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Aufhauser DD, Stalter L, Marka N, Leverson G, Al-Adra DP, Foley DP. Detrimental impact of early biopsy-proven rejection in liver transplantation. Clin Transplant 2024; 38:e15206. [PMID: 38041491 PMCID: PMC10843795 DOI: 10.1111/ctr.15206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/07/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
Existing literature offers conflicting conclusions about whether early acute cellular rejection influences long-term outcomes in liver transplantation. We retrospectively collected donor and recipient data on all adult, first-time liver transplants performed at a single center between 2008 and 2020. We divided this population into two cohorts based on the presence of early biopsy-proven acute cellular rejection (EBPR) within the first 90 days post-transplant and compared outcomes between the groups. There were 896 liver transplants that met inclusion criteria with 112 cases (12.5%) of EBPR. Recipients who developed EBPR had higher biochemical Model for End-Stage Liver Disease scores (28 vs. 24, p < .01), but other donor and recipient characteristics were similar. Recipients with EBPR had similar overall survival compared to patients without EBPR (p = .09) but had decreased graft survival (p < .05). EBPR was also associated with decreased time to first episode of late (> 90 days post-transplant) rejection (p < .0001) and increased vulnerability to bacterial and viral infection (p < .05). In subgroup analysis of recipients with autoimmune indications for liver transplantation, EBPR had a more pronounced association with patient death (hazard ratio [HR] 3.9, p < .05) and graft loss (HR 4.0, p < .01). EBPR after liver transplant is associated with inferior graft survival, increased susceptibility to late rejections, and increased vulnerability to infection.
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Affiliation(s)
- David D Aufhauser
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Nicholas Marka
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David P Al-Adra
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - David P Foley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Hong SK, Lee KW, Kim JY, Lee J, Kim J, Choi HH, Hong SY, Lee JM, Choi Y, Yi NJ, Suh KS. Factors associated with rituximab-mediated B cell depletion in ABO-incompatible adult living donor liver transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2023; 37:170-178. [PMID: 37694598 PMCID: PMC10583967 DOI: 10.4285/kjt.23.0031] [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: 06/08/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
Background Pretransplant therapies such as rituximab and plasmapheresis have led to an increase in ABO-incompatible (ABOi) living donor liver transplantation (LDLT), thus helping to overcome organ shortages. This study evaluated the changes in anti-A/B titers and CD19 levels over time in patients undergoing ABOi LT and aimed to understand the effect of single-nucleotide polymorphisms (SNPs) in Fc gamma receptor (FcγR) on rituximab therapy. Methods Two SNPs of FCGR2A (131H/R) and FCGR3A (158F/V) were identified. The clinical data on 44 patients who underwent ABOi LDLT between May 2019 and October 2021 at Seoul National University Hospital were reviewed retrospectively. Results Following desensitization with rituximab and subsequent LDLT, the anti-A/B titer recovered within 1 week, but decreased thereafter. The CD19 level increased at 3 months after LT. The genotyping data for FCGR3A (158F/V) indicated that two patients had the V/V genotype, and 42 had the F/V genotype. In the genotyping data for FCGR2A (131H/R), 21 patients had the H/H genotype, three had the R/R genotype, and 20 had the H/R genotype. However, there were no significant differences in anti-A/B and CD19 levels, bacteremia rates, T cell-mediated rejection, antibody-mediated rejection, or the survival rate among the FCGR2A types. Conclusions There were significant changes in the anti-A/B titers and CD19 levels over time in each patient after ABOi LDLT. The difference in outcomes following LT according to the FcγR SNP type for rituximab was unclear. Further studies with larger sample sizes are needed to confirm the effect of FcγR SNPs on rituximab therapy.
