151
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Screening for De Novo Anti-Human Leukocyte Antigen Antibodies in Nonsensitized Kidney Transplant Recipients Does Not Predict Acute Rejection. Transplantation 2010; 89:178-84. [DOI: 10.1097/tp.0b013e3181c3503e] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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152
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Lammers AE, Roberts P, Brown KL, Fenton M, Rees P, Sebire NJ, Burch M. Acute rejection after paediatric heart transplantation: far less common and less severe. Transpl Int 2010; 23:38-46. [DOI: 10.1111/j.1432-2277.2009.00941.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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153
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Bhowmik DM, Dinda AK, Mahanta P, Agarwal SK. The evolution of the Banff classification schema for diagnosing renal allograft rejection and its implications for clinicians. Indian J Nephrol 2010; 20:2-8. [PMID: 20535263 PMCID: PMC2878403 DOI: 10.4103/0971-4065.62086] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Till the early 1990s there was no standardized international classification of renal allograft biopsies resulting in considerable heterogeneity in reporting among the various centers. A group of dedicated renal pathologists, nephrologists, and transplant surgeons developed a schema in Banff, Canada in 1991. Subsequently there have been updates at regular intervals. The following review presents the evolution of the Banff classification and its utility for clinicians.
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Affiliation(s)
- D. M. Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - A. K. Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - P. Mahanta
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - S. K. Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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154
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Heidt S, Roelen DL, Eijsink C, Eikmans M, van Kooten C, Claas FHJ, Mulder A. Calcineurin inhibitors affect B cell antibody responses indirectly by interfering with T cell help. Clin Exp Immunol 2009; 159:199-207. [PMID: 19922499 DOI: 10.1111/j.1365-2249.2009.04051.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In general, humoral immune responses depend critically upon T cell help. In transplantation, prevention or treatment of humoral rejection therefore require drugs that ideally inhibit both B cell and T helper cell activity. Here, we studied the effects of commonly used immunosuppressive drugs [tacrolimus, cyclosporin, mycophenolic acid (MPA) and rapamycin] on T cell helper activity and on T cell-dependent B cell responses. T cells were activated polyclonally in the presence of immunosuppressive drugs in order to analyse the effect of these drugs on T cell proliferation, co-stimulatory ligand expression and cytokines. The impact of immunosuppressive drugs on T cell-dependent immunoglobulin production by B cells was addressed in T-B cell co-cultures. All drugs affected T cell proliferation and attenuated T cell co-stimulatory ligand (CD154 and CD278) expression when T cells were activated polyclonally. Tacrolimus, cyclosporin and rapamycin also attenuated B cell stimulatory cytokine mRNA levels in T cells. As a consequence, a decrease in immunoglobulin levels was observed in autologous T-B cell co-cultures, where T cell help is essential for immunoglobulin production. In contrast, when pre-activated T cells were used to stimulate autologous B cells, calcineurin inhibitors failed to inhibit B cell immunoglobulin production, whereas MPA and rapamycin did show inhibition. From these studies, it is evident that calcineurin inhibitors affect the humoral immune response by interfering with T helper signals, but not by targeting B cells directly. Furthermore, our studies support the necessity of intervening in T cell helper function to attenuate humoral responses.
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Affiliation(s)
- S Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
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155
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Cheunsuchon B, Vongwiwatana A, Premasathian N, Shayakul C, Parichatikanond P. The Prevalence of C4d-Positive Renal Allografts in 134 Consecutive Biopsies in Thai Patients. Transplant Proc 2009; 41:3697-700. [DOI: 10.1016/j.transproceed.2009.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 04/13/2009] [Indexed: 01/21/2023]
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156
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Hidalgo LG, Campbell PM, Sis B, Einecke G, Mengel M, Chang J, Sellares J, Reeve J, Halloran PF. De novo donor-specific antibody at the time of kidney transplant biopsy associates with microvascular pathology and late graft failure. Am J Transplant 2009; 9:2532-41. [PMID: 19843031 DOI: 10.1111/j.1600-6143.2009.02800.x] [Citation(s) in RCA: 256] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We studied whether de novo donor-specific antibodies (DSA) in sera from patients undergoing kidney transplant biopsies associate with specific histologic lesions in the biopsy and prognosis. DSA were assessed in 145 patients at the time of biopsy between 7 days to 31 years posttransplant. DSA was detected in 54 patients (37%), of which 32 represented de novo DSA. De novo DSA was more frequent in patients having late biopsies (34%) versus early biopsies (4%), and was usually either against class II alone or class I and II but rarely against class I alone. Microcirculation inflammation (glomerulitis, capillaritis) and damage (glomuerulopathy, capillary basement membrane multilayering), and C4d staining were associated with de novo DSA. However, the degree of scarring, arterial fibrosis and tubulo-interstitial inflammation did not correlate with the presence of de novo DSA. De novo DSA correlated with reduced graft survival after the biopsy. Thus, de novo DSA at the time of a late biopsy for clinical indication is primarily against class II, and associates with microcirculation changes in the biopsy and subsequent graft failure. We propose careful assessment of de novo DSA, particularly against class II, be performed in all late kidney transplant biopsies.
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Affiliation(s)
- L G Hidalgo
- Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
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157
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Einecke G, Sis B, Reeve J, Mengel M, Campbell PM, Hidalgo LG, Kaplan B, Halloran PF. Antibody-mediated microcirculation injury is the major cause of late kidney transplant failure. Am J Transplant 2009; 9:2520-31. [PMID: 19843030 DOI: 10.1111/j.1600-6143.2009.02799.x] [Citation(s) in RCA: 544] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We studied the phenotype of late kidney graft failure in a prospective study of unselected kidney transplant biopsies taken for clinical indications. We analyzed histopathology, HLA antibodies and death-censored graft survival in 234 consecutive biopsies from 173 patients, taken 6 days to 31 years posttransplant. Patients with late biopsies (>1 year) frequently displayed donor-specific HLA antibody (particularly class II) and microcirculation changes, including glomerulitis, glomerulopathy, capillaritis, capillary multilayering and C4d staining. Grafts biopsied early rarely failed (1/68), whereas grafts biopsied late often progressed to failure (27/105) within 3 years. T-cell-mediated rejection and its lesions were not associated with an increased risk of failure after biopsy. In multivariable analysis, graft failure correlated with microcirculation inflammation and scarring, but C4d staining was not significant. When microcirculation changes and HLA antibody were used to define antibody-mediated rejection, 17/27 (63%) of late kidney failures after biopsy were attributable to antibody-mediated rejection, but many were C4d negative and missed by current diagnostic criteria. Glomerulonephritis accounted for 6/27 late losses, whereas T-cell-mediated rejection, drug toxicity and unexplained scarring were uncommon. The major cause of late kidney transplant failure is antibody-mediated microcirculation injury, but detection of this phenotype requires new diagnostic criteria.
