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Subburayalu J. Immune surveillance and humoral immune responses in kidney transplantation - A look back at T follicular helper cells. Front Immunol 2023; 14:1114842. [PMID: 37503334 PMCID: PMC10368994 DOI: 10.3389/fimmu.2023.1114842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/22/2023] [Indexed: 07/29/2023] Open
Abstract
T follicular helper cells comprise a specialized, heterogeneous subset of immune-competent T helper cells capable of influencing B cell responses in lymphoid tissues. In physiology, for example in response to microbial challenges or vaccination, this interaction chiefly results in the production of protecting antibodies and humoral memory. In the context of kidney transplantation, however, immune surveillance provided by T follicular helper cells can take a life of its own despite matching of human leukocyte antigens and employing the latest immunosuppressive regiments. This puts kidney transplant recipients at risk of subclinical and clinical rejection episodes with a potential risk for allograft loss. In this review, the current understanding of immune surveillance provided by T follicular helper cells is briefly described in physiological responses to contrast those pathological responses observed after kidney transplantation. Sensitization of T follicular helper cells with the subsequent emergence of detectable donor-specific human leukocyte antigen antibodies, non-human leukocyte antigen antibodies their implication for kidney transplantation and lessons learnt from other transplantation "settings" with special attention to antibody-mediated rejection will be addressed.
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Affiliation(s)
- Julien Subburayalu
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies (CRTD), Technische Universität Dresden, Dresden, Germany
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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2
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Halverson LP, Hachem RR. Antibody-Mediated Rejection: Diagnosis and Treatment. Clin Chest Med 2023; 44:95-103. [PMID: 36774172 PMCID: PMC10148231 DOI: 10.1016/j.ccm.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Antibody-mediated rejection (AMR) is a form of lung allograft rejection that is emerging as an important risk factor for chronic lung allograft dysfunction and decreased long-term survival. In this review, we provide a brief overview of our current understanding of its pathophysiology with an emphasis on donor-specific antibodies before moving on to focus on the current diagnostic criteria and treatment strategies. Our goal is to discuss the limitations of our current knowledge and explore how novel diagnostic and therapeutic options aim to improve outcomes through earlier definitive diagnosis and preemptive targeted treatment.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA.
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA
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3
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Hiho SJ, Levvey B, Carroll R, Nicolson I, Mihaljcic M, Diviney MB, Snell GI, Sullivan LC, Westall GP. The clinical utility and thresholds of Virtual and Halifaster Flow crossmatches in lung transplantation. HLA 2022; 99:580-589. [PMID: 35340124 DOI: 10.1111/tan.14613] [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: 11/10/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Immune sensitization, defined as the presence of alloreactive donor-specific antibodies (DSA), is associated with increased wait-times and inferior transplant outcomes. Identifying pre-transplant DSA with a physical cell-based assay is critical in defining immunological risk. However, improved solid phase antibody detection has provided the potential to forgo this physical assay. Here, we evaluated the association between DSA mean fluorescence intensity (MFI) and the recently introduced Halifaster Flow cytometry crossmatch (FXM) to determine if MFI could predict the outcome of FXM and whether a virtual crossmatch (VXM) would provide an accurate risk assessment. METHODS Sera from 134 waitlisted lung patients was retrospectively assessed by Halifaster FXM against lymphocytes preparations from 32 donors, resulting in 265 FXMs. HLA typing was performed to 2-field allelic level and Luminex single antigen beads (SAB) used to identify DSA. The association between FXM and Luminex MFI was calculated using ROC analysis. MFI threshold accuracy was confirmed using a separate validation cohort (174 recipient sera and 34 donors), whereby both virtual crossmatch (VXM) and FXMs were compared. RESULTS From the 265 FXM performed, 48 (18%) T-cell (TFXM) and 56 (21%) B-cell (BFXM) were positive. In the evaluation cohort, MFI thresholds of 2000 for HLA-A, B, DRB1 and >4000 for DQB1, were predictive of a positive FXM. The validation cohort of 233 paired FXM and VXM confirmed these MFI thresholds for both TFXM and BFXM with an accuracy of 91.4% and 89.3% respectively. CONCLUSION A positive VXM, defined with HLA-specific MFI thresholds predicts Halifaster FXM reactivity, and can potentially expedite organ allocation, by minimising the need for the more time-consuming flow cytometry crossmatch. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Steven J Hiho
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia.,Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics, Melbourne, Australia
| | - Bronwyn Levvey
