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Han F, Shi X, Liao T, Zhang W, Ma M, Leng Q, Jiang W, Na N, Miao Y, Huang Z. Bruton's tyrosine kinase ablation inhibits B cell responses and antibody production for the prevention of chronic rejection in cardiac transplantation. Clin Immunol 2024; 261:109941. [PMID: 38365047 DOI: 10.1016/j.clim.2024.109941] [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: 12/25/2023] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
Chronic rejection is the primary cause of late allograft failure, however, the current treatments for chronic rejection have not yielded desirable therapeutic effects. B cell activation and donor-specific antibody (DSA) production are the primary factors leading to chronic rejection. Bruton's tyrosine kinase (BTK) plays a key role in the activation and differentiation of B cells and in antibody production. This study investigated the efficacy of blocking BTK signalling in the prevention of chronic rejection. BTK signalling was blocked using the BTK inhibitor ibrutinib and gene knockout. In vitro assays were conducted to examine the consequences and underlying mechanisms of BTK blockade in regards to B cell activation, differentiation, and antibody secretion. Additionally, we established a cardiac transplantation mouse model of chronic rejection to explore the preventive effects and mechanisms of BTK ablation on chronic rejection. Ablating BTK signalling in vitro resulted in the inhibition of B cell activation, differentiation, and antibody production. In vivo experiments provided evidence that ablating BTK signalling alleviated chronic rejection, leading to reduced damage in myocardial tissue, neointimal hyperplasia, interstitial fibrosis, inflammatory cell infiltration, and C4d deposition. Allograft survival was prolonged, and B cell responses and DSA production were inhibited as a result. We confirmed that ablation of BTK signalling inhibited B cell response by blocking downstream PLCγ2 phosphorylation and inhibiting the NF-κB, NFAT, and ERK pathways. Our findings demonstrated that ablation of BTK signalling inhibited B cell activation and differentiation, reduced DSA production, and effectively prevented chronic rejection.
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Affiliation(s)
- Fei Han
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyi Shi
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tao Liao
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Zhang
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Maolin Ma
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qianghua Leng
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Weichen Jiang
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ning Na
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yun Miao
- Department of Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Zhengyu Huang
- Organ Transplantation Research Institution, Division of Kidney Transplantation, Department of Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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2
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Samson C, Thiolat A, Moktefi A, Cohen JL, Pilon C, Grimbert P. Belatacept inhibit human B cell germinal center development in immunodeficient mice. Sci Rep 2023; 13:13816. [PMID: 37620431 PMCID: PMC10449885 DOI: 10.1038/s41598-023-40700-w] [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: 03/15/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
The humoral response mediated by alloantibodies directed against donor HLA molecules (DSAs) is one of the main causes of graft loss in kidney transplantation. Understanding the pathophysiology leading to humoral kidney rejection as the development of therapeutic tools is therefore a main objective in the field of solid organ transplantation and necessitate adapted experimental models. Among the immunosuppressive agents used in renal transplantation, belatacept, a fusion protein targeting T costimulatory molecules has shown its ability to prevent more efficiently the secretion of DSA by different mechanisms including a direct action on plasma cells but also on B lymphocytes and follicular helper T lymphocytes (Tfh) cooperation. This cellular cooperation occurs within germinal centers (GC), the seat of B lymphocytes differentiation. Here, we aimed to develop a dedicated mouse model in which human GC would be functional to study the effect of belatacept on GC formation and the ability of B lymphocytes to secrete immunoglobulin. We next demonstrate that belatacept inhibits the formation of these GCs, by inhibiting the frequency of Tfh and B lymphocytes. This alters the B maturation and therefore the generation of plasma cells and consequently, immunoglobulin secretion.
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Affiliation(s)
- Chloé Samson
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
| | - Allan Thiolat
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
| | - Anissa Moktefi
- Groupe Hospitalo-Universitaire Chenevier Mondor, Service d'Anatomopathologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - José L Cohen
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - Caroline Pilon
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France
- Inserm, U955, 94000, Créteil, France
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France
| | - Philippe Grimbert
- Université Paris-Est, UMR_U955, UPEC, 94000, Créteil, France.
- Inserm, U955, 94000, Créteil, France.
- Groupe Hospitalo-Universitaire Chenevier Mondor, Centre d'Investigation Clinique Biothérapie, Fédération Hospitalo-Universitaire TRUE, Assistance Publique-Hôpitaux de Paris (AP-HP), 94000, Créteil, France.
- Groupe Hospitalo-Universitaire Chenevier Mondor, Service de Néphrologie-Transplantation, AP-HP, 94000, Créteil, France.
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3
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Crane C, Loop L, Anterasian C, Geng B, Ingulli E. Balancing B cell responses to the allograft: implications for vaccination. Front Immunol 2022; 13:948379. [PMID: 35967363 PMCID: PMC9363634 DOI: 10.3389/fimmu.2022.948379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Balancing enough immunosuppression to prevent allograft rejection and yet maintaining an intact immune system to respond to vaccinations, eliminate invading pathogens or cancer cells is an ongoing challenge to transplant physicians. Antibody mediated allograft rejection remains problematic in kidney transplantation and is the most common cause of graft loss despite current immunosuppressive therapies. The goal of immunosuppressive therapies is to prevent graft rejection; however, they prevent optimal vaccine responses as well. At the center of acute and chronic antibody mediated rejection and vaccine responses is the B lymphocyte. This review will highlight the role of B cells in alloimmune responses including the dependency on T cells for antibody production. We will discuss the need to improve vaccination rates in transplant recipients and present data on B cell populations and SARS-CoV-2 vaccine response rates in pediatric kidney transplant recipients.