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Affiliation(s)
- G Einecke
- Alberta Transplant Applied Genomics Centre, Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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158
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159
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Kozakowski N, Regele H. Biopsy diagnostics in renal allograft rejection: from histomorphology to biological function. Transpl Int 2009; 22:945-53. [DOI: 10.1111/j.1432-2277.2009.00885.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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160
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Abstract
For the past 40 years, T cells have been considered the primary threat to the survival of allografts. However, antibodies can induce severe vascular disease of organ transplants, and this disease, particularly "antibody-mediated" rejection, has become a major clinical challenge. Not only do antibodies cause rejection, the rejection caused by antibodies resists treatment by conventional drug regimens. On the other hand, antibodies can induce a condition in which grafts seemingly resist antibody-mediated injury, which is accommodation. In this communication, we discuss the role of antibodies in the diagnosis and pathogenesis of rejection and accommodation, and suggest what we considered the major gaps in knowledge and directions research into this subject might productively take.
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Affiliation(s)
| | - Jeffrey L. Platt
- Departments of Surgery and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan 48109
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161
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162
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Sis B, Jhangri GS, Bunnag S, Allanach K, Kaplan B, Halloran PF. Endothelial gene expression in kidney transplants with alloantibody indicates antibody-mediated damage despite lack of C4d staining. Am J Transplant 2009; 9:2312-23. [PMID: 19681822 DOI: 10.1111/j.1600-6143.2009.02761.x] [Citation(s) in RCA: 367] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Anti-HLA alloantibody is a risk factor for graft loss, but does not indicate which kidneys are experiencing antibody-mediated rejection (ABMR). C4d staining in biopsies is specific for ABMR but insensitive. We hypothesized that altered expression of endothelial genes due to alloantibody acting on the microcirculation would be sensitive indicator of ABMR. We identified 119 endothelial-associated transcripts (ENDATs) from literature, and studied their expression by microarrays in 173 renal allograft biopsies for cause. Mean ENDAT expression was increased in all rejection but was higher in ABMR than in T-cell-mediated rejection and correlated with histopathologic lesions of ABMR, and alloantibody. Many individual ENDATs were increased in ABMR and predicted graft loss. Kidneys with high ENDATs and antibody showed increased lesions of ABMR and worse prognosis in comparison to controls. Only 40% of kidneys with high ENDAT expression and chronic ABMR or graft loss were diagnosed by C4d positivity. High ENDAT expression with antibody predicts graft loss with higher sensitivity (77% vs. 31%) and slightly lower specificity (71% vs. 94%) than C4d. The results were validated in independent set of 82 kidneys. High renal endothelial transcript expression in patients with alloantibody is indicator of active antibody-mediated allograft damage and poor graft outcome.
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Affiliation(s)
- Banu Sis
- Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
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163
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Kieran N, Wang X, Perkins J, Davis C, Kendrick E, Bakthavatsalam R, Dunbar N, Warner P, Nelson K, Smith KD, Nicosia RF, Alpers CE, Leca N, Kowalewska J. Combination of peritubular c4d and transplant glomerulopathy predicts late renal allograft failure. J Am Soc Nephrol 2009; 20:2260-8. [PMID: 19729438 DOI: 10.1681/asn.2009020199] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The histologic associations and clinical implications of peritubular capillary C4d staining from long-term renal allografts are unknown. We identified 99 renal transplant patients who underwent an allograft biopsy for renal dysfunction at least 10 yr after transplantation, 25 of whom were C4d-positive and 74 of whom were C4d-negative. The average time of the index biopsy from transplantation was 14 yr in both groups. Compared with C4d-negative patients, C4d-positive patients were younger at transplantation (29 +/- 13 versus 38 +/- 12 yr; P < 0.05) and were more likely to have received an allograft from a living donor (65 versus 35%; P < 0.001). C4d-positive patients had more inflammation, were more likely to have transplant glomerulopathy, and had worse graft outcome. The combined presence of C4d positivity, transplant glomerulopathy, and serum creatinine of >2.3 mg/dl at biopsy were very strong predictors of rapid graft loss. C4d alone did not independently predict graft loss. Retrospective staining of historical samples from C4d-positive patients demonstrated C4d deposition in the majority of cases. In summary, these data show that in long-term renal allografts, peritubular capillary staining for C4d occurs in approximately 25% of biopsies, can persist for many years after transplantation, and strongly predicts graft loss when combined with transplant glomerulopathy.
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Affiliation(s)
- Niamh Kieran
- Department of Medicine, Division of Nephrology,University of Washington, Seattle, Washington 98195-6521, USA.
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164
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Locke JE, Zachary AA, Warren DS, Segev DL, Houp JA, Montgomery RA, Leffell MS. Proinflammatory events are associated with significant increases in breadth and strength of HLA-specific antibody. Am J Transplant 2009; 9:2136-9. [PMID: 19663896 DOI: 10.1111/j.1600-6143.2009.02764.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Identification of factors responsible for an increase in the breadth or strength of HLA-specific antibody (HSA) is critical to the continued successful management and transplantation of sensitized patients. A retrospective review of our HLA registry identified 107 patients with known HSA and sufficient information in their electronic patient record to determine the presence or absence of a proinflammatory event. The patients were stratified according to transplant status [sensitized and on the transplant waitlist (n = 65); immunosuppressed recipients of a positive crossmatch (+XM) transplant (n = 42)]. Eighty-three percent of waitlist candidates and 55% of sensitized kidney transplant recipients with a documented proinflammatory event had an associated increase in HSA. Interestingly, among patients with a culture-proven infection, 97% of the waitlist patients and 54.8% of +XM recipients had an associated rise in HSA. Overall, proinflammatory events were associated with a greater increase among waitlist patients than +XM recipients, 5.3-fold [IRR 5.25, (95% CI 4.03-6.85), p < 0.001] versus 2.5-fold [IRR 2.54, (95% CI 1.64-3.95), p < 0.001] increase in HSA. Therefore, sensitized patients known to have an infection or undergoing surgery should be monitored for expansion of HSA.
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Affiliation(s)
- J E Locke
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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165
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Nickerson P. Post-transplant monitoring of renal allografts: are we there yet? Curr Opin Immunol 2009; 21:563-8. [PMID: 19713093 DOI: 10.1016/j.coi.2009.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 07/28/2009] [Indexed: 11/30/2022]
Abstract
Transplantation has emerged as the therapy of choice for many patients with end organ failure. One of the major goals is to tailor immunosuppressive therapy to the individual needs of every patient to balance the risk for rejection and over-immunosuppression. This will require diagnostic tools that can detect harmful processes in the allograft early, and that can be measured repeatedly. This review will consider recent advances in our understanding of the molecular nature of these processes and how this information is being utilized to design novel diagnostic assays to non-invasively monitor allografts. Highlighted is the need for large-scale prospective multi-centre studies to validate assays that show early promise in single centre studies.
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Affiliation(s)
- Peter Nickerson
- Manitoba Centre for Proteomics and Systems Biology, University of Manitoba, 799 John Buhler Research Centre, 715 McDermot Avenue, Winnipeg, Manitoba, Canada R3E 3P4.