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Robert Carroll
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics, Melbourne, Australia.,Medical Sciences University of South Australia, Australia
| | - Ian Nicolson
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics, Melbourne, Australia
| | - Masa Mihaljcic
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics, Melbourne, Australia
| | - Mary B Diviney
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics, Melbourne, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Lucy C Sullivan
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia.,Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Australia.,Australian Red Cross LifeBlood, South Australian Transplantation and Immunogenetics, Adelaide, Australia
| | - Glen P Westall
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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Subramani MV, Pandit S, Gadre SK. Acute rejection and post lung transplant surveillance. Indian J Thorac Cardiovasc Surg 2022; 38:271-279. [PMID: 35340687 PMCID: PMC8938213 DOI: 10.1007/s12055-021-01320-z] [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: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose The purpose of this review is to summarize the current evidence on the evaluation and treatment of acute rejection after lung transplantation. Results Despite significant progress in the field of transplant immunology, acute rejection remains a frequent complication after transplantation. Almost 30% of lung transplant recipients experience at least one episode of acute cellular rejection (ACR) during the first year after transplant. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well-defined histopathologic diagnostic criteria and grading. The diagnosis of antibody-mediated rejection after lung transplantation requires a multidisciplinary approach. Antibody-mediated rejection may cause acute allograft failure. Conclusions Acute rejection is a risk factor for development of chronic rejection. Further investigations are required to better define risk factors, surveillance strategies, and optimal management strategies for acute allograft rejection.
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Affiliation(s)
| | - Sumir Pandit
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Shruti Kumar Gadre
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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Narula T, Khouzam S, Alvarez F, Erasmus D, Li Z, Abdelmoneim Y, Elrefaei M. Antithymocyte globulin is associated with a lower incidence of de novo donor-specific antibody detection in lung transplant recipients: A single-center experience. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1418-1427. [PMID: 34310850 PMCID: PMC8589359 DOI: 10.1002/iid3.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022]
Abstract
Purpose Induction immunosuppression has improved the long‐term outcomes after lung transplant. This is the first report exploring the association of induction immunosuppression with the development of de novo donor‐specific human leukocyte antigen (HLA) antibodies (DSA) in lung transplant recipients (LTR). Methods Sixty‐seven consecutive primary LTR were followed for 3 years posttransplant. A total of 41/67 (61%) LTR‐received induction immunosuppression using a single dose of rabbit Antithymocyte Globulin (rATG; 1.5 mg/kg) within 24 h of transplant. All recipients had a negative flow cytometry crossmatch on the day of transplant. Serum samples at 1, 3, 6, and 12 months posttransplant were assessed for the presence of de novo HLA DSA. Results De novo HLA DSA were detected in 22/67 (32.8%) LTR within 1‐year posttransplant. Of these, 9/41 (21.9%) occurred in the induction therapy group and 13/26 (50%) in the noninduction group. Class II DSA were detected in 3/41 (7.3%) LTR who received induction compared to 9/26 (34.6%) LTR without induction immunosuppression (p = .005). Differences in overall survival or freedom from chronic lung allograft dysfunction rates between the two groups were not statistically significant. Conclusion Induction immunosuppression utilizing a modified regimen of single‐dose rATG is associated with a significant reduction in de novo DSA production in LTR.
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Affiliation(s)
- Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Samir Khouzam
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco Alvarez
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - David Erasmus
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Zhuo Li
- Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
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Young KA, Ali HA, Beermann KJ, Reynolds JM, Snyder LD. Lung Transplantation and the Era of the Sensitized Patient. Front Immunol 2021; 12:689420. [PMID: 34122454 PMCID: PMC8187850 DOI: 10.3389/fimmu.2021.689420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Long term outcomes in lung transplant are limited by the development of chronic lung allograft dysfunction (CLAD). Within the past several decades, antibody-mediated rejection (AMR) has been recognized as a risk factor for CLAD. The presence of HLA antibodies in lung transplant candidates, "sensitized patients" may predispose patients to AMR, CLAD, and higher mortality after transplant. This review will discuss issues surrounding the sensitized patient, including mechanisms of sensitization, implications within lung transplant, and management strategies.
