + cv) scores, renal function, and the burden of renal disease measured by area under the curve (serum creatinine, mg mo/dL) were compared. RESULTS Baseline characteristics were similar except for mean donor age and Kidney Donor Profile index scores. Patients with C-TCMR had higher mean serum creatinine, lower mean estimated glomerular filtration rate, and higher area under the curve with 95% confidence interval (75.2 [67.7-82.7]) as opposed to patients with SC-TCMR and No-TCMR (58.3 [53.6-62.9], 65.1 [58.8-71.5]), P = 0.0004. Chronicity scores were higher at 3 months in C-TCMR (2.30 ± 1.58) compared with SC-TCMR (2.02 ± 1.42) and No-TCMR (1.31 ± 1.18), P = 0.0001 and also at 12 months. At last follow-up, 18.8% patients with C-TCMR had ≥50% decline in estimated glomerular filtration rate from 3 months compared with 7% and 1% among No-TCMR and SC-TCMR groups (P = 0.038). Multivariate analyses revealed higher odds of Δ-creatinine ≥ 0.5 mg/dL from 3 months to last follow-up for C-TCMR (3.39 [95% confidence interval, 1.25-9.20]) versus No-TCMR (P = 0.016). CONCLUSIONS Kidney transplant recipients with C-/SC-TCMR have heightened early allograft chronicity and worse renal function compared with those with No-TCMR. Progressive renal dysfunction was noted among patients with C-TCMR as opposed to SC-TCMR and No-TCMR.
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113
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Shaw BI, Cheng DK, Acharya CR, Ettenger RB, Lyerly HK, Cheng Q, Kirk AD, Chambers ET. An age-independent gene signature for monitoring acute rejection in kidney transplantation. Theranostics 2020; 10:6977-6986. [PMID: 32550916 PMCID: PMC7295062 DOI: 10.7150/thno.42110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Acute rejection (AR) remains a significant problem that negatively impacts long-term renal allograft survival. Numerous therapies are used to prevent AR that differ by center and recipient age. This variability confounds diagnostic methods. Methods: To develop an age-independent gene signature for AR effective across a broad array of immunosuppressive regimens, we compiled kidney transplant biopsy (n=1091) and peripheral blood (n=392) gene expression profiles from 12 independent public datasets. After removing genes differentially expressed in pediatric and adult patients, we compared gene expression profiles from biopsy and peripheral blood samples of patients with AR to those who were stable (STA), using Mann-Whitney U Tests with validation in independent testing datasets. We confirmed this signature in pediatric and adult patients (42 AR and 47 STA) from our institutional biorepository. Results: We identified a novel age-independent gene network that identified AR from both kidney and blood samples. We developed a 90-probe set signature targeting 76 genes that differentiated AR from STA and found an 8 gene subset (DIP2C, ENOSF1, FBXO21, KCTD6, PDXDC1, REXO2, HLA-E, and RAB31) that was associated with AR. Conclusion: We used publicly available datasets to create a gene signature of AR that identified AR irrespective of immunosuppression regimen or recipient age. This study highlights a novel model to screen and validate biomarkers across multiple treatment regimens.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University Medical Center, Durham, United States
| | - Daniel K. Cheng
- Department of Pediatrics, Duke University Medical Center, Durham, United States
| | | | - Robert B Ettenger
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, United States
| | - Herbert Kim Lyerly
- Department of Surgery, Duke University Medical Center, Durham, United States
| | - Qing Cheng
- Department of Surgery, Duke University Medical Center, Durham, United States
| | - Allan D Kirk
- Department of Surgery, Duke University Medical Center, Durham, United States
- Department of Pediatrics, Duke University Medical Center, Durham, United States
| | - Eileen T Chambers
- Department of Surgery, Duke University Medical Center, Durham, United States
- Department of Pediatrics, Duke University Medical Center, Durham, United States
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114
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Thongprayoon C, Vaitla P, Craici IM, Leeaphorn N, Hansrivijit P, Salim SA, Bathini T, Cabeza Rivera FH, Cheungpasitporn W. The Use of Donor-Derived Cell-Free DNA for Assessment of Allograft Rejection and Injury Status. J Clin Med 2020; 9:E1480. [PMID: 32423115 PMCID: PMC7290747 DOI: 10.3390/jcm9051480] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Patient monitoring after kidney transplantation (KT) for early detection of allograft rejection remains key in preventing allograft loss. Serum creatinine has poor predictive value to detect ongoing active rejection as its increase is not sensitive, nor specific for acute renal allograft rejection. Diagnosis of acute rejection requires allograft biopsy and histological assessment, which can be logistically challenging in some cases and carries inherent risk for complications related to procedure. Donor-derived cell-free DNA (dd-cfDNA), DNA of donor origin in the blood of KT recipient arising from cells undergoing injury and death, has been examined as a potential surrogate marker for allograft rejection. A rise in dd-cfDNA levels precedes changes in serum creatinine allows early detections and use as a screening tool for allograft rejection. In addition, when used in conjunction with donor-specific antibodies (DSA), it increases the pre-biopsy probability of antibody-mediated rejection (ABMR) aiding the decision-making process. Advancements in noninvasive biomarker assays such as dd-cfDNA may offer the opportunity to improve and expand the spectrum of available diagnostic tools to monitor and detect risk for rejection and positively impact outcomes for KT recipients. In this this article, we discussed the evolution of dd-cfDNA assays and recent evidence of assessment of allograft rejection and injury status of KT by the use of dd-cfDNA.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (I.M.C.)
| | - Pradeep Vaitla
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Iasmina M. Craici
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (I.M.C.)
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke’s Health System, Kansas City, MO 64111, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Sohail Abdul Salim
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Franco H. Cabeza Rivera
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
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115
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Patient Survival After Kidney Transplantation: Important Role of Graft-sustaining Factors as Determined by Predictive Modeling Using Random Survival Forest Analysis. Transplantation 2020; 104:1095-1107. [DOI: 10.1097/tp.0000000000002922] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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116
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Hanssen O, Weekers L, Lovinfosse P, Jadoul A, Bonvoisin C, Bouquegneau A, Grosch S, Huynen A, Anglicheau D, Hustinx R, Jouret F. Diagnostic yield of 18 F-FDG PET/CT imaging and urinary CXCL9/creatinine levels in kidney allograft subclinical rejection. Am J Transplant 2020; 20:1402-1409. [PMID: 31841263 DOI: 10.1111/ajt.15742] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 01/25/2023]
Abstract
Subclinical kidney allograft acute rejection (SCR) corresponds to "the unexpected histological evidence of acute rejection in a stable patient." SCR detection relies on surveillance biopsy. Noninvasive approaches may help avoid biopsy-associated complications. From November 2015 to January 2018, we prospectively performed positron emission tomography/computed tomography (PET/CT) after injection of F18 -fluorodeoxyglucose (18 F-FDG) in adult kidney transplant recipients with surveillance biopsy at ~3 months posttransplantation. The Banff-2017 classification was used. The ratio of the mean standard uptake value (mSUVR) between kidney cortex and psoas muscle was measured. Urinary levels of CXCL-9 were concomitantly quantified. Our 92-patient cohort was categorized upon histology: normal (n = 70), borderline (n = 16), and SCR (n = 6). No clinical or biological difference was observed between groups. The mSUVR reached 1.87 ± 0.55, 1.94 ± 0.35, and 2.41 ± 0.54 in normal, borderline, and SCR groups, respectively. A significant difference in mSUVR was found among groups. Furthermore, mSUVR was significantly higher in the SCR vs normal group. The area under the receiver operating characteristic curve (AUC) was 0.79, with 83% sensitivity using an mSUVR threshold of 2.4. The AUC of urinary CXCL-9/creatinine ratios comparatively reached 0.79. The mSUVR positively correlated with ti and acute composite Banff scores. 18 F-FDG-PET/CT helps noninvasively exclude SCR, with a negative predictive value of 98%. External validations are required.