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166
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Shimizu T, Ishida H, Shirakawa H, Omoto K, Tsunoyama K, Iida S, Tanabe K, Yamaguchi Y. Clinicopathological analysis of transplant glomerulopathy cases. Clin Transplant 2009; 23 Suppl 20:39-43. [DOI: 10.1111/j.1399-0012.2009.01008.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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167
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Magro CM, Calomeni EP, Nadasdy T, Shusterman BD, Pope-Harman AL, Ross P. Ultrastructure as a Diagnostic Adjunct in the Evaluation of Lung Allograft Biopsies. Ultrastruct Pathol 2009; 29:95-106. [PMID: 16028666 DOI: 10.1080/019131290924108] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Humoral immunity contributes significantly to lung graft dysfunction. Recognizing a role of ultrastructural studies in the evaluation and diagnosis of chronic humoral allograft rejection in the kidney, the authors sought to explore its utility as a diagnostic adjunct in lung allograft biopsies. Ultrastructural studies were conducted on 44 biopsies from 26 lung transplant recipients. Endothelial cell activation and necrosis were seen in the setting of acute humoral allograft rejection. Septal chronic vasculopathic changes of thickening and lamellation of the basement membrane zone (BMZ) and BMZ collagen deposition were correlated with greater numbers of humoral allograft rejection episodes and with the development of chronic graft dysfunction/bronchiolitis obliterans syndrome. There was a positive correlation between the extent of septal fibrosis and certain chronic vasculopathic changes, namely collagen deposition in the BMZ and BMZ wrinkling. Patients with chronic graft dysfunction and multiple rejection episodes manifested low diffusion capacities (less than 50% predicted). The results indicate that ultrastructural analysis is useful in identification of septal fibrosis and chronic vasculopathy of the septal microvasculature, correlating with chronic graft dysfunction, encompassing not only fibrotic sequelae of the bronchial wall but also irreversible terminal lung parenchymal changes, the latter associated with repeated episodes of humoral rejection.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology, The Ohio State University, N305 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210-1218, USA.
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168
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Murata K, Baldwin WM. Mechanisms of complement activation, C4d deposition, and their contribution to the pathogenesis of antibody-mediated rejection. Transplant Rev (Orlando) 2009; 23:139-50. [PMID: 19362461 PMCID: PMC2797368 DOI: 10.1016/j.trre.2009.02.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Complement split products have emerged as useful markers of antibody-mediated rejection in solid organ transplants. One split product, C4d, is now widely accepted as a marker for antibody-mediated rejection in renal and cardiac allografts. This review summarizes the rationale for the use of C4d as a marker of antibody-mediated rejection, along with the clinical evidence supporting its use in the clinical diagnosis of antibody-mediated rejection. Antibody-independent mechanisms by which C4d can be activated by the classical and lectin pathways of complement activation are also identified. Finally, mechanisms by which complement activation stimulates effector cells (neutrophils, monocytes, macrophages, platelets, and B and T lymphocytes) as well as target cells (endothelial cells) are discussed in relation to antibody-mediated allograft rejection.
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Affiliation(s)
- Kazunori Murata
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - William M Baldwin
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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169
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Haller H, Richter N, Bröcker V, Gwinner W, Gueler F, Schwarz A. [Current problems of kidney transplantation]. Internist (Berl) 2009; 50:523-35. [PMID: 19396413 DOI: 10.1007/s00108-008-2269-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The long-term problems after kidney transplantation have changed considerably in recent years. While formerly immunosuppression and prevention of acute rejection were of prime concern, now attention focuses on chronic alterations of the transplanted organ and long-term survival of the patients. The transplantation procedure itself has evolved into a standardized technique with a high level of surgical quality. Problems involving organ preservation and ischemia/reperfusion damage also play a role, especially in view of chronic aspects. Monitoring of long-term complications should follow a program for the transplanted organ as well as a program for the patient. Monitoring kidney function should address the organ more precisely than has previously been the case. Serum creatinine level and proteinuria alone provide insufficient information and only change long after cellular deterioration has begun. Hence it is imperative that new testing methods be developed. One possibility is offered by protocol biopsies that allow histological and molecular analysis of the kidney at regular intervals. The patient programs concentrate on diagnostics and treatment of the cardiovascular diseases. Furthermore, the patients must be screened for occurrence of neoplasia. There are no prospective studies covering all cardiovascular risk factors after kidney transplantation. This pertains particularly to the subject of hypertension.
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Affiliation(s)
- H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover.
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170
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Rostaing L, Guilbeau-Frugier C, Fort M, Mekhlati L, Kamar N. Treatment of symptomatic transplant glomerulopathy with rituximab. Transpl Int 2009; 22:906-13. [PMID: 19453996 DOI: 10.1111/j.1432-2277.2009.00896.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Kidney transplant glomerulopathy (TG) has a poor outcome as there are no known effective therapies. Therefore, we investigated whether rituximab therapy (RTx) could halt progression of established TG. Fourteen kidney-transplant patients (nine of whom were men), with median age of 54 (range: 30-74) years, of whom seven had biologic markers for HCV infection, underwent a kidney biopsy (KB) at 118 months post-transplant because of impaired allograft function, associated with albuminuria (95-13430 mg/day), within nephrotic-range albuminuria in seven patients. KBs showed no evidence of acute cellular rejection but showed TG. Donor-specific anti-HLA antibodies were present in six cases. When diagnosis of TG was made, patients were placed on rituximab therapy (RTx) (2-4 injections of 375 mg/m2 week), and other concurrent immunosuppression treatments were not modified. By last follow up post-RTx (30 months), seven (50%) patients had lost their kidney within 6-26 months and the other seven had stable creatinine (182 vs. 161 micromol/l; NS), and albuminuria had decreased from 2660 to 500 mg/day (P = 0.03). There was prolonged B-cell lymphopenia (from 71 to 0/mm3) whereas immunoglobulin G, A, M levels remained stable, and four patients (28.5%) experienced severe infectious complications. We conclude that long-term RTx in kidney-transplant patients with TG is associated with allograft function/stabilization in 50% of cases.
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Affiliation(s)
- Lionel Rostaing
- Department of Nephrology, Dialysis and Multiorgan Transplantation, Toulouse University Hospital, CHU Rangueil, Toulouse Cédex, France.