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Affiliation(s)
- Clarkson Crane
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Lauren Loop
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Christine Anterasian
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington and Seattle Children's Hospital, Seattle, WA, United States
| | - Bob Geng
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Elizabeth Ingulli
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
- *Correspondence: Elizabeth Ingulli,
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4
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Matar AJ, Crepeau RL, Mundinger GS, Cetrulo CL, Torabi R. Large Animal Models of Vascularized Composite Allotransplantation: A Review of Immune Strategies to Improve Allograft Outcomes. Front Immunol 2021; 12:664577. [PMID: 34276656 PMCID: PMC8278218 DOI: 10.3389/fimmu.2021.664577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022] Open
Abstract
Over the past twenty years, significant technical strides have been made in the area of vascularized composite tissue allotransplantation (VCA). As in solid organ transplantation, the allogeneic immune response remains a significant barrier to long-term VCA survival and function. Strategies to overcome acute and chronic rejection, minimize immunosuppression and prolong VCA survival have important clinical implications. Historically, large animals have provided a valuable model for testing the clinical translatability of immune modulating approaches in transplantation, including tolerance induction, co-stimulation blockade, cellular therapies, and ex vivo perfusion. Recently, significant advancements have been made in these arenas utilizing large animal VCA models. In this comprehensive review, we highlight recent immune strategies undertaken to improve VCA outcomes with a focus on relevant preclinical large animal models.
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Affiliation(s)
- Abraham J Matar
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Rebecca L Crepeau
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Gerhard S Mundinger
- Department of Surgery, Division of Plastic and Reconstructive Surgery, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Curtis L Cetrulo
- Department of Surgery, Division of Plastic Surgery, Massachusetts General Hospital, Boston, MA, United States.,Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Shriner's Hospital for Children, Department of Plastic and Reconstructive Surgery, Boston, MA, United States
| | - Radbeh Torabi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, United States
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5
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Meier RPH, Longchamp A, Mohiuddin M, Manuel O, Vrakas G, Maluf DG, Buhler LH, Muller YD, Pascual M. Recent progress and remaining hurdles toward clinical xenotransplantation. Xenotransplantation 2021; 28:e12681. [PMID: 33759229 DOI: 10.1111/xen.12681] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/12/2021] [Accepted: 02/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Xenotransplantation has made tremendous progress over the last decade. METHODS We discuss kidney and heart xenotransplantation, which are nearing initial clinical trials. RESULTS Life sustaining genetically modified kidney xenografts can now last for approximately 500 days and orthotopic heart xenografts for 200 days in non-human primates. Anti-swine specific antibody screening, preemptive desensitization protocols, complement inhibition and targeted immunosuppression are currently being adapted to xenotransplantation with the hope to achieve better control of antibody-mediated rejection (AMR) and improve xenograft longevity. These newest advances could probably facilitate future clinical trials, a significant step for the medical community, given that dialysis remains difficult for many patients and can have prohibitive costs. Performing a successful pig-to-human clinical kidney xenograft, that could last for more than a year after transplant, seems feasible but it still has significant potential hurdles to overcome. The risk/benefit balance is progressively reaching an acceptable equilibrium for future human recipients, e.g. those with a life expectancy inferior to two years. The ultimate question at this stage would be to determine if a "proof of concept" in humans is desirable, or whether further experimental/pre-clinical advances are still needed to demonstrate longer xenograft survival in non-human primates. CONCLUSION In this review, we discuss the most recent advances in kidney and heart xenotransplantation, with a focus on the prevention and treatment of AMR and on the recipient's selection, two aspects that will likely be the major points of discussion in the first pig organ xenotransplantation clinical trials.
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Affiliation(s)
- Raphael P H Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alban Longchamp
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Muhammad Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Oriol Manuel
- Transplantation Center, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Georgios Vrakas
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel G Maluf
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Leo H Buhler
- Faculty of Science and Medicine, Section of Medicine, University of Fribourg, Fribourg, Switzerland
| | - Yannick D Muller
- Division of Immunology and Allergy, University Hospital of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
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Hiramitsu T, Tomosugi T, Futamura K, Okada M, Nishihira M, Goto N, Ichimori T, Narumi S, Kobayashi T, Uchida K, Watarai Y. Optimal blood levels of (extended-release) tacrolimus in living donor kidney transplantation to prevent de novo donor-specific antibody production: A retrospective cohort study. Int Immunopharmacol 2020; 91:107038. [PMID: 33388731 DOI: 10.1016/j.intimp.2020.107038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 01/25/2023]
Abstract
Chronic antibody-mediated rejection, caused by de novo donor-specific antibody (dnDSA) production, results in poor graft survival. To prevent dnDSA production, optimal blood levels of immunosuppressive drugs in living donor kidney transplant recipients were determined. A total of 772 recipients underwent living donor kidney transplantation between January 2008 and December 2017. Graft survival and risk factors for dnDSA production were investigated in 647 recipients. Optimal blood levels of tacrolimus (TAC) and extended-release TAC (TACER) were measured in recipients receiving steroids and mycophenolate mofetil, combined with TAC (n = 53) or TACER (n = 135). Receiver operating characteristic (ROC) curve analysis and comparisons between dnDSA-negative and dnDSA-positive recipients were carried out. The Kaplan-Meier method revealed significantly poor graft survival in dnDSA-positive recipients (P < 0.001). Cox regression models indicated calcineurin inhibitor withdrawal as a significant risk for dnDSA production (P < 0.001; hazard ratio 6.637; 95% confidence interval 2.667-6.517). Average trough levels of TAC and TACER in dnDSA-negative recipients were significantly higher than those in dnDSA-positive recipients (4.88 vs 3.69 ng TAC/ml, P = 0.023, and 4.60 vs 3.85 ng TACER/ml, P = 0.001). ROC curve analysis indicated 4.325 and 3.990 ng/ml as the best trough levels under TAC- and TACER-based regimens, respectively, to prevent dnDSA production (areas under the curve: 0.788 and 0.813, respectively). Maintenance of the trough levels of TAC > 4.325 ng/ml and TACER > 3.990 ng/ml may prevent dnDSA production.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan.