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Affiliation(s)
- Oriane Hanssen
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
| | - Laurent Weekers
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
| | - Pierre Lovinfosse
- Division of Nuclear Medicine, Department of Medical Physics, University of Liège Hospital, Liège, Belgium
| | - Alexandre Jadoul
- Division of Nuclear Medicine, Department of Medical Physics, University of Liège Hospital, Liège, Belgium
| | - Catherine Bonvoisin
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
| | - Antoine Bouquegneau
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
| | - Stéphanie Grosch
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium.,Division of Renal Pathology, Unilab, University of Liège Hospital, Liège, Belgium
| | - Alexandre Huynen
- Structural Engineering Division, Faculty of Applied Sciences, University of Liège, Liège, Belgium
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, RTRS Centaure, LabEx Transplantex, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Roland Hustinx
- Division of Nuclear Medicine, Department of Medical Physics, University of Liège Hospital, Liège, Belgium
| | - Francois Jouret
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium.,Groupe Interdisciplinaire de Géno-protéomique Appliquée, Cardiovascular Sciences, University of Liège, Liège, Belgium
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117
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Madill-Thomsen K, Perkowska-Ptasińska A, Böhmig GA, Eskandary F, Einecke G, Gupta G, Halloran PF. Discrepancy analysis comparing molecular and histology diagnoses in kidney transplant biopsies. Am J Transplant 2020; 20:1341-1350. [PMID: 31846554 DOI: 10.1111/ajt.15752] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 01/25/2023]
Abstract
Discrepancy analysis comparing two diagnostic platforms offers potential insights into both without assuming either is always correct. Having optimized the Molecular Microscope Diagnostic System (MMDx) in renal transplant biopsies, we studied discrepancies within MMDx (reports and sign-out comments) and between MMDx and histology. Interpathologist discrepancies have been documented previously and were not assessed. Discrepancy cases were classified as "clear" (eg, antibody-mediated rejection [ABMR] vs T cell-mediated rejection [TCMR]), "boundary" (eg, ABMR vs possible ABMR), or "mixed" (eg, Mixed vs ABMR). MMDx report scores showed 99% correlations; sign-out interpretations showed 7% variation between observers, all located around boundaries. Histology disagreed with MMDx in 37% of biopsies, including 315 clear discrepancies, all with implications for therapy. Discrepancies were distributed widely in all histology diagnoses but increased in some scenarios; for example, histology TCMR contained 14% MMDx ABMR and 20% MMDx no rejection. MMDx usually gave unambiguous diagnoses in cases with ambiguous histology, for example, borderline and transplant glomerulopathy. Histology lesions or features associated with more frequent discrepancies (eg, tubulitis, arteritis, and polyomavirus nephropathy) were not associated with increased MMDx uncertainty, indicating that MMDx can clarify biopsies with histologic ambiguity. The patterns of histology-MMDx discrepancies highlight specific histology diagnoses in which MMDx assessment should be considered for guiding therapy.
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Affiliation(s)
- Katelynn Madill-Thomsen
- Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gunilla Einecke
- Department of Nephrology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia
| | - Philip F Halloran
- Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada.,Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada
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Peddi VR, Patel PS, Schieve C, Rose S, First MR. Serial Peripheral Blood Gene Expression Profiling to Assess Immune Quiescence in Kidney Transplant Recipients with Stable Renal Function. Ann Transplant 2020; 25:e920839. [PMID: 32341330 PMCID: PMC7204430 DOI: 10.12659/aot.920839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background TruGraf is a blood-based biomarker test that measures differential expression of a collection of genes that have been shown to correlate with surveillance biopsy results. However, in the majority of U.S. transplant centers, surveillance biopsies are not performed. The objectives of this study were to evaluate the clinical validity of TruGraf in stable kidney transplant recipients and to demonstrate the potential clinical utility of serial TruGraf testing in a center not utilizing surveillance biopsies. Material/Methods Serum creatinine levels, TruGraf testing at multiple time points, and subsequent clinical follow-up were obtained for 28 patients. Results Overall concordance of TruGraf results, when compared with independent clinical assessment of testing, was 77% (54/70) for all tests; 79% (22/28) for test 1, 75% (21/28) for test 2, and 79% (11/14) for test 3. The negative predictive value (NPV) was 98.0%. Analysis of clinical utility indicated that 77% of TruGraf results would have been useful in patient management. Conclusions Our results indicate the value of serial TruGraf testing in those transplant centers that do not perform surveillance biopsies as part of their standard of care. The high negative predictive value indicates the ability of TruGraf to confirm immune quiescence with a high degree of probability in patients with a Transplant eXcellence (TX) result, without the need to perform a surveillance biopsy.
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Affiliation(s)
- V Ram Peddi
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA, USA
| | - Parul S Patel
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA, USA
| | | | - Stan Rose
- Transplant Genomics Inc., Mansfield, MA, USA
| | - M Roy First
- Transplant Genomics Inc., Mansfield, MA, USA
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119
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Shim YJ, Khedraki R, Dhar J, Fan R, Dvorina N, Valujskikh A, Fairchild RL, Baldwin WM. Early T cell infiltration is modulated by programed cell death-1 protein and its ligand (PD-1/PD-L1) interactions in murine kidney transplants. Kidney Int 2020; 98:897-905. [PMID: 32763116 DOI: 10.1016/j.kint.2020.03.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 03/10/2020] [Accepted: 03/26/2020] [Indexed: 11/16/2022]
Abstract
Allogeneic transplants elicit dynamic T cell responses that are modulated by positive and negative co-stimulatory receptors. Understanding mechanisms that intrinsically modulate the immune responses to transplants is vital to develop rational treatment for rejection. Here, we have investigated the impact of programed cell death-1 (PD-1) protein, a negative co-stimulatory receptor, on the rejection of MHC incompatible kidney transplants in mice. T cells were found to rapidly infiltrate the kidneys of A/J mice transplanted to C57BL/6 mice, which peaked at six days and decline by day 14. The T cells primarily encircled tubules with limited infiltration of the tubular epithelium. Lipocalin 2 (LCN2), a marker of tubular injury, also peaked in the urine at day six and then declined. Notably, flow cytometry demonstrated that most of the T cells expressed PD-1 (over 90% of CD8 and about 75% of CD4 cells) at day six. Administration of blocking antibody to PD-L1, the ligand for PD-1, before day six increased T cell infiltrates and urinary LCN2, causing terminal acute rejection. In contrast, blocking PD-1/PD-L1 interactions after day six caused only a transient increase in urinary LCN2. Depleting CD4 and CD8 T cells virtually eliminated LCN2 in the urine in support of T cells injuring tubules. Thus, our data indicate that PD-1/PD-L1 interactions are not just related to chronic antigenic stimulation of T cells but are critical for the regulation of acute T cell responses to renal transplants.
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Affiliation(s)
- Young Jun Shim
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Raneem Khedraki
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Jayeeta Dhar
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Ran Fan
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Nina Dvorina
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Anna Valujskikh
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Robert L Fairchild
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - William M Baldwin
- Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA.
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120
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The Pathophysiology and Impact of Inflammation in Nonscarred Renal Interstitium: The Banff i Lesion. Transplantation 2020; 104:835-846. [DOI: 10.1097/tp.0000000000002887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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121
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Abeling T, Scheffner I, Karch A, Broecker V, Koch A, Haller H, Schwarz A, Gwinner W. Risk factors for death in kidney transplant patients: analysis from a large protocol biopsy registry. Nephrol Dial Transplant 2020; 34:1171-1181. [PMID: 29860340 DOI: 10.1093/ndt/gfy131] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Identification and quantification of the relevant factors for death can improve patients' individual risk assessment and decision-making. We used a well-documented patient cohort (n = 892) in a renal transplant programme with protocol biopsies to establish multivariable Cox models for risk assessment at 3 and 12 months post-transplantation. METHODS Patients transplanted between 2000 and 2007 were observed up to 11 years (total observation 5227 patient-years; median 5.9 years). Loss to follow-up was negligible (n = 15). A total of 2251 protocol biopsies and 1214 biopsies for cause were performed. All rejections and clinical borderline rejections in protocol biopsies were treated. RESULTS Overall 10-year patient survival was 78%, with inferior survival of patients with graft loss and superior survival of patients with living-donor transplantation. Eight factors were common in the models at 3 and 12 months, including age, pre-transplant heart failure and a score of cardiovascular disease and type 2 diabetes, post-transplant urinary tract infection, treatment of rejection, new-onset heart failure, coronary events and malignancies. Additional variables of the model at 3 months included deceased donor transplantation, transplant lymphocele, BK virus nephropathy and severe infections. Graft function and graft loss were significant factors of the model at 12 months. Internal validation and validation with a separate cohort of patients (n = 349) demonstrated good discrimination of the models. CONCLUSIONS The identified factors indicate the important areas that need special attention in the pre- and post-transplant care of renal transplant patients. On the basis of these models, we provide nomograms as a tool to weigh individual risks that may contribute to decreased survival.