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171
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Using Biomarkers of Tolerance and Rejection to Identify High- and Low-Risk Patients Following Kidney Transplantation. Transplantation 2009; 87:S95-9. [DOI: 10.1097/tp.0b013e3181a2e295] [Citation(s) in RCA: 15] [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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172
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Perkowska-Ptasińska A, Ciszek M, Chmura A, Galazka Z, Paczek L, Durlik M. Transplant glomerulopathy: clinical and pathological correlations. Transplant Proc 2009; 41:141-9. [PMID: 19249499 DOI: 10.1016/j.transproceed.2008.10.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 10/20/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Chronic transplant glomerulopathy (TG) is one of the leading causes of severe posttransplantation proteinuria and graft loss. Our current knowledge about risk factors for the development of TG, as well as factors that affect its dynamics and prognosis, is poor. We sought to describe the pathological and clinical risk factors and correlations of TG as well as parameters that influenced the survival of grafts with that pathology. MATERIALS AND METHODS We retrospectively reevaluated 86 kidney transplant cases with TG that have been recognized on the basis of an indication biopsy since 1997. All TG as well as all pre-TG (previous) biopsies were characterized for the presence of C4d deposits in the graft. RESULTS Younger recipient age and minimal immunosuppression due to drug withdrawal or suboptimal drug doses/blood levels within 3 to 6 months preceding the biopsy were associated with C4d deposition in peritubular capillaries (PTC; P = .0053 and P = .0365, respectively). Diffuse PTC-itis (P = .029, RR [95% confidence interval] = 3.349 [1.131-9.919]) and total interstitial inflammation score (P = .015, RR [95% confidence interval] = 9.662 [1.784-52.329]) were observed to show a negative impact on graft survival. C4d deposition in PTC and glomeruli, the level of pretransplantation sensitization, episodes of acute rejection, and C4d in previous (pre-TG) biopsies did not influence the survival of grafts with TG. CONCLUSIONS Younger recipient age and minimal immunosuppression were associated with C4d positivity in grafts with TG. The survival of kidney grafts with TG was significantly affected by the magnitude of inflammation in the interstitium and PTC, but not by C4d positivity in PTC and glomeruli.
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Affiliation(s)
- A Perkowska-Ptasińska
- Department of Transplantology and Nephrology, Warsaw Medical University, Warsaw, Poland.
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173
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Kedainis RL, Koch MJ, Brennan DC, Liapis H. Focal C4d+ in renal allografts is associated with the presence of donor-specific antibodies and decreased allograft survival. Am J Transplant 2009; 9:812-9. [PMID: 19344468 PMCID: PMC2730653 DOI: 10.1111/j.1600-6143.2009.02555.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Diffuse peritubular capillary C4d deposition in renal allograft biopsies is associated with donor-specific antibodies (DSA) and graft failure. The significance of focal C4d+ is unclear. We reviewed 368 biopsies from 301 patients performed for renal dysfunction or proteinuria over 5 years. Diffuse C4d+, focal C4d+ and C4d- detected by immunofluorescence occurred in 9.5%, 20.9% and 69.4% of biopsies, respectively. Patients were similar in gender, age, cause of renal disease, donor source, HLA mismatch, serum creatinine at baseline and interval from transplantation to biopsy. Diffuse and focal C4d+ were associated with acute cellular rejection (p < 0.001). Transplant glomerulopathy was associated with diffuse C4d+. DSA at the time of biopsy, were positive in 79.3% of diffusely C4d+ patients, 68.8% of those with focal C4d+ (p = 0.27) and 9.9% of patients with C4d- (p < 0.001, compared to either the focal or diffuse groups, respectively). Allograft survival at 40 months was lower in diffuse C4d+ compared to the C4d- group (p = 0.014), but not when compared to the focal C4d+ group. There was a clear trend toward worse graft survival in patients with focal C4d+ in this time interval, but focal C4d+ compared to both diffuse C4d+ and C4d-groups was not statistically significant (p = 0.08).
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Affiliation(s)
- Rasa L. Kedainis
- Department of Internal Medicine, Renal Division, Washington University, St Louis, MO
| | - Matthew J. Koch
- Department of Internal Medicine, Renal Division, Washington University, St Louis, MO
| | - Daniel C. Brennan
- Department of Internal Medicine, Renal Division, Washington University, St Louis, MO
| | - Helen Liapis
- Department of Internal Medicine, Renal Division, Washington University, St Louis, MO,Department of Pathology and Immunology, Washington University, St Louis, MO
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174
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Singh N, Pirsch J, Samaniego M. Antibody-mediated rejection: treatment alternatives and outcomes. Transplant Rev (Orlando) 2009; 23:34-46. [PMID: 19027615 DOI: 10.1016/j.trre.2008.08.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Over the past 10 years, thanks to the development of sensitive methods of antibody detection and markers of antibody injury such as C4d staining, the role of anti-human leukocyte antigen (HLA) and non-HLA alloantibodies as effectors of acute and chronic immune allograft injury has been revisited. Antibody-mediated rejection (AMR) defines all allograft rejection caused by antibodies directed against donor-specific HLA molecules, blood group antigen (ABO)-isoagglutinins, or endothelial cell antigens. Antibody-mediated rejection can be a recalcitrant process, resistant to therapy and carries an ominous prognosis to the graft. In concordance with these views, treatment protocols for AMR use permutations of a multiple-prong approach that include (1) the suppression of the T-cell dependent antibody response, (2) the removal of donor reactive antibody, (3) the blockade of the residual alloantibody, and (4) the depletion of naive and memory B-cells. Although all published protocols report a variable rate of success, a major weakness of all current protocols is the lack of effective anti-plasma cell agents. In comparison to acute AMR, the treatment for chronic AMR (CAMR) is not well characterized. Although in acute AMR large titers of pre-existent alloantibodies result in massive activation of the complement system and lytic injury of the graft endothelium, thereby requiring aggressive and fast removal of the offending agents, in CAMR, complement activation results in sublytic endothelial cell injury and activation. Although this type of injury results in chronic graft failure, its slow progression likely renders it amenable of suppression by heightening of maintenance immunosuppression and anti-idiotypic blockade of the circulating alloantibody without the need of plasma exchange. In this review, we will discuss the rationale behind the design of treatment protocols for acute AMR and CAMR as well as their reported results and complications.