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Affiliation(s)
- Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Yoon Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jaewon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Hwa Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Su young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Kok G, Ilcken EF, Houwen RH, Lindemans CA, Nieuwenhuis EE, Spierings E, Fuchs SA. The Effect of Genetic HLA Matching on Liver Transplantation Outcome: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2023; 4:e334. [PMID: 37746594 PMCID: PMC10513352 DOI: 10.1097/as9.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 08/11/2023] [Indexed: 09/26/2023] Open
Abstract
Objective We aim to investigate the effects of genetically based HLA matching on patient and graft survival, and acute and chronic rejection after liver transplantation. Background Liver transplantation is a common treatment for patients with end-stage liver disease. In contrast to most other solid organ transplantations, there is no conclusive evidence supporting human leukocyte antigen (HLA) matching for liver transplantations. With emerging alternatives such as transplantation of bankable (stem) cells, HLA matching becomes feasible, which may decrease the need for immunosuppressive therapy and improve transplantation outcomes. Methods We systematically searched the PubMed, Embase, and Cochrane databases and performed a meta-analysis investigating the effect of genetic HLA matching on liver transplantation outcomes (acute/chronic rejection, graft failure, and mortality). Results We included 14 studies with 2682 patients. HLA-C mismatching significantly increased the risk of acute rejection (full mismatching: risk ratio = 1.90, 95% confidence interval = 1.08 to 3.33, P = 0.03; partial mismatching: risk ratio = 1.33, 95% confidence interval = 1.07 to 1.66, P = 0.01). We did not discern any significant effect of HLA mismatching per locus on acute rejection for HLA-A, -B, -DR, and -DQ, nor on chronic rejection, graft failure, or mortality for HLA-DR, and -DQ. Conclusions We found evidence that genetic HLA-C matching reduces the risk of acute rejection after liver transplantation while matching for other loci does not reduce the risk of acute rejection, chronic rejection, graft failure, or mortality.
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Affiliation(s)
- Gautam Kok
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Eveline F. Ilcken
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Roderick H.J. Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Caroline A. Lindemans
- Department of Immunology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Hematopoietic Cell Transplantation, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Edward E.S. Nieuwenhuis
- Department of Pediatric Gastroenterology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Eric Spierings
- Center of Translational Immunology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Sabine A. Fuchs
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
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Lemieux W, Fleischer D, Yang AY, Niemann M, Oualkacha K, Klement W, Richard L, Polychronakos C, Liwski R, Claas F, Gebel HM, Keown PA, Lewin A, Sapir-Pichhadze R. Dissecting the impact of molecular T-cell HLA mismatches in kidney transplant failure: A retrospective cohort study. Front Immunol 2022; 13:1067075. [PMID: 36505483 PMCID: PMC9730505 DOI: 10.3389/fimmu.2022.1067075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Kidney transplantation is the optimal treatment in end-stage kidney disease, but de-novo donor specific antibody development continues to negatively impact patients undergoing kidney transplantation. One of the recent advances in solid organ transplantation has been the definition of molecular mismatching between donors and recipients' Human Leukocyte Antigens (HLA). While not fully integrated in standard clinical care, cumulative molecular mismatch at the level of eplets (EMM) as well as the PIRCHE-II score have shown promise in predicting transplant outcomes. In this manuscript, we sought to study whether certain T-cell molecular mismatches (TcEMM) were highly predictive of death-censored graft failure (DCGF). Methods We studied a retrospective cohort of kidney donor:recipient pairs from the Scientific Registry of Transplant Recipients (2000-2015). Allele level HLA-A, B, C, DRB1 and DQB1 types were imputed from serologic types using the NMDP algorithm. TcEMMs were then estimated using the PIRCHE-II algorithm. Multivariable Accelerated Failure Time (AFT) models assessed the association between each TcEMM and DCGF. To discriminate between TcEMMs most predictive of DCGF, we fit multivariable Lasso penalized regression models. We identified co-expressed TcEMMs using weighted correlation network analysis (WGCNA). Finally, we conducted sensitivity analyses to address PIRCHE and IMGT/HLA version updates. Results A total of 118,309 donor:recipient pairs meeting the eligibility criteria were studied. When applying the PIRCHE-II algorithm, we identified 1,935 distinct TcEMMs at the population level. A total of 218 of the observed TcEMM were independently associated with DCGF by AFT models. The Lasso penalized regression model with post selection inference identified a smaller subset of 86 TcEMMs (56 and 30 TcEMM derived from HLA Class I and II, respectively) to be highly predictive of DCGF. Of the observed TcEMM, 38.14% appeared as profiles of highly co-expressed TcEMMs. In addition, sensitivity analyses identified that the selected TcEMM were congruent across IMGT/HLA versions. Conclusion In this study, we identified subsets of TcEMMs highly predictive of DCGF and profiles of co-expressed mismatches. Experimental verification of these TcEMMs determining immune responses and how they may interact with EMM as predictors of transplant outcomes would justify their consideration in organ allocation schemes and for modifying immunosuppression regimens.