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Morikuni Nishihira
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, 453-8566 35-28 Takehashi-cho, Nakamura-ku, Nagoya, Aichi, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, 480-1195 1-1 Yazakokarimata, Nagakute, Aichi, Japan
| | - Kazuharu Uchida
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan; Department of Renal Transplant Surgery, Masuko Memorial Hospital, 453-8566 35-28 Takehashi-cho, Nakamura-ku, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan
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7
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Kummer L, Zaradzki M, Vijayan V, Arif R, Weigand MA, Immenschuh S, Wagner AH, Larmann J. Vascular Signaling in Allogenic Solid Organ Transplantation - The Role of Endothelial Cells. Front Physiol 2020; 11:443. [PMID: 32457653 PMCID: PMC7227440 DOI: 10.3389/fphys.2020.00443] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/09/2020] [Indexed: 12/12/2022] Open
Abstract
Graft rejection remains the major obstacle after vascularized solid organ transplantation. Endothelial cells, which form the interface between the transplanted graft and the host’s immunity, are the first target for host immune cells. During acute cellular rejection endothelial cells are directly attacked by HLA I and II-recognizing NK cells, macrophages, and T cells, and activation of the complement system leads to endothelial cell lysis. The established forms of immunosuppressive therapy provide effective treatment options, but the treatment of chronic rejection of solid organs remains challenging. Chronic rejection is mainly based on production of donor-specific antibodies that induce endothelial cell activation—a condition which phenotypically resembles chronic inflammation. Activated endothelial cells produce chemokines, and expression of adhesion molecules increases. Due to this pro-inflammatory microenvironment, leukocytes are recruited and transmigrate from the bloodstream across the endothelial monolayer into the vessel wall. This mononuclear infiltrate is a hallmark of transplant vasculopathy. Furthermore, expression profiles of different cytokines serve as clinical markers for the patient’s outcome. Besides their effects on immune cells, activated endothelial cells support the migration and proliferation of vascular smooth muscle cells. In turn, muscle cell recruitment leads to neointima formation followed by reduction in organ perfusion and eventually results in tissue injury. Activation of endothelial cells involves antibody ligation to the surface of endothelial cells. Subsequently, intracellular signaling pathways are initiated. These signaling cascades may serve as targets to prevent or treat adverse effects in antibody-activated endothelial cells. Preventive or therapeutic strategies for chronic rejection can be investigated in sophisticated mouse models of transplant vasculopathy, mimicking interactions between immune cells and endothelium.
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Affiliation(s)
- Laura Kummer
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Institute of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Vijith Vijayan
- Institute for Transfusion Medicine, Hannover Medical School, Hanover, Germany
| | - Rawa Arif
- Institute of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stephan Immenschuh
- Institute for Transfusion Medicine, Hannover Medical School, Hanover, Germany
| | - Andreas H Wagner
- Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
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8
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Lee CY, Yang CY, Lin WC, Chen CC, Tsai MK. Prognostic factors for renal transplant graft survival in a retrospective cohort of 1000 cases: The role of desensitization therapy. J Formos Med Assoc 2019; 119:829-837. [PMID: 31818714 DOI: 10.1016/j.jfma.2019.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/08/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To review the results of renal transplantation after promulgation of the Human Organ Transplant Act in Taiwan in 1987, we conducted a retrospective study in the first 1000 cases performed in our hospital. Prognostic factors for graft survival were assessed with emphasis on the impact of donor-specific antibody (DSA). METHODS Between January 1988 and April 2014, there were 1000 cases of renal transplantation performed in our hospital. Excluding 30 patients of ABO-incompatible transplantation, we reviewed 970 cases of ABO-compatible renal transplantation to analyze the prognostic factors for graft survival. The patients were grouped according to the dates of operations before (the Early group: 503 cases) and after (the Late group: 467 cases) the introduction of detection and desensitization of alloantibody in our hospital in 2004. RESULTS The overall 5-year graft survival rate were 82.6%, which was significantly lower in the Early group (79.2%) than the Late group (86.3%) (p = 0.0012). The 1-year rejection-free survival was significantly lower in the Early group (78.3%) than the Late group (91.2%) (p = 0.0165). The difference between the two groups became insignificant when the time of observation extended beyond 12 months. In a multivariate regression model, we identified significant factors for poor graft survival, including HLA mismatches, delayed graft function with or without recovery, and antibody-mediate rejection (AMR). CONCLUSION HLA mismatches, delayed graft function with or without recovery, and AMR were significant factors for poor graft survival. Detection and desensitization of DSA currently might be inadequate to improve the long-term outcome of renal transplantation.
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Affiliation(s)
- Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Chia Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Meng-Kun Tsai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan.
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9
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Leibler C, Matignon M, Moktefi A, Samson C, Zarour A, Malard S, Boutin E, Pilon C, Salomon L, Natella PA, Durrbach A, Robert T, Canoui-Poitrine F, Grimbert P. Belatacept in renal transplant recipient with mild immunologic risk factor: A pilot prospective study (BELACOR). Am J Transplant 2019; 19:894-906. [PMID: 30582270 DOI: 10.1111/ajt.15229] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 11/21/2018] [Accepted: 12/06/2018] [Indexed: 01/25/2023]
Abstract
The benefit of belatacept on antibody-mediated rejection (ABMR) incidence after kidney transplant with preformed donor-specific antibodies (DSAs) has never been assessed. Between 2014 and 2016, we conducted a multicenter prospective clinical trial with 49 patients to determine kidney allograft outcome in recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000) treated with belatacept (BELACOR trial). Immunosuppressive strategy included antithymocyte globulin, belatacept, mycophenolate mofetil, and steroids. An ancillary control group was designed retrospectively, including patients fulfilling the same inclusion criteria treated with calcineurin inhibitors. In BELACOR group, no patient exhibited acute ABMR, patient and allograft survival at 1 year was 100% and 95.4%, respectively, and the estimated glomerular filtration rate was 53.2 mL/min/1.73 m2 . However, the 12-month incidence of acute T cell-mediated rejection was 25.4% (14.5% to 42.4%). Comparison with the control group showed significantly higher T cell-mediated rejection incidence only in the BELACOR group (P = .003). Considering the DSAs, the outcome was similar in the 2 groups except a significantly higher number of patients displayed a complete disappearance of class II DSAs in the BELACOR group (P = .001). Belatacept was not associated with an acute ABMR increased risk and may be considered as immunosuppressive strategy in transplant recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000). Prospective randomized trials are needed to confirm these results.