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Affiliation(s)
- Neeraj Singh
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53713, USA
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175
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The use of C3d and C4d immunohistochemistry on formalin-fixed tissue as a diagnostic adjunct in the assessment of inflammatory skin disease. J Am Acad Dermatol 2009; 59:822-33. [PMID: 19119098 DOI: 10.1016/j.jaad.2008.06.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Revised: 06/03/2008] [Accepted: 06/13/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Direct immunofluorescent (DIF) testing defines an important diagnostic adjunct in the classification of various inflammatory skin conditions; it requires fresh tissue, a laboratory equipped to perform the procedure, and a pathologist skilled in its interpretation. Although advances have been made in the development of antibodies that can be applied to paraffin-embedded tissue, there has been no reported success on the application of paraffin tissue-based immunohistochemistry as a potential substitute for DIF testing on skin biopsy material. OBJECTIVE We applied C3d and C4d immunohistochemistry on paraffin-embedded, formalin-fixed tissue to define a potential application of these two antibodies as a diagnostic adjunct in the evaluation of various inflammatory skin diseases. DESIGN A natural language search identified cases submitted for both light microscopic and DIF studies from July 2006 to August 2007. We prospectively included similar cases encountered from August 2007 to March 2008. We correlated the C3d and C4d staining pattern with the DIF and light microscopic findings. RESULTS All cases of scarring discoid lupus erythematosus (LE) (20/20) and systemic LE (5/5) showed prominent granular C3d along the dermoepidermal junction (DEJ) and a positive lupus band test result in the latter by DIF. All systemic LE cases demonstrated granular DEJ C4d with C3d or C4d in blood vessels (BV). There was a negative lupus band test result without DEJ C3d or C4d in all cases of subacute cutaneous lupus erythematosus (SCLE) (15/15). There were, however, deposits of C4d within epidermal keratinocytes (7/7), corresponding to IgG decoration of keratinocytes by DIF and the presence of anti-Ro antibodies. Dermatomyositis cases showed prominent mural C3d and C4d in BV corresponding to C5b-9 by DIF (12/12) and one case of hydroxyurea-induced dermatomyositis lacked this staining. Although by DIF all dermatomyositis cases had a negative lupus band test result, 25% of cases showed staining for C3d along the DEJ (3/9). Bullous pemphigoid cases demonstrated homogenous DEJ C3d (17/17) whereas C4d was characteristically negative; there was 100% concordance with linear IgG and C3d by DIF. Eighty two percent of pemphigus cases demonstrated prominent intercellular C3d and C4d, roughly mirroring the intercellular pattern for IgG and complement seen by DIF (9/11). Porphyria cases showed homogeneous and granular C3d (11/11) and C4d (7/11), mirroring the vascular immunoglobulin and C5b-9 by DIF. All cases of urticarial (5), leukocytoclastic (6), and lymphocytic (1) vasculitis exhibited prominent mural C3d and C4d in BV, whereas Henoch-Schönlein purpura (10/10) showed primarily mural BV C3d without C4d, with IgA by DIF. Three cases of relapsing polychondritis showed C3d and C4d within chondrocyte nuclei (3/3), in contrast to negative staining in chondrodermatitis nodularis helicis (0/2). Hypersensitivity reactions were negative for C3d and C4d. LIMITATIONS The small sample size in each category is a limitation. The lack of literature precedent with regard to immunohistochemical assessment of extracellular antigens on paraffin-embedded tissue in skin samples is another limitation of this study. CONCLUSIONS When correlated with the light microscopic and clinical findings, the C3d and C4d assay has significant application in the assessment of select inflammatory skin diseases including vasculopathic conditions, collagen vascular disease, and autoimmune vesiculobullous disorder. It may prompt further DIF testing or, in some instances, may even define a reasonable substitute for DIF and/or add to the morphologic assessment of a biopsy specimen submitted for routine light microscopic assessment primarily in the setting of autoimmune vesiculobullous disease and collagen vascular disease.
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176
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Nickerson P, Heeger PS. Proteomic Portrayal of Transplant Pathologies. J Am Soc Nephrol 2009; 20:236-8. [DOI: 10.1681/asn.2008121243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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177
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Yamamoto I, Horita S, Takahashi T, Kobayashi A, Toki D, Tanabe K, Hattori M, Teraoka S, Aita K, Nagata M, Yamaguchi Y. Caveolin-1 expression is a distinct feature of chronic rejection-induced transplant capillaropathy. Am J Transplant 2008; 8:2627-35. [PMID: 19032226 DOI: 10.1111/j.1600-6143.2008.02421.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Peritubular capillary basement membrane multilayering (PTCBMML) is a pathological landmark of chronic rejection-induced transplant capillaropathy (TC), but its cellular mechanisms are not fully understood. We observed de novo caveolae formation in endothelial cells in TC under electron microscopy. To examine the role of caveolae and their structural components in TC, biopsy samples from cases of chronic rejection were double-immunostained for Caveolin-1 (Cav-1) and Pathologische Anatomie Leiden-endothelium (PAL-E; a marker of peritubular capillary [PC]). Thirty-two cases of chronic rejection (group I) were compared with 18 cases of interstitial fibrosis and tubular atrophy with no evidence of any specific etiology (IF/TA; group II) and eight cases of peritubular capillaritis (group III). The Cav-1/PAL-E immunoreactivities in groups I-III (%Cav-1/PAL-E) were 41.8+/-23.1%, 8.1+/-7.3% (p < 0.01 vs. group I) and 12.7+/-7.4% (p < 0.01 vs. group I), respectively. Furthermore, multiple linear regression models demonstrated that %Cav-1/PAL-E was independently associated with the PTCBMML grade and reduced PC number. No correlation was observed between %Cav-1/PAL-E and PC C4d deposition in group I. We conclude that de novo caveolae formation in PC endothelia is involved in TC in chronic rejection.
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Affiliation(s)
- I Yamamoto
- Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
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178
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Mandal SK, Jasuja S. Antibody Mediated Rejection and Role of C4d Staining. APOLLO MEDICINE 2008. [DOI: 10.1016/s0976-0016(11)60170-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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179
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Effects of immunosuppressive drugs on purified human B cells: evidence supporting the use of MMF and rapamycin. Transplantation 2008; 86:1292-300. [PMID: 19005412 DOI: 10.1097/tp.0b013e3181874a36] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Humoral immunity is increasingly recognized as an important factor in the rejection of organ transplants. In general, humoral rejection is treated with standard immunosuppressive drugs. The direct effect of these immunosuppressive drugs on B cells is not well known. METHODS Purified human B cells devoid of T cells were stimulated with CD40L expressing L cells, or by anti-CD40 mAb with or without Toll-like receptor triggering, all in the presence of B-cell activating cytokines. These three protocols resulted in various degrees of B-cell stimulation. We added four commonly used immunosuppressive drugs (tacrolimus, cyclosporin, mycophenolic acid [MPA], and rapamycin) to these cultures and tested a variety of parameters of B-cell activity including proliferation, apoptosis induction, and both IgM and IgG production. RESULTS Tacrolimus and cyclosporin marginally inhibited B-cell proliferation and immunoglobulin production, and the extent of inhibition depended on the degree of the B-cell stimulation. In contrast, MPA and rapamycin profoundly inhibited both B-cell proliferation and immunoglobulin production, which was independent of the degree of B-cell stimulation. Both drugs induced B-cell apoptosis. Moreover, rapamycin caused a reduction in the number of B cells capable of producing immunoglobulins. CONCLUSIONS Our data show that MPA and rapamycin are capable of strongly inhibiting B cells responses. This provides a rationale for the use of both MPA and rapamycin to prevent or counteract humoral responses.
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180
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Péfaur J, Díaz P, Panace R, Salinas P, Fiabane A, Quinteros N, Chea R, Naranjo E, Wurgaft A, Beltran E, Elgueta S, Wegmann M, Gajardo J, Contreras L. Early and Late Humoral Rejection: A Clinicopathologic Entity in Two Times. Transplant Proc 2008; 40:3229-36. [DOI: 10.1016/j.transproceed.2008.03.123] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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181
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Yang L, Lu Y, Luo G, Song J, Shi Y, Li YP. C4d Deposition Is Associated With Chronic Allograft Nephropathy in Rats and Could Be Influenced by Immunosuppressants. Transplant Proc 2008; 40:2782-5. [DOI: 10.1016/j.transproceed.2008.07.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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182
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Haas M, Segev DL, Racusen LC, Bagnasco SM, Locke JE, Warren DS, Simpkins CE, Lepley D, King KE, Kraus ES, Montgomery RA. C4d deposition without rejection correlates with reduced early scarring in ABO-incompatible renal allografts. J Am Soc Nephrol 2008; 20:197-204. [PMID: 18776120 DOI: 10.1681/asn.2008030279] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
C4d deposition in peritubular capillaries is a specific marker for the presence of antidonor antibodies in renal transplant recipients and is usually associated with antibody-mediated rejection (AMR) in conventional allografts. In ABO-incompatible grafts, however, peritubular capillary C4d is often present on protocol biopsies lacking histologic features of AMR; the significance of C4d in this setting remains unclear. For addressing this, data from 33 patients who received ABO-incompatible renal allografts (after desensitization) were retrospectively reviewed. Protocol biopsies were performed at 1 and/or 3 and 6 mo after transplantation in each recipient and at 12 mo in 28 recipients. Twenty-one patients (group A) had strong, diffuse peritubular capillary C4d staining without histologic evidence of AMR or cellular rejection on their initial protocol biopsies. The remaining 12 patients (group B) had negative or weak, focal peritubular capillary C4d staining. Three grafts (two in group B) were lost but not as a result of AMR. Excluding these three patients, serum creatinine levels were similar in the two groups at 6 and 12 mo after transplantation and at last follow-up; however, recipients in group A developed significantly fewer overall chronic changes, as scored by the sum of Banff chronic indices, than group B during the first year after transplantation. These results suggest that diffuse peritubular capillary C4d deposition without rejection is associated with a lower risk for scarring in ABO-incompatible renal allografts; the generalizability of these results to conventional allografts remains unknown.