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Affiliation(s)
- Tanja Abeling
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Irina Scheffner
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Annika Karch
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | - Verena Broecker
- Department of Clinical Pathology and Genetics, University of Gothenburg, Gothenburg, Sweden
| | - Armin Koch
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Anke Schwarz
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Wilfried Gwinner
- Department of Nephrology, Hannover Medical School, Hannover, Germany
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Abstract
Advances in immunosuppressive therapy have drastically improved acute rejection rates in kidney transplant recipients over the past five decades. Nevertheless, it should remain high on any differential diagnosis of unexplained graft dysfunction because of the potential negative effect on graft longevity. Understanding the pre- and post-transplant risk factors for acute rejection can help estimate the probability of immunologic graft damage, and accurate identification of the type and severity of acute rejection will guide appropriate treatment. Tissue biopsy remains the gold standard for evaluating immunologic graft damage, and the histologic definition of acute rejection has evolved in recent years. Intravenous steroids and T cell depletion remain the standard therapy for T cell-mediated rejection and are effective in reversing most cases. Plasma exchange and intravenous Ig, with or without rituximab, are most commonly used for the treatment of antibody-mediated rejection and several newer agents have recently been investigated for severe cases. This review aims to provide the general nephrologist caring for transplant recipients with an approach to immunologic risk assessment and a summary of recent advances in the diagnosis and treatment of acute graft rejection.
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Affiliation(s)
- James E Cooper
- Division of Renal Disease and Hypertension, Transplant Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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124
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The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article. Transplantation 2020; 104:e46-e56. [DOI: 10.1097/tp.0000000000003012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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125
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Pretransplant Donor-Specific Anti-HLA Antibodies and the Risk for Rejection-Related Graft Failure of Kidney Allografts. J Transplant 2020; 2020:5694670. [PMID: 32099669 PMCID: PMC7008278 DOI: 10.1155/2020/5694670] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023] Open
Abstract
Background The presence of donor-specific antibodies (DSAs) against HLA before kidney transplantation has been variably associated with decreased long-term graft survival. Data on the relation of pretransplant DSA with rejection and cause of graft failure in recipients of donor kidneys are scarce. Methods Patients transplanted between 1995 and 2005 were included and followed until 2016. Donor-specific antibodies before transplantation were determined retrospectively. For cause, renal transplant biopsies were reviewed. Results Pretransplant DSAs were found in 160 cases on a total of 734 transplantations (21.8%). In 80.5% of graft failures, a diagnostic renal biopsy was performed. The presence of pretransplant DSA (DSApos) increased the risk of graft failure within the first 3 months after transplantation (5.2% vs. 9.4%) because of rejection with intragraft thrombosis (p < 0.01). One year after transplantation, DSApos recipients had an increased hazard for antibody-mediated rejection at 10 years (9% DSAneg vs. 15% DSApos, p < 0.01). One year after transplantation, DSApos recipients had an increased hazard for antibody-mediated rejection at 10 years (9% DSAneg vs. 15% DSApos, p < 0.01). One year after transplantation, DSApos recipients had an increased hazard for antibody-mediated rejection at 10 years (9% DSAneg vs. 15% DSApos. Conclusions Pretransplant DSAs are a risk factor for early graft loss and increase the incidence for humoral rejection and graft loss but do not affect the risk for T cell-mediated rejection.
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126
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Complement fragments are biomarkers of antibody-mediated endothelial injury. Mol Immunol 2019; 118:142-152. [PMID: 31884386 DOI: 10.1016/j.molimm.2019.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
Abstract
Antibody-mediated rejection (AbMR) adversely affects long-term graft survival in kidney transplantation. Currently, the diagnosis of AbMR requires a kidney biopsy, and detection of complement C4d deposition in the allograft is one of the diagnostic criteria. Complement activation also generates several soluble fragments which could potentially provide non-invasive biomarkers of the process. Furthermore, microvesicles released into the plasma from injured cells can serve as biomarkers of vascular injury. To explore whether soluble complement fragments or complement fragments bound to endothelial microvesicles can be used to non-invasively detect AbMR, we developed an in vitro model in which human endothelial cells were exposed to anti-HLA antibodies and complement sufficient serum. We found that complement fragments C4a and sC5b-9 were increased in the supernatants of cells exposed to complement-sufficient serum compared to cells treated complement-deficient serum. Furthermore, complement activation on the cell surface was associated with the release of microvesicles bearing C4 and C3 fragments. We next measured these analytes in plasma from kidney transplant recipients with biopsy-proven acute AbMR (n = 9) and compared the results with those from transplant recipients who also had impaired allograft function but who did not have AbMR (n = 30). Consistent with the in vitro results, complement fragments C4a and Ba were increased in plasma from patients with AbMR compared to control subjects (P < 0.001 and P < 0.01, respectively). Endothelial microvesicle counts were not increased in patients with AbMR, however, and the number of microvesicles with C4 and C3 bound to the surface was actually lower compared to control subjects (both P < 0.05). Our results suggest that plasma complement activation fragments may be useful as non-invasive biomarkers of antibody-mediated complement activation within the allograft. Complement-opsonized endothelial microvesicles are decreased in patients with AbMR, possibly due to enhanced clearance of microvesicles opsonized with C3 and C4 fragments.
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127
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Lee CY, Yang CY, Lin WC, Chen CC, Tsai MK. Prognostic factors for renal transplant graft survival in a retrospective cohort of 1000 cases: The role of desensitization therapy. J Formos Med Assoc 2019; 119:829-837. [PMID: 31818714 DOI: 10.1016/j.jfma.2019.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/08/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To review the results of renal transplantation after promulgation of the Human Organ Transplant Act in Taiwan in 1987, we conducted a retrospective study in the first 1000 cases performed in our hospital. Prognostic factors for graft survival were assessed with emphasis on the impact of donor-specific antibody (DSA). METHODS Between January 1988 and April 2014, there were 1000 cases of renal transplantation performed in our hospital. Excluding 30 patients of ABO-incompatible transplantation, we reviewed 970 cases of ABO-compatible renal transplantation to analyze the prognostic factors for graft survival. The patients were grouped according to the dates of operations before (the Early group: 503 cases) and after (the Late group: 467 cases) the introduction of detection and desensitization of alloantibody in our hospital in 2004. RESULTS The overall 5-year graft survival rate were 82.6%, which was significantly lower in the Early group (79.2%) than the Late group (86.3%) (p = 0.0012). The 1-year rejection-free survival was significantly lower in the Early group (78.3%) than the Late group (91.2%) (p = 0.0165). The difference between the two groups became insignificant when the time of observation extended beyond 12 months. In a multivariate regression model, we identified significant factors for poor graft survival, including HLA mismatches, delayed graft function with or without recovery, and antibody-mediate rejection (AMR). CONCLUSION HLA mismatches, delayed graft function with or without recovery, and AMR were significant factors for poor graft survival. Detection and desensitization of DSA currently might be inadequate to improve the long-term outcome of renal transplantation.
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Affiliation(s)
- Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Chia Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Meng-Kun Tsai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan.
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Kamburova EG, Gruijters ML, Kardol‐Hoefnagel T, Wisse BW, Joosten I, Allebes WA, van der Meer A, Hilbrands LB, Baas MC, Spierings E, Hack CE, van Reekum FE, van Zuilen AD, Verhaar MC, Bots ML, Drop ACAD, Plaisier L, Melchers RCA, Seelen MAJ, Sanders JS, Hepkema BG, Lambeck AJA, Bungener LB, Roozendaal C, Tilanus MGJ, Voorter CE, Wieten L, van Duijnhoven EM, Gelens MACJ, Christiaans MHL, van Ittersum FJ, Nurmohamed SA, Lardy NM, Swelsen W, van der Pant KAMI, van der Weerd NC, ten Berge IJM, Hoitsma A, van der Boog PJM, de Fijter JW, Betjes MGH, Heidt S, Roelen DL, Claas FH, Bemelman FJ, Otten HG. Antibodies against ARHGDIB are associated with long-term kidney graft loss. Am J Transplant 2019; 19:3335-3344. [PMID: 31194283 PMCID: PMC6899679 DOI: 10.1111/ajt.15493] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/03/2019] [Accepted: 05/04/2019] [Indexed: 01/25/2023]
Abstract
The clinical significance of non-HLA antibodies on renal allograft survival is a matter of debate, due to differences in reported results and lack of large-scale studies incorporating analysis of multiple non-HLA antibodies simultaneously. We developed a multiplex non-HLA antibody assay against 14 proteins highly expressed in the kidney. In this study, the presence of pretransplant non-HLA antibodies was correlated to renal allograft survival in a nationwide cohort of 4770 recipients transplanted between 1995 and 2006. Autoantibodies against Rho GDP-dissociation inhibitor 2 (ARHGDIB) were significantly associated with graft loss in recipients transplanted with a deceased-donor kidney (N = 3276) but not in recipients of a living-donor kidney (N = 1496). At 10 years after deceased-donor transplantation, recipients with anti-ARHGDIB antibodies (94/3276 = 2.9%) had a 13% lower death-censored covariate-adjusted graft survival compared to the anti-ARHGDIB-negative (3182/3276 = 97.1%) population (hazard ratio 1.82; 95% confidence interval, 1.32-2.53; P = .0003). These antibodies occur independently from donor-specific anti-HLA antibodies (DSA) or other non-HLA antibodies investigated. No significant relations with graft loss were found for the other 13 non-HLA antibodies. We suggest that pretransplant risk assessment can be improved by measuring anti-ARHGDIB antibodies in all patients awaiting deceased-donor transplantation.