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Affiliation(s)
- Claire Leibler
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Marie Matignon
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Anissa Moktefi
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Pathology Department, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Chloé Samson
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Anissa Zarour
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Stéphanie Malard
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d' Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Emmanuelle Boutin
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Caroline Pilon
- Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Laurent Salomon
- Assistance Publique-Hôpitaux de Paris, Urology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Pierre-André Natella
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Antoine Durrbach
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Thomas Robert
- Department of Nephrology, Transplantation and Emergency, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Florence Canoui-Poitrine
- Assistance Publique-Hôpitaux de Paris, Public Health Department/Clinical Research Unit (URC-Mondor), Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,Département Hospitalo-Universitaire A-TVB, Institut Mondor de Recherche Biomédicale - EA 7376 Clinical Epidemiology and Ageing Unit, Université Paris-Est-Créteil, Créteil, France
| | - Philippe Grimbert
- Assistance Publique-Hôpitaux de Paris, Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,Université Paris-Est-Créteil, Département Hospitalo-Universitaire Virus-Immunité-Cancer, Institut Mondor de Recherche Biomédicale, Créteil, France.,Assistance Publique-Hôpitaux de Paris, CIC-BT 504, Créteil, France
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Leibler C, Thiolat A, Elsner RA, El Karoui K, Samson C, Grimbert P. Costimulatory blockade molecules and B-cell-mediated immune response: current knowledge and perspectives. Kidney Int 2019; 95:774-786. [PMID: 30711200 DOI: 10.1016/j.kint.2018.10.028] [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: 07/09/2018] [Revised: 09/17/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022]
Abstract
There is an urgent need for therapeutic agents that target humoral alloimmunity in solid organ transplantation. This includes sensitized patients with preformed donor-specific human leukocyte antigen antibodies and patients who develop de novo donor-specific antibodies, both of which are associated with acute and chronic antibody-mediated rejection and allograft loss. In the last decade, both experimental and clinical studies highlighted the major impact of costimulation molecules in the control of immune responses both in the field of transplantation and autoimmune disease. Although these molecules have been initially developed to control the early steps of T-cell activation, recent evidence also supports their influence at several steps of the humoral response. In this review, we aim to provide an overview of the current knowledge of the effects of costimulatory blockade agents on humoral responses in both autoimmune and allogeneic contexts. We first present the effects of costimulatory molecules on the different steps of alloantibody production. We then summarize mechanisms and clinical results observed using cytotoxic T lymphocyte antigen-4 (CTLA4)-Ig molecules both in transplantation and autoimmunity. Finally, we present the potential interest and implications of other costimulatory family members as therapeutic targets, with emphasis on combinatorial approaches, for the optimal control of the alloantigen-specific humoral response.
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Affiliation(s)
- Claire Leibler
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Allan Thiolat
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Rebecca A Elsner
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Chloe Samson
- Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Pôle Cancérologie-Immunité-Transplantation-Infectiologie, Paris-Est Creteil, France; Institut National de la Santé et de la Recherch Médicale, U955, Equipe 21 and Université Paris-Est, Créteil, France.
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Oleinika K, Mauri C, Salama AD. Effector and regulatory B cells in immune-mediated kidney disease. Nat Rev Nephrol 2018; 15:11-26. [DOI: 10.1038/s41581-018-0074-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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12
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13
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Human Cytomegalovirus Infection Increases Both Antibody- and Non-Antibody-Dependent Cellular Reactivity by Natural Killer Cells. Transplant Direct 2017. [PMID: 29536036 PMCID: PMC5828690 DOI: 10.1097/txd.0000000000000750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Supplemental digital content is available in the text. Background Antibody-mediated rejection in solid organ transplantation is an important immunological barrier to successful long-term graft survival. Next to complement activation, natural killer (NK) cells have been implicated in the process. Human cytomegalovirus (CMV), independently associated with decreased graft survival, has a strong imprint on the immune response. Here, we assessed the effect of CMV status on alloreactive NK cell reactivity. Methods We compared antibody-mediated NK cell cytolytic activity (CD107a expression) and IFNγ production between healthy CMV-seropositive (n = 8) and CMV-seronegative (n = 11) individuals, in cocultures of NK cells with anti-HLA class I or rituximab (control) antibody-coated Raji cells. Results First, we showed that within the NKG2C+ NK cells, it is specifically the NKG2C+/A− subset that is enriched in CMV+ individuals. We then observed that in particular the NK cell antibody-dependent cell mediated cytotoxicity (ADCC), but also non-ADCC alloreactivity toward HLA-positive target cells was increased in CMV+ individuals as compared to CMV− ones. This enhanced ADCC as well as non-ADCC NK cell reactivity in CMV+ individuals was particularly characterized by a significantly higher number of ILT2+ and NKG2C+ NK cells that possessed cytolytic activity and/or produced IFNγ in response to HLA-positive target cells. Conclusions With regard to organ transplantation, these data suggest that CMV infection enhances NK cell alloreactivity, which may pose an additional adverse effect on graft survival, especially in the presence of donor specific antibodies.