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Affiliation(s)
- Katherine A Young
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Hakim A Ali
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Kristi J Beermann
- Department of Pharmacy, Duke University Hospital, Durham, NC, United States
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
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Halverson LP, Hachem RR. Antibody-Mediated Rejection and Lung Transplantation. Semin Respir Crit Care Med 2021; 42:428-435. [PMID: 34030204 DOI: 10.1055/s-0041-1728796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antibody-mediated rejection (AMR) is now a widely recognized form of lung allograft rejection, with mounting evidence for AMR as an important risk factor for the development of chronic lung allograft dysfunction and markedly decreased long-term survival. Despite the recent development of the consensus diagnostic criteria, it remains a challenging diagnosis of exclusion. Furthermore, even after diagnosis, treatment directed at pulmonary AMR has been nearly exclusively derived from practices with other solid-organ transplants and other areas of medicine, such that there is a significant lack of data regarding the efficacy for these in pulmonary AMR. Lastly, outcomes after AMR remain quite poor despite aggressive treatment. In this review, we revisit the history of AMR in lung transplantation, describe our current understanding of its pathophysiology, discuss the use and limitations of the consensus diagnostic criteria, review current treatment strategies, and summarize long-term outcomes. We conclude with a synopsis of our most pressing gaps in knowledge, introduce recommendations for future directions, and highlight promising areas of active research.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
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Bery AI, Hachem RR. Antibody-mediated rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:411. [PMID: 32355855 PMCID: PMC7186640 DOI: 10.21037/atm.2019.11.86] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibody-mediated rejection (AMR) has been identified as a significant form of acute allograft dysfunction in lung transplantation. The development of consensus diagnostic criteria has created a uniform definition of AMR; however, significant limitations of these criteria have been identified. Treatment modalities for AMR have been adapted from other areas of medicine and data on the effectiveness of these therapies in AMR are limited. AMR is often refractory to these therapies, and graft failure and death are common. AMR is associated with increased rates of chronic lung allograft dysfunction (CLAD) and poor long-term survival. In this review, we discuss the history of AMR and describe known mechanisms, application of the consensus diagnostic criteria, data for current treatment strategies, and long-term outcomes. In addition, we highlight current gaps in knowledge, ongoing research, and future directions to address these gaps. Promising diagnostic techniques are actively being investigated that may allow for early detection and treatment of AMR. We conclude that further investigation is required to identify and define chronic and subclinical AMR, and head-to-head comparisons of currently used treatment protocols are necessary to identify an optimal treatment approach. Gaps in knowledge regarding the epidemiology, mechanisms, diagnosis, and treatment of AMR continue to exist and future research should focus on these aspects.
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Affiliation(s)
- Amit I Bery
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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10
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11
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Radeczky P, Ghimessy ÁK, Farkas A, Csende K, Mészáros L, Török K, Fazekas L, Agócs L, Kocsis Á, Bartók T, Dancs T, Tóth KK, Schönauer N, Bogyó L, Bohács A, Madurka I, Elek J, Döme B, Rényi-Vámos F, Lang G, Gieszer B. Antibody-Mediated Rejection in a Multiple Lung Transplant Patient: A Case Report. Transplant Proc 2019; 51:1296-1298. [PMID: 31101218 DOI: 10.1016/j.transproceed.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Lung transplant is an effective way to treat many end-stage lung diseases. However, one of the main barriers of allograft organ transplant is still the immunologic rejection of transplanted tissue, which is a response of the HLA molecules. Rejection is a complex process involving both T-cell-mediated delayed-type hypersensitivity reactions and antibody-mediated hypersensitivity reactions to histocompatibility molecules on foreign grafts. We report the case of a 25-year-old female patient with cystic fibrosis who underwent 2 lung transplants because of her initial diagnosis and appearance of bronchiolitis obliterans syndrome after the first transplant. Only 13 months after the second transplant, despite the therapies applied, a new rejection occurred associated with high mean fluorescent intensity donor-specific antibody levels, which resulted later in the death of the patient. The present case draws attention to the importance of matching HLA molecules between donor and recipient in addition to immunosuppressive therapy.