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Affiliation(s)
- Mark Haas
- Department of Pathology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Pathology 712, Baltimore, MD 21287, USA.
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183
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Minimization of calcineurin inhibitors to improve long-term outcomes in kidney transplantation. Transpl Immunol 2008; 20:21-8. [PMID: 18775494 DOI: 10.1016/j.trim.2008.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 08/07/2008] [Indexed: 12/28/2022]
Abstract
Long-term outcomes after kidney transplantation remain suboptimal, despite the great achievements observed in recent years with the use of modern immunosuppressive drugs. Currently, the calcineurin inhibitors (CNI) cyclosporine and tacrolimus remain the cornerstones of immunosuppressive regimens in many centers worldwide, regardless of their well described side-effects, including nephrotoxicity. In this article, we review recent CNI-minimization strategies in kidney transplantation, while emphasizing on the importance of long-term follow-up and patient monitoring. Finally, accumulating data indicate that low-dose CNI-based regimens would provide an interesting balance between efficacy and toxicity.
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184
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Detecting and monitoring human leukocyte antigen-specific antibodies. Hum Immunol 2008; 69:591-604. [PMID: 18692106 DOI: 10.1016/j.humimm.2008.06.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Revised: 06/16/2008] [Accepted: 06/17/2008] [Indexed: 01/26/2023]
Abstract
Renewed awareness of the relevance of HLA-specific antibodies to transplantation and the development of protocols to reduce or eliminate sensitization have made monitoring of antibodies and accurate interpretation of test results increasingly important. Here we review the various tests available and provide guidelines for the development of monitoring protocols.
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185
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Smith RN, Kawai T, Boskovic S, Nadazdin O, Sachs DH, Cosimi AB, Colvin RB. Four stages and lack of stable accommodation in chronic alloantibody-mediated renal allograft rejection in Cynomolgus monkeys. Am J Transplant 2008; 8:1662-72. [PMID: 18557724 PMCID: PMC2796366 DOI: 10.1111/j.1600-6143.2008.02303.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The etiology of immunologically mediated chronic renal allograft failure is unclear. One cause is thought to be alloantibodies. Previously in Cynomolgus monkeys, we observed a relationship among donor-specific alloantibodies (DSA), C4d staining, allograft glomerulopathy, allograft arteriopathy and progressive renal failure. To define the natural history of chronic antibody-mediated rejection and its effect on renal allograft survival, we now extend this report to include 417 specimens from 143 Cynomolgus monkeys with renal allografts. A subset of animals with long-term renal allografts made DSA (48%), were C4d positive (29%), developed transplant glomerulopathy (TG) (22%) and chronic allograft arteriopathy (CAA) (19%). These four features were highly correlated and associated with statistically significant shortened allograft survival. Acute cellular rejection, either Banff type 1 or 2, did not correlate with alloantibodies, C4d deposition or TG. However, endarteritis (Banff type 2) correlated with later CAA. Sequential analysis identified four progressive stages of chronic antibody-mediated rejection: (1) DSA, (2) deposition of C4d, (3) TG and (4) rising creatinine/renal failure. These new findings provide strong evidence that chronic antibody-mediated rejection develops without enduring stable accommodation, progresses through four defined clinical pathological stages and shortens renal allograft survival.
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186
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Rowshani AT, Bemelman FJ, Lardy NM, Ten Berge IJ. Humoral immunity in renal transplantation: clinical significance and therapeutic approach. Clin Transplant 2008; 22:689-99. [DOI: 10.1111/j.1399-0012.2008.00872.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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187
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Anti-Human Leukocyte Antigen Antibodies, Vascular C4d Deposition and Increased Soluble C4d in Broncho-Alveolar Lavage of Lung Allografts. Transplantation 2008; 86:342-7. [DOI: 10.1097/tp.0b013e31817cf2e2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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188
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Gloor J, Cosio F, Lager DJ, Stegall MD. The spectrum of antibody-mediated renal allograft injury: implications for treatment. Am J Transplant 2008; 8:1367-73. [PMID: 18510643 DOI: 10.1111/j.1600-6143.2008.02262.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Improvements in anti-HLA antibody detection and diagnostic criteria have increased recognition of antibody-mediated rejection (AMR) following renal transplantation. Therapy of acute AMR is directed toward rapidly lowering circulating donor-specific antibody (DSA) activity. Despite reversal of acute renal dysfunction, however, antibody-secreting plasma cells in spleen and bone marrow are not depleted by treatment and circulating DSA commonly remains detectable in peripheral blood. Sequential ultrastructural studies of renal allografts during acute AMR show progression of microvascular endothelial abnormalities from necrosis and apoptosis to glomerular and peritubular capillary basement membrane duplication, termed transplant glomerulopathy (TG), a manifestation of chronic AMR. Additionally, long-term exposure to anti-HLA antibodies (particularly against class II antigens) is associated with shortened allograft survival and TG even in the absence of documented acute AMR. The association of TG with prior acute AMR and with circulating DSA provides evidence that antibody-mediated allograft injury exists as a spectrum of renal injury. Although effective therapy is available for acute AMR, allografts remain at risk for chronic AMR and shortened survival. The optimum approach to treatment for chronic AMR remains to be determined.
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Affiliation(s)
- J Gloor
- Department of Nephrology and Internal Medicine, Mayo Clinic and Foundation, Rochester, MN, USA.
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189
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Abstract
PURPOSE OF REVIEW Despite dramatic declines in acute rejection and early graft failure, long-term outcomes after kidney transplantation have improved little during the past 25 years. Most late allograft failure is attributed to chronic allograft nephropathy, but this is a clinicopathological description and not a diagnosis, and its pathogenesis and treatment are largely unknown. RECENT FINDINGS Recent studies suggest that acute rejection during the first few months, and calcineurin inhibitor toxicity thereafter, may both contribute to chronic allograft nephropathy. There is also accumulating evidence that injury from antibody-mediated rejection may play an important pathogenic role in at least some patients with chronic allograft nephropathy, particularly those with transplant glomerulopathy. Therapeutic measures, including protocols to reduce calcineurin inhibitor exposure, remain largely unproven. SUMMARY Understanding why so many kidney allografts fail, despite effective preventive measures for early acute rejection, is one of the most important areas of research in kidney transplantation today.