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Abstract
Complement is a major contributor to inflammation and graft injury. This system is especially important in ischemia-reperfusion injury/delayed graft function as well as in acute and chronic antibody-mediated rejection (AMR). The latter is increasingly recognized as a major cause of late graft loss, for which we have few effective therapies. C1 inhibitor (C1-INH) regulates several pathways which contribute to both acute and chronic graft injuries. However, C1-INH spares the alternative pathway and the membrane attack complex (C5–9) so innate antibacterial defenses remain intact. Plasma-derived C1-INH has been used to treat hereditary angioedema for more than 30 years with excellent safety. Studies with C1-INH in transplant recipients are limited, but have not revealed any unique toxicity or serious adverse events attributed to the protein. Extensive data from animal and ex vivo models suggest that C1-INH ameliorates ischemia-reperfusion injury. Initial clinical studies suggest this effect may allow transplantation of donor organs which are now discarded because the risk of primary graft dysfunction is considered too great. Although the incidence of severe early AMR is declining, accumulating evidence strongly suggests that complement is an important mediator of chronic AMR, a major cause of late graft loss. Thus, C1-INH may also be helpful in preserving function of established grafts. Early clinical studies in transplantation suggest significant beneficial effects of C1-INH with minimal toxicity. Recent results encourage continued investigation of this already-available therapeutic agent.
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15
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Boratyńska M, Patrzałek D. Transplantology: Challenges for Today. Arch Immunol Ther Exp (Warsz) 2017; 64:37-45. [PMID: 28083612 PMCID: PMC5334381 DOI: 10.1007/s00005-016-0439-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/20/2016] [Indexed: 02/06/2023]
Abstract
Clinical transplantology in Poland had its 50th anniversary this year. With the early and long results comparable to the best achieved in the world leading centers, we face old and completely new challenges for this medical speciality. Main and growing challenge is insufficient number of available organs. With less than 15 donors/mln population/year Poland stay in the lower row of European countries in this measurement of transplant activity. Donation system is not efficient enough and we lose a big number of potential donors still. Living donation (with the exception for the fragments of the liver) remains low despite of different initiatives made so far on the national and local levels. Donation after cardiac death is possible from the point of Polish juridical regulations, but since last 3 years had not showed real impact on country donation rates (only three procedures done). Methods of tissue typing remain slow and cause relatively long times of cold ischemia for kidney programs. Second main challenge is chronic rejection causing loss of organs in the long-term follow-up and no efficient treatment employed. The emerging possibility of tolerance induction despite of plenty of new protocols proposition in the publications does not show up a clinical everyday practice in work. The same is with xenotransplantation promises; even we were informed recently that till 2030 such genetically modified porcine organs will be available. The next challenge is production of organs and tissues from own recipients cells installed on the different scaffolds or 3D printed. Other challenge is the personnel working in this field. We observe like in the other European countries lack of new candidates for work in this field together with serious problems of nursing staff, being a catastrophic perspective in country medical service in general, not only in transplant centers. The last but not least challenge is financial side of transplant programs.
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Affiliation(s)
- Maria Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Dariusz Patrzałek
- Department of Clinical Basics of Physiotherapy, Faculty of Health Science, Wroclaw Medical University, Wrocław, Poland.
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16
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Desensitization: Overcoming the Immunologic Barriers to Transplantation. J Immunol Res 2017; 2017:6804678. [PMID: 28127571 PMCID: PMC5239985 DOI: 10.1155/2017/6804678] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/14/2016] [Indexed: 12/17/2022] Open
Abstract
HLA (Human Leucocyte Antigen) sensitization is a significant barrier to successful kidney transplantation. It often translates into difficult crossmatch before transplant and increased risk of acute and chronic antibody mediated rejection after transplant. Over the last decade, several immunomodulatory therapies have emerged allowing for increased access to kidney transplantation for the immunologically disadvantaged group of HLA sensitized end stage kidney disease patients. These include IgG inactivating agents, anti-cytokine antibodies, costimulatory molecule blockers, complement inhibitors, and agents targeting plasma cells. In this review, we discuss currently available agents for desensitization and provide a brief analysis of data on novel biologics, which will likely improve desensitization outcomes, and have potential implications in treatment of antibody mediated rejection.
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17
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Demetris AJ, Bellamy C, Hübscher SG, O'Leary J, Randhawa PS, Feng S, Neil D, Colvin RB, McCaughan G, Fung JJ, Del Bello A, Reinholt FP, Haga H, Adeyi O, Czaja AJ, Schiano T, Fiel MI, Smith ML, Sebagh M, Tanigawa RY, Yilmaz F, Alexander G, Baiocchi L, Balasubramanian M, Batal I, Bhan AK, Bucuvalas J, Cerski CTS, Charlotte F, de Vera ME, ElMonayeri M, Fontes P, Furth EE, Gouw ASH, Hafezi-Bakhtiari S, Hart J, Honsova E, Ismail W, Itoh T, Jhala NC, Khettry U, Klintmalm GB, Knechtle S, Koshiba T, Kozlowski T, Lassman CR, Lerut J, Levitsky J, Licini L, Liotta R, Mazariegos G, Minervini MI, Misdraji J, Mohanakumar T, Mölne J, Nasser I, Neuberger J, O'Neil M, Pappo O, Petrovic L, Ruiz P, Sağol Ö, Sanchez Fueyo A, Sasatomi E, Shaked A, Shiller M, Shimizu T, Sis B, Sonzogni A, Stevenson HL, Thung SN, Tisone G, Tsamandas AC, Wernerson A, Wu T, Zeevi A, Zen Y. 2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection. Am J Transplant 2016; 16:2816-2835. [PMID: 27273869 DOI: 10.1111/ajt.13909] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/01/2016] [Accepted: 05/25/2016] [Indexed: 02/06/2023]
Abstract
The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.
