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Narula T, Alvarez F, Abdelmoneim Y, Erasmus D, Li Z, Elrefaei M. Induction immunosuppression strategies and outcomes post-lung transplant: A single center experience. Transpl Immunol 2024; 85:102081. [PMID: 38986916 DOI: 10.1016/j.trim.2024.102081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Currently 80% of lung transplant centers use induction immunosuppression. However, there is a lack of standardization of induction protocols within and across lung transplant centers. This study explores the association of two different induction immunosuppression strategies used at our center [single dose rabbit antithymocyte globulin (rATG) vs. alemtuzumab] compared to no induction with immunologic and clinical outcomes after lung transplantation. METHODS A total of 174 consecutive lung transplant recipients (LTR) between 2016 and 2019 were included in the analysis. Twenty nine LTR (16.7%) received no induction, 22 LTR (12.6%) received alemtuzumab, 123 LTR (70.6%) received a single dose of rATG; 1.5 mg/kg within 24 h of transplant for induction. All LTR had a negative flow cytometry crossmatch on the day of the transplant. All LTR were assessed for de novo HLA donor-specific antibodies (DSA) development and clinical outcomes, including the risk of acute cellular rejection (ACR), antibody-mediated rejection (AMR), chronic lung allograft dysfunction (CLAD), and overall survival post-transplant. RESULTS The median lung allocation score (LAS) was significantly higher in LTR that did not receive Induction immunosuppression (76; range = 35.3-94.3) compared to induction with rATG (41.6; range = 31.6-91) and alemtuzumab (51; range = 33.1-88.2) (p < 0.001). De novo HLA DSA were detected in 50/174 (28.7%) LTR within 12 months post-transplant. They were detected in 13/29 (44.8%) LTR without induction immunosuppression compared to 28/123 (22.8%) and 9/22 (40.9%) LTR with rATG and alemtuzumab induction, respectively (p = 0.02). The percent freedom from ACR rates between LTR who received alemtuzumab induction was significantly higher compared to LTR who received rATG or no induction at 1 (p = 0.02), 2 (p = 0.01) and 3 (p = 0.05) years post-transplant. In addition, the overall 1-year survival rates were significantly higher in LTR who received rATG or alemtuzumab induction compared to LTR without induction immunosuppression (p = 0.02). CONCLUSION Induction immunosuppression strategies utilizing rATG or Alemtuzumab have unique and contrasting benefits in LTR. Combination of alemtuzumab induction and a lower dose of maintenance immunosuppression may reduce the incidence of ACR in LTR. Single-dose rATG or alemtuzumab induction immunosuppression may also improve the 1 year overall LTR survival compared to no induction.
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Affiliation(s)
- Tathagat Narula
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, FL, United States of America
| | - Francisco Alvarez
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, FL, United States of America
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States of America
| | - David Erasmus
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Zhuo Li
- Health Sciences Research, Mayo Clinic, Jacksonville, FL, United States of America
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States of America.
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Brandon W, Dunn C, Bollineni S, Joerns J, Lawrence A, Mohanka M, Timofte I, Torres F, Kaza V. Management of donor-specific antibodies in lung transplantation. FRONTIERS IN TRANSPLANTATION 2023; 2:1248284. [PMID: 38993917 PMCID: PMC11235237 DOI: 10.3389/frtra.2023.1248284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/23/2023] [Indexed: 07/13/2024]
Abstract
The formation of antibodies against donor human leukocyte antigens poses a challenging problem both for donor selection as well as postoperative graft function in lung transplantation. These donor-specific antibodies limit the pool of potential donor organs and are associated with episodes of antibody-mediated rejection, chronic lung allograft dysfunction, and increased mortality. Optimal management strategies for clearance of DSAs are poorly defined and vary greatly by institution; most of the data supporting any particular strategy is limited to small-scale retrospective cohort studies. A typical approach to antibody depletion may involve the use of high-dose steroids, plasma exchange, intravenous immunoglobulin, and possibly other immunomodulators or small-molecule therapies. This review seeks to define the current understanding of the significance of DSAs in lung transplantation and outline the literature supporting strategies for their management.
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Affiliation(s)
- William Brandon
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Colin Dunn
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Srinivas Bollineni
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - John Joerns
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Adrian Lawrence
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Manish Mohanka
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Irina Timofte
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Liao M, Wang C, Zhang M, Qiao K. Insight on immune cells in rejection and infection postlung transplant. Immun Inflamm Dis 2023; 11:e868. [PMID: 37506156 PMCID: PMC10336664 DOI: 10.1002/iid3.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE The aim of this study is to provide a concise overview of the role of immune cells in rejection and infection after lung transplantation. METHODS Based on previous clinical and basic studies, the role of various types of immune cells in the development of rejection and infection after lung transplantation is summarized. RESULTS Immune cell functional status is strongly associated with common complications after lung transplantation, such as primary graft dysfunction, infection and occlusive bronchitis syndrome. Targeted balancing of immune cell tolerance and rejection is an important tool for successful lung transplantation. CONCLUSION A comprehensive understanding of immune cell function and the mechanisms that balance immune tolerance and immune rejection may be a crucial factor in improving survival after lung transplantation.
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Affiliation(s)
- Mingfeng Liao
- Guangdong Key Lab for Diagnosis & Treatment of Emerging Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Chaoxi Wang
- Department of Thoracic Surgery, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Mingxia Zhang
- Guangdong Key Lab for Diagnosis & Treatment of Emerging Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Kun Qiao
- Department of Thoracic Surgery, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
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Stoker A, Hicks A, Wright MC, Ali A, Klapper J, Poisson J, Zaffiri L, Chen D, Hartwig M, Ghadimi K, Welsby I, Bottiger B. Development of New Donor-Specific and Human Leukocyte Antigen Antibodies After Transfusion in Adult Lung Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00274-4. [PMID: 37263806 DOI: 10.1053/j.jvca.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The development of new human leukocyte antigens (HLAs) and donor-specific antibodies (DSAs) in patients are associated with worse outcomes following lung transplantation. The authors aimed to examine the relationship between blood product transfusion in the first 72 hours after lung transplantation and the development of HLA antibodies, including DSAs. DESIGN A retrospective observational study. SETTING At a single academic tertiary center. PARTICIPANTS Adult lung transplant recipients who underwent transplantation between September 2014 and June 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 380 patients were included in this study, and 87 (23%) developed de novo donor-specific antibodies in the first year after transplantation. Eighty-five patients (22%) developed new HLA antibodies that were not donor-specific, and 208 patients (55%) did not develop new HLA antibodies in the first year after transplantation. Factors associated with increased HLA and DSA development included donor pulmonary infection, non-infectious indication for transplant, increased recipient body mass index, and a preoperative calculated panel reactive antibody value above 0. Multivariate analysis identified platelet transfusion associated with an increased risk of de novo HLA antibody development compared to the negative group (odds ratio [OR; 95% CI] 1.18 [1.02-1.36]; p = 0.025). Cryoprecipitate transfusion was associated with de novo DSA development compared to the negative group (OR [95% CI] 2.21 [1.32-3.69] for 1 v 0 units; p = 0.002). CONCLUSIONS Increased perioperative transfusion of platelets and cryoprecipitate are associated with de novo HLA and DSA development, respectively, in lung transplant recipients during the first year after transplantation.
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Affiliation(s)
- Alexander Stoker
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC
| | - Anne Hicks
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC
| | - Mary Cooter Wright
- Department of Anesthesiology, Biostatistics, Duke University Medical Center, Durham, NC
| | - Azfar Ali
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Jacob Klapper
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Jessica Poisson
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Lorenzo Zaffiri
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Dongfeng Chen
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Matthew Hartwig
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC; Department of Anesthesiology, Critical Care Medicine Division, Duke University Medical Center, Durham, NC
| | - Ian Welsby
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC; Department of Anesthesiology, Critical Care Medicine Division, Duke University Medical Center, Durham, NC
| | - Brandi Bottiger
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC.
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Keller M, Yang S, Ponor L, Bon A, Cochrane A, Philogene M, Bush E, Shah P, Mathew J, Brown AW, Kong H, Charya A, Luikart H, Nathan SD, Khush KK, Jang M, Agbor-Enoh S. Preemptive treatment of de novo donor-specific antibodies in lung transplant patients reduces subsequent risk of chronic lung allograft dysfunction or death. Am J Transplant 2023; 23:559-564. [PMID: 36732088 PMCID: PMC10079558 DOI: 10.1016/j.ajt.2022.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023]
Abstract
The development of donor-specific antibodies after lung transplantation is associated with downstream acute cellular rejection, antibody-mediated rejection (AMR), chronic lung allograft dysfunction (CLAD), or death. It is unknown whether preemptive (early) treatment of de novo donor-specific antibodies (dnDSAs), in the absence of clinical signs and symptoms of allograft dysfunction, reduces the risk of subsequent CLAD or death. We performed a multicenter, retrospective cohort study to determine if early treatment of dnDSAs in lung transplant patients reduces the risk of the composite endpoint of CLAD or death. In the cohort of 445 patients, 145 patients developed dnDSAs posttransplant. Thirty patients received early targeted treatment for dnDSAs in the absence of clinical signs and symptoms of AMR. Early treatment of dnDSAs was associated with a decreased risk of CLAD or death (hazard ratio, 0.36; 95% confidence interval, 0.17-0.76; P < .01). Deferring treatment until the development of clinical AMR was associated with an increased risk of CLAD or death (hazard ratio, 3.00; 95% confidence interval, 1.46-6.18; P < .01). This study suggests that early, preemptive treatment of donor-specific antibodies in lung transplant patients may reduce the subsequent risk of CLAD or death.