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Exploring pre-surgery donor-specific antibodies in the context of organ shortage in liver transplant. Langenbecks Arch Surg 2019; 404:865-874. [PMID: 31748871 DOI: 10.1007/s00423-019-01831-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is a growing disparity between the number of liver transplant (LT) candidates and availability of suitable liver allografts. Antibody-mediated rejection (AMR), secondary to positive donor-specific antibodies (DSA), remains a concern in liver transplantation. This study aimed to correlate expression of DSA on pre-transplant screening and outcomes of LT, specifically development of AMR in liver allografts and liver function profile in the post-operative period. METHODS Data of consecutive patients undergoing orthotopic LT (OLT) at the South Australian Liver Transplant Unit was analysed. All patients underwent DSA testing pre-transplant. RESULTS Within a cohort of 96 patients, over a post-OLT median follow-up of 849 days, only 2 patients (2%) developed AMR. While both patients had a positive DSA test preoperatively, overall DSA positivity was noted in 31% patients, with a specificity for prediction of AMR of 0.708. No significant association was noted between AMR (p = 0.092), T cell-mediated rejection/TCMR (p = 0.797) or late hepatic artery thrombosis/LHAT (p = 0.521). There was no significant interaction effect between DSA positivity and serum bilirubin or transaminases over a period of 100 days. CONCLUSION AMR following LT is uncommon. A positive DSA pre-transplant does not imply a definite risk of AMR. Also, there does not exist a significant interaction in time between DSA expression and serum bilirubin or transaminase levels. Until there emerges evidence to the contrary, it appears reasonable to consider DSA-positive donors within the broad context of marginal donors in the context of a worldwide shortage of LT donor allografts.
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130
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Oellerich M, Shipkova M, Asendorf T, Walson PD, Schauerte V, Mettenmeyer N, Kabakchiev M, Hasche G, Gröne H, Friede T, Wieland E, Schwenger V, Schütz E, Beck J. Absolute quantification of donor-derived cell-free DNA as a marker of rejection and graft injury in kidney transplantation: Results from a prospective observational study. Am J Transplant 2019; 19:3087-3099. [PMID: 31062511 PMCID: PMC6899936 DOI: 10.1111/ajt.15416] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/04/2019] [Accepted: 04/28/2019] [Indexed: 01/25/2023]
Abstract
Donor-derived cell-free DNA (dd-cfDNA) is a noninvasive biomarker for comprehensive monitoring of allograft injury and rejection in kidney transplantation (KTx). dd-cfDNA quantification of copies/mL plasma (dd-cfDNA[cp/mL]) was compared to dd-cfDNA fraction (dd-cfDNA[%]) at prespecified visits in 189 patients over 1 year post KTx. In patients (N = 15, n = 22 samples) with biopsy-proven rejection (BPR), median dd-cfDNA(cp/mL) was 3.3-fold and median dd-cfDNA(%) 2.0-fold higher (82 cp/mL; 0.57%, respectively) than medians in Stable Phase patients (N = 83, n = 408) without rejection (25 cp/mL; 0.29%). Results for acute tubular necrosis (ATN) were not significantly different from those with biopsy-proven rejection (BPR). dd-cfDNA identified unnecessary biopsies triggered by a rise in plasma creatinine. Receiver operating characteristic (ROC) analysis showed superior performance (P = .02) of measuring dd-cfDNA(cp/mL) (AUC = 0.83) compared to dd-cfDNA(%) (area under the curve [AUC] = 0.73). Diagnostic odds ratios were 7.31 for dd-cfDNA(cp/mL), and 6.02 for dd-cfDNA(%) at thresholds of 52 cp/mL and 0.43%, respectively. Plasma creatinine showed a low correlation (r = 0.37) with dd-cfDNA(cp/mL). In a patient subset (N = 24) there was a significantly higher rate of patients with elevated dd-cfDNA(cp/mL) with lower tacrolimus levels (<8 μg/L) compared to the group with higher tacrolimus concentrations (P = .0036) suggesting that dd-cfDNA may detect inadequate immunosuppression resulting in subclinical graft damage. Absolute dd-cfDNA(cp/mL) allowed for better discrimination than dd-cfDNA(%) of KTx patients with BPR and is useful to avoid unnecessary biopsies.
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Affiliation(s)
- Michael Oellerich
- Department of Clinical PharmacologyUniversity Medical Center GoettingenGoettingenGermany
| | - Maria Shipkova
- Central Institute for Clinical Chemistry and Laboratory MedicineKlinikum StuttgartStuttgartGermany
| | - Thomas Asendorf
- Department of Medical StatisticsUniversity Medical Center GoettingenGoettingenGermany
| | - Philip D. Walson
- Department of Clinical PharmacologyUniversity Medical Center GoettingenGoettingenGermany
| | - Verena Schauerte
- Department of NephrologyTransplant CenterKlinikum StuttgartStuttgartGermany
| | - Nina Mettenmeyer
- Department of Clinical PharmacologyUniversity Medical Center GoettingenGoettingenGermany
- Chronix BiomedicalGoettingenGermany
| | - Mariana Kabakchiev
- Central Institute for Clinical Chemistry and Laboratory MedicineKlinikum StuttgartStuttgartGermany
| | | | - Hermann‐Josef Gröne
- Department of Cellular and Molecular PathologyGerman Cancer Research CenterHeidelbergGermany
| | - Tim Friede
- Department of Medical StatisticsUniversity Medical Center GoettingenGoettingenGermany
| | - Eberhard Wieland
- Central Institute for Clinical Chemistry and Laboratory MedicineKlinikum StuttgartStuttgartGermany
| | - Vedat Schwenger
- Department of NephrologyTransplant CenterKlinikum StuttgartStuttgartGermany
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131
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Banff lesions and renal allograft survival in chronic-active antibody mediated rejection. Transpl Immunol 2019; 56:101213. [DOI: 10.1016/j.trim.2019.101213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 01/05/2023]
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132
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Fischman C, Fribourg M, Fabrizio G, Cioni M, Comoli P, Nocera A, Cardillo M, Cantarelli C, Gallon L, Petrosyan A, Da Sacco S, Perin L, Cravedi P. Circulating B Cells With Memory and Antibody-Secreting Phenotypes Are Detectable in Pediatric Kidney Transplant Recipients Before the Development of Antibody-Mediated Rejection. Transplant Direct 2019; 5:e481. [PMID: 31579809 PMCID: PMC6739044 DOI: 10.1097/txd.0000000000000914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
Development of anti-human leukocyte antigen donor-specific antibodies (DSAs) is associated with antibody-mediated rejection (AMR) and reduced allograft survival in kidney transplant recipients. Whether changes in circulating lymphocytes anticipate DSA or AMR development is unclear. METHODS We used time-of-flight mass cytometry to analyze prospectively collected peripheral blood mononuclear cells (PBMC) from pediatric kidney transplant recipients who developed DSA (DSA-positive recipients [DSAPOS], n = 10). PBMC were obtained at 2 months posttransplant, 3 months before DSA development, and at DSA detection. PBMC collected at the same time points posttransplant from recipients who did not develop DSA (DSA-negative recipients [DSANEG], n = 11) were used as controls. RESULTS DSAPOS and DSANEG recipients had similar baseline characteristics and comparable frequencies of total B and T cells. Within DSAPOS recipients, there was no difference in DSA levels (mean fluorescence intensity [MFI]: 13 687 ± 4159 vs 11 375 ± 1894 in DSAPOSAMR-positive recipients (AMRPOS) vs DSAPOSAMR-negative recipients (AMRNEG), respectively; P = 0.630), C1q binding (5 DSAPOSAMRPOS [100%] vs 4 DSAPOSAMRNEG [80%]; P = 1.000), or C3d binding (3 DSAPOSAMRPOS [60%] vs 1 DSAPOSAMRNEG [20%]; P = 0.520) between patients who developed AMR and those who did not. However, DSAPOS patients who developed AMR (n = 5; 18.0 ± 3.6 mo post-DSA detection) had increased B cells with antibody-secreting (IgD-CD27+CD38+; P = 0.002) and memory (IgD-CD27+CD38-; P = 0.003) phenotypes compared with DSANEG and DSAPOSAMRNEG recipients at DSA detection. CONCLUSIONS Despite the small sample size, our comprehensive phenotypic analyses show that circulating B cells with memory and antibody-secreting phenotypes are present at DSA onset, >1 year before biopsy-proven AMR in pediatric kidney transplant recipients.