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Affiliation(s)
- A J Demetris
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - C Bellamy
- The University of Edinburgh, Edinburgh, Scotland
| | | | - J O'Leary
- Baylor University Medical Center, Dallas, TX
| | - P S Randhawa
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - S Feng
- University of California San Francisco Medical Center, San Francisco, CA
| | - D Neil
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - R B Colvin
- Massachusetts General Hospital, Boston, MA
| | - G McCaughan
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | - F P Reinholt
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - H Haga
- Kyoto University Hospital, Kyoto, Japan
| | - O Adeyi
- University Health Network and University of Toronto, Toronto, Canada
| | - A J Czaja
- Mayo Clinic College of Medicine, Rochester, MN
| | - T Schiano
- Mount Sinai Medical Center, New York, NY
| | - M I Fiel
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - M L Smith
- Mayo Clinic Health System, Scottsdale, AZ
| | - M Sebagh
- AP-HP Hôpital Paul-Brousse, Paris, France
| | - R Y Tanigawa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - F Yilmaz
- University of Ege, Faculty of Medicine, Izmir, Turkey
| | | | - L Baiocchi
- Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - I Batal
- Columbia University College of Physicians and Surgeons, New York, NY
| | - A K Bhan
- Massachusetts General Hospital, Boston, MA
| | - J Bucuvalas
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - C T S Cerski
- Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - M ElMonayeri
- Ain Shams University, Wady El-Neel Hospital, Cairo, Egypt
| | - P Fontes
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - E E Furth
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - A S H Gouw
- University Medical Center Groningen, Groningen, the Netherlands
| | | | - J Hart
- University of Chicago Hospitals, Chicago, IL
| | - E Honsova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - W Ismail
- Beni-Suef University, Beni-Suef, Egypt
| | - T Itoh
- Kobe University Hospital, Kobe, Japan
| | | | - U Khettry
- Lahey Hospital and Medical Center, Burlington, MA
| | | | - S Knechtle
- Duke University Health System, Durham, NC
| | - T Koshiba
- Soma Central Hospital, Soma, Fukushima, Japan
| | - T Kozlowski
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - C R Lassman
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - J Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - J Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - L Licini
- Pope John XXIII Hospital, Bergamo, Italy
| | - R Liotta
- Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - G Mazariegos
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - M I Minervini
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - J Misdraji
- Massachusetts General Hospital, Boston, MA
| | - T Mohanakumar
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ
| | - J Mölne
- University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Nasser
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - J Neuberger
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M O'Neil
- University of Kansas Medical Center, Kansas City, KS
| | - O Pappo
- Hadassah Medical Center, Jerusalem, Israel
| | - L Petrovic
- University of Southern California, Los Angeles, CA
| | - P Ruiz
- University of Miami, Miami, FL
| | - Ö Sağol
- School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | | | - E Sasatomi
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - A Shaked
- University of Pennsylvania Health System, Philadelphia, PA
| | - M Shiller
- Baylor University Medical Center, Dallas, TX
| | - T Shimizu
- Toda Chuo General Hospital, Saitama, Japan
| | - B Sis
- University of Alberta Hospital, Edmonton, Canada
| | - A Sonzogni
- Pope John XXIII Hospital, Bergamo, Italy
| | | | - S N Thung
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - G Tisone
- University of Rome-Tor Vergata, Rome, Italy
| | | | - A Wernerson
- Karolinska University Hospital, Stockholm, Sweden
| | - T Wu
- Tulane University School of Medicine, New Orleans, LA
| | - A Zeevi
- University of Pittsburgh, Pittsburgh, PA
| | - Y Zen
- Kobe University Hospital, Kobe, Japan
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Prevention and treatment of liver allograft antibody-mediated rejection and the role of the 'two-hit hypothesis'. Curr Opin Organ Transplant 2016; 21:209-18. [PMID: 26918881 DOI: 10.1097/mot.0000000000000275] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The review outlines the diagnosis, prevention strategies, and possible treatment options for acute and chronic antibody-mediated rejection (AMR). RECENT FINDINGS Although rare, severe acute AMR (aAMR) usually occurs in patients with high mean fluorescence intensity despite serial dilutions or high-titer preformed class I donor-specific alloantibodies (DSA). The diagnosis is suspected when allograft dysfunction occurs with DSA, diffuse C4d staining, and a microvascular injury, and may be aided by the aAMR score. However, the incidence of and treatment approach to combined T-cell-mediated rejection (TCMR) with DSA present and some but not all features of AMR is yet to be determined. Chronic liver allograft AMR is characterized by low-grade chronic inflammation and progressive fibrosis with DSA, the chronic AMR (cAMR) score may facilitate diagnosis. The 'two-hit' hypothesis, whereby a coexistent insult upregulates human leukocyte antigen class II target antigens on the microvascular endothelium, may explain why suboptimal donors with lower sensitization levels might suffer from acute AMR and those with chronic complications (e.g., recurrent original disease) might be more susceptible to chronic AMR. Although treatment algorithms are needed, prevention is preferable and at a minimum includes transfusion minimization, and medication adherence. SUMMARY Severe acute AMR is rare but diagnosable, and there is need to determine the incidence of and optimal therapy for less severe combined AMR and TCMR. Chronic AMR is likely more common and of significant relevance to long-term allograft survival improvement. The two-hit hypothesis may help to explain the rarity of both findings and shed insight onto future prevention and treatment strategies.
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Immunopathology of rejection: do the rules of solid organ apply to vascularized composite allotransplantation? Curr Opin Organ Transplant 2016; 20:596-601. [PMID: 26536419 DOI: 10.1097/mot.0000000000000242] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW As both the number of vascularized composite allotransplants (VCAs) recipients and the duration of their follow-up are limited, immunopathology of VCA rejection remains incompletely understood. VCAs have several immunological peculiarities, which make inaccurate a direct extrapolation of all rules established for solid organs. RECENT FINDINGS Despite their bone marrow content, VCA do not induce chimerism in recipient and are therefore not spontaneously tolerated. Skin compartment of VCA contains a high density of antigen-presenting cells (APCs), some with self-renewal capacity. Donor APCs are responsible for continuous direct allosensitization of recipient's T cells that explains the high incidence of skin T-cell-mediated rejection and their occurrence beyond 1 year.Regenerative capability of the skin prevents the development of chronic rejection of this compartment as long as immunosuppression is maintained. In contrast, VCA can develop graft arteriosclerosis, which could be because of T cell and/or chronic antibody-mediated rejection (AMR). VCA recipients can indeed develop donor-specific antibodies (DSA). Whether DSA can also trigger acute AMR of VCA remains to be clarified. SUMMARY A better understanding of the specificities of the immunopathology of VCA rejection should pave the way for the rationalization of immunosuppressive strategies aiming at optimizing long-term outcome.