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Affiliation(s)
- Michael Keller
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Song Yang
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Lucia Ponor
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Ann Bon
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Mary Philogene
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Johns Hopkins Immunogenetics Laboratory, Baltimore, Maryland, USA
| | - Errol Bush
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Pali Shah
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joby Mathew
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne W Brown
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Hyesik Kong
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Ananth Charya
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Helen Luikart
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA; Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Kiran K Khush
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Moon Jang
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Sean Agbor-Enoh
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Courtwright A, Atkinson C, Pelaez A. The Highly Sensitized Recipient: Pretransplant and Posttransplant Considerations. Clin Chest Med 2023; 44:85-93. [PMID: 36774171 DOI: 10.1016/j.ccm.2022.10.007] [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
Highly sensitized patients, who are often black and Hispanic women, are less likely to be listed for lung transplant and are at higher risk for prolonged waitlist time and waitlist death. In this review, the authors discuss strategies for improving access to transplant in this population, including risk stratification of crossing pretransplant donor-specific antibodies, based on antibody characteristics. The authors also review institutional protocols, such as perioperative desensitization, for tailoring transplant immunosuppression in the highly sensitized population. The authors conclude with suggestions for future research, including development of novel donor-specific antibody-directed therapeutics.
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Affiliation(s)
- Andrew Courtwright
- Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Carl Atkinson
- University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Andres Pelaez
- Jackson Health System, University of Miami, Miller School of Medicine, Miami Transplant Institute, 1801 Northwest 9th Avenue, Miami, FL 33136, USA.
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7
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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8
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Assessment of Anti-Human Leukocyte Antigen (HLA)-Antibody-Dependent Humoral Response in Patients before and after Lung Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121771. [PMID: 36556973 PMCID: PMC9781897 DOI: 10.3390/medicina58121771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Testing for anti-human leukocyte antigen (HLA) antibodies both before and after transplantation is of fundamental significance for the success of lung transplantation. The aim of this study was the evaluation of anti-HLA immunization of patients before and after lung transplant who were subjected to qualification and transplantation. Materials and Methods: Prior to the transplantation, patients were examined for the presence of IgG class anti-HLA antibodies (anti-human leukocyte antigen), the so-called panel-reactive antibodies (PRA), using the flow cytometry method. After the transplantation, the class and specificity of anti-HLA antibodies (also IgG) were determined using Luminex. Results: In the group examined, the PRA results ranged from 0.1% to 66.4%. Low (30%) and average (30-80%) immunization was found in only 9.7% of the group examined. Presence of class I anti-HLA antibodies with MFI (mean fluorescence intensity) greater than 1000 was found in 42.7% of the patients examined, while class II anti-HLA antibodies were found in 38.4%. Immunization levels before and after the transplantation were compared. In 10.87% of patients, DSA antibodies (donor-specific antibodies) with MFI of over 1000 were found. Conclusions: It seems that it is possible to confirm the correlation between pre- and post-transplantation immunization with the use of the two presented methods of determining IgG class anti-HLA antibodies by increasing the size of the group studied and conducting a long-term observation thereof.
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9
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Bos S, Milross L, Filby AJ, Vos R, Fisher AJ. Immune processes in the pathogenesis of chronic lung allograft dysfunction: identifying the missing pieces of the puzzle. Eur Respir Rev 2022; 31:31/165/220060. [PMID: 35896274 DOI: 10.1183/16000617.0060-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Lung transplantation is the optimal treatment for selected patients with end-stage chronic lung diseases. However, chronic lung allograft dysfunction remains the leading obstacle to improved long-term outcomes. Traditionally, lung allograft rejection has been considered primarily as a manifestation of cellular immune responses. However, in reality, an array of complex, interacting and multifactorial mechanisms contribute to its emergence. Alloimmune-dependent mechanisms, including T-cell-mediated rejection and antibody-mediated rejection, as well as non-alloimmune injuries, have been implicated. Moreover, a role has emerged for autoimmune responses to lung self-antigens in the development of chronic graft injury. The aim of this review is to summarise the immune processes involved in the pathogenesis of chronic lung allograft dysfunction, with advanced insights into the role of innate immune pathways and crosstalk between innate and adaptive immunity, and to identify gaps in current knowledge.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Luke Milross
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Andrew J Filby
- Flow Cytometry Core and Innovation, Methodology and Application Research Theme, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Vos
- Dept of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium.,University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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10
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Charmetant X, Chen CC, Hamada S, Goncalves D, Saison C, Rabeyrin M, Rabant M, Duong van Huyen JP, Koenig A, Mathias V, Barba T, Lacaille F, le Pavec J, Brugière O, Taupin JL, Chalabreysse L, Mornex JF, Couzi L, Graff-Dubois S, Jeger-Madiot R, Tran-Dinh A, Mordant P, Paidassi H, Defrance T, Morelon E, Badet L, Nicoletti A, Dubois V, Thaunat O. Inverted direct allorecognition triggers early donor-specific antibody responses after transplantation. Sci Transl Med 2022; 14:eabg1046. [PMID: 36130013 DOI: 10.1126/scitranslmed.abg1046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The generation of antibodies against donor-specific major histocompatibility complex (MHC) antigens, a type of donor-specific antibodies (DSAs), after transplantation requires that recipient's allospecific B cells receive help from T cells. The current dogma holds that this help is exclusively provided by the recipient's CD4+ T cells that recognize complexes of recipient's MHC II molecules and peptides derived from donor-specific MHC alloantigens, a process called indirect allorecognition. Here, we demonstrated that, after allogeneic heart transplantation, CD3ε knockout recipient mice lacking T cells generate a rapid, transient wave of switched alloantibodies, predominantly directed against MHC I molecules. This is due to the presence of donor CD4+ T cells within the graft that recognize intact recipient's MHC II molecules expressed by B cell receptor-activated allospecific B cells. Indirect evidence suggests that this inverted direct pathway is also operant in patients after transplantation. Resident memory donor CD4+ T cells were observed in perfusion liquids of human renal and lung grafts and acquired B cell helper functions upon in vitro stimulation. Furthermore, T follicular helper cells, specialized in helping B cells, were abundant in mucosa-associated lymphoid tissue of lung and intestinal grafts. In the latter, more graft-derived passenger T cells correlated with the detection of donor T cells in recipient's circulation; this, in turn, was associated with an early transient anti-MHC I DSA response and worse transplantation outcomes. We conclude that this inverted direct allorecognition is a possible explanation for the early transient anti-MHC DSA responses frequently observed after lung or intestinal transplantations.
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Affiliation(s)
- Xavier Charmetant
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - Chien-Chia Chen
- Department of Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Sarah Hamada
- French National Blood Service (EFS), HLA Laboratory, 69150 Décines, France
| | - David Goncalves
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - Carole Saison
- French National Blood Service (EFS), HLA Laboratory, 69150 Décines, France
| | - Maud Rabeyrin
- Department of Pathology, Hospices Civils de Lyon, Groupement Hospitalier Est, 69500 Bron, France
| | - Marion Rabant
- Pathology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, 75015 Paris, France
| | | | - Alice Koenig
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), 69008 Lyon, France
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, 69003 Lyon, France
| | - Virginie Mathias
- French National Blood Service (EFS), HLA Laboratory, 69150 Décines, France
| | - Thomas Barba
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - Florence Lacaille
- Pediatric Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker-Enfants malades, 75015 Paris, France
| | - Jérôme le Pavec
- Department of Pulmonology and Lung Transplantation, Marie Lannelongue Hospital, 92350 Le Plessis Robinson, France
| | - Olivier Brugière
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, 92150 Suresnes, France
| | - Jean-Luc Taupin
- Laboratory of Immunology and Histocompatibility, Hôpital Saint-Louis APHP, 75010 Paris, France
- INSERM U976 Institut de Recherche Saint-Louis, Université Paris Diderot, 75010 Paris, France
| | - Lara Chalabreysse
- Department of Pathology, Hospices Civils de Lyon, Groupement Hospitalier Est, 69500 Bron, France
| | - Jean-François Mornex
- Université de Lyon, Université Lyon 1, INRAE, IVPC, UMR754, 69000 Lyon, France
- Department of Pneumology, GHE, Hospices Civils de Lyon, 69000 Lyon, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis, Apheresis, Pellegrin Hospital, 33000 Bordeaux, France
| | - Stéphanie Graff-Dubois
- Sorbonne Université, INSERM, Immunology-Immunopathology-Immunotherapy (i3), 75013 Paris, France
| | - Raphaël Jeger-Madiot
- Sorbonne Université, INSERM, Immunology-Immunopathology-Immunotherapy (i3), 75013 Paris, France
| | - Alexy Tran-Dinh
- Université de Paris, LVTS, INSERM U1148, 75018 Paris, France
| | - Pierre Mordant
- Department of Vascular and Thoracic Surgery, Assistance Publique-Hôpitaux de Paris, Bichat-Claude Bernard Hospital, 75018 Paris, France
| | - Helena Paidassi
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - Thierry Defrance
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - Emmanuel Morelon
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), 69008 Lyon, France
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, 69003 Lyon, France
| | - Lionel Badet
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), 69008 Lyon, France
- Department of Urology and Transplantation Surgery, Hospices Civils de Lyon, Edouard Herriot Hospital, 69003 Lyon, France
| | | | - Valérie Dubois
- French National Blood Service (EFS), HLA Laboratory, 69150 Décines, France
| | - Olivier Thaunat
- CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, INSERM U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
- Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), 69008 Lyon, France
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, 69003 Lyon, France
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11
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Shah SZ, Abdelmoneim Y, Pham SM, Elrefaei M. Association between SARS-CoV-2 infection and de novo HLA donor specific antibody production in lung transplant recipients: Single-center study. Hum Immunol 2022; 83:749-754. [PMID: 35987702 PMCID: PMC9376302 DOI: 10.1016/j.humimm.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic has led to significant morbidity and mortality in lung transplant recipients. Respiratory viral infections may be associated with de-novo HLA donor-specific antibody production and impact lung transplant outcome. Since one of the immunomodulation strategies post-SARS-CoV-2 infection in lung transplant recipients include decreasing or holding anti-metabolites, concerns have been raised for higher incidence of de-novo HLA donor specific antibody production in lung transplant recipients. We performed a retrospective chart review of 24 consecutive lung transplant recipients diagnosed with COVID-19 to investigate this concern. We observed no significant differences in the CPRA or MFI levels of HLA class I and II antibodies pre- COVID-19 compared to 1 and 6 months post-COVID-19 diagnosis in 11/24 (45.8 %) LTR (p = 0.98 and p = 0.63 respectively). HLA class I and II DSA were detected in 5/24 LTR pre-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.89). De-novo HLA class I and II DSA were detected in 1/24 (4.2 %) LTR at one month post-COVID-19 diagnosis and persisted with no significant differences in the median MFI levels at 1 and 6 months post-COVID-19 diagnosis (p = 0.54). Our results suggest that there was no significant association between SARS-CoV-2 infection and immunomodulation on pre-existing or de novo HLA donor specific antibodies.