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Affiliation(s)
- P Radeczky
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary.
| | - Á K Ghimessy
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - A Farkas
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - K Csende
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary
| | - L Mészáros
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - K Török
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - L Fazekas
- Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary; The Heart and Vascular Center of Semmelweis University, Budapest, Hungary
| | - L Agócs
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - Á Kocsis
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - T Bartók
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - T Dancs
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - K K Tóth
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - N Schönauer
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - L Bogyó
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
| | - A Bohács
- Semmelweis University, Department of Pulmonology, Budapest, Hungary
| | - I Madurka
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - J Elek
- National Institute of Oncology, Department of Anaesthesiology and Intensive Care, Budapest, Hungary
| | - B Döme
- Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary; National Koranyi Institute of TB and Pulmonology, Budapest, Hungary
| | - F Rényi-Vámos
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary; Medical University of Vienna, Department of Thoracic Surgery, Wien, Austria
| | - G Lang
- Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary; Medical University of Vienna, Department of Thoracic Surgery, Wien, Austria
| | - B Gieszer
- National Institute of Oncology, Department of Thoracic Surgery, Budapest, Hungary; Semmelweis University, Department of Thoracic Surgery, Budapest, Hungary
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Prevalence of antibodies to lung self-antigens (Kα1 tubulin and collagen V) and donor specific antibodies to HLA in lung transplant recipients and implications for lung transplant outcomes: Single center experience. Transpl Immunol 2019; 54:65-72. [PMID: 30794945 DOI: 10.1016/j.trim.2019.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/15/2019] [Accepted: 02/17/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE For patients with end stage lung disease, lung transplantation (LT) remains the only definitive treatment option. Long term survival post LT is limited by acute and chronic allograft dysfunction. Antibodies to lung self-antigens Kα1Tubulin and collagen V (autoantibodies) have been implicated in adverse outcomes post LT. The aim of our study was to determine the prevalence of autoantibodies in pre- and post-transplant sera, evaluate the impact on post-transplant outcomes. METHODS In a prospective observational cohort analysis, 44 patients were enrolled who received LT between 09/01/2014 and 10/31/2015. Pre- and post-transplant sera were analyzed using enzyme-linked immunosorbent assay (ELISA) for the presence of antibodies to collagen I, collagen V, and K-alpha 1 tubulin. The outcome variables are presence of primary graft dysfunction (PGD), cumulative acute cellular rejection (ACR), treatment with pulse steroids for clinical rejection, association with DSA, and onset of Bronchiolitis Obliterans Syndrome (BOS). RESULTS In our cohort, 33 patients (75%) tested positive for the presence of autoantibodies. Pre-transplant autoantibodies were present in 23 patients (70%). Only a small percentage (26%) cleared these antibodies with standard immunosuppression. Some developed de novo post-transplant (n = 10). PGD was observed in 34% of our cohort, however the presence of autoantibodies did not correlate with increase in the incidence or severity of PGD. The prevalence of donor specific antibodies (DSA) in the entire cohort was 73%, with an increased prevalence of DSA noted in the autoantibody positive group (78.7% vs. 54.5%) than in the autoantibody negative group. BOS was observed in 20% of the cohort, with a median time to onset of 291 days' post-transplant. Patients with pre-transplant autoantibodies had a statistically significant decrease in BOS-free survival (p = 0.029 by log-rank test). CONCLUSIONS In our cohort, we observed a high prevalence of autoantibodies and DSA in lung transplant recipients. Pre-transplant autoantibodies were associated with de novo development of DSA along with a decrease in BOS-free survival. Limitations to our study include the small sample size and single center enrollment, along with limited time for follow-up.
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Roux A, Thomas KA, Sage E, Suberbielle-Boissel C, Beaumont-Azuar L, Parquin F, Le Guen M, Harre N, Hamid AM, Reed EF. Donor-specific HLA antibody-mediated complement activation is a significant indicator of antibody-mediated rejection and poor long-term graft outcome during lung transplantation: a single center cohort study. Transpl Int 2018; 31:761-772. [PMID: 29537702 PMCID: PMC5995657 DOI: 10.1111/tri.13149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/12/2017] [Accepted: 03/02/2018] [Indexed: 12/20/2022]
Abstract
Complement-mediated allograft injury, elicited by donor-specific HLA antibodies (DSA), is a defining pathophysiological characteristic of allograft damage. We aimed to study DSA-induced complement activation as a diagnostic marker of antibody-mediated rejection (AMR) and a risk stratification tool for graft loss in the context of lung transplantation (LT). We identified 38 DSA-positive patients whose serum samples were submitted for C3d deposition testing via the C3d assay. Among these 38 patients, 15 had AMR (DSAPos AMRPos ). Results were reported for each patient as the C3d ratio for each DSA, the immunodominant DSA, and the C3d ratio for all DSA present in a sample (C3d ratioSUM ). DSAPos AMRPos patients had higher C3d ratioSUM values (58.66 (-1.32 to 118.6) vs. 1.52 (0.30 to 2.74), P = 0.0016) and increased immunodominant C3d ratios (41.87 (1.72 to 82.02) vs. 0.69 (0.21 to 1.19), P = 0.001) when compared with DSAPos AMRNeg patients. Specificity and calculated positive predictive value of the immunodominant C3d ratio and BCMsum tests for AMR diagnosis were both 100% (CI = 17.4-100) in this cohort. Worst graft survival was associated with both immunodominant C3d ratio ≥4 or C3d ratioSUM ≥10 or BCMsum >7000, suggesting that the antibody composition and/or strength are the principal determinants of an HLA DSA's capacity to activate complement.