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Affiliation(s)
- William Lemieux
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of McGill University Health Centre, Montréal, QC, Canada,Medical Affairs & Innovation, Héma-Québec, Montréal, QC, Canada
| | - David Fleischer
- Department of Mathematics and Statistics, McGill University, Montreal, QC, Canada
| | - Archer Yi Yang
- Department of Mathematics and Statistics, McGill University, Montreal, QC, Canada
| | | | - Karim Oualkacha
- Department of Mathematics, Université du Québec à Montreal, Montreal, QC, Canada
| | - William Klement
- Division of Organ Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Lucie Richard
- Transfusion medicine/Reference Laboratory, Héma-Québec, Montréal, QC, Canada
| | - Constantin Polychronakos
- Department of Pediatrics, The Research Institute of the McGill University Health Centre and the Montreal Children’s Hospital, Montréal, QC, Canada
| | - Robert Liwski
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | - Frans Claas
- Department of Immunology, Leiden University Medical Centre, Leiden, Netherlands
| | - Howard M. Gebel
- Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - Paul A. Keown
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Antoine Lewin
- Medical Affairs & Innovation, Héma-Québec, Montréal, QC, Canada,Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ruth Sapir-Pichhadze
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of McGill University Health Centre, Montréal, QC, Canada,Division of Nephrology and the Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montréal, QC, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada,*Correspondence: Ruth Sapir-Pichhadze,
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Parajuli S, Hidalgo LG, Foley D. Immunology of simultaneous liver and kidney transplants with identification and prevention of rejection. FRONTIERS IN TRANSPLANTATION 2022; 1:991546. [PMID: 38994375 PMCID: PMC11235231 DOI: 10.3389/frtra.2022.991546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/12/2022] [Indexed: 07/13/2024]
Abstract
Simultaneous liver and kidney (SLK) transplantation is considered the best treatment modality among selected patients with both chronic kidney disease (CKD) and end-stage liver disease (ESLD). Since the first SLK transplant in 1983, the number of SLK transplants has increased worldwide, and particularly in the United States since the implementation of the MELD system in 2002. SLK transplants are considered a relatively low immunological risk procedure evidenced by multiple studies displaying the immunomodulatory properties of the liver on the immune system of SLK recipients. SLK recipients demonstrate lower rates of both cellular and antibody-mediated rejection on the kidney allograft when compared to kidney transplant-alone recipients. Therefore, SLK transplants in the setting of preformed donor-specific HLA antibodies (DSA) are a common practice, at many centers. Acceptance and transplantation of SLKs are based solely on ABO compatibility without much consideration of crossmatch results or DSA levels. However, some studies suggest an increased risk for rejection for SLK recipients transplanted across high levels of pre-formed HLA DSA. Despite this, there is no consensus regarding acceptable levels of pre-formed DSA, the role of pre-transplant desensitization, splenectomy, or immunosuppressive management in this unique population. Also, the impact of post-transplant DSA monitoring on long-term outcomes is not well-studied in SLK recipients. In this article, we review recent and relevant past articles in this field with a focus on the immunological risk factors among SLK recipients, and strategies to mitigate the negative outcomes among them.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Luis G Hidalgo
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - David Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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