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Rabant M, Adam BA, Aubert O, Böhmig GA, Clahsen Van-Groningen M, Cornell LD, de Vries APJ, Huang E, Kozakowski N, Perkowska-Ptasinska A, Riella LV, Rosales IA, Schinstock C, Simmonds N, Thaunat O, Willicombe M. Banff 2022 Kidney Commentary: Reflections and Future Directions. Transplantation 2024:00007890-990000000-00793. [PMID: 38886879 DOI: 10.1097/tp.0000000000005112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
In September 2022, in Banff, Alberta, Canada, the XVIth Banff meeting, corresponding to the 30th anniversary of the Banff classification, was held, leading to 2 recent publications. Discussions at the Banff meeting focused on proposing improvements to the Banff process as a whole. In line with this, a unique opportunity was offered to a selected group of 16 representatives from the pathology and transplant nephrology community, experts in the field of kidney transplantation, to review these 2 Banff manuscripts. The aim was to provide an insightful commentary, to gauge any prospective influence the proposed changes may have, and to identify any potential areas for future enhancement within the Banff classification. The group expressed its satisfaction with the incorporation of 2 new entities, namely "microvascular inflammation/injury donor-specific antibodies-negative and C4d negative" and "probable antibody-mediated rejection," into category 2. These changes expand the classification, facilitating the capture of more biopsies and providing an opportunity to explore the clinical implications of these lesions further. However, we found that the Banff classification remains complex, potentially hindering its widespread utilization, even if a degree of complexity may be unavoidable given the intricate pathophysiology of kidney allograft pathology. Addressing the histomorphologic diagnosis of chronic active T cell-mediated rejection (CA TCMR), potentially reconsidering a diagnostic-agnostic approach, as for category 2, to inflammation in interstitial fibrosis and tubular atrophy and chronic active T cell-mediated rejection was also an important objective. Furthermore, we felt a need for more evidence before molecular diagnostics could be routinely integrated and emphasized the need for clinical and histologic context determination and the substantiation of its clinical impact through rigorous clinical trials. Finally, our discussions stressed the ongoing necessity for multidisciplinary decision-making regarding patient care.
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Affiliation(s)
- Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Olivier Aubert
- Kidney Transplant Department, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georg A Böhmig
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marian Clahsen Van-Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Aiko P J de Vries
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Leonardo V Riella
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Carrie Schinstock
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naomi Simmonds
- Department of Pathology, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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Augusto JF, Benden C, Diekmann F, Zuckermann A. The value of extracorporeal photopheresis as an immunosuppression-modifying approach in solid organ transplantation: a potential solution to an unmet medical need. Front Immunol 2024; 15:1371554. [PMID: 38846942 PMCID: PMC11154098 DOI: 10.3389/fimmu.2024.1371554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Allograft rejection is a critical issue following solid organ transplantation (SOT). Immunosuppressive therapies are crucial in reducing risk of rejection yet are accompanied by several significant side effects, including infection, malignancy, cardiovascular diseases, and nephrotoxicity. There is a current unmet medical need with a lack of effective minimization strategies for these side effects. Extracorporeal photopheresis (ECP) has shown potential as an immunosuppression (IS)-modifying technique in several SOT types, with improvements seen in acute and recurrent rejection, allograft survival, and associated side effects, and could fulfil this unmet need. Through a review of the available literature detailing key areas in which ECP may benefit patients, this review highlights the IS-modifying potential of ECP in the four most common SOT procedures (heart, lung, kidney, and liver transplantation) and highlights existing gaps in data. Current evidence supports the use of ECP for IS modification following SOT, however there is a need for further high-quality research, in particular randomized control trials, in this area.