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Affiliation(s)
- Antoine Roux
- Pneumology, Adult CF Center and Lung Transplantation department, Foch Hospital, Suresnes France
- Université Versailles Saint-Quentin-en-Yvelines, Montigny le Bretonneux
| | - Kimberly A. Thomas
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles CA, USA
| | - Edouard Sage
- Thoracic Surgery Department, Foch Hospital, Suresnes France
| | - Caroline Suberbielle-Boissel
- Laboratoire Régional d’Histocompatibilité, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurence Beaumont-Azuar
- Pneumology, Adult CF Center and Lung Transplantation department, Foch Hospital, Suresnes France
| | | | - Morgan Le Guen
- Université Versailles Saint-Quentin-en-Yvelines, Montigny le Bretonneux
- Anesthesiology Department, Foch Hospital, Suresnes France
| | - Nicholas Harre
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles CA, USA
| | - Abdul Monem Hamid
- Pneumology, Adult CF Center and Lung Transplantation department, Foch Hospital, Suresnes France
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles CA, USA
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Abstract
Despite induction immunosuppression and the use of aggressive maintenance immunosuppressive regimens, acute allograft rejection following lung transplantation is still a problem with important diagnostic and therapeutic challenges. As well as causing early graft loss and mortality, acute rejection also initiates the chronic alloimmune responses and airway-centred inflammation that predispose to bronchiolitis obliterans syndrome (BOS), also known as chronic lung allograft dysfunction (CLAD), which is a major source of morbidity and mortality after lung transplantation. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, but the influence of humoral immunity is increasingly recognised. As with other several other solid organ transplants, antibody-mediated rejection (AMR) is now a well-accepted and distinct clinical entity in lung transplantation. While acute cellular rejection (ACR) has defined histopathological criteria, transbronchial biopsy is less useful in AMR and its diagnosis is complicated by challenges in the measurement of antibodies directed against donor HLA, and a determination of their significance. Increasing awareness of the importance of non-HLA antigens further clouds this issue. Here, we review the pathophysiology, diagnosis, clinical presentation and treatment of ACR and AMR in lung transplantation, and discuss future potential biomarkers of both processes that may forward our understanding of these conditions.
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Affiliation(s)
- Mark Benzimra
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - Greg L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Allan R Glanville
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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15
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Acute postoperative management after lung transplantation. Best Pract Res Clin Anaesthesiol 2017; 31:273-284. [DOI: 10.1016/j.bpa.2017.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/03/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
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Lama VN, Belperio JA, Christie JD, El-Chemaly S, Fishbein MC, Gelman AE, Hancock WW, Keshavjee S, Kreisel D, Laubach VE, Looney MR, McDyer JF, Mohanakumar T, Shilling RA, Panoskaltsis-Mortari A, Wilkes DS, Eu JP, Nicolls MR. Models of Lung Transplant Research: a consensus statement from the National Heart, Lung, and Blood Institute workshop. JCI Insight 2017; 2:93121. [PMID: 28469087 DOI: 10.1172/jci.insight.93121] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Lung transplantation, a cure for a number of end-stage lung diseases, continues to have the worst long-term outcomes when compared with other solid organ transplants. Preclinical modeling of the most common and serious lung transplantation complications are essential to better understand and mitigate the pathophysiological processes that lead to these complications. Various animal and in vitro models of lung transplant complications now exist and each of these models has unique strengths. However, significant issues, such as the required technical expertise as well as the robustness and clinical usefulness of these models, remain to be overcome or clarified. The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop in March 2016 to review the state of preclinical science addressing the three most important complications of lung transplantation: primary graft dysfunction (PGD), acute rejection (AR), and chronic lung allograft dysfunction (CLAD). In addition, the participants of the workshop were tasked to make consensus recommendations on the best use of these complimentary models to close our knowledge gaps in PGD, AR, and CLAD. Their reviews and recommendations are summarized in this report. Furthermore, the participants outlined opportunities to collaborate and directions to accelerate research using these preclinical models.