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Affiliation(s)
- Sadia Z Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States.
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12
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Sommer W, Avsar M, Aburahma K, Salman J, Kaufeld KT, Rojas SV, Meyer AL, Chichelnitskiy E, Süsal C, Kreusser MM, Verboom M, Hallensleben M, Bara C, Blasczyk R, Falk C, Karck M, Haverich A, Ius F, Warnecke G. Heart transplantation across preformed donor-specific antibody barriers using a perioperative desensitization protocol. Am J Transplant 2022; 22:2064-2076. [PMID: 35426974 DOI: 10.1111/ajt.17060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 01/25/2023]
Abstract
Heart transplantation across preformed donor-specific HLA-antibody barriers is associated with impaired short- and long-term survival. Therefore, in recipients with preformed anti-HLA antibodies, waiting for crossmatch-negative donors is standard practice. As an alternative strategy, recipients with preformed anti-HLA donor specific antibodies have been managed at our institutions with a perioperative desensitization regimen. A retrospective analysis was performed comparing heart transplant recipients with preformed donor-specific HLA-antibodies to recipients without donor-specific antibodies. Recipients with a positive virtual crossmatch received a perioperative desensitization protocol including tocilizumab intraoperatively, plasma exchange and rituximab followed by a six-month course of IgGAM. Among the 117 heart-transplanted patients, 19 (16%) patients underwent perioperative desensitization, and the remaining 98 (84%) patients did not. Cold ischemic time, posttransplant extracorporeal life support for primary graft dysfunction, and intensive care unit stay time did not differ between groups. At 1-year follow-up, freedom from pulsed steroid therapy for presumed rejection and biopsy-confirmed acute cellular or humoral rejection did not differ between groups. One-year survival amounted to 94.7% in the treated patients and 81.4% in the control group. Therefore, heart transplantation in sensitized recipients undergoing a perioperative desensitization appears safe with comparable postoperative outcomes as patients with a negative crossmatch.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Khalil Aburahma
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Klaus Tim Kaufeld
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Sebastian V Rojas
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Anna L Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Evgeny Chichelnitskiy
- Department of Transplantation Immunology, Hannover Medical School, Hannover, Germany
| | - Caner Süsal
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | | | - Murielle Verboom
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael Hallensleben
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Christoph Bara
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Christine Falk
- Department of Transplantation Immunology, Hannover Medical School, Hannover, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Vascular and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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13
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Ravichandran R, Bansal S, Rahman M, Sureshbabu A, Sankpal N, Fleming T, Bharat A, Mohanakumar T. Extracellular Vesicles Mediate Immune Responses to Tissue-Associated Self-Antigens: Role in Solid Organ Transplantations. Front Immunol 2022; 13:861583. [PMID: 35572510 PMCID: PMC9094427 DOI: 10.3389/fimmu.2022.861583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Transplantation is a treatment option for patients diagnosed with end-stage organ diseases; however, long-term graft survival is affected by rejection of the transplanted organ by immune and nonimmune responses. Several studies have demonstrated that both acute and chronic rejection can occur after transplantation of kidney, heart, and lungs. A strong correlation has been reported between de novo synthesis of donor-specific antibodies (HLA-DSAs) and development of both acute and chronic rejection; however, some transplant recipients with chronic rejection do not have detectable HLA-DSAs. Studies of sera from such patients demonstrate that immune responses to tissue-associated antigens (TaAgs) may also play an important role in the development of chronic rejection, either alone or in combination with HLA-DSAs. The synergistic effect between HLA-DSAs and antibodies to TaAgs is being established, but the underlying mechanism is yet to be defined. We hypothesize that HLA-DSAs damage the transplanted donor organ resulting in stress and leading to the release of extracellular vesicles, which contribute to chronic rejection. These vesicles express both donor human leukocyte antigen (HLA) and non-HLA TaAgs, which can activate antigen-presenting cells and lead to immune responses and development of antibodies to both donor HLA and non-HLA tissue-associated Ags. Extracellular vesicles (EVs) are released by cells under many circumstances due to both physiological and pathological conditions. Primarily employing clinical specimens obtained from human lung transplant recipients undergoing acute or chronic rejection, our group has demonstrated that circulating extracellular vesicles display both mismatched donor HLA molecules and lung-associated Ags (collagen-V and K-alpha 1 tubulin). This review focuses on recent studies demonstrating an important role of antibodies to tissue-associated Ags in the rejection of transplanted organs, particularly chronic rejection. We will also discuss the important role of extracellular vesicles released from transplanted organs in cross-talk between alloimmunity and autoimmunity to tissue-associated Ags after solid organ transplantation.
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Affiliation(s)
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohammad Rahman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Narendra Sankpal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ankit Bharat
- Department of Surgery-Thoracic, Northwestern University, Chicago, IL, United States
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14
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Michel E, Galen Hartwig M, Sommer W. Lung Retransplantation. Thorac Surg Clin 2022; 32:259-268. [PMID: 35512943 DOI: 10.1016/j.thorsurg.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lung retransplantation remains the standard treatment of irreversible lung allograft failure. The most common indications for lung retransplantation are acute graft failure, chronic lung allograft dysfunction, and postoperative airway complications. Careful patient selection with regards to indications, anatomy, extrapulmonary organ dysfunction (specifically renal dysfunction), and immunologic consideration are of utmost importance. The conduct of the lung retransplantation operation is arduous with special considerations given to operative approach, type of surgery (single vs bilateral), use of extracorporeal circulatory support, and hematological management. Outcomes have improved significantly for most patients, nearing short and midterm outcomes of primary lung recipients in select cases.
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Affiliation(s)
- Eriberto Michel
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Cox 630, Boston, MA 02114, USA
| | - Matthew Galen Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, DUMC 3863, Durham, NC 27710, USA.
| | - Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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15
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Silva TD, Voisey J, Hopkins P, Apte S, Chambers D, O'Sullivan B. Markers of rejection of a lung allograft: state of the art. Biomark Med 2022; 16:483-498. [PMID: 35315284 DOI: 10.2217/bmm-2021-1013] [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: 11/21/2022] Open
Abstract
Chronic lung allograft dysfunction (CLAD) affects approximately 50% of all lung transplant recipients by 5 post-operative years and is the leading cause of death in lung transplant recipients. Early CLAD diagnosis or ideally prediction of CLAD is essential to enable early intervention before significant lung injury occurs. New technologies have emerged to facilitate biomarker discovery, including epigenetic modification and single-cell RNA sequencing. This review examines new and existing technologies for biomarker discovery and the current state of research on biomarkers for identifying lung transplant rejection.
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Affiliation(s)
- Tharushi de Silva
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia
| | - Joanne Voisey
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Peter Hopkins
- Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Simon Apte
- Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Daniel Chambers
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Brendan O'Sullivan
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
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16
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Anti-HLA immunization of patients qualified for lung transplantation – Single center study. Transpl Immunol 2022; 71:101553. [DOI: 10.1016/j.trim.2022.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022]
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17
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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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18
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Cone BD, Zhang JQ, Sosa RA, Calabrese F, Reed EF, Fishbein GA. Phosphorylated S6 ribosomal protein expression by immunohistochemistry correlates with de novo donor-specific HLA antibodies in lung allograft recipients. J Heart Lung Transplant 2021; 40:1164-1171. [PMID: 34330604 DOI: 10.1016/j.healun.2021.06.021] [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: 10/26/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Per the ISHLT 2016 definition, a C4d-positive lung biopsy is required to meet criteria for definite antibody-mediated rejection (AMR). Unfortunately, C4d has poor sensitivity and specificity, and low inter-rater reliability. Phosphorylated S6 ribosomal protein (p-S6RP) expressed via the mTOR pathway has been shown to be a biomarker of AMR and correlates with donor-specific antibodies (DSA) in heart allografts. However, p-S6RP immunohistochemistry (IHC) in the setting of pulmonary AMR has yet to be evaluated. We sought to determine whether p-S6RP IHC performed on lung biopsies correlates with de novo DSA. METHODS IHC for p-S6RP performed on 26 biopsies from lung transplant recipients with de novo HLA DSA (DSA+) and 28 biopsies from patients with no DSA (DSA-) were evaluated by 3 pathologists who independently scored the degree of alveolar macrophage and pneumocyte staining. Staining in ≥50% of the biopsy as determined by at least 2 pathologists was considered positive. RESULTS Twenty-one (81%) DSA+ biopsies stained positive for p-S6RP in pneumocytes and 21 (81%) in macrophages. Six DSA- biopsies (21%) stained positive for p-S6RP in pneumocytes, 6 (21%) were positive in macrophages. Pneumocyte p-S6RP staining was 81% sensitive and 79% specific for DSA. Macrophage staining showed the same sensitivity and specificity but with lower inter-rater agreement (κ = 0.53 vs 0.68). CONCLUSIONS This study demonstrates a positive relationship between de novo DSA and p-S6RP expression in pneumocytes and macrophages using IHC. p-S6RP is relatively sensitive and specific, and has superior inter-rater reliability compared to C4d.