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Affiliation(s)
- Clara Fischman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Miguel Fribourg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ginevri Fabrizio
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto G. Gaslini, Genova, Italy
| | - Michela Cioni
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto G. Gaslini, Genova, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Arcangelo Nocera
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto G. Gaslini, Genova, Italy
| | - Massimo Cardillo
- Department Transplantation Immunology, IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Chiara Cantarelli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Dipartimento di Medicina e Chirurgia Università di Parma, UO Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Lorenzo Gallon
- Department of Medicine, Division of Nephrology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Astgik Petrosyan
- Division of Urology GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Stefano Da Sacco
- Division of Urology GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Laura Perin
- Division of Urology GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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133
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Impact of Adopting Routine Luminex-Based Pretransplant Assessment of HLA Antibodies on Clinical Practice and Outcomes in Kidney Transplantation. Transplant Proc 2019; 51:2241-2244. [DOI: 10.1016/j.transproceed.2019.01.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/21/2019] [Indexed: 01/06/2023]
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134
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Louis K, Hertig A, Taupin JL, Buob D, Jamme M, Brocheriou I, Luque Y, Jouanneau C, Ouali N, Audouin M, Rondeau E, Xu-Dubois YC. Markers of graft microvascular endothelial injury may identify harmful donor-specific anti-HLA antibodies and predict kidney allograft loss. Am J Transplant 2019; 19:2434-2445. [PMID: 30836425 DOI: 10.1111/ajt.15340] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 01/25/2023]
Abstract
Graft microvasculature is a major target of donor-specific antibodies (DSA) and endothelial damage is direct evidence of antibody-mediated rejection (ABMR). Using immunohistochemistry, we analyzed the expression of three microvascular endothelial activation markers (fascin, vimentin, and hsp47), suggestive of endothelial-to-mesenchymal transition (EndMT) in 351 graft biopsies from 248 kidney recipients, with concomitant screening of circulating antihuman leukocyte antigen (HLA) DSA at the time of the biopsy. The factors associated with EndMT marker expression were DSA and the presence of microvascular inflammation (MI). EndMT expressing grafts had significantly more allograft loss compared to EndMT negative grafts (P < .0001). The expression of EndMT markers positively correlated with anti-HLA DSA class II mean fluorescence intensity (MFI) levels and especially identified DQ and DR antibodies as being more closely associated with microvascular injury. Moreover, only DSA linked to positive EndMT score affected allograft survival, regardless of DSA MFI levels or presence of C4d deposition. Thus, EndMT markers could represent a clinically relevant tool for early identification of ongoing endothelial injury, harmful DSA, and patients at high risk for allograft failure.
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Affiliation(s)
- Kevin Louis
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France
| | - Alexandre Hertig
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMR S 1155, Paris, France
| | - Jean-Luc Taupin
- AP-HP, Hôpital Saint Louis, Laboratoire d'immunologie et d'histocompatibilité, Paris, France
| | - David Buob
- Sorbonne Universités, UPMC Université Paris 06, UMR S 1155, Paris, France.,AP-HP, Hôpital Tenon, Service d'Anatomo-Pathologie, Paris, France
| | - Matthieu Jamme
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France
| | - Isabelle Brocheriou
- Sorbonne Universités, UPMC Université Paris 06, UMR S 1155, Paris, France.,AP-HP, Hôpital Pitié-Salpétrière, Service d'Anatomo-Pathologie, Paris, France
| | - Yosu Luque
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMR S 1155, Paris, France
| | - Chantal Jouanneau
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France
| | - Nacera Ouali
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France
| | - Marie Audouin
- APHP, Hôpital Tenon, Service d'urologie, Paris, France
| | - Eric Rondeau
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMR S 1155, Paris, France
| | - Yi-Chun Xu-Dubois
- Sorbonne University, Inserm UMR_S1155, AP-HP, Hôpital Tenon, F-75020, Paris, France.,APHP, Hôpital Tenon, Service de Santé publique, Paris, France
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135
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Subclinical Antibody-mediated Rejection After Kidney Transplantation: Treatment Outcomes. Transplantation 2019; 103:1722-1729. [PMID: 30507740 DOI: 10.1097/tp.0000000000002566] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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136
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Van Loon E, Gazut S, Yazdani S, Lerut E, de Loor H, Coemans M, Noël LH, Thorrez L, Van Lommel L, Schuit F, Sprangers B, Kuypers D, Essig M, Gwinner W, Anglicheau D, Marquet P, Naesens M. Development and validation of a peripheral blood mRNA assay for the assessment of antibody-mediated kidney allograft rejection: A multicentre, prospective study. EBioMedicine 2019; 46:463-472. [PMID: 31378695 PMCID: PMC6710906 DOI: 10.1016/j.ebiom.2019.07.028] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/10/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background Antibody-mediated rejection, a leading cause of renal allograft graft failure, is diagnosed by histological assessment of invasive allograft biopsies. Accurate non-invasive biomarkers are not available. Methods In the multicentre, prospective BIOMARGIN study, blood samples were prospectively collected at time of renal allograft biopsies between June 2011 and August 2016 and analyzed in three phases. The discovery and derivation phases of the study (N = 117 and N = 183 respectively) followed a case-control design and included whole genome transcriptomics and targeted mRNA expression analysis to construct and lock a multigene model. The primary end point was the diagnostic accuracy of the locked multigene assay for antibody-mediated rejection in a third validation cohort of serially collected blood samples (N = 387). This trial is registered with ClinicalTrials.gov, number NCT02832661. Findings We identified and locked an 8-gene assay (CXCL10, FCGR1A, FCGR1B, GBP1, GBP4, IL15, KLRC1, TIMP1) in blood samples from the discovery and derivation phases for discrimination between cases with (N = 49) and without (N = 134) antibody-mediated rejection. In the validation cohort, this 8-gene assay discriminated between cases with (N = 41) and without antibody-mediated rejection (N = 346) with good diagnostic accuracy (ROC AUC 79·9%; 95% CI 72·6 to 87·2, p < 0·0001). The diagnostic accuracy of the 8-gene assay was retained both at time of stable graft function and of graft dysfunction, within the first year and also later after transplantation. The 8-gene assay is correlated with microvascular inflammation and transplant glomerulopathy, but not with the histological lesions of T-cell mediated rejection. Interpretation We identified and validated a novel 8-gene expression assay that can be used for non-invasive diagnosis of antibody-mediated rejection. Funding The Seventh Framework Programme (FP7) of the European Commission.
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Affiliation(s)
- Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium; University Hospitals Leuven, Department of Nephrology and Renal Transplantation, Leuven, Belgium
| | - Stéphane Gazut
- CEA, LIST, Laboratory for Data Analysis and Systems' Intelligence, Gif-sur-Yvette, France
| | - Saleh Yazdani
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium
| | - Evelyne Lerut
- University Hospitals Leuven, Department of Morphology and Molecular Pathology, Leuven, Belgium
| | - Henriette de Loor
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium
| | - Laure-Hélène Noël
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research U1151, France
| | - Lieven Thorrez
- KU Leuven Department of Development and Regeneration, campus KULAK, Kortrijk, Belgium
| | - Leentje Van Lommel
- KU Leuven Gene Expression Unit, Department of Cellular and Molecular Medicine, Leuven, Belgium
| | - Frans Schuit
- KU Leuven Gene Expression Unit, Department of Cellular and Molecular Medicine, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium; University Hospitals Leuven, Department of Nephrology and Renal Transplantation, Leuven, Belgium; KU Leuven Laboratory of Molecular Immunology, Rega Institute, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium; University Hospitals Leuven, Department of Nephrology and Renal Transplantation, Leuven, Belgium
| | - Marie Essig
- CHU Limoges, Department of Nephrology, Dialysis and Transplantation, Univ. Limoges, U850 INSERM, Limoges, France
| | - Wilfried Gwinner
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Dany Anglicheau
- Paris Descartes, Sorbonne Paris Cité University, INSERM U1151, Paris, France; Department of Nephrology and Kidney Transplantation, RTRS Centaure, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Marquet
- CHU Limoges, Univ. Limoges, U850 INSERM, Limoges, France
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Leuven, Belgium; University Hospitals Leuven, Department of Nephrology and Renal Transplantation, Leuven, Belgium.