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Affiliation(s)
- Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, Angers, France
| | | | - Fritz Diekmann
- Renal Transplantation Unit, Department of Nephrology and Kidney Transplantation, Hospital Clinic, Barcelona, Spain
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Hirt-Minkowski P, Schaub S. Urine CXCL10 as a biomarker in kidney transplantation. Curr Opin Organ Transplant 2024; 29:138-143. [PMID: 38235748 PMCID: PMC10919271 DOI: 10.1097/mot.0000000000001135] [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: 01/19/2024]
Abstract
PURPOSE OF REVIEW Urine CXCL10 is a promising biomarker for posttransplant renal allograft monitoring but is currently not widely used for clinical management. RECENT FINDINGS Large retrospective studies and data from a prospective randomized trial as well as a prospective cohort study demonstrate that low urine CXCL10 levels are associated with a low risk of rejection and can exclude BK polyomavirus replication with high certainty. Urine CXCL10 can either be used as part of a multiparameter based risk assessment tool, or as an individual biomarker taking relevant confounders into account. A novel Luminex-based CXCL10 assay has been validated in a multicenter study, and proved to be robust, reproducible, and accurate. SUMMARY Urine CXCL10 is a well characterized inflammation biomarker, which can be used to guide performance of surveillance biopsies. Wide implementation into clinical practice depends on the availability of inexpensive, thoroughly validated assays with approval from regulatory authorities.
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Affiliation(s)
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology
- HLA-Diagnostic and lmmunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
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Roufosse C, Naesens M, Haas M, Lefaucheur C, Mannon RB, Afrouzian M, Alachkar N, Aubert O, Bagnasco SM, Batal I, Bellamy COC, Broecker V, Budde K, Clahsen-Van Groningen M, Coley SM, Cornell LD, Dadhania D, Demetris AJ, Einecke G, Farris AB, Fogo AB, Friedewald J, Gibson IW, Horsfield C, Huang E, Husain SA, Jackson AM, Kers J, Kikić Ž, Klein A, Kozakowski N, Liapis H, Mangiola M, Montgomery RA, Nankinvell B, Neil DAH, Nickerson P, Rabant M, Randhawa P, Riella LV, Rosales I, Royal V, Sapir-Pichhadze R, Sarder P, Sarwal M, Schinstock C, Stegall M, Solez K, van der Laak J, Wiebe C, Colvin RB, Loupy A, Mengel M. The Banff 2022 Kidney Meeting Work Plan: Data-driven refinement of the Banff Classification for renal allografts. Am J Transplant 2024; 24:350-361. [PMID: 37931753 PMCID: PMC11135910 DOI: 10.1016/j.ajt.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
The XVIth Banff Meeting for Allograft Pathology was held in Banff, Alberta, Canada, from September 19 to 23, 2022, as a joint meeting with the Canadian Society of Transplantation. In addition to a key focus on the impact of microvascular inflammation and biopsy-based transcript analysis on the Banff Classification, further sessions were devoted to other aspects of kidney transplant pathology, in particular T cell-mediated rejection, activity and chronicity indices, digital pathology, xenotransplantation, clinical trials, and surrogate endpoints. Although the output of these sessions has not led to any changes in the classification, the key role of Banff Working Groups in phrasing unanswered questions, and coordinating and disseminating results of investigations addressing these unanswered questions was emphasized. This paper summarizes the key Banff Meeting 2022 sessions not covered in the Banff Kidney Meeting 2022 Report paper and also provides an update on other Banff Working Group activities relevant to kidney allografts.
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Affiliation(s)
- Candice Roufosse
- Department of Immunology and Inflammation, Faculty Medicine, Imperial College London, London, UK.