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Affiliation(s)
- Brian D Cone
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Q Zhang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rebecca A Sosa
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Elaine F Reed
- David Geffen School of Medicine at UCLA, Los Angeles, California
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19
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Klapper JA, Hicks AC, Ledbetter L, Poisson J, Hartwig MG, Hashmi N, Welsby I, Bottiger BA. Blood product transfusion and lung transplant outcomes: A systematic review. Clin Transplant 2021; 35:e14404. [PMID: 34176163 DOI: 10.1111/ctr.14404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 12/01/2022]
Abstract
The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.3 In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.
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Affiliation(s)
- Jacob A Klapper
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Anne C Hicks
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Leila Ledbetter
- Duke University, Medical Center Library, Durham, North California, USA
| | - Jessica Poisson
- Department of Pathology, Duke University, Durham, North California, USA
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Nazish Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Brandi A Bottiger
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
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20
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Assessment of Carfilzomib Treatment Response in Lung Transplant Recipients With Antibody-mediated Rejection. Transplant Direct 2021; 7:e680. [PMID: 33748409 PMCID: PMC7969244 DOI: 10.1097/txd.0000000000001131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 01/31/2023] Open
Abstract
Supplemental Digital Content is available in the text. Data supporting the use of carfilzomib (CFZ) for treatment of antibody-mediated rejection (AMR) in lung transplantation in combination with plasmapheresis and intravenous immunoglobulin suggest positive outcomes through donor-specific antibody (DSA) depletion or conversion to noncomplement-activating antibodies. Herein, we describe our center’s experience treating AMR with CFZ.
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21
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Joean O, Kayser MZ, Valtin C, Ewen R, Gottlieb J. Characteristics and clinical implications of pleural effusions after lung transplantation: A retrospective analysis of 195 thoracocenteses in 113 patients. Clin Transplant 2021; 35:e14267. [PMID: 33615592 DOI: 10.1111/ctr.14267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/30/2021] [Accepted: 02/17/2021] [Indexed: 12/20/2022]
Abstract
Despite advances in lung transplantation (LTx), morbidity, and mortality are high. We hypothesized that pleural effusions requiring thoracocentesis lead to poor outcomes after LTx. We performed a single-center retrospective analysis of thoracocenteses after initial hospital discharge in LTx patients between March 2008 and September 2020 to identify risk factors, etiologies, and outcomes. Of the 1223 patients included, 113 patients (9.2%) required a total of 195 thoracocenteses. The cumulative incidence of thoracocentesis was 10.6% at 1 year and 14.2% at 5 years after transplantation. We observed a bimodal distribution of pleural effusion onset with a threshold at 6 months. Late-onset effusions were mostly of malignant or cardiac origin. We observed a high rate of nonspecific effusions (41.5%) irrespective of the timepoint post-transplantation. Patients with late-onset effusions had significantly lower survival compared to a matched controlled group (HR 2.43; 95% CI (1.27-4.62). All pulmonary function parameters were significantly decreased in patients requiring thoracocentesis compared to matched controls. Male sex and re-transplantation were risk factors for pleural effusions. In conclusion, pleural effusions requiring thoracocentesis occur frequently in LTx patients and lead to a reduced long-term allograft function. Late-onset effusions are associated with a lower survival.
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Affiliation(s)
- Oana Joean
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-stage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
| | - Moritz Z Kayser
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-stage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
| | - Christina Valtin
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Raphael Ewen
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-stage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
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22
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Werlein C, Seidel A, Warnecke G, Gottlieb J, Laenger F, Jonigk D. Lung Transplant Pathology: An Overview on Current Entities and Procedures. Surg Pathol Clin 2020; 13:119-140. [PMID: 32005428 DOI: 10.1016/j.path.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alloimmune reactions are, besides various infections, the major cause for impaired lung allograft function following transplant. Acute cellular rejection is not only a major trigger of acute allograft failure but also contributes to development of chronic lung allograft dysfunction. Analogous to other solid organ transplants, acute antibody-mediated rejection has become a recognized entity in lung transplant pathology. Adequate sensitivity and specificity in the diagnosis of alloimmune reactions in the lung can only be achieved by synoptic analysis of histopathologic, clinical, and radiological findings together with serologic and microbiologic findings.
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Affiliation(s)
- Christopher Werlein
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
| | - Allison Seidel
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Gregor Warnecke
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Jens Gottlieb
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Pneumology, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Florian Laenger
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Danny Jonigk
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
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23
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Kaza V, Zhu C, Terada LS, Wang L, Torres F, Bollineni S, Mohanka M, Banga A, Joerns J, Mohanakumar T, Li QZ. Self-reactive antibodies associated with bronchiolitis obliterans syndrome subtype of chronic lung allograft dysfunction. Hum Immunol 2020; 82:25-35. [PMID: 33129576 DOI: 10.1016/j.humimm.2020.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic Lung Allograft Dysfunction (CLAD) remains the major limitation in long term survival after lung transplantation. Our objective is to evaluate for the presence of autoantibodies to self-antigens, which is a pathway along with complex interplay with immune as well as non-immune mechanisms that leads to a fibroproliferative process resulting in CLAD. METHODS Serum profiles of IgG autoantibodies were evaluated using customized proteomic microarray with 124 antigens. Output from microarray analyzed as antibody scores is correlated with bronchiolitis obliterans (BOS) subtype of CLAD using Mann-Whitney U test or Fisher exact test. Autoantibodies were evaluated for their predictive value for progressive BOS using a Cox proportional hazard model. BOS free survival and overall survival was analyzed using Kaplan-Meier survival analysis. RESULTS Forty- two patients included in the study are grouped into "stable BOS" and "progressive BOS" for comparisons. Pulmonary fibrosis is the major indication for lung transplantation in our cohort. Progressive BOS group had significantly worse survival (p < 0.005). Sixteen IgG autoantibodies are significantly elevated at baseline in progressive BOS group. Six among them correlated with worse BOS free survival (p < 0.05). In addition, these six IgG autoantibodies remain elevated at three months and one year after lung transplantation. CONCLUSION Pre-existing IgG autoantibodies correlate with progressive BOS and survival in a single center, small cohort of lung transplant recipients. Further validation with larger sample size, external cohort and confirmation with additional tissue, bronchoalveolar lavage samples are necessary to confirm the preliminary findings in our study.
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Affiliation(s)
- Vaidehi Kaza
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
| | - Chengsong Zhu
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lance S Terada
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Li Wang
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Fernando Torres
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Srinivas Bollineni
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Manish Mohanka
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Amit Banga
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - John Joerns
- Division of Pulmonary Critical Care, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Quan-Zhen Li
- Department of Immunology, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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24
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Courtwright AM, Kamoun M, Kearns J, Diamond JM, Golberg HJ. The impact of HLA-DR mismatch status on retransplant-free survival and bronchiolitis obliterans syndrome‒free survival among sensitized lung transplant recipients. J Heart Lung Transplant 2020; 39:1455-1462. [PMID: 33071182 DOI: 10.1016/j.healun.2020.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Donor‒recipient HLA-DR locus matching may be protective against bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. It is unknown whether this benefit is more significant among sensitized (calculated panel reactive antibodies (CPRAs) of >0%) and highly sensitized (CPRAs of ≥80%) recipients who may be at a higher risk for BOS. METHODS This was a retrospective cohort study of adults in the Scientific Registry of Transplant Recipients who underwent lung transplantation between May 5, 2005 and May 31, 2019. Retransplant-free survival and BOS-free survival were compared among recipients with 0 vs ≥1 DR mismatches, grouped according to sensitization. RESULTS Among all 20,355 included recipients, 0 DR mismatch status was associated with improved retransplant-free survival (hazard ratio [HR] = 0.83, 95% CI = 0.74-0.93, p = 0.002) and BOS-free survival (HR = 0.86, 95% CI = 0.77-0.96, p = 0.007). Among sensitized recipients, 0 DR mismatch status was also associated with improved retransplant-free survival (HR = 0.79, 95% CI = 0.65-0.97, p = 0.02) and BOS-free survival (HR = 0.82, 95% CI = 0.67-1.00, p = 0.04). There was however no difference in retransplant-free or BOS-free survival between sensitized and non-sensitized recipients with 0 DR mismatches. Among highly sensitized recipients, 0 DR mismatch status was not associated with retransplant-free or BOS-free survival. Among sensitized and highly sensitized recipients, 0 DR mismatch status was not associated with reduced use of plasmapheresis or reduced biopsy-proven, treated acute cellular rejection compared with non-sensitized recipients. CONCLUSIONS HLA-DR matching is associated with a similar improvement in retransplant-free and BOS-free survival among non-sensitized and sensitized lung transplant recipients. DR matching does not confer a more substantial retransplant-free or BOS-free survival benefit to highly sensitized recipients than to non-sensitized recipients.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Kearns
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hilary J Golberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boson, Massachusetts
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25
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Kulkarni HS, Tsui K, Sunder S, Ganninger A, Tague LK, Witt CA, Byers DE, Trulock EP, Nava R, Puri V, Kreisel D, Mohanakumar T, Gelman AE, Hachem RR. Pseudomonas aeruginosa and acute rejection independently increase the risk of donor-specific antibodies after lung transplantation. Am J Transplant 2020; 20:1028-1038. [PMID: 31677358 PMCID: PMC7103544 DOI: 10.1111/ajt.15687] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/06/2019] [Accepted: 10/24/2019] [Indexed: 01/25/2023]
Abstract
Factors contributing to donor-specific HLA antibody (DSA) development after lung transplantation have not been systematically evaluated. We hypothesized that the isolation of Pseudomonas aeruginosa in respiratory specimens would increase the risk of DSA development. Our objective was to determine the risk of DSA development associated with the isolation of Pseudomonas aeruginosa after lung transplantation. We conducted a single-center retrospective cohort study of primary lung transplant recipients and examined risk factors for DSA development using Cox regression models. Of 460 recipients, 205 (45%) developed DSA; the majority developed Class II DSA (n = 175, 85%), and 145 of 205 (71%) developed DSA to HLA-DQ alleles. Univariate time-dependent analyses revealed that isolation of Pseudomonas from respiratory specimens, acute cellular rejection, and lymphocytic bronchiolitis are associated with an increased risk of DSA development. In multivariable analyses, Pseudomonas isolation, acute cellular rejection, and lymphocytic bronchiolitis remained independent risk factors for DSA development. Additionally, there was a direct association between the number of positive Pseudomonas cultures and the risk of DSA development. Our findings suggest that pro-inflammatory events including acute cellular rejection, lymphocytic bronchiolitis, and Pseudomonas isolation after transplantation are associated with an increased risk of DSA development.