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Affiliation(s)
- Vibha N Lama
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - John A Belperio
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Souheil El-Chemaly
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, UCLA Center for the Health Sciences, Los Angeles, California, USA
| | - Andrew E Gelman
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wayne W Hancock
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Victor E Laubach
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Mark R Looney
- Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - John F McDyer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Rebecca A Shilling
- Department of Medicine, University of Illinois College of Medicine at Chicago, Illinois, USA
| | - Angela Panoskaltsis-Mortari
- Departments of Pediatrics, and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David S Wilkes
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jerry P Eu
- National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Mark R Nicolls
- Department of Medicine, Stanford University School of Medicine/VA Palo Alto Health Care System, Stanford, California, USA
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Abstract
Antibody-mediated rejection (AMR) has been identified among the most important factors limiting long-term outcome in cardiac and renal transplantation. Therapeutic management remains challenging and the development of effective treatment modalities is hampered by insufficient understanding of the underlying pathophysiology. However, recent findings indicate that in addition to AMR-triggered activation of the classical complement pathway, antibody-dependent cellular cytotoxicity by innate immune cell subsets also promotes vascular graft injury. This review summarizes the accumulating evidence for the contribution of natural killer cells, the key mediators of antibody-dependent cellular cytotoxicity, to human AMR in allotransplantation and xenotransplantation and illustrates the current mechanistic conceptions drawn from animal models.
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18
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Roux A, Bendib Le Lan I, Holifanjaniaina S, Thomas KA, Hamid AM, Picard C, Grenet D, De Miranda S, Douvry B, Beaumont-Azuar L, Sage E, Devaquet J, Cuquemelle E, Le Guen M, Spreafico R, Suberbielle-Boissel C, Stern M, Parquin F. Antibody-Mediated Rejection in Lung Transplantation: Clinical Outcomes and Donor-Specific Antibody Characteristics. Am J Transplant 2016; 16:1216-28. [PMID: 26845386 DOI: 10.1111/ajt.13589] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/13/2015] [Accepted: 10/17/2015] [Indexed: 01/25/2023]
Abstract
In the context of lung transplant (LT), because of diagnostic difficulties, antibody-mediated rejection (AMR) remains a matter of debate. We retrospectively analyzed an LT cohort at Foch Hospital to demonstrate the impact of AMR on LT prognosis. AMR diagnosis requires association of clinical symptoms, donor-specific antibodies (DSAs), and C4d(+) staining and/or histological patterns consistent with AMR. Prospective categorization split patients into four groups: (i) DSA positive, AMR positive (DSA(pos) AMR(pos) ); (ii) DSA positive, AMR negative (DSA(pos) AMR(neg) ); (iii) DSA limited, AMR negative (DSA(Lim) ; equal to one specificity, with mean fluorescence intensity of 500-1000 once); and (iv) DSA negative, AMR negative (DSA(neg) ). AMR treatment consisted of a combination of plasmapheresis, intravenous immunoglobulin and rituximab. Among 206 transplanted patients, 10.7% were DSA(pos) AMR(pos) (n = 22), 40.3% were DSA(pos) AMR(neg) (n = 84), 6% were DSA(Lim) (n = 13) and 43% were DSA(neg) (n = 88). Analysis of acute cellular rejection at month 12 showed higher cumulative numbers (mean plus or minus standard deviation) in the DSA(pos) AMR(pos) group (2.1 ± 1.7) compared with DSA(pos) AMR(neg) (1 ± 1.2), DSA(Lim) (0.75 ± 1), and DSA(neg) (0.7 ± 1.23) groups. Multivariate analysis demonstrated AMR as a risk factor for chronic lung allograft dysfunction (hazard ratio [HR] 8.7) and graft loss (HR 7.56) for DSA(pos) AMR(pos) patients. Our results show a negative impact of AMR on LT clinical course and advocate for an early active diagnostic approach and evaluation of therapeutic strategies to improve prognosis.