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Nephrology and Transplantation, Saint-Louis Hospital, Paris, France
| | - Roslyn B Mannon
- Department of Internal Medicine, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marjan Afrouzian
- Department of Pathology, University of Texas Medical Branch at Galveston, Texas, USA
| | - Nada Alachkar
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olivier Aubert
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ibrahim Batal
- Pathology & Cell Biology, Columbia University Irving Medical Center, New York, USA
| | | | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
| | - Marian Clahsen-Van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus University Center Rotterdam, Rotterdam, Netherlands; Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Shana M Coley
- Transplant Translational Research, Arkana Laboratories, Arkansas, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Darshana Dadhania
- Department Medicine, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Anthony J Demetris
- UPMC Hepatic and Transplantation Pathology, Pittsburg, Pennsylvania, USA
| | - Gunilla Einecke
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Germany
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Friedewald
- Comprehensive Transplant Center, Northwestern University, USA
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
| | | | - Edmund Huang
- Department of Medicine, Division of Nephrology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Syed A Husain
- Division of Nephrology, Columbia University, New York, New York, USA
| | | | - Jesper Kers
- Department of Pathology, Leiden University Medical Center, Netherlands; Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | | | | | - Helen Liapis
- Ludwig Maximillian University Munich, Nephrology Center, Germany
| | | | | | - Brian Nankinvell
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Desley A H Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Peter Nickerson
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Marion Rabant
- Pathology department, Necker-Enfants Malades Hospital, Paris, France
| | - Parmjeet Randhawa
- Pathology, Thomas E. Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leonardo V Riella
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Immunopathology Research Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginie Royal
- Maisonneuve-Rosemont Hospital, University of Montreal, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology & Multiorgan Transplant Program, McGill University, Montreal, Quebec, Canada
| | - Pinaki Sarder
- Department of Medicine-Quantitative Health, University of Florida College of Medicine, Florida, USA
| | - Minnie Sarwal
- Division of MultiOrgan Transplantation, UCSF, San Francisco, California, USA
| | - Carrie Schinstock
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Stegall
- Department Transplantation Surgery, Mayo Clinic, Rochester, Massachusetts, USA
| | - Kim Solez
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | | | - Chris Wiebe
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandre Loupy
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
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Hirt-Minkowski P, Handschin J, Stampf S, Hopfer H, Menter T, Senn L, Hönger G, Wehmeier C, Amico P, Steiger J, Koller M, Dickenmann M, Schaub S. Randomized Trial to Assess the Clinical Utility of Renal Allograft Monitoring by Urine CXCL10 Chemokine. J Am Soc Nephrol 2023; 34:1456-1469. [PMID: 37228005 PMCID: PMC10400101 DOI: 10.1681/asn.0000000000000160] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
SIGNIFICANCE STATEMENT This study is the first randomized controlled trial to investigate the clinical utility of a noninvasive monitoring biomarker in renal transplantation. Although urine CXCL10 monitoring could not demonstrate a beneficial effect on 1-year outcomes, the study is a rich source for future design of trials aiming to explore the clinical utility of noninvasive biomarkers. In addition, the study supports the use of urine CXCL10 to assess the inflammatory status of the renal allograft. BACKGROUND Urine CXCL10 is a promising noninvasive biomarker for detection of renal allograft rejection. The aim of this study was to investigate the clinical utility of renal allograft monitoring by urine CXCL10 in a randomized trial. METHODS We stratified 241 patients, 120 into an intervention and 121 into a control arm. In both arms, urine CXCL10 levels were monitored at three specific time points (1, 3, and 6 months post-transplant). In the intervention arm, elevated values triggered performance of an allograft biopsy with therapeutic adaptations according to the result. In the control arm, urine CXCL10 was measured, but the results concealed. The primary outcome was a combined end point at 1-year post-transplant (death-censored graft loss, clinical rejection between month 1 and 1-year, acute rejection in 1-year surveillance biopsy, chronic active T-cell-mediated rejection in 1-year surveillance biopsy, development of de novo donor-specific HLA antibodies, or eGFR <25 ml/min). RESULTS The incidence of the primary outcome was not different between the intervention and the control arm (51% versus 49%; relative risk (RR), 1.04 [95% confidence interval, 0.81 to 1.34]; P = 0.80). When including 175 of 241 (73%) patients in a per-protocol analysis, the incidence of the primary outcome was also not different (55% versus 49%; RR, 1.11 [95% confidence interval, 0.84 to 1.47]; P = 0.54). The incidence of the individual end points was not different as well. CONCLUSIONS This study could not demonstrate a beneficial effect of urine CXCL10 monitoring on 1-year outcomes (ClinicalTrials.gov_ NCT03140514 ).