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137
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Hassler J, Tanriover B, Ariyamutu V, Burguete D, Hendricks AR, Torrealba JR. 2013 Banff Criteria for Acute Antibody-Mediated Rejection Are Superior to 2007 Banff Criteria in the Diagnosis and Assessment of Renal Allograft Outcomes. Transplant Proc 2019; 51:1791-1795. [DOI: 10.1016/j.transproceed.2019.04.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/22/2019] [Indexed: 01/06/2023]
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138
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Nair P, Gheith O, Al-Otaibi T, Mostafa M, Rida S, Sobhy I, Halim MA, Mahmoud T, Abdul-Hameed M, Maher A, Emam M. Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Recipients: Single-Center Experience. EXP CLIN TRANSPLANT 2019; 17:113-119. [PMID: 30777534 DOI: 10.6002/ect.mesot2018.o58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Data on the management of chronic antibody-mediated rejection after kidney transplantation are limited. We aimed to assess the impact of treatment of biopsy-proven chronic active antibodymediated rejection with combined plasma exchange, intravenous immunoglobulin, and rituximab treatment versus intravenous immunoglobulin alone or conservative management on the evolution of renal function in renal transplant recipients. MATERIALS AND METHODS In this retrospective study, we compared patients diagnosed with chronic active antibody-mediated rejection who were treated with standard of care steroids, intravenous immunoglobulin, plasma exchange, and rituximab (n = 40) at our center versus those who received intravenous immunoglobulin only or just intensified maintenance immunosuppression (n = 28). All patients were followed for 12 months clinically and by laboratory tests for graft and patient outcomes. RESULTS The two groups were matched regarding mean recipient age (41.9 ± 15.4 vs 37.8 ± 15.5 y in patients with conservative versus combined treatment), recipient sex, mean body weight, and the cause of end-stage kidney disease. Most patients and their donors were males. Glomerulonephritis represented the most common cause of end-stage kidney disease in both groups followed by diabetic nephropathy. The type of induction and pretransplant comorbidities were not different between groups (P > .05) except for the significantly higher number of chronic hepatitis C infections in patients who received conservative treatment (P = .007). Mean serum creatinine values before and after treatment of chronic active antibodymediated rejection were comparable between groups (P > .05). Active treatment with heavier immunosuppression (rituximab and plasma exchange) was associated with posttreatment viral (cytomegalovirus and BK virus) and bacterial infections that necessitated more hospitalization (P > .05). However, graft and patient outcomes were significantly better in the active treatment group than in patients with conservative treatment (P = .002 and .028, respectively). CONCLUSIONS Combined treatment of chronic active antibody-mediated rejection with plasma exchange, intravenous immunoglobulin, and rituximab can significantly improve outcomes after renal transplant.
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Affiliation(s)
- Prasad Nair
- From the Kuwait Ministry of Health, Hamed Al-Essa Organ Transplant Center, Sabah area, Kuwait
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139
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Zhang W, Yi Z, Wei C, Keung KL, Sun Z, Xi C, Woytovich C, Farouk S, Gallon L, Menon MC, Magee C, Najafian N, Samaniego MD, Djamali A, Alexander SI, Rosales IA, Smith RN, O'Connell PJ, Colvin R, Cravedi P, Murphy B. Pretransplant transcriptomic signature in peripheral blood predicts early acute rejection. JCI Insight 2019; 4:127543. [PMID: 31167967 DOI: 10.1172/jci.insight.127543] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/23/2019] [Indexed: 12/19/2022] Open
Abstract
Commonly available clinical parameters fail to predict early acute cellular rejection (EAR, occurring within 6 months after transplant), a major risk factor for graft loss after kidney transplantation. We performed whole-blood RNA sequencing at the time of transplant in 235 kidney transplant recipients enrolled in a prospective cohort study (Genomics of Chronic Allograft Rejection [GoCAR]) and evaluated the relationship of pretransplant transcriptomic profiles with EAR. EAR was associated with downregulation of NK and CD8+ T cell gene signatures in pretransplant blood. We identified a 23-gene set that predicted EAR in the discovery (n = 81, and AUC = 0.80) and validation (n = 74, and AUC = 0.74) sets. Exclusion of recipients with 5 or 6 HLA donor mismatches increased the AUC to 0.89. The risk score derived from the gene set was also significantly associated with acute cellular rejection after 6 months, antibody-mediated rejection and/or de novo donor-specific antibodies, and graft loss in a cohort of 154 patients, combining the validation set and additional GoCAR patients with surveillance biopsies between 6 and 24 months (n = 80) posttransplant. This 23-gene set is a potentially important new tool for determination of the recipient's immunological risk before kidney transplantation, and facilitation of an individualized approach to immunosuppressive therapy.
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Affiliation(s)
- Weijia Zhang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhengzi Yi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chengguo Wei
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen L Keung
- Department of Medicine, Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Zeguo Sun
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Caixia Xi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Woytovich
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samira Farouk
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lorenzo Gallon
- Department of Medicine-Nephrology and Surgery-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ciara Magee
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nader Najafian
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Stephen I Alexander
- Department of Medicine, Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rex Neal Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philip J O'Connell
- Department of Medicine, Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Robert Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paolo Cravedi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Barbara Murphy
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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140
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Crossing low-level donor-specific antibodies in heart transplantation. Curr Opin Organ Transplant 2019; 24:227-232. [DOI: 10.1097/mot.0000000000000628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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141
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Peabody J, Billings P, Valdenor C, Demko Z, Moshkevich S, Paculdo D, Tran M. Variation in Assessing Renal Allograft Rejection: A National Assessment of Nephrology Practice. Int J Nephrol 2019; 2019:5303284. [PMID: 31214362 PMCID: PMC6535838 DOI: 10.1155/2019/5303284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/25/2019] [Accepted: 04/14/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The clinical utility of early detection and treatment of allograft rejection is well-established. Despite frequent testing called for by standard of care protocols, the five-year kidney allograft survival rate is estimated to be as low as 71%. Herein, we report on posttransplant care provided to kidney allograft recipients by board-certified nephrologists in the United States. METHODS We measured clinical practice in a representative sample of 175 practicing nephrologists. All providers cared for simulated patients' status after renal transplant ranging from 30-75 years in age and 3-24 months after transplant. Our sample of nephrologists cared for a total of 525 allograft cases. Provider responses to the cases were reviewed by trained clinicians, and care was compared to evidence-based care standards and accepted standard of care protocols. RESULTS Among nephrologists, practicing in settings ranging from transplant centers to community practice, we found that the clinical workup of kidney injury in posttransplant patients is highly variable and frequently deviates from evidence-based care. In cases with pathologic evidence of rejection, only 29.1% (102/350) received an appropriate, evidence-based biopsy, whereas, in cases with no pathological evidence of rejection, 41.3% (45/109) received low-value, unnecessary biopsies. CONCLUSION Clinical care in the posttransplant setting is highly variable. Biopsies are often ordered in cases where their results do not alter treatment. Additionally, we found that misdiagnosis was common as were opportunities for earlier biopsy and detection of rejection. This evidence suggests that better diagnostic tools may be helpful to determine which transplant patients should be biopsied and which should not. This study suggests that nephrologists and transplant patients need better tests than creatinine and proteinuria and less invasive approaches than routine biopsies to determine when transplant patients should be investigated for rejection and additional treatment.
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Affiliation(s)
- John Peabody
- University of California, San Francisco, Department of Epidemiology and Biostatistics, 550 16th St, San Francisco, CA 94158, USA
- University of California, Los Angeles, Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095, USA
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94131, USA
| | - Paul Billings
- Natera, Inc., 201 Industrial Rd, San Carlos, CA 94070, USA
| | - Czarlota Valdenor
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94131, USA
| | - Zach Demko
- Natera, Inc., 201 Industrial Rd, San Carlos, CA 94070, USA
| | | | - David Paculdo
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94131, USA
| | - Mary Tran
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94131, USA
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142
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Donor-Specific Antibodies in the Absence of Rejection Are Not a Risk Factor for Allograft Failure. Kidney Int Rep 2019; 4:1057-1065. [PMID: 31440696 PMCID: PMC6698321 DOI: 10.1016/j.ekir.2019.04.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/10/2019] [Accepted: 04/09/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction Donor-specific antibodies (DSAs) are considered an important risk factor for graft injury and failure. However, there is limited information on long-term outcomes for kidney transplant recipients with positive DSAs in the absence of rejection on biopsy. Methods We evaluated all patients at the University of Wisconsin who underwent a kidney allograft biopsy between January 1, 2013, and December 31, 2016. All patients with clinical indication or protocol biopsies that were negative for acute rejection and lacked significant acute pathological features were included in the study and divided into 2 groups based on DSAs at the time of biopsy. There were a total of 1102 kidney biopsies during the study period of which 587 fulfilled our selection criteria (DSA+, n = 192, and DSA−, n = 395). The incidence of subsequent rejection and death-censored graft failure (DCGF) were outcomes of interest. Results There was no difference in acute (i + t + v + c4d + ptc + g = 0 in both groups) or chronic (ci + ct + cv + cg = 2.4 ± 2.2 vs. 2.7 ± 2.4; cg = 0.12 ± 0.48 vs. 0.13 ± 0.48) Banff scores in the index biopsy. Patients were followed for a mean of 33.1 ± 16.8 months. Kaplan-Meier analyses demonstrated a higher incidence of DCGF in DSA− group (n = 83) but this was not observed for subsequent rejection (n = 76). In multivariate Cox regression analyses, the interval from transplant to biopsy, de novo DSA, and younger age remained independently associated with increased risk of subsequent rejection. Notably, there was no association between subsequent rejection or DSA (pretransplant, de novo, persistant, Class I/II, MFIsum, or MFImax) and graft failure. Conclusion This study suggests that in the absence of biopsy-proven rejection and acute inflammation, human leukocyte antigen (HLA) DSAs are not associated with increased risk of graft failure.