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Affiliation(s)
- A Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA.,Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - I Bendib Le Lan
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | | | - K A Thomas
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA
| | - A M Hamid
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - C Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - D Grenet
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - S De Miranda
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - B Douvry
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - L Beaumont-Azuar
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - E Sage
- Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France.,Thoracic Surgery Department, Foch Hospital, Suresnes, France
| | - J Devaquet
- Intensive Care Unit, Foch Hospital, Suresnes, France
| | - E Cuquemelle
- Thoracic Intensive Care Unit, Foch Hospital, Suresnes, France
| | - M Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - R Spreafico
- Department of Microbiology,Immunology and Molecular Genetics, University of California Los Angeles, Los Angeles, CA.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA
| | - C Suberbielle-Boissel
- Laboratoire Régional d'Histocompatibilité, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Stern
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - F Parquin
- Thoracic Intensive Care Unit, Foch Hospital, Suresnes, France
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19
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Kulkarni HS, Bemiss BC, Hachem RR. Antibody-mediated Rejection in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2015; 2:316-323. [PMID: 27896040 PMCID: PMC5123809 DOI: 10.1007/s40472-015-0074-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There has been increasing awareness of antibody-mediated rejection (AMR) as an important cause of graft failure after lung transplantation in recent years. However, the diagnostic criteria for pulmonary AMR are not well defined. All four tenets of AMR in kidney and heart transplantation, graft dysfunction, complement component deposition, circulating donor-specific antibodies (DSA), and histopathologic changes consistent with AMR, are infrequently present in lung transplantation. Nonetheless, the lung transplant community has made important progress recognizing cases of AMR and developing a definition. However, AMR is often refractory to therapy resulting in graft failure and death. In this review, we discuss the progress and challenges in the diagnosis and therapeutic options for pulmonary AMR. In addition, we briefly examine emerging paradigms of C4d-negative AMR and chronic AMR, and conclude that significant progress is needed to mitigate the effects of humoral immune responses after lung transplantation.
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Affiliation(s)
- Hrishikesh S. Kulkarni
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Bradford C. Bemiss
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8762, Fax: (314) 454-7524
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, Tel: (314) 454-8766, Fax: (314) 454-7956
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20
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Tsai EW, Reed EF. MHC class I signaling: new functional perspectives for an old molecule. ACTA ACUST UNITED AC 2015; 83:375-81. [PMID: 24828054 DOI: 10.1111/tan.12381] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Donor-specific antibodies are associated with refractory rejection episodes and poor allograft outcomes in solid organ transplantation. Our understanding of antibody-mediated allograft injury is expanding beyond complement deposition. In fact, unique mechanisms of alloantibodies are advancing our knowledge about transplant vasculopathy and antibody-mediated rejection. These include direct effects on the endothelium, resulting in the recruitment of leukocytes, chemokine and cytokine production, and stimulation of innate and adaptive alloresponses. These effects will be the focus of the following review.
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Affiliation(s)
- E W Tsai
- Mattel Children's Hospital UCLA, Division of Pediatric Nephrology, Los Angeles, CA, USA
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21
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22
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Abstract
Lung transplantation has become an important therapeutic option for patients with end-stage organ dysfunction; however, its clinical usefulness has been limited by the relatively early onset of chronic allograft dysfunction and progressive clinical decline. Obliterative bronchiolitis is characterized histologically by luminal fibrosis of the respiratory bronchioles and clinically by bronchiolitis obliterans syndrome (BOS) which is defined by a measured decline in lung function based on forced expiratory volume (FEV1). Since its earliest description, a number of risk factors have been associated with the development of BOS, including acute rejection, lymphocytic bronchiolitis, primary graft dysfunction, infection, donor specific antibodies, and gastroesophageal reflux disease. However, despite this broadened understanding, the pathogenesis underlying BOS remains poorly understood and once begun, there are relatively few treatment options to battle the progressive deterioration in lung function.