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Affiliation(s)
- Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Joelle Handschin
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Helmut Hopfer
- Department of Pathology, University Hospital Basel, Basel, Switzerland
| | - Thomas Menter
- Department of Pathology, University Hospital Basel, Basel, Switzerland
| | - Lisa Senn
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Gideon Hönger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
- HLA-Diagnostics and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patrizia Amico
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Michael Koller
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Molecular Immune Regulation, Department of Biomedicine, University of Basel, Basel, Switzerland
- HLA-Diagnostics and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
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Mizera J, Pilch J, Giordano U, Krajewska M, Banasik M. Therapy in the Course of Kidney Graft Rejection-Implications for the Cardiovascular System-A Systematic Review. Life (Basel) 2023; 13:1458. [PMID: 37511833 PMCID: PMC10381422 DOI: 10.3390/life13071458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Kidney graft failure is not a homogenous disease and the Banff classification distinguishes several types of graft rejection. The maintenance of a transplant and the treatment of its failure require specific medications and differ due to the underlying molecular mechanism. As a consequence, patients suffering from different rejection types will experience distinct side-effects upon therapy. The review is focused on comparing treatment regimens as well as presenting the latest insights into innovative therapeutic approaches in patients with an ongoing active ABMR, chronic active ABMR, chronic ABMR, acute TCMR, chronic active TCMR, borderline and mixed rejection. Furthermore, the profile of cardiovascular adverse effects in relation to the applied therapy was subjected to scrutiny. Lastly, a detailed assessment and comparison of different approaches were conducted in order to identify those that are the most and least detrimental for patients suffering from kidney graft failure.
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Affiliation(s)
- Jakub Mizera
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Justyna Pilch
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Ugo Giordano
- University Clinical Hospital, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
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Tsuji T. Key Points of the Banff 2019 Classification of Renal Allograft Pathology. Nephron Clin Pract 2023; 147 Suppl 1:6-8. [PMID: 37231863 DOI: 10.1159/000530917] [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: 12/21/2022] [Accepted: 03/28/2023] [Indexed: 05/27/2023] Open
Abstract
The Banff 2019 Kidney Meeting Report was published following the 15th Banff Conference for Allograft Pathology, which was held in Pittsburgh on September 23-28, 2019. The diagnosis of renal transplant rejection based on the Banff 2019 classification is globally utilized. The Banff 2019 classification of renal allograft pathology includes several changes. This mini-review summarizes the key points and issues of the Banff 2019 classification. The criteria for borderline change have been reverted to ≥ i1, the t-IFTA score has been incorporated into the classification, the histological classification of polyoma virus nephropathy has been adopted, and a category was added for chronic (inactive) antibody-mediated rejection. In addition, whether the spread is diffuse or focal should now be noted in the presence of peritubular capillaritis. One of the issues with the Banff 2019 classification is the continuing lack of clarity regarding the definition of the t score, which is used to evaluate tubulitis not only in non-scarred areas but also in moderately atrophic tubules that are assumed to be present in scarred areas, which constitutes a contradiction in the definition.
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Affiliation(s)
- Takahiro Tsuji
- Department of Pathology, Sapporo City General Hospital, Sapporo, Japan
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Yamamoto I, Kawabe M, Hayashi A, Kobayashi A, Yamamoto H, Yokoo T. Challenges Posed by the Banff Classification: Diagnosis and Treatment of Chronic Active T-Cell-Mediated Rejection. Nephron Clin Pract 2023; 147 Suppl 1:74-79. [PMID: 36928337 DOI: 10.1159/000530158] [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: 12/15/2022] [Accepted: 02/14/2023] [Indexed: 03/18/2023] Open
Abstract
The three primary sites of acute T-cell-mediated rejection (TCMR) in transplanted kidneys are the tubular epithelial cells, interstitium, and the vascular endothelial cells. The pathology of acute lesions is characterized by inflammatory cell infiltration; the final diagnosis suggested by the Banff 2019 classification is guided by grading of tubulitis (the t score), interstitial inflammation (the i score), and endarteritis (the v score). Consistent major issues when using the Banff classification are the etiological classifications of interstitial fibrosis and tubular atrophy (IFTA). From 2015 to 2019, technological advances (i.e., genetic analysis in paraffin sections) increased our understanding of IFTA status in patients with smoldering acute TCMR and the roles played by inflammatory cell infiltration (the i-IFTA score) and tubulitis (the t-IFTA score) in IFTA. These two scores were introduced when establishing the diagnostic criteria for chronic active TCMR. Despite the increase in complexity and the lack of a consensus treatment for chronic active TCMR, the Banff classification may evolve as new techniques (i.e., genetic analysis in paraffin sections and deep learning of renal pathology) are introduced. The Banff conference proceeded as follows. First, lesions were defined. Next, working groups were established to better understand the lesions and to derive better classification methods. Finally, the new Banff classification was developed. This approach will continue to evolve; the Banff classification will become a very useful diagnostic standard. This paper overviews the history of TCMR diagnosis using the Banff classification, and the clinical importance, treatment, and prospects for acute and chronic active TCMR.