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143
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Hanssen O, Lovinfosse P, Weekers L, Hustinx R, Jouret F. [ 18F-FDG positron emission tomography in non-oncological renal pathology: Current indications and perspectives]. Nephrol Ther 2019; 15:430-438. [PMID: 30982747 DOI: 10.1016/j.nephro.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 11/28/2018] [Indexed: 12/26/2022]
Abstract
Positron emission tomography combined with computed tomography (PET/CT) is a nuclear imaging technique which provides anatomical and functional information. PET/CT is increasingly used in non-oncological nephrology since conventional radiological approaches after injection of contrast agents are relatively contra-indicated in patients with chronic kidney disease (CKD). PET/CT after i.v. injection of 18F-fluoro-deoxy-glucose (FDG) is not toxic and is characterized by a high sensitivity. The level of irradiation (∼5mSv) is acceptable. CKD does not significantly influence tissue uptake of 18F-FDG. The purpose of the present review aims at detailing the non-oncological indications of 18F-FDG PET/CT in general nephrology and after kidney transplantation. Particularly, 18F-FDG PET/CT appears useful in the diagnosis of cyst infection in patients with autosomal dominant polycystic kidney disease, as well as in the characterization of retroperitoneal fibrosis. In kidney transplant recipients, 18F-FDG PET/CT may help in the diagnostic work-up of suspected acute rejection, thereby eventually avoiding unnecessary kidney transplant biopsy. Perspectives in 18F-FDG PET/CT imaging are discussed, including innovative approaches of image analysis.
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Affiliation(s)
- Oriane Hanssen
- Service de néphrologie, centre hospitalier universitaire de Liège, avenue Hippocrate 13, 4000 Liège, Belgique
| | - Pierre Lovinfosse
- Service de médecine nucléaire et imagerie oncologique, centre hospitalier universitaire de Liège, avenue Hippocrate 13, 4000 Liège, Belgique
| | - Laurent Weekers
- Service de médecine nucléaire et imagerie oncologique, centre hospitalier universitaire de Liège, avenue Hippocrate 13, 4000 Liège, Belgique
| | - Roland Hustinx
- Service de médecine nucléaire et imagerie oncologique, centre hospitalier universitaire de Liège, avenue Hippocrate 13, 4000 Liège, Belgique
| | - François Jouret
- Service de néphrologie, centre hospitalier universitaire de Liège, avenue Hippocrate 13, 4000 Liège, Belgique; Groupe interdisciplinaire de géno-protéomique appliquée (GIGA), sciences cardiovasculaires, université de Liège, Liège, Belgique.
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144
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Ho J, Sharma A, Kroeker K, Carroll R, De Serres S, Gibson IW, Hirt-Minkowski P, Jevnikar A, Kim SJ, Knoll G, Rush DN, Wiebe C, Nickerson P. Multicentre randomised controlled trial protocol of urine CXCL10 monitoring strategy in kidney transplant recipients. BMJ Open 2019; 9:e024908. [PMID: 30975673 PMCID: PMC6500325 DOI: 10.1136/bmjopen-2018-024908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Subclinical inflammation is an important predictor of death-censored graft loss, and its treatment has been shown to improve graft outcomes. Urine CXCL10 outperforms standard post-transplant surveillance in observational studies, by detecting subclinical rejection and early clinical rejection before graft functional decline in kidney transplant recipients. METHODS AND ANALYSIS This is a phase ii/iii multicentre, international randomised controlled parallel group trial to determine if the early treatment of rejection, as detected by urine CXCL10, will improve kidney allograft outcomes. Incident adult kidney transplant patients (n~420) will be enrolled to undergo routine urine CXCL10 monitoring postkidney transplant. Patients at high risk of rejection, defined as confirmed elevated urine CXCL10 level, will be randomised 1:1 stratified by centre (n=250). The intervention arm (n=125) will undergo a study biopsy to check for subclinical rejection and biopsy-proven rejection will be treated per protocol. The control arm (n=125) will undergo routine post-transplant monitoring. The primary outcome at 12 months is a composite of death-censored graft loss, clinical biopsy-proven acute rejection, de novo donor-specific antibody, inflammation in areas of interstitial fibrosis and tubular atrophy (Banff i-IFTA, chronic active T-cell mediated rejection) and subclinical tubulitis on 12-month surveillance biopsy. The secondary outcomes include decline of graft function, microvascular inflammation at 12 months, development of IFTA at 12 months, days from transplantation to clinical biopsy-proven rejection, albuminuria, EuroQol five-dimension five-level instrument, cost-effectiveness analysis of the urine CXCL10 monitoring strategy and the urine CXCL10 kinetics in response to rejection therapy. ETHICS AND DISSEMINATION The study has been approved by the University of Manitoba Health Research Ethics Board (HS20861, B2017:076) and the local research ethics boards of participating centres. Recruitment commenced in March 2018 and results are expected to be published in 2023. De-identified data may be shared with other researchers according to international guidelines (International Committee of Medical Journal Editors [ICJME]). TRIAL REGISTRATION NUMBER NCT03206801; Pre-results.
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Affiliation(s)
- Julie Ho
- Internal Medicine, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
- Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Atul Sharma
- Data Science, George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Kristine Kroeker
- Data Science, George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Robert Carroll
- Transplant Nephrology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sacha De Serres
- Internal Medicine & Nephrology, Universite Laval, Québec, Québec, Canada
| | - Ian W Gibson
- Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anthony Jevnikar
- Internal Medicine & Nephrology, Western University, London, Ontario, Canada
| | - S Joseph Kim
- Internal Medicine & Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Greg Knoll
- Internal Medicine & Nephrology, University of Ottawa, Ottawa, Ontario, Canada
| | - David N Rush
- Internal Medicine, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
| | - Chris Wiebe
- Internal Medicine, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
| | - Peter Nickerson
- Internal Medicine, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
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145
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Post-transplant donor specific antibody is associated with poor kidney transplant outcomes only when combined with both T-cell-mediated rejection and non-adherence. Kidney Int 2019; 96:202-213. [PMID: 31029504 DOI: 10.1016/j.kint.2019.01.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/17/2019] [Accepted: 01/24/2019] [Indexed: 11/24/2022]
Abstract
Post-transplant donor specific antibody (DSA) is associated with poor renal allograft outcomes. However, variable timing of DSA assessment and inclusion of patients who undergo desensitization treatments have hindered our understanding of its consequences and limited its predictive value. Here we prospectively studied non-desensitized patients to determine factors associated with poor four-year outcomes in patients who developed post-transplant DSA. Using serial monitoring, 67 of 294 patients were found to develop DSA by one year. Compared to patients who do not develop DSA, those with DSA exhibit an increased incidence of both clinical and subclinical T-cell-mediated rejection (TCMR). The combination of TCMR plus DSA led to an almost three-fold increase in graft loss compared to either DSA or TCMR alone. Moreover, DSA was associated with higher Banff grade TCMR and chronic changes at one year. Antibody-mediated rejection was uncommon and always associated with TCMR. Amongst factors independently associated with DSA plus TCMR; non-adherence is potentially modifiable. Non-adherence, measured as intra-patient variability of calcineurin trough levels during the first post-transplant year, further risk-stratified patients with DSA plus TCMR such that about 75% of these patients had impending graft loss by four years, whereas adherent patients with DSA plus TCMR had outcomes comparable to other patient groups. Thus, early post-transplant DSA, especially in non-adherent patients, is associated with increased incidence of TCMR and represents a high-risk group of patients who might benefit from targeted therapeutic interventions.