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Affiliation(s)
| | - Kevin Tsui
- Advocate Christ Medical Center, Chicago, IL
| | - Suraj Sunder
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Alex Ganninger
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Laneshia K. Tague
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Chad A. Witt
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Derek E. Byers
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Elbert P. Trulock
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Ruben Nava
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | | | - Andrew E. Gelman
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Ramsey R. Hachem
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
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26
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Ius F, Müller C, Sommer W, Verboom M, Hallensleben M, Salman J, Siemeni T, Kühn C, Avsar M, Bobylev D, Poyanmehr R, Erdfelder C, Böthig D, Carlens J, Bayir L, Hansen G, Blasczyk R, Falk C, Tecklenburg A, Haverich A, Tudorache I, Schwerk N, Warnecke G. Six-year experience with treatment of early donor-specific anti-HLA antibodies in pediatric lung transplantation using a human immunoglobulin-based protocol. Pediatr Pulmonol 2020; 55:754-764. [PMID: 31909902 DOI: 10.1002/ppul.24639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/27/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Experience with the treatment of early donor-specific anti-HLA antibodies (eDSA) after lung transplantation in children is very limited. At our institution, we have treated patients with eDSA since 2013 with successive infusions of intravenous human immunoglobulins (IVIG), combined in some cases with a single dose of Rituximab and plasmapheresis (therapeutic plasma exchange [tPE]) or immunoabsorption. The aim of this study was to present the 6-year results of IVIG-based therapy in pediatric lung recipients. METHODS Records of pediatric (<18 years old) patients transplanted at our institution between 01/2013 and 03/2019 were reviewed. Outcomes were compared between patients with eDSA treated with IVIG (IVIG group) and without eDSA (control group). Median (interquartile range [IQR]) follow-up amounted to 28 (12-52) months. RESULTS During the study period, 66 lung-transplanted pediatric patients were included, of which 27 (41%) formed the IVIG group and 38 (57%) the control group. Among the IVIG patients, 14 (52%) patients showed concomitant graft dysfunction (possible clinical antibody-mediated rejection). The median time to eDSA detection was 24 (14-63) days after transplantation. eDSA were cleared in 25 (96%) of the 26 patients which completed treatment. At 3 years, graft survival (%) was 73 vs 85 (P = .65); freedom (%) from chronic lung allograft rejection (CLAD) was 89 vs 78 (P = .82); and from infection 47 vs 31 (P = .15), in IVIG vs control patients, respectively. CONCLUSIONS After lung transplantation, an IVIG-based treatment for eDSA yielded high eDSA clearance. IVIG and control patients showed similar CLAD-free and graft survival.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Murielle Verboom
- Institute of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | | | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Böthig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Carlens
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Lale Bayir
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Christine Falk
- German Center for Lung Research (DZL/BREATH), Hannover, Germany.,Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Clinic for Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
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27
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Ius F, Salman J, Knoefel AK, Sommer W, Nakagiri T, Verboom M, Siemeni T, Poyanmehr R, Bobylev D, Kuehn C, Avsar M, Erdfelder C, Hallensleben M, Boethig D, Hecker H, Schwerk N, Mueller C, Welte T, Falk C, Preissler G, Haverich A, Tudorache I, Warnecke G. Increased frequency of CD4 + CD25 high CD127 low T cells early after lung transplant is associated with improved graft survival - a retrospective study. Transpl Int 2020; 33:503-516. [PMID: 31903646 DOI: 10.1111/tri.13568] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/04/2019] [Accepted: 12/20/2019] [Indexed: 12/30/2022]
Abstract
In this retrospective study, we analyzed the presence of any association of three CD4+ CD25high regulatory T-cell subpopulations at 3 weeks after lung transplantation with the later incidence of chronic lung allograft dysfunction and graft survival. Among lung-transplanted patients between January 2009 and April 2018, only patients with sufficient T-cell measurements at 3 weeks after transplantation were included into the study. Putative regulatory T cells were defined as CD4+ CD25high T cells, detected in peripheral blood and further analyzed for CD127low , FoxP3+ , and CD152+ using fluorescence-activated cell sorting (FACS) analysis. Associations of regulatory T cells with chronic lung allograft dysfunction (CLAD) and graft survival were evaluated using Cox analysis. During the study period, 724 (71%) patients were included into the study. Freedom from chronic lung allograft dysfunction (CLAD) and graft survival amounted to 66% and 68% at 5 years. At the multivariable analysis, increasing frequencies of CD127low were associated with better freedom from CLAD (hazard ratio for each 1% increase of %CD127low , HR = 0.989, 95% CI = 0.981-0.996, P = 0.003) and better graft survival (HR = 0.991, 95% CI = 0.984-0.999, P = 0.026). A higher frequency of CD127low regulatory T cells in peripheral blood early after lung transplantation estimated a protective effect against chronic lung allograft dysfunction, mortality, and re-transplantation.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ann-Kathrin Knoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
| | - Tomoyuki Nakagiri
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hartmut Hecker
- Institute for Biometry, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Carsten Mueller
- Department of pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Christine Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Gerhard Preissler
- German Center for Lung Research (DZL), Hannover, Germany.,Department of Surgery, Munich Lung Transplant Group, Ludwig-Maximilian's University, Munich, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
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28
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Dick A, Humpe A, Kauke T. Impact, Screening, and Therapy of HLA Antibodies in Patients before and after Lung Transplantation. Transfus Med Hemother 2019; 46:337-347. [PMID: 31832059 DOI: 10.1159/000502124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/13/2019] [Indexed: 12/29/2022] Open
Abstract
Since almost 30 years, lung transplantation is a considerable therapeutic option in patients suffering from end-stage lung disease. Up to now, the impact of donor-specific antibodies directed against donor HLA (human leukocyte antigen) before and after transplantation is still a matter of debate. As histocompatibility testing is not required for each patient according to the current national guidelines and Eurotransplant recommendations for lung transplantation, each transplantation unit has to establish a local protocol together with the tissue typing laboratory how to implement an immunological risk assessment strategy for their patients while enabling access to transplantation. Desensitization regimens might help in case of highly alloimmunized patients waiting for urgent transplantation.
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Affiliation(s)
- Andrea Dick
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Andreas Humpe
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Teresa Kauke
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany.,Division of Thoracic Surgery, University Clinic LMU Munich, Munich, Germany
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29
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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30
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Ius F, Verboom M, Sommer W, Poyanmehr R, Knoefel A, Salman J, Kuehn C, Avsar M, Siemeni T, Erdfelder C, Hallensleben M, Boethig D, Schwerk N, Mueller C, Welte T, Falk C, Haverich A, Tudorache I, Warnecke G. Preemptive treatment of early donor-specific antibodies with IgA- and IgM-enriched intravenous human immunoglobulins in lung transplantation. Am J Transplant 2018; 18:2295-2304. [PMID: 29719115 PMCID: PMC6585979 DOI: 10.1111/ajt.14912] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/11/2018] [Accepted: 04/19/2018] [Indexed: 01/25/2023]
Abstract
This retrospective study presents our 4-year experience of preemptive treatment of early anti-HLA donor specific antibodies with IgA- and IgM-enriched immunoglobulins. We compared outcomes between patients with antibodies and treatment (case patients) and patients without antibodies (control patients). Records of patients transplanted at our institution between March 2013 and November 2017 were reviewed. The treatment protocol included one single 2 g/kg immunoglobulin infusion followed by successive 0.5 g/kg infusions for a maximum of 6 months, usually combined with a single dose of anti-CD20 antibody and, in case of clinical rejection or positive crossmatch, with plasmapheresis or immunoabsorption. Among the 598 transplanted patients, 128 (21%) patients formed the case group and 452 (76%) the control group. In 116 (91%) patients who completed treatment, 106 (91%) showed no antibodies at treatment end. Fourteen (13%) patients showed antibody recurrence thereafter. In case versus control patients and at 4-year follow-up, respectively, graft survival (%) was 79 versus 81 (P = .59), freedom (%) from biopsy-confirmed rejection 57 versus 53 (P = .34), and from chronic lung allograft dysfunction 82 versus 78 (P = .83). After lung transplantation, patients with early donor-specific antibodies and treated with IgA- and IgM-enriched immunoglobulins had 4-year graft survival similar to patients without antibodies and showed high antibody clearance.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Murielle Verboom
- Department of TransfusionMedicine Hannover Medical SchoolHannoverGermany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Ann‐Kathrin Knoefel
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | | | - Dietmar Boethig
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Nicolaus Schwerk
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Department of PaediatricsHannover Medical SchoolHannoverGermany
| | - Carsten Mueller
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Department of PaediatricsHannover Medical SchoolHannoverGermany
| | - Tobias Welte
- German Center for Lung Research (DZL/BREATH)HannoverGermany,Department of Respiratory MedicineHannover Medical SchoolHannoverGermany
| | - Christine Falk
- Institute of Transplant ImmunologyHannover Medical SchoolHannoverGermany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant, and Vascular SurgeryHannover Medical SchoolHannoverGermany,German Center for Lung Research (DZL/BREATH)HannoverGermany
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31
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Hachem RR, Kamoun M, Budev MM, Askar M, Ahya VN, Lee JC, Levine DJ, Pollack MS, Dhillon GS, Weill D, Schechtman KB, Leard LE, Golden JA, Baxter-Lowe L, Mohanakumar T, Tyan DB, Yusen RD. Human leukocyte antigens antibodies after lung transplantation: Primary results of the HALT study. Am J Transplant 2018; 18:2285-2294. [PMID: 29687961 PMCID: PMC6117197 DOI: 10.1111/ajt.14893] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/20/2018] [Accepted: 04/17/2018] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) are associated with worse outcomes after lung transplantation. To determine the incidence and characteristics of DSA early after lung transplantation, we conducted a prospective multicenter observational study that used standardized treatment and testing protocols. Among 119 transplant recipients, 43 (36%) developed DSA: 6 (14%) developed DSA only to class I HLA, 23 (53%) developed DSA only to class II HLA, and 14 (33%) developed DSA to both class I and class II HLA. The median DSA mean fluorescence intensity (MFI) was 3197. We identified a significant association between the Lung Allocation Score and the development of DSA (HR = 1.02, 95% CI: 1.001-1.03, P = .047) and a significant association between DSA with an MFI ≥ 3000 and acute cellular rejection (ACR) grade ≥ A2 (HR = 2.11, 95% CI: 1.04-4.27, P = .039). However, we did not detect an association between DSA and survival. We conclude that DSA occur frequently early after lung transplantation, and most target class II HLA. DSA with an MFI ≥ 3000 have a significant association with ACR. Extended follow-up is necessary to determine the impact of DSA on other important outcomes.