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Rodriguez-Barbosa JI, Fernandez-Renedo C, Moral AMB, Bühler L, Del Rio ML. T follicular helper expansion and humoral-mediated rejection are independent of the HVEM/BTLA pathway. Cell Mol Immunol 2016; 14:497-510. [PMID: 26924526 DOI: 10.1038/cmi.2015.101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/02/2015] [Accepted: 11/14/2015] [Indexed: 12/22/2022] Open
Abstract
The molecular pathways contributing to humoral-mediated allograft rejection are poorly defined. In this study, we assessed the role of the herpesvirus entry mediator/B- and T-lymphocyte attenuator (HVEM/BTLA) signalling pathway in the context of antibody-mediated allograft rejection. An experimental setting was designed to elucidate whether the blockade of HVEM/BTLA interactions could modulate de novo induction of host antidonor-specific antibodies during the course of graft rejection. To test this hypothesis, fully allogeneic major histocompatibility complex-mismatched skin grafts were transplanted onto the right flank of recipient mice that were treated with isotype control, anti-CD40L or modulatory antibodies of the HVEM/BTLA signalling pathway. The frequencies of CD4 T follicular helper (Tfh) cells (B220-, CD4+ CXCR5+ PD-1high), extrafollicular helper cells (B220-, CD4+ CXCR5- PD-1+ and PD-1-) and germinal centre (GC) B cells (B220+Fas+ GL7+) were analysed by flow cytometry in draining and non-draining lymph nodes at day 10 post transplantation during the acute phase of graft rejection. The host antidonor isotype-specific humoral immune response was also assessed. Whereas blockade of the CD40/CD40L pathway was highly effective in preventing the allogeneic humoral immune response, antibody-mediated blockade of the HVEM/BTLA-interacting pathway affected neither the expansion of Tfh cells nor the expansion of GC B cells. Consequently, the course of the host antidonor antibody-mediated response proceeded normally, without detectable evidence of impaired development. In summary, these data indicate that HVEM/BTLA interactions are dispensable for the formation of de novo host antidonor isotype-specific antibodies in transplantation.
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Affiliation(s)
- Jose-Ignacio Rodriguez-Barbosa
- Transplantation Immunobiology Section, Institute of Biomedicine, University of Leon and Castilla and Leon Regional Transplantation Coordination, Leon University Hospital, Leon, Spain
| | - Carlos Fernandez-Renedo
- Transplantation Immunobiology Section, Institute of Biomedicine, University of Leon and Castilla and Leon Regional Transplantation Coordination, Leon University Hospital, Leon, Spain
| | - Ana María Bravo Moral
- Department of Veterinary Clinical Sciences, University of Santiago de Compostela, Veterinary Faculty, Lugo, Spain
| | - Leo Bühler
- Visceral and Transplantation Surgery, Department of Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Maria-Luisa Del Rio
- Transplantation Immunobiology Section, Institute of Biomedicine, University of Leon and Castilla and Leon Regional Transplantation Coordination, Leon University Hospital, Leon, Spain
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21
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O'Leary JG, Cai J, Freeman R, Banuelos N, Hart B, Johnson M, Jennings LW, Kaneku H, Terasaki PI, Klintmalm GB, Demetris AJ. Proposed Diagnostic Criteria for Chronic Antibody-Mediated Rejection in Liver Allografts. Am J Transplant 2016; 16:603-14. [PMID: 26469278 DOI: 10.1111/ajt.13476] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/11/2015] [Accepted: 07/19/2015] [Indexed: 01/25/2023]
Abstract
Donor-specific alloantibodies (DSA) can cause acute antibody-mediated rejection (AMR) in all solid organ allografts. However, long-term outcome in patients with posttransplant DSA needs further study. We retrospectively evaluated prospectively collected paired serum, tissue, and data on 45 matched DSA- positive [DSA+; mean florescence intensity (MFI) ≥10,000] and -negative (DSA-) recipients of a primary liver-only allograft from January 2000 to April 2009. Blinded histopathologic evaluation demonstrated that DSA+ versus DSA- patients were more likely to have subtle inflammation and unique patterns of fibrosis, despite normal or near-normal liver function tests. Stepwise multivariable modeling developed a score (putatively named the chronic AMR [cAMR] score) that included interface activity, lobular inflammation, portal tract collagenization, portal venopathy, sinusoidal fibrosis, and hepatitis C virus status. The score was developed (c = 0.811) and cross-validated (c = 0.704) to predict allograft failure. Two cutoffs were employed to optimize sensitivity and specificity (80% each); a value >27.5 predicted 50% 10-year allograft failure. We propose chronic AMR as a potential new entity defined by (1) a high cAMR score, (2) DSA, and (3) elimination of other potential causes of a similar injury pattern. In conclusion, cAMR score calculation identified liver allograft recipients with DSA at highest risk for allograft loss, although independent validation is needed.
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Affiliation(s)
- J G O'Leary
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - J Cai
- Terasaki Foundation Laboratory, Los Angeles, CA
| | - R Freeman
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - N Banuelos
- Terasaki Foundation Laboratory, Los Angeles, CA
| | - B Hart
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - M Johnson
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - L W Jennings
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - H Kaneku
- Terasaki Foundation Laboratory, Los Angeles, CA
| | | | - G B Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - A J Demetris
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
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Stocks BT, Wilhelm AJ, Wilson CS, Marshall AF, Putnam NE, Major AS, Moore DJ. Lupus-Prone Mice Resist Immune Regulation and Transplant Tolerance Induction. Am J Transplant 2016; 16:334-41. [PMID: 26372909 PMCID: PMC4718751 DOI: 10.1111/ajt.13449] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/26/2015] [Accepted: 07/09/2015] [Indexed: 01/25/2023]
Abstract
The strongly immunogenic environment in autoimmune diseases such as lupus may pose a stringent barrier to transplantation. Despite available murine models of lupus, transplant tolerance in this setting has yet to be fully investigated in highly penetrant genetic models of disease. Such studies are of clear clinical importance because lupus is a transplant indication in which transplanted kidneys have a substantially increased risk of rejection including a role for recurrent nephritis. In the fully penetrant B6.SLE123 mouse, we determined that CD4 T follicular helper and germinal center B cells were significantly expanded compared with healthy controls. We traced this expansion to resistance of effector CD4 T and B cells in B6.SLE123 mice to regulation by either CD4 T regulatory cells (CD4Tregs) or CD8 T regulatory cells (CD8Tregs), despite demonstrating normal function by Tregs in this strain. Finally, we determined that B6.SLE123 mice resist anti-CD45RB-mediated tolerance induction to foreign islet allografts, even in the absence of islet autoimmunity. Overall, B6.SLE123 lupus-prone mice are highly resistant to transplant tolerance induction, which provides a new model of failed tolerance in autoimmunity that may elucidate barriers to clinical transplantation in lupus through further cellular and genetic dissection.