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146
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Goutaudier V, Perrochia H, Mucha S, Bonnet M, Delmas S, Garo F, Garrigue V, Lepreux S, Pernin V, Serre JE, Szwarc I, Merville P, Ramounau-Pigot A, René C, Visentin J, Morgan BP, Frémeaux-Bacchi V, Mourad G, Couzi L, Le Quintrec M. C5b9 Deposition in Glomerular Capillaries Is Associated With Poor Kidney Allograft Survival in Antibody-Mediated Rejection. Front Immunol 2019; 10:235. [PMID: 30906289 PMCID: PMC6418012 DOI: 10.3389/fimmu.2019.00235] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/28/2019] [Indexed: 12/17/2022] Open
Abstract
C4d deposition in peritubular capillaries (PTC) reflects complement activation in antibody-mediated rejection (ABMR) of kidney allograft. However, its association with allograft survival is controversial. We hypothesized that capillary deposition of C5b9-indicative of complement-mediated injury-is a severity marker of ABMR. This pilot study aimed to determine the frequency, location and prognostic impact of these deposits in ABMR. We retrospectively selected patients diagnosed with ABMR in two French transplantation centers from January 2005 to December 2014 and performed C4d and C5b9 staining by immunohistochemistry. Fifty-four patients were included. Median follow-up was 52.5 (34.25-73.5) months. Thirteen patients (24%) had C5b9 deposits along glomerular capillaries (GC). Among these, seven (54%) had a global and diffuse staining pattern. Twelve of the C5b9+ patients also had deposition of C4d in GC and PTC. C4d deposits along GC and PTC were not associated with death-censored allograft survival (p = 0.42 and 0.69, respectively). However, death-censored allograft survival was significantly lower in patients with global and diffuse deposition of C5b9 in GC than those with a segmental pattern or no deposition (median survival after ABMR diagnosis, 6 months, 40.5 months and 44 months, respectively; p = 0.015). Double contour of glomerular basement membrane was diagnosed earlier after transplantation in C5b9+ ABMR than in C5b9- ABMR (median time after transplantation, 28 vs. 85 months; p = 0.058). In conclusion, we identified a new pattern of C5b9+ ABMR, associated with early onset of glomerular basement membrane duplication and poor allograft survival. Complement inhibitors might be a therapeutic option for this subgroup of patients.
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Affiliation(s)
- Valentin Goutaudier
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Hélène Perrochia
- Department of Pathology, Gui de Chauliac Hospital, Montpellier University Hospital, Montpellier, France
| | - Simon Mucha
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Marie Bonnet
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Sylvie Delmas
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Florian Garo
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Valérie Garrigue
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Sébastien Lepreux
- Department of Pathology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Pernin
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France.,INSERM U1183, Institute for Regenerative Medicine and Biotherapy, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Jean-Emmanuel Serre
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Ilan Szwarc
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Annie Ramounau-Pigot
- Department of Immunology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Céline René
- Department of Immunology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Jonathan Visentin
- UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France.,Department of Immunology and Immunogenetics, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Bryan Paul Morgan
- School of Medicine, Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | | | - Georges Mourad
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Moglie Le Quintrec
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France.,INSERM U1183, Institute for Regenerative Medicine and Biotherapy, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier, France
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147
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Senev A, Coemans M, Lerut E, Van Sandt V, Daniëls L, Kuypers D, Sprangers B, Emonds MP, Naesens M. Histological picture of antibody-mediated rejection without donor-specific anti-HLA antibodies: Clinical presentation and implications for outcome. Am J Transplant 2019; 19:763-780. [PMID: 30107078 DOI: 10.1111/ajt.15074] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/31/2018] [Accepted: 08/07/2018] [Indexed: 01/25/2023]
Abstract
In this cohort study (n = 935 transplantations), we investigated the phenotype and risk of graft failure in patients with histological criteria for antibody-mediated rejection (ABMR) in the absence of circulating donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA), and compared this to patients with definite ABMR and HLA-DSA-positivity. The histological picture did not differ between HLA-DSA-positive (n = 85) and HLA-DSA-negative (n = 123) cases of ABMR histology, apart from increased complement split product 4d (C4d) deposition in the peritubular capillaries in HLA-DSA-positive cases. Histology of ABMR without HLA-DSA was more transient than DSA-positive ABMR, and patients with ABMR histology without HLA-DSA had graft survival superior to that of HLA-DSA-positive patients, independent of concomitant T cell-mediated rejection (38.2%) or borderline changes (17.9%). Multivariate analysis showed that the risk of graft failure was not higher in patients with histological picture of ABMR (ABMRh ) in the absence of HLA-DSA, compared to patients without ABMRh . Despite an association between C4d deposition and HLA-DSA-positivity, using C4d deposition as alternative for the DSA criterion in the diagnosis of ABMR, as proposed in Banff 2017, did not contribute to the prognosis of graft function and graft failure. We concluded that biopsies with ABMRh but without detectable HLA-DSA represent a distinct, often transient phenotype with superior allograft survival.
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Affiliation(s)
- Aleksandar Senev
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Coemans
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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148
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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149
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Hanaoka K, Maeda M, Tsujimoto S, Oshima S, Fukahori H, Nakamura K, Noto T, Higashi Y, Hirose J, Takakura S, Morokata T. Benefits of a loading dose of tacrolimus on graft survival of kidney transplants in nonhuman primates. Transpl Immunol 2019. [DOI: 10.1016/j.trim.2018.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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150
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Marsh CL, Kurian SM, Rice JC, Whisenant TC, David J, Rose S, Schieve C, Lee D, Case J, Barrick B, Peddi VR, Mannon RB, Knight R, Maluf D, Mandelbrot D, Patel A, Friedewald JJ, Abecassis MM, First MR. Application of TruGraf v1: A Novel Molecular Biomarker for Managing Kidney Transplant Recipients With Stable Renal Function. Transplant Proc 2019; 51:722-728. [PMID: 30979456 DOI: 10.1016/j.transproceed.2019.01.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/10/2018] [Accepted: 01/17/2019] [Indexed: 01/22/2023]
Abstract
TruGraf v1 is a laboratory-developed DNA microarray-based gene expression blood test to enable proactive noninvasive serial assessment of kidney transplant recipients with stable renal function. It has been previously validated in patients identified as Transplant eXcellence (TX: stable serum creatinine, normal biopsy results, indicative of immune quiescence), and not-TX (renal dysfunction and/or rejection on biopsy results). TruGraf v1 is intended for use in subjects with stable renal function to measure the immune status as an alternative to invasive, expensive, and risky surveillance biopsies. MATERIALS AND METHODS In this study, simultaneous blood tests and clinical assessments were performed in 192 patients from 7 transplant centers to evaluate TruGraf v1. The molecular testing laboratory was blinded to renal function and biopsy results. RESULTS Overall, TruGraf v1 accuracy (concordance between TruGraf v1 result and clinical and/or histologic assessment) was 74% (142/192), and a result of TX was accurate in 116 of 125 (93%). The negative predictive value for TruGraf v1 was 90%, with a sensitivity 74% and specificity of 73%. Results did not significantly differ in patients with a biopsy-confirmed diagnosis vs those without a biopsy. CONCLUSIONS TruGraf v1 can potentially support a clinical decision enabling unnecessary surveillance biopsies with high confidence, making it an invaluable addition to the transplant physician's tool kit for managing patients. TruGraf v1 testing can potentially avoid painful and risky invasive biopsies, reduce health care costs, and enable frequent assessment of patients with stable renal function to confirm the presence of immune quiescence in the peripheral blood.
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Affiliation(s)
- C L Marsh
- Scripps Center for Organ Transplantation, La Jolla, California, United States; Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States.
| | - S M Kurian
- Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States
| | - J C Rice
- Scripps Center for Organ Transplantation, La Jolla, California, United States
| | - T C Whisenant
- University of California, San Diego, School of Medicine, Center for Computational Biology and Bioinformatics, La Jolla, California, United States
| | - J David
- Transplant Genomics Inc, Mansfield, Massachusetts, United States
| | - S Rose
- Transplant Genomics Inc, Mansfield, Massachusetts, United States
| | - C Schieve
- Transplant Genomics Inc, Mansfield, Massachusetts, United States
| | - D Lee
- Transplant Genomics Inc, Mansfield, Massachusetts, United States
| | - J Case
- Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States
| | - B Barrick
- Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States
| | - V R Peddi
- California Pacific Medical Center, San Francisco, California, United States
| | - R B Mannon
- University of Alabama School of Medicine, Birmingham, Alabama, United States
| | - R Knight
- Houston Methodist Hospital, Houston, Texas, United States
| | - D Maluf
- University of Virginia, Charlottesville, Virginia, United States
| | - D Mandelbrot
- University of Wisconsin, Madison, Wisconsin, United States
| | - A Patel
- Henry Ford Hospital, Detroit, Michigan, United States
| | - J J Friedewald
- Comprehensive Transplant Center, Northwestern University, Chicago, Illionis, United States
| | - M M Abecassis
- Comprehensive Transplant Center, Northwestern University, Chicago, Illionis, United States
| | - M R First
- Transplant Genomics Inc, Mansfield, Massachusetts, United States; Comprehensive Transplant Center, Northwestern University, Chicago, Illionis, United States
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