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Affiliation(s)
- Ramsey R. Hachem
- Pulmonary and Critical Care, Washington University School of Medicine
| | - Malek Kamoun
- Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine
| | | | | | - Vivek N. Ahya
- Pulmonary and Critical Care, University of Pennsylvania School of Medicine
| | - James C. Lee
- Pulmonary and Critical Care, University of Pennsylvania School of Medicine
| | - Deborah J. Levine
- Pulmonary and Critical Care, University of Texas Health Science Center, San Antonio
| | | | | | - David Weill
- Pulmonary and Critical Care, Stanford University School of Medicine
| | | | - Lorriana E. Leard
- Pulmonary and Critical Care, University of California, San Francisco
| | - Jeffrey A. Golden
- Pulmonary and Critical Care, University of California, San Francisco
| | - LeeAnn Baxter-Lowe
- Pediatrics, Keck School of Medicine of University of Southern California
| | | | | | - Roger D. Yusen
- Pulmonary and Critical Care, Washington University School of Medicine
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Brugière O, Roux A, Le Pavec J, Sroussi D, Parquin F, Pradère P, Dupin C, Bunel V, Mourin G, Jebrak G, Dauriat G, Castier Y, Mordant P, Lortat-Jacob B, Jean-Baptiste S, Mal H, Suberbielle C, Gautreau C, Caillat-Zucman S, Cazes A, Thabut G, Taupin JL. Role of C1q-binding anti-HLA antibodies as a predictor of lung allograft outcome. Eur Respir J 2018; 52:13993003.01898-2017. [DOI: 10.1183/13993003.01898-2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 06/13/2018] [Indexed: 12/24/2022]
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Schmitzer M, Winter H, Kneidinger N, Meimarakis G, Dick A, Schramm R, Klotz LV, Preissler G, Strobl N, von Dossow V, Schneider C, Weig T, Hatz R, Kauke T. Persistence of de novo donor specific HLA-Antibodies after lung transplantation: a potential marker of decreased patient survival. HLA 2018; 92:24-32. [PMID: 29888557 DOI: 10.1111/tan.13306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/23/2018] [Accepted: 06/07/2018] [Indexed: 01/08/2023]
Abstract
The impact of de novo donor-specific anti-HLA antibodies (DSA) on outcomes in lung transplantation is still a matter of debate. We hypothesize that differentiating DSA by persistent and transient appearance may offer an additional risk assessment. The clinical relevance of HLA-antibodies was investigated prospectively in 72 recipients with a median follow-up period of 21 months. The presence of HLA-antibodies was analysed by single antigen bead assay prior to and after (3 weeks, 3, 6, 12 and 18 months) transplantation. In 23 patients (32%) de novo DSA were detected. In 10 of these patients (44%) DSA persisted throughout the follow-up period whereas 13 of these patients (56%) had transient DSA. There was a trend towards lower one-year-survival in DSA positive compared to DSA negative patients (83% versus 94%; p=0.199). Remarkably, patients with persistent DSA had significantly reduced survival (one-year survival 60%) compared with both patients without DSA and those with transient DSA (p=0.005). Persistent DSA represented an independent prognostic factor for reduced overall survival in multivariate analysis (HR 8.3, 95% CI 1.8-37.0; p=0.006). Persistence of DSA during the first year after transplantation seems to be more harmful for lung allograft function than transiently detected DSA at an early stage. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M Schmitzer
- Department of Thoracic Surgery at that time
- Department of Internal Medicine V, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL)
| | - H Winter
- Department of Thoracic Surgery at that time
- Department of Thoracic Surgery, University Hospital Heidelberg
| | - N Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL)
| | - G Meimarakis
- Department of Vascular and Endovascular Surgery Klinikum Landshut
| | - A Dick
- Laboratory for Immunogenetics, Department of Transfusion Medicine
| | - R Schramm
- Department of Cardiac Surgery at that time
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Ruhr-University of Bochum
| | - L V Klotz
- Comprehensive Pneumology Center Munich (CPC-M), Institute of Lung Biology and Disease, Helmholtz Zentrum München; Member of the German Center for Lung Research (DZL) at that time
- Department of Thoracic Surgery, University Hospital Heidelberg
| | | | - N Strobl
- Department of Thoracic Surgery at that time
| | - V von Dossow
- Department of Anaesthesiology at that time, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich
- Anaesthesiology, HDZ Bad Oeynhausen, University Hospital of the Ruhr-University of Bochum Munich Lung Transplant Group (MLTP)
| | | | - T Weig
- Department of Anaesthesiology at that time, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich
| | - R Hatz
- Department of Thoracic Surgery at that time
| | - T Kauke
- Department of Thoracic Surgery at that time
- Laboratory for Immunogenetics, Department of Transfusion Medicine
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Halloran K, Aversa M, Tinckam K, Martinu T, Binnie M, Chaparro C, Chow CW, Waddell T, McRae K, Pierre A, de Perrot M, Yasufuku K, Cypel M, Keshavjee S, Singer LG. Comprehensive outcomes after lung retransplantation: A single-center review. Clin Transplant 2018; 32:e13281. [DOI: 10.1111/ctr.13281] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Kieran Halloran
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Kathryn Tinckam
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Matthew Binnie
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Cecilia Chaparro
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Tom Waddell
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Karen McRae
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program; Toronto General Hospital; University Health Network; Toronto ON Canada
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Nayak DK, Zhou F, Xu M, Huang J, Tsuji M, Yu J, Hachem R, Gelman AE, Bremner RM, Smith MA, Mohanakumar T. Zbtb7a induction in alveolar macrophages is implicated in anti-HLA-mediated lung allograft rejection. Sci Transl Med 2018; 9:9/398/eaal1243. [PMID: 28701473 DOI: 10.1126/scitranslmed.aal1243] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/24/2017] [Accepted: 05/05/2017] [Indexed: 12/28/2022]
Abstract
Chronic rejection significantly limits long-term success of solid organ transplantation. De novo donor-specific antibodies (DSAs) to mismatched donor human leukocyte antigen after human lung transplantation predispose lung grafts to chronic rejection. We sought to delineate mediators and mechanisms of DSA pathogenesis and to define early inflammatory events that trigger chronic rejection in lung transplant recipients and obliterative airway disease, a correlate of human chronic rejection, in mouse. Induction of transcription factor zinc finger and BTB domain containing protein 7a (Zbtb7a) was an early response critical in the DSA-induced chronic rejection. A cohort of human lung transplant recipients who developed DSA and chronic rejection demonstrated greater Zbtb7a expression long before clinical diagnosis of chronic rejection compared to nonrejecting lung transplant recipients with stable pulmonary function. Expression of DSA-induced Zbtb7a was restricted to alveolar macrophages (AMs), and selective disruption of Zbtb7a in AMs resulted in less bronchiolar occlusion, low immune responses to lung-restricted self-antigens, and high protection from chronic rejection in mice. Additionally, in an allogeneic cell transfer protocol, antigen presentation by AMs was Zbtb7a-dependent where AMs deficient in Zbtb7a failed to induce antibody and T cell responses. Collectively, we demonstrate that AMs play an essential role in antibody-induced pathogenesis of chronic rejection by regulating early inflammation and lung-restricted humoral and cellular autoimmunity.
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Affiliation(s)
- Deepak K Nayak
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA.
| | - Fangyu Zhou
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Min Xu
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jing Huang
- HIV and Malaria Vaccine Program, Aaron Diamond AIDS Research Center, Affiliate of the Rockefeller University, New York, NY 10016, USA
| | - Moriya Tsuji
- HIV and Malaria Vaccine Program, Aaron Diamond AIDS Research Center, Affiliate of the Rockefeller University, New York, NY 10016, USA
| | - Jinsheng Yu
- Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ramsey Hachem
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Andrew E Gelman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Mulley WR, Dendle C, Ling JEH, Knight SR. Does vaccination in solid-organ transplant recipients result in adverse immunologic sequelae? A systematic review and meta-analysis. J Heart Lung Transplant 2018; 37:844-852. [PMID: 29609844 DOI: 10.1016/j.healun.2018.03.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/27/2017] [Accepted: 03/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clinical guidelines recommend vaccinations for solid-organ transplant recipients. However, concern exists that vaccination may stimulate adverse alloimmune responses. METHODS We systematically reviewed the published literature regarding this aspect of vaccine safety. Electronic databases were searched for interventional and observational studies assessing de novo donor-specific antibodies (DSA) and rejection episodes after vaccination against infectious pathogens. Graft loss was also assessed. A meta-analysis was conducted for prospective, controlled studies. PRISMA reporting guidelines were followed. RESULTS Ninety studies (15,645 vaccinated patients and 42,924 control patients) were included. Twelve studies included control groups. The incidence of de novo DSA (14 studies) was 23 of 1,244 patients (1.85%) at 21 to 94 days. The incidence of rejection (83 studies) was 107 episodes in 5,116 patients (2.1%) at 0.7 to 6 months. Meta-analysis of prospective controlled studies (n = 8) showed no increased rejection risk with vaccination compared with no vaccination (RR 1.12, 95% CI 0.75 to 1.70). This finding was supported by data from 3 registry analyses. CONCLUSIONS Although the current evidence lacks high-quality, controlled studies, the currently available data provide reassurance that clinicians should recommend appropriate vaccination for their transplant patients as the risk of de novo DSA and rejection is relatively low.