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Affiliation(s)
- Christine M Lin
- 1University of Colorado, Denver - Anschutz Medical Campus, 12700 East 19th Avenue, Room 9470E, Aurora, CO 80045 USA
| | - Martin R Zamora
- 2University of Colorado, Denver - Anschutz Medical Campus, 1635 Aurora Court, Room 7082, Mail Stop F749, Aurora, CO 80045 USA
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23
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Scheffert JL, Raza K. Immunosuppression in lung transplantation. J Thorac Dis 2014; 6:1039-53. [PMID: 25132971 DOI: 10.3978/j.issn.2072-1439.2014.04.23] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/16/2014] [Indexed: 01/10/2023]
Abstract
Lung transplantation can be a life-saving procedure for those with end-stage lung diseases. Unfortunately, long term graft and patient survival are limited by both acute and chronic allograft rejection, with a median survival of just over 6 years. Immunosuppressive regimens are employed to reduce the rate of rejection, and while protocols vary from center to center, conventional maintenance therapy consists of triple drug therapy with a calcineurin inhibitor (cyclosporine or tacrolimus), antiproliferative agents [azathioprine (AZA), mycophenolate, sirolimus (srl), everolimus (evl)], and corticosteroids (CS). Roughly 50% of lung transplant centers also utilize induction therapy, with polyclonal antibody preparations [equine or rabbit anti-thymocyte globulin (ATG)], interleukin 2 receptor antagonists (IL2RAs) (daclizumab or basiliximab), or alemtuzumab. This review summarizes these agents and the data surrounding their use in lung transplantation, as well as additional common and novel therapies in lung transplantation. Despite the progression of the management of lung transplant recipients, they continue to be at high risk of treatment-related complications, and poor graft and patient survival. Randomized clinical trials are needed to allow for the development of better agents, regimens and techniques to address above mentioned issues and reduce morbidity and mortality among lung transplant recipients.
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Affiliation(s)
- Jenna L Scheffert
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
| | - Kashif Raza
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
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24
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Anti-donor HLA class I antibodies: pathways to endothelial cell activation and cell-mediated allograft rejection. Transplantation 2014; 96:258-66. [PMID: 23823649 DOI: 10.1097/tp.0b013e3182985504] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The development of donor-specific human leukocyte antigen (HLA) class I antibodies after organ transplantation is associated with subsequent acute and chronic rejection. The aim of this study was to examine the role of anti-HLA class I antibody in modulating endothelium-leukocyte interaction. METHODS Human microvascular endothelial cells (HMEC-1) stimulated with HLA class I antibody (W6/32) or allospecific antibodies from sensitized patients (n=6) were examined for activation of transcription factor CREB by Western blotting. Up-regulation of endothelial adhesion molecules and chemokines was measured by flow cytometry and quantitative polymerase chain reaction, respectively. Leukocyte adhesion was evaluated by chemotaxis and in vitro flow-based assays. RESULTS Treatment of HMEC-1 cells with HLA class I antibody resulted in the phosphorylation of CREB in protein kinase A-dependent pathway. Furthermore, there was a significant increase in the expression of cell surface VCAM-1 (Akt-dependent) and ICAM-1 in Akt-dependent and extracellular signal-regulated kinase-dependent manner (P<0.001). Additionally, exposure to W6/32 antibody induced significant expression of interleukin-6, CXCL8, CXCL10, and CCL5. Knockdown of CREB produced a reduction in W6/32-induced CXCL8 expression (P<0.001). Media from W6/32-treated endothelial cells induced a significant monocyte chemotaxis (P<0.001) and flow-based adhesion assay demonstrated an increase in monocyte adhesion to endothelial cells compared with the control group (P<0.001). Importantly, allospecific antibodies from sensitized patients also activated endothelial CREB and significantly up-regulated VCAM-1, ICAM-1, and CXCL8. CONCLUSION These findings suggest that donor-specific HLA class I antibodies directly activate endothelial cells leading to an increase in their potential to recruit and bind recipient leukocytes, thereby increasing the potential for allograft inflammation.
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25
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Wallace WD, Weigt SS, Farver CF. Update on pathology of antibody-mediated rejection in the lung allograft. Curr Opin Organ Transplant 2014; 19:303-8. [DOI: 10.1097/mot.0000000000000079] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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26
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Late and chronic antibody-mediated rejection: main barrier to long term graft survival. Clin Dev Immunol 2013; 2013:859761. [PMID: 24222777 PMCID: PMC3816029 DOI: 10.1155/2013/859761] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/03/2013] [Indexed: 12/02/2022]
Abstract
Antibody-mediated rejection (AMR) is an important cause of graft loss after organ transplantation. It is caused by anti-donor-specific antibodies especially anti-HLA antibodies. C4d had been regarded as a diagnosis marker for AMR. Although most early AMR episodes can be successfully controlled or reversed, late and chronic AMR remains the leading cause of late graft loss. The strategies which work in early AMR have limited effect on late/chronic episodes. Here, we reviewed the lines of evidence that late/chronic AMR is the leading cause of late graft loss, characteristics of late AMR, and current strategies in managing late/chronic AMR. More effort should be put on the management of late/chronic AMR to make a better long term graft survival.
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