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190
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Goers TA, Ramachandran S, Aloush A, Trulock E, Patterson GA, Mohanakumar T. De novo production of K-alpha1 tubulin-specific antibodies: role in chronic lung allograft rejection. THE JOURNAL OF IMMUNOLOGY 2008; 180:4487-94. [PMID: 18354170 DOI: 10.4049/jimmunol.180.7.4487] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Lung transplantation is the treatment option for a variety of end-stage pulmonary diseases. Posttransplant development of Abs against donor HLA and non-HLA Ags have been associated with acute and chronic rejection of transplanted organs. Development of bronchiolitis obliterans syndrome (BOS) following lung transplantation has been correlated with de novo production of anti-donor-HLA Abs. However, only a portion of the patients with BOS demonstrate detectable anti-donor-HLA Abs. Airway epithelium is considered as a major target for lung allograft rejection. In this study we demonstrate that many BOS(+) patients (12 of 36) develop Abs reactive to epithelial cell Ag that are distinct from HLA. Furthermore, de novo production of antiepithelial cell Ab precedes clinical onset of BOS. N-terminal sequencing and blastx analysis as well as blocking with K-alpha1 tubulin-specific Ab identified the epithelial Ag as K-alpha1 tubulin. Binding of the de novo-produced anti-K-alpha1 tubulin Abs to the airway epithelial cells resulted in the increased expression of transcription factors (TCF5 and c-Myc), leading to increased expression of fibrogenic growth factors, activation of cell cycle signaling, and fibroproliferation, the central events in immunopathogenesis of BOS following human lung transplantation.
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Affiliation(s)
- Trudie A Goers
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO 63110, USA
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191
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Demirci C, Sen S, Sezak M, Sarsik B, Hoşcoşkun C, Töz H. Incidence and importance of c4d deposition in renal allograft dysfunction. Transplant Proc 2008; 40:174-7. [PMID: 18261578 DOI: 10.1016/j.transproceed.2007.11.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recent studies showed that peritubular capillary deposition of C4d is a marker of humoral immune responses directed against a renal allograft. The aim of this retrospective study was to investigate the incidence, clinical features, and prognostic implications of C4d deposition in renal allograft biopsy specimens. The biopsies had been performed due to acute graft dysfunction. This study of 104 renal allograft biopsies performed in 2004 classified histopathological findings according to Banff criteria. All paraffin-embedded biopsy samples were stained with an immunohistochemical method for C4d deposition. Demographic data, clinical findings, and biochemical findings were obtained from patients' charts. C4d staining was positive in 15/104 (14%) samples. The staining pattern was diffuse in 8 and focal in 7 patients. Nine patients were males. The overall mean age was 33 +/- 6 years. Ten received live-donor grafts. The biopsy occurred at a mean of 1007 +/- 1415 (range, 15-4712) days after the operation with a mean serum creatinine (SCr) level of 2.8 +/- 1.5 (1.25-6.0) mg/dL. Patients were divided into 2 groups according to the occurrence time: early (before 100 days) and late (after 100 days). Among the early group (n = 5), the mean SCr level was 2.8 +/- 1.5 mg/dL; a diffuse staining pattern was seen in 4 (80%) patients. Histological findings were acute rejection in 3, borderline changes in 1, or thrombotic microangiopathy in 1 patient. Two patients were treated with pulse steroids and 3 with ATG, intravenous immunoglobulin, and plasmapheresis. Three patients lost their grafts at the mean of 118 +/- 100 days after the biopsy. In the late group (n = 10), the mean SCr level was 2.8 +/- 1.7 mg/dL with a diffuse staining pattern in 4 (40%) patients. The histological findings included acute rejection in 6, chronic vascular rejection in 2, thrombotic microangiopathy in 1, and chronic allograft nephropathy in 1 patient. Six patients were treated with pulse steroids, and 3 with ATG and intravenous immunoglobulin. Five patients lost their grafts at a mean of 200 +/- 270 days. The overall incidence of C4d deposition was 14%; it was seen both in the early and late posttransplantation period. Although a diffuse staining pattern was more frequently seen in the early period, C4d deposition indicated a poor allograft prognosis in both periods. Introduction of C4d staining into the routine may guide more specific treatments directed toward the humoral alloresponse.
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Affiliation(s)
- C Demirci
- Nephrology Division, Ege University Medical School, Izmir, Turkey.
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192
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Jevnikar AM, Mannon RB. Late kidney allograft loss: what we know about it, and what we can do about it. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S56-67. [PMID: 18309004 DOI: 10.2215/cjn.03040707] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite dramatic improvements in immunosuppression, late graft loss after kidney transplantation remains a common and difficult problem. Histologic evaluation may reveal changes related to BK polyomavirus infection, hypertension, or calcineurin inhibitor toxicity, which can help to guide therapy. The designation chronic allograft nephropathy should thus be reserved for biopsies with tubular atrophy and interstitial fibrosis without an apparent cause. Although the cause clearly includes both antigen-dependent and antigen-independent events, the approach remains largely to exclude immune mechanisms. Although this review discusses the potential contribution of antibody to chronic injury, it focuses on the basic elements of kidney injury, the role of parenchymal cells in promoting injury, and the proliferative and inflammatory responses that accompanying injury. Strategies to manage these recipients include close attention to accompanying hypertension, diabetes, and hyperlipidemia, as well as consideration for altering immunosuppression; however, therapies that limit epithelial-to-mesenchymal transition or directly block fibrosis pathways may reduce chronic allograft fibrosis and may prove to be useful. Understanding the basic pathogenesis sufficiently to allow early intervention may finally benefit patients who are at high risk for tubular atrophy and interstitial fibrosis and promote their long-term graft function.