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Affiliation(s)
- Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Ayaka Hayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akimitsu Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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The Histological Spectrum and Clinical Significance of T Cell-mediated Rejection of Kidney Allografts. Transplantation 2022; 107:1042-1055. [PMID: 36584369 DOI: 10.1097/tp.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
T cell-mediated rejection (TCMR) remains a significant cause of long-term kidney allograft loss, either indirectly through induction of donor-specific anti-HLA alloantibodies or directly through chronic active TCMR. Whether found by indication or protocol biopsy, Banff defined acute TCMR should be treated with antirejection therapy and maximized maintenance immunosuppression. Neither isolated interstitial inflammation in the absence of tubulitis nor isolated tubulitis in the absence of interstitial inflammation results in adverse outcomes, and neither requires antirejection treatment. RNA gene expression analysis of biopsy material may supplement conventional histology, especially in ambiguous cases. Lesser degrees of tubular and interstitial inflammation (Banff borderline) may portend adverse outcomes and should be treated when found on an indication biopsy. Borderline lesions on protocol biopsies may resolve spontaneously but require close follow-up if untreated. Following antirejection therapy of acute TCMR, surveillance protocol biopsies should be considered. Minimally invasive blood-borne assays (donor-derived cell-free DNA and gene expression profiling) are being increasingly studied as a means of following stable patients in lieu of biopsy. The clinical benefit and cost-effectiveness require confirmation in randomized controlled trials. Treatment of acute TCMR is not standardized but involves bolus corticosteroids with lymphocyte depleting antibodies for severe, refractory, or relapsing cases. Arteritis may be found with acute TCMR, active antibody-mediated rejection, or mixed rejections and should be treated accordingly. The optimal treatment ofchronic active TCMR is uncertain. Randomized controlled trials are necessary to optimally define therapy.
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Chronic Active T-Cell Mediated Kidney Rejection as a Clinically Significant Type of Allograft Loss? Diagnostics (Basel) 2022; 12:diagnostics12123220. [PMID: 36553226 PMCID: PMC9777502 DOI: 10.3390/diagnostics12123220] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
The purpose of this article is to assess the present knowledge about chronic active (CA) T-cell mediated rejection (TCMR) of a kidney. In the research authors review current Banff diagnostic criteria used in kidney rejection, focus on their possible future evolution, and investigate the role of currently available molecular methods that could be implemented into the diagnostic scheme. Research also points out previously and currently available treatment methods applied to CA TCMR and takes into account possible side effects consequent upon the therapy. Moreover, attention is being paid to the CA TCMR coincidence with other kidney rejection types such as antibody-mediated rejection (ABMR) and its influence on the treatment approach. Authors also mark the possibility of non-HLA antibodies coexistence in patients with CA TCMR and describe its possible resonance on kidney allograft function. Nonetheless, it seems that current knowledge about CA TCMR is not sufficient and requires further investigation.