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Affiliation(s)
- William R Mulley
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia.
| | - Claire Dendle
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia; Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Jonathan E H Ling
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia; Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, UK
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Chaigne B, Geneugelijk K, Bédat B, Ahmed MA, Hönger G, De Seigneux S, Demuylder-Mischler S, Berney T, Spierings E, Ferrari-Lacraz S, Villard J. Immunogenicity of Anti-HLA Antibodies in Pancreas and Islet Transplantation. Cell Transplant 2018; 25:2041-2050. [PMID: 27196533 DOI: 10.3727/096368916x691673] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The aim of the current study was to characterize the anti-HLA antibodies before and after pancreatic islet or pancreas transplantation. We assessed the risk of anti-donor-specific antibody (DSA) sensitization in a single-center, retrospective clinical study at Geneva University Hospital. Data regarding clinical characteristics, graft outcome, HLA mismatch, donor HLA immunogenicity, and anti-HLA antibody characteristics were collected. Between January 2008 and July 2014, 18 patients received islet transplants, and 26 patients received a pancreas transplant. Eleven out of 18 patients (61.1%) in the islet group and 12 out of 26 patients (46.2%) in the pancreas group had anti-HLA antibodies. Six patients (33.3%) developed DSAs against HLA of the islets, and 10 patients (38.4%) developed DSAs against HLA of the pancreas. Most of the DSAs were at a low level. Several parameters such as gender, number of times cells were transplanted, HLA mismatch, eplet mismatch and PIRCHE-II numbers, rejection, and infection were analyzed. Only the number of PIRCHE-II was associated with the development of anti-HLA class II de novo DSAs. Overall, the development of de novo DSAs did not influence graft survival as estimated by insulin independence. Our results indicated that pretransplant DSAs at low levels do not restrict islet or pancreas transplantation [especially islet transplantation (27.8% vs. 15.4.%)]. De novo DSAs do occur at a similar rate in both pancreas and islet transplant recipients (mainly of class II), and the immunogenicity of donor HLA is a parameter that should be taken into consideration. When combined with an immunosuppressive regimen and close follow-up, development of low levels of DSAs was not found to result in reduced graft survival or graft function in the current study.
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Affiliation(s)
- Benjamin Chaigne
- Transplantation Immunology Unit, Service of Immunology and Allergy and Service of Laboratory Medicine, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Kirsten Geneugelijk
- Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Benoît Bédat
- Service of Transplantation and Visceral Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Mohamed Alibashe Ahmed
- Service of Transplantation and Visceral Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Gideon Hönger
- Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Sophie De Seigneux
- Service of Nephrology, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Sandrine Demuylder-Mischler
- Service of Transplantation and Visceral Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Thierry Berney
- Service of Transplantation and Visceral Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Eric Spierings
- Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sylvie Ferrari-Lacraz
- Transplantation Immunology Unit, Service of Immunology and Allergy and Service of Laboratory Medicine, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Jean Villard
- Transplantation Immunology Unit, Service of Immunology and Allergy and Service of Laboratory Medicine, Geneva University Hospital and Medical School, Geneva, Switzerland
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Courtwright A, Diamond JM, Wood I, Guleria I, Milford E, El-Chemaly S, Goldberg HJ. Detection and clinical impact of human leukocyte antigen antibodies in lung transplantation: A systematic review and meta-analysis. HLA 2017; 91:102-111. [PMID: 29178607 DOI: 10.1111/tan.13185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/14/2017] [Accepted: 11/21/2017] [Indexed: 01/09/2023]
Abstract
There is significant variability in lung transplant centers' approach to HLA antibodies, creating heterogeneity regarding their clinical significance. Some institutions use beads coated with multiple HLA to screen candidate sera and then use single antigen bead (SAB) to determine antibody identity if the pre-screen is positive. Other centers do not pre-screen, using SAB alone, which may detect low-level antibodies of unknown significance. The primary objective of this study was to review the current literature to identify sources of heterogeneity in the identification of pre- and post-lung transplant HLA antibodies, particularly regarding antibody-detection methods. A random effects model meta-analysis was used to evaluate the relationship between pre-transplant HLA antibodies and the development of de novo donor-specific antibodies (dnDSA) and dnDSA and chronic lung allograft dysfunction (CLAD). Each outcome was stratified by the method of antibody detection (pre-screen followed by SAB vs SAB alone). We identified 13 cohort studies with a total of 3039 patients. The use of pre-screening followed by SAB testing and the use of induction immunosuppression were associated with lower prevalence of dnDSA. Patients with pre-transplant HLA antibodies were more likely to develop dnDSA (hazard ratio [HR] = 1.49, 95% confidence interval [CI]: 1.19-1.86, P < .001). dnDSA was associated with CLAD (HR = 2.02, 95% CI = 1.37-2.97, P < .001). When considering studies using SAB alone, however, pre-transplant antibody status was no longer associated with dnDSA and dnDSA was no longer associated with CLAD. Based on the current literature, SAB-alone testing may detect less clinically relevant antibodies than pre-screening followed by SAB.
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Affiliation(s)
- A Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J M Diamond
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - I Wood
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts
| | - I Guleria
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts
| | - E Milford
- Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.,Renal Transplant Program, Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - S El-Chemaly
- Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - H J Goldberg
- Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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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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Abstract
PURPOSE OF REVIEW In recent years, there has been increasing awareness and appreciation for the role of humoral immune responses in lung allograft rejection. This review summarizes our current understanding of this role and the associated challenges. RECENT FINDINGS Recent studies have described a syndrome of acute antibody-mediated rejection with a generally poor response to therapy and a high mortality. In addition, there is significant evidence implicating donor-specific human leukocyte antigen antibodies in the development of chronic lung allograft dysfunction. However, the optimal intervention to mitigate the risk of chronic lung allograft dysfunction after donor-specific human leukocyte antigen antibodies development remains unclear. SUMMARY There is mounting evidence that humoral immune responses play an important role in lung allograft rejection. However, therapeutic implications of this increased awareness have been limited. Indeed, there is insufficient evidence to adequately guide therapy, and the optimal treatment is unknown.
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Diamond JM, Arcasoy S, Kennedy CC, Eberlein M, Singer JP, Patterson GM, Edelman JD, Dhillon G, Pena T, Kawut SM, Lee JC, Girgis R, Dark J, Thabut G. Report of the International Society for Heart and Lung Transplantation Working Group on Primary Lung Graft Dysfunction, part II: Epidemiology, risk factors, and outcomes—A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1104-1113. [DOI: 10.1016/j.healun.2017.07.020] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022] Open
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The Presence of Pretransplant HLA Antibodies Does Not Impact the Development of Chronic Lung Allograft Dysfunction or CLAD-Related Death. Transplantation 2017; 101:2207-2212. [DOI: 10.1097/tp.0000000000001494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zaffiri L, Hulbert A, Snyder LD. Pre-transplant Sensitization for Patient Awaiting Lung Transplant: Are We Concerned? CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0155-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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IgM-Enriched Human Intravenous Immunoglobulin-Based Treatment of Patients With Early Donor Specific Anti-HLA Antibodies After Lung Transplantation. Transplantation 2017; 100:2682-2692. [PMID: 26714123 PMCID: PMC5120772 DOI: 10.1097/tp.0000000000001027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND At our institution, until April 2013, patients who showed early donor specific anti-HLA antibodies (DSA) after lung transplantation were preemptively treated with therapeutic plasma exchange (tPE) and a single dose of Rituximab. In April 2013, we moved to a therapy based on IgM-enriched human immunoglobulins (IVIG), repeated every 4 weeks, and a single dose of Rituximab. METHODS This observational study was designed to evaluate the short-term patient and graft survival in patients who underwent IVIG-based DSA treatment (group A, n = 57) versus contemporary patients transplanted between April 2013 and January 2015 without DSA (group C, n = 180), as well as to evaluate DSA clearance in IVIG-treated patients versus historic patients who had undergone tPE-based treatment (group B, n = 56). Patient records were retrospectively reviewed. Follow-up ended on April 1, 2015. RESULTS At 6 months and 1 year of follow-up, group A had a survival similar to group C (P = 0.81) but better than group B (P = 0.008). Group A showed statistically nonsignificant trends toward improved freedom from pulsed-steroid therapy and biopsy-confirmed rejection over groups B and C. The DSA clearance was better in group A than group B at treatment end (92% vs 64%; P = 0.002) and last DSA control (90% vs 75%; P = 0.04). CONCLUSIONS Patients with new early DSA but without graft dysfunction that are treated with IVIG and Rituximab have similarly good early survival as contemporary lung transplant recipients without early DSA. The IVIG yielded increased DSA clearance compared with historic tPE-based treatment, yet spontaneous clearance of new DSA also remains common.