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Affiliation(s)
- Anthony M Jevnikar
- Department of Medicine, Lawson Health Research Institute and Robarts Research Institute, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
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193
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YUEN SZEK, MAK YUENF, TANG HONL, YONG SAIP, CHOW KAIM, CHU KWOKH, FUNG KAS, CHAN WAIHH, TONG KWOKL. Renal allograft C4d deposition in Chinese: Hong Kong perspective. Nephrology (Carlton) 2008; 13:256-63. [DOI: 10.1111/j.1440-1797.2008.00923.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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194
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Ashton-Chess J, Giral M, Mengel M, Renaudin K, Foucher Y, Gwinner W, Braud C, Dugast E, Quillard T, Thebault P, Chiffoleau E, Braudeau C, Charreau B, Soulillou JP, Brouard S. Tribbles-1 as a novel biomarker of chronic antibody-mediated rejection. J Am Soc Nephrol 2008; 19:1116-27. [PMID: 18369086 DOI: 10.1681/asn.2007101056] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Diagnosis of the specific cause of late allograft injury is necessary if more personalized and efficient immunosuppressive regimens are to be introduced. This study sought previously unrecognized biomarkers for specific histologic diagnoses of late graft scarring by comparison of gene sets from published microarray studies. Tribbles-1 (TRIB1), a human homolog of Drosophila tribbles, was identified to be a potentially informative biomarker. For testing this, mRNA expression in 76 graft biopsies, 71 blood samples, and 11 urine samples were profiled from independent cohorts of renal transplant patients with different histologic diagnoses recruited at two European centers. TRIB1 but not TRIB2 or TRIB3 was found to be a potential blood and tissue biomarker of chronic antibody-mediated rejection, an active immune-mediated form of chronic allograft failure associated with a poor prognosis. TRIB1 mRNA levels in peripheral blood mononuclear cells discriminated patients with chronic antibody-mediated rejection from those with other types of late allograft injury with high sensitivity and specificity. TRIB1 was also upregulated in a rodent model of chronic cardiac vasculopathy, suggesting that this biomarker may be useful in other solid-organ transplants and across species. It was determined that TRIB1 is expressed primarily by antigen-presenting cells and activated endothelial cells. Overall, these data support the potential use of TRIB1 as a biomarker of chronic antibody-mediated allograft failure.
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Affiliation(s)
- Joanna Ashton-Chess
- INSERM U643, Centre Hospitalier Universitaire Nantes, Institut de Transplantation et de Recherche en Transplantation, Nantes, France
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195
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SV40 Infection Associated With Rituximab Treatment After Kidney Transplantation in Nonhuman Primates. Transplantation 2008; 85:893-902. [DOI: 10.1097/tp.0b013e3181668ecc] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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196
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Al-Aly Z, Reddivari V, Moiz A, Balasubramanian G, Cortese CM, Salinas-Madrigal L, Bastani B. Renal allograft biopsies in the era of C4d staining: the need for change in the Banff classification system. Transpl Int 2008; 21:268-75. [DOI: 10.1111/j.1432-2277.2007.00604.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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197
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Bickerstaff A, Nozaki T, Wang JJ, Pelletier R, Hadley G, Nadasdy G, Nadasdy T, Fairchild RL. Acute humoral rejection of renal allografts in CCR5(-/-) recipients. Am J Transplant 2008; 8:557-66. [PMID: 18294152 DOI: 10.1111/j.1600-6143.2007.02125.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Increasing detection of acute humoral rejection (AHR) of renal allografts has generated the need for appropriate animal models to investigate underlying mechanisms. Murine recipients lacking the chemokine receptor CCR5 reject cardiac allografts with marked C3d deposition in the parenchymal capillaries and high serum donor-reactive antibody titers, features consistent with AHR. The rejection of MHC-mismatched renal allografts from A/J (H-2(a)) donors by B6.CCR5(-/-) (H-2(b)) recipients was investigated. A/J renal allografts survived longer than 100 days in wild-type C57BL/6 recipients with normal blood creatinine levels (28 +/- 7 micromol/L). All CCR5(-/-) recipients rejected renal allografts within 21 days posttransplant (mean 13.3 +/- 4 days) with elevated creatinine (90 +/- 31 micromol/L). The rejected allografts had neutrophil and macrophage margination and diffuse C3d deposition in peritubular capillaries, interstitial hemorrhage and edema, and glomerular fibrin deposition. Circulating donor-reactive antibody titers were 40-fold higher in B6.CCR5(-/-) versus wild-type recipients. Depletion of recipient CD8 T cells did not circumvent rejection of the renal allografts by CCR5-deficient recipients. In contrast, microMT(-/-)/CCR5(-/-) recipients, incapable of producing antibody, did not reject most renal allografts. Collectively, these results indicate the rapid rejection of renal allografts in CCR5(-/-) recipients with many histopathologic features observed during AHR of human renal allografts.
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Affiliation(s)
- A Bickerstaff
- Department of Surgery, Transplantation Division, The Ohio State University College of Medicine, Columbus, OH, USA
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198
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Abstract
Transplant glomerulopathy (TG) is a histologic entity described more than four decades ago. In the last few years, our understanding of TG has improved significantly. Current evidence supports the postulate that TG is a unique pathologic and pathogenic entity distinct from other forms of chronic allograft injury. Detailed electron microscopic studies have shown basement membrane abnormalities in glomerular and peritubular capillaries, indicating that this is a disease of the entire renal capillary network. Staining biopsies for the complement fragment, C4d, showed positivity in subgroups of TG, suggesting the participation of antidonor antibodies. Consistent with this postulate, the incidence of TG is increased in patients with antidonor HLA antibodies prior to the transplant. The use of surveillance biopsies has demonstrated that TG can develop during the first few months after transplantation, although it may remain clinically quiescent for several years. However, TG is progressive, leading to reduced graft survival. Recent studies demonstrated a close association between TG and anti-HLA class II antibodies. Current therapies for TG are likely of limited value. However, it is also likely that an improved understanding of TG pathogenesis will result in the development of effective therapies for this form of progressive kidney allograft damage.
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Affiliation(s)
- F G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN, USA.
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199
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Miyamoto N, Ishida H, Furusawa M, Shimizu T, Shirakawa H, Omoto K, Tanabe K, Toma H. Immunological status in three patients, thirty years after living related renal transplantation. Transpl Immunol 2008; 18:368-72. [DOI: 10.1016/j.trim.2007.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Accepted: 10/04/2007] [Indexed: 10/22/2022]
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200
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Pascual J, Samaniego MD, Torrealba JR, Odorico JS, Djamali A, Becker YT, Voss B, Leverson GE, Knechtle SJ, Sollinger HW, Pirsch JD. Antibody-mediated rejection of the kidney after simultaneous pancreas-kidney transplantation. J Am Soc Nephrol 2008; 19:812-24. [PMID: 18235091 DOI: 10.1681/asn.2007070736] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The prevalence, risk factors, and outcome of antibody-mediated rejection (AMR) of the kidney after simultaneous pancreas-kidney transplantation are unknown. In 136 simultaneous pancreas-kidney recipients who were followed for an average of 3.1 yr, 21 episodes of AMR of the kidney allograft were identified. Eight episodes occurred early (</=90 d) after transplantation, and 13 occurred later. Histologic evidence of concomitant acute cellular rejection was noted in 12 cases; the other nine had evidence only of humoral rejection. In 13 cases, clinical rejection of the pancreas was diagnosed simultaneously, and two of these were biopsy proven and were positive for C4d immunostaining. Multivariate analysis identified only one significant risk factor: Female patients were three times more likely to experience AMR. Nearly all early episodes resolved with treatment and did not predict graft loss, but multivariate Cox models revealed that late AMR episodes more than tripled the risk for kidney and pancreas graft loss; therefore, new strategies are needed to prevent and to treat late AMR in simultaneous pancreas-kidney transplant recipients.
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Affiliation(s)
- Julio Pascual
- Department of Surgery, Division of Transplantation, University of Wisconsin Hospital and Clinics, H4/772 CSC, 600 Highland Avenue, Madison, WI 53792-7375, USA
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