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Noguchi H, Matsukuma Y, Nakagawa K, Ueki K, Tsuchimoto A, Nakano T, Sato Y, Kaku K, Okabe Y, Nakamura M. Treatment of chronic active T cell-mediated rejection after kidney transplantation: A retrospective cohort study of 37 transplants. Nephrology (Carlton) 2022; 27:632-638. [PMID: 35478476 DOI: 10.1111/nep.14048] [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: 01/28/2022] [Revised: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 11/27/2022]
Abstract
AIM Data on the treatment of chronic active T cell-mediated rejection (CA-TCMR) are scarce, and therapeutical strategies for CA-TCMR have not been established. We retrospectively evaluated the outcomes and effects of treatment on pathological and clinical findings in patients with CA-TCMR. METHODS This study comprised 37 patients who underwent kidney transplantation at our institute who were diagnosed with CA-TCMR between January 2018 and December 2020. Patients were followed until October 2021. RESULTS Thirty-two of the 37 patients were treated. During the observation period, two patients died (5%), and five patients developed allograft loss (13%). A univariate Cox proportional hazards model showed that indication biopsy, higher spot urine protein/creatinine ratio (UPCR), and Banff ci/ct scores were risk factors for allograft loss. Of the treated patients, 23 underwent follow-up biopsies. The Wilcoxon signed-rank test showed significant improvement in the Baff scores for "ti", "i-IFTA", "t", and "t-IFTA" after treatment. On pathology, 13 (57%) of the patients who underwent follow-up biopsy improved to "no evidence of rejection" or "borderline change". Assuming that improvement in pathology to "borderline change" or "no evidence of rejection" on follow-up biopsy indicates response to treatment, multivariate logistic analysis showed that lower UPCR was a predictive factor for response to treatment. No specific effect of treatment type was observed. CONCLUSIONS Our results indicate that treatment could improve the pathological findings in CA-TCMR. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Matsukuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kaneyasu Nakagawa
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Nephrology, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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von Samson-Himmelstjerna FA, Esser G, Schulte K, Kolbrink B, Krautter M, Schwenger V, Weinmann-Menke J, Matschkal J, Schraml F, Pahl A, Braunisch M, Amann K, Feldkamp T, Kunzendorf U, Renders L, Heemann U. Study protocol: the TRAnsplant BIOpsies (TRABIO) study - a prospective, observational, multicentre cohort study to assess the treatment of kidney graft rejections. BMJ Open 2022; 12:e048122. [PMID: 35450886 PMCID: PMC9024278 DOI: 10.1136/bmjopen-2020-048122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Despite continued efforts, long-term outcomes of kidney transplantation remain unsatisfactory. Kidney graft rejections are independent risk factors for graft failure. At the participating centres of the TRAnsplant BIOpsies study group, a common therapeutic standard has previously been defined for the treatment of graft rejections. The outcomes of this strategy will be assessed in a prospective, observational cohort study. METHODS AND ANALYSIS A total of 800 kidney transplantation patients will be enrolled who undergo a graft biopsy because of deteriorating kidney function. Patients will be stratified according to the Banff classification, and the influence of the treatment strategy on end points will be assessed using regression analysis. Primary end points will be all-cause mortality and graft survival. Secondary end points will be worsening of kidney function (≥30% decline of estimated Glomerular Filtration Rate [eGFR] or new-onset large proteinuria), recurrence of graft rejection and treatment response. Baseline data and detailed histopathology data will be entered into an electronic database on enrolment. During a first follow-up period (within 14 days) and subsequent yearly follow-ups (for 5 years), treatment strategies and clinical course will be recorded. Recruitment at the four participating centres started in September 2016. As of August 2020, 495 patients have been included. ETHICS AND DISSEMINATION Ethical approval for the study has been obtained from the ethics committee of Kiel (AZ B 278/16) and was confirmed by the committees of Munich, Mainz and Stuttgart. The results will be reported in a peer-reviewed journal, according to the Strengthening the Reporting of Observational Studies in Epidemiology criteria. TRIAL REGISTRATION NUMBER ISRCTN78772632; Pre-results.
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Affiliation(s)
| | - Grit Esser
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Markus Krautter
- Transplant Center, Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Transplant Center, Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, University Medical Center Mainz, Department of Internal Medicine I, Mainz, Germany
| | - Julia Matschkal
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Florian Schraml
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Anne Pahl
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Matthias Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thorsten Feldkamp
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
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13
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Loupy A, Mengel M, Haas M. 30 years of the International Banff Classification for Allograft Pathology: The Past, Present and Future of Kidney Transplant Diagnostics. Kidney Int 2021; 101:678-691. [DOI: 10.1016/j.kint.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
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14
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Mengel M, Lubetzky M. Do we need to treat chronic active T cell-mediated rejection? Kidney Int 2021; 100:275-277. [PMID: 34294207 DOI: 10.1016/j.kint.2021.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 10/20/2022]
Abstract
Chronic active T cell-mediated rejection, demonstrated by the presence of inflammation in areas of fibrosis, is associated with long-term allograft loss. Kung et al., in this issue of Kidney International, describe a series of cases of CA TCMR and analyze their clinical, molecular, and pathologic features as well as their response to therapy. Their translational study aids in understanding this diverse phenotype and provides future direction for managing these patients.
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Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
| | - Michelle Lubetzky
- Division of Nephrology and Transplantation, Weill Cornell Medicine, New York, New York, USA
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