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Prevalence and Clinical Impact of Donor-Specific Alloantibody Among Intestinal Transplant Recipients. Transplantation 2017; 101:873-882. [PMID: 27490417 DOI: 10.1097/tp.0000000000001391] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rejection remains the leading cause of allograft loss, and a major barrier to improving long-term outcomes after intestinal transplantation. Our aim is to define the prevalence and investigate the role of donor-specific antibody (DSA) on intestinal graft outcomes. METHODS The study includes 109 transplants performed in 95 recipients at a single center. Patients were screened for DSA pretransplant, monitored regularly posttransplant and when clinically indicated using the single-antigen bead Luminex assay. Standard induction immunosuppression was with interleukin-2 receptor antagonists, and antithymocyte globulin in high-risk recipients. Maintenance regimens were tacrolimus-based. RESULTS Pretransplant DSA was detected in 12 (11%) recipients with 50% continuing to have circulating antibodies posttransplant. An additional 24 (25%) patients developed de novo DSA, and of these, 71% had persistent antibodies. Recipients with preformed DSA demonstrated elevated risks of early graft failure, whereas those with de novo DSA experienced accelerated graft loss once DSA was detected, reaching a 28% failure rate within 2 years. HLA-DQ mismatch is a significant risk factor for de novo DSA emergence, whereas the persistence of antibodies is predicted by DSA strength and specificity. Although inclusion of the liver in the intestinal allograft imparts an immunological advantage against rejection-related graft loss, this protective effect was lost among recipients with persistent DSA. CONCLUSIONS The presence of DSA is associated with inferior graft outcomes among intestinal transplant recipients. An enhanced understanding of the mechanisms by which DSA causes allograft injury, and effective strategies targeting humoral immune reactivity are needed to improve long-term intestinal graft outcomes.
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Abbas AA, Diamond J, Chehoud C, Chang B, Kotzin J, Young J, Imai I, Haas A, Cantu E, Lederer D, Meyer K, Milewski R, Olthoff K, Shaked A, Christie J, Bushman F, Collman R. The Perioperative Lung Transplant Virome: Torque Teno Viruses Are Elevated in Donor Lungs and Show Divergent Dynamics in Primary Graft Dysfunction. Am J Transplant 2017; 17:1313-1324. [PMID: 27731934 PMCID: PMC5389935 DOI: 10.1111/ajt.14076] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) is a principal cause of early morbidity and mortality after lung transplantation, but its pathogenic mechanisms are not fully clarified. To date, studies using standard clinical assays have not linked microbial factors to PGD. We previously used comprehensive metagenomic methods to characterize viruses in lung allografts >1 mo after transplant and found that levels of Anellovirus, mainly torque teno viruses (TTVs), were significantly higher than in nontransplanted healthy controls. We used quantitative polymerase chain reaction to analyze TTV and shotgun metagenomics to characterize full viral communities in acellular bronchoalveolar lavage from donor organs and postreperfusion allografts in PGD and non-PGD lung transplant recipient pairs. Unexpectedly, TTV DNA levels were elevated 100-fold in donor lungs compared with healthy adults (p = 0.0026). Although absolute TTV levels did not differ by PGD status, PGD cases showed a smaller increase in TTV levels from before to after transplant than did control recipients (p = 0.041). Metagenomic sequencing revealed mainly TTV and bacteriophages of respiratory tract bacteria, but no viral taxa distinguished PGD cases from controls. These findings suggest that conditions associated with brain death promote TTV replication and that greater immune activation or tissue injury associated with PGD may restrict TTV abundance in the lung.
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Affiliation(s)
- A. A. Abbas
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J.M. Diamond
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - C. Chehoud
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - B. Chang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J.J. Kotzin
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J.C. Young
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - I. Imai
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - A.R. Haas
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - E. Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - D.J. Lederer
- Departments of Medicine and Epidemiology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - K. Meyer
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - R.K. Milewski
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - K.M. Olthoff
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - A. Shaked
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J.D. Christie
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - F.D. Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Corresponding authors: Frederic Bushman: , Ronald Collman:
| | - R.G. Collman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Corresponding authors: Frederic Bushman: , Ronald Collman:
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47
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Ensor CR, Yousem SA, Marrari M, Morrell MR, Mangiola M, Pilewski JM, D'Cunha J, Wisniewski SR, Venkataramanan R, Zeevi A, McDyer JF. Proteasome Inhibitor Carfilzomib-Based Therapy for Antibody-Mediated Rejection of the Pulmonary Allograft: Use and Short-Term Findings. Am J Transplant 2017; 17:1380-1388. [PMID: 28173620 DOI: 10.1111/ajt.14222] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/08/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
We present this observational study of lung transplant recipients (LTR) treated with carfilzomib (CFZ)-based therapy for antibody-mediated rejection (AMR) of the lung. Patients were considered responders to CFZ if complement-1q (C1q)-fixing ability of their immunodominant (ID) donor-specific anti-human leukocyte antibody (DSA) was suppressed after treatment. Treatment consisted of CFZ plus plasma exchange and immunoglobulins. Fourteen LTRs underwent CFZ for 20 ID DSA AMR. Ten (71.4%) of LTRs responded to CFZ. DSA IgG mean fluorescence intensity (MFI) fell from 7664 (IQR 3230-11 874) to 1878 (653-7791) after therapy (p = 0.001) and to 1400 (850-8287) 2 weeks later (p = 0.001). DSA C1q MFI fell from 3596 (IQR 714-14 405) to <30 after therapy (p = 0.01) and <30 2 weeks later (p = 0.02). Forced expiratory volume in 1s ( FEV1 ) fell from mean 2.11 L pre-AMR to 1.92 L at AMR (p = 0.04). FEV1 was unchanged after CFZ (1.91 L) and subsequently rose to a maximum of 2.13 L (p = 0.01). Mean forced expiratory flow during mid forced vital capacity (25-75) (FEF25-75 ) fell from mean 2.5 L pre-AMR to 1.95 L at AMR (p = 0.01). FEF25-75 rose after CFZ to 2.54 L and reached a maximum of 2.91 L (p = 0.01). Responders had less chronic lung allograft dysfunction or progression versus nonresponders (25% vs. 83%, p = 0.04). No deaths occurred within 120 days and 7 patients died post CFZ therapy of allograft failure. Larger prospective interventional studies are needed to further describe the benefit of CFZ-based therapy for pulmonary AMR.
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Affiliation(s)
- C R Ensor
- School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S A Yousem
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M Marrari
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M R Morrell
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - M Mangiola
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J M Pilewski
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J D'Cunha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S R Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R Venkataramanan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J F McDyer
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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48
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Repeated human leukocyte antigen mismatches in lung re-transplantation. Transpl Immunol 2017; 40:1-7. [DOI: 10.1016/j.trim.2016.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 11/20/2022]
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Courtwright AM, El-Chemaly S, Dellaripa PF, Goldberg HJ. Survival and outcomes after lung transplantation for non-scleroderma connective tissue-related interstitial lung disease. J Heart Lung Transplant 2016; 36:763-769. [PMID: 28131664 DOI: 10.1016/j.healun.2016.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/28/2016] [Accepted: 12/26/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with non-scleroderma connective tissue-related lung disease (NS-CTLD), including rheumatoid arthritis, idiopathic inflammatory myopathies, Sjögren syndrome, mixed connective tissue disease, and systemic lupus erythematosus, may be at risk for worse outcomes after lung transplantation because of immune dysregulation or extrapulmonary manifestations of their underlying disease. We compared survival, acute and chronic rejection, and extrapulmonary organ dysfunction after transplantation in patients with NS-CTLD and idiopathic pulmonary fibrosis (IPF). METHODS This was a retrospective cohort study of patients with NS-CTLD and IPF who were listed in the Scientific Registry of Transplant Recipients and underwent lung transplantation from May 5, 2005, to March 1, 2016. RESULTS Patients with NS-CTLD (n = 275) were younger, a higher percentage female and non-white than patients with IPF (n = 6,346). NS-CTLD patients did not have worse adjusted survival (hazard ratio, 1.14, 95% confidence interval [CI], 0.92-1.42; p = 0.24). They were not more likely to have an episode of acute cellular rejection (odds ratio, 0.96; 95% CI, 0.72-1.28; p = 0.77) or to develop bronchiolitis obliterans syndrome (odds ratio, 0.82; 95% CI, 0.60-1.12; p = 0.21). Patients with NS-CTLD were not more likely to require plasmapheresis or dialysis or to develop a lymphoproliferative malignancy or liver disease after transplantation. CONCLUSIONS We found no significant differences in survival, acute or chronic rejection, or extrapulmonary organ dysfunction in patients who underwent lung transplantation for NS-CTLD compared with IPF. In appropriately selected candidates, NS-CTLD should not be considered a contraindication to lung transplantation.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul F Dellaripa
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts.
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50
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Nayak DK, Saravanan PB, Bansal S, Naziruddin B, Mohanakumar T. Autologous and Allogenous Antibodies in Lung and Islet Cell Transplantation. Front Immunol 2016; 7:650. [PMID: 28066448 PMCID: PMC5179571 DOI: 10.3389/fimmu.2016.00650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/14/2016] [Indexed: 01/02/2023] Open
Abstract
The field of organ transplantation has undoubtedly made great strides in recent years. Despite the advances in donor-recipient histocompatibility testing, improvement in transplantation procedures, and development of aggressive immunosuppressive regimens, graft-directed immune responses still pose a major problem to the long-term success of organ transplantation. Elicitation of immune responses detected as antibodies to mismatched donor antigens (alloantibodies) and tissue-restricted self-antigens (autoantibodies) are two major risk factors for the development of graft rejection that ultimately lead to graft failure. In this review, we describe current understanding on genesis and pathogenesis of antibodies in two important clinical scenarios: lung transplantation and transplantation of islet of Langerhans. It is evident that when compared to any other clinical solid organ or cellular transplant, lung and islet transplants are more susceptible to rejection by combination of allo- and autoimmune responses.
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Affiliation(s)
- Deepak Kumar Nayak
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | | | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
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