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Affiliation(s)
- B. T. Stocks
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN
| | - A. J. Wilhelm
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN
| | - C. S. Wilson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN
| | - A. F. Marshall
- Department of Pediatrics, Ian Burr Division of Endocrinology and Diabetes, Vanderbilt University, Nashville, TN
| | | | - A. S. Major
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN,Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN
| | - D. J. Moore
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN,Department of Pediatrics, Ian Burr Division of Endocrinology and Diabetes, Vanderbilt University, Nashville, TN,Corresponding author: Daniel J. Moore,
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Abstract
B cells play a central role in the immunopathogenesis of glomerulonephritides and transplant rejection. B cells secrete antibodies that contribute to tissue injury via multiple mechanisms. In addition, B cells contribute to disease pathogenesis in autoimmunity and alloimmunity by presenting antigens as well as providing costimulation and cytokines to T cells. B cells also play an immunomodulatory role in regulating the immune response by secreting cytokines that inhibit disease onset and/or progression. B cell-targeted approaches for treating immune diseases of the kidney and other organs have gained significant momentum. However, much remains to be understood about B-cell biology in order to determine the timing, duration, and context of optimal therapeutic response to B cell-targeted approaches. In this review, we discuss the multifaceted roles of B cells as enhancers and regulators of immunity with relevance to kidney disease and transplantation.
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Affiliation(s)
| | - Fadi G Lakkis
- Departments of Medicine (Renal-Electrolyte), Surgery, and Immunology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Geetha Chalasani
- Departments of Medicine (Renal-Electrolyte), Surgery, and Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Renal Section, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
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24
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Association of a coding polymorphism in Fc gamma receptor 2A and graft survival in re-transplant candidates. Hum Immunol 2015; 76:759-64. [DOI: 10.1016/j.humimm.2015.09.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 08/03/2015] [Accepted: 09/27/2015] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW Liver allograft antibody-mediated rejection (AMR) studies have lagged behind parallel efforts in kidney and heart because of a comparative inherent hepatic resistance to AMR. Three developments, however, have increased interest: first, solid phase antibody testing enabled more precise antibody characterization; second, increased expectations for long-term, morbidity-free survival; and third, immunosuppression minimization trials. RECENT FINDINGS Two overlapping liver allograft AMR phenotypic expressions are beginning to emerge: acute and chronic AMR. Acute AMR usually occurs within the several weeks after transplantation and characterized clinically by donor-specific antibodies (DSA) persistence, allograft dysfunction, thrombocytopenia, and hypocomplementemia. Acute AMR appears histopathologically similar to acute AMR in other organs: diffuse microvascular endothelial cell hypertrophy, C4d deposits, neutrophilic, eosinophilic, and macrophag-mediated microvasculitis/capillaritis, along with liver-specific ductular reaction, centrilobular hepatocyte swelling, and hepatocanalicular cholestasis often combined with T-cell-mediated rejection (TCMR). Chronic AMR is less well defined, but strongly linked to serum class II DSA and associated with late-onset acute TCMR, fibrosis, chronic rejection, and decreased survival. Unlike acute AMR, chronic AMR is a slowly evolving insult with a number of potential manifestations, but most commonly appears as low-grade lymphoplasmacytic portal and perivenular inflammation accompanied by unusual fibrosis patterns and variable microvascular C4d deposition; capillaritis can be more difficult to identify than in acute AMR. SUMMARY More precise DSA characterization, increasing expectations for long-term survival, and immunosuppression weaning precipitated a re-emergence of liver allograft AMR interest. Pathophysiological similarities exist between heart, kidney, and liver allografts, but liver-specific considerations may prove critical to our ultimate understanding of all solid organ AMR.
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26
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Böhmig GA, Kikic Z, Wahrmann M, Eskandary F, Aliabadi AZ, Zlabinger GJ, Regele H, Feucht HE. Detection of alloantibody-mediated complement activation: A diagnostic advance in monitoring kidney transplant rejection? Clin Biochem 2015; 49:394-403. [PMID: 26118475 DOI: 10.1016/j.clinbiochem.2015.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 05/23/2015] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Antibody-mediated rejection (ABMR) is an important cause of kidney allograft injury. In the last two decades, detection of complement split product C4d along transplant capillaries, a footprint of antibody-mediated classical complement activation, has evolved as a useful diagnostic marker of ABMR. While it was recognized that ABMR may occur also in the absence of C4d, numerous studies have shown that C4d deposition may indicate a more severe rejection phenotype associated with poor graft survival. Such studies suggest a possible diagnostic benefit of ex vivo monitoring the complement-activating capability of circulating alloantibodies. DESIGN AND METHODS We reviewed the literature between 1993 and 2015, focusing on in vivo (biopsy work-up) and in vitro detection (modified bead array technology) of HLA antibody-triggered classical complement activation in kidney transplantation. RESULTS Precise HLA antibody detection methods, in particular Luminex-based single antigen bead (SAB) assays, have provided a valuable basis for the design of techniques for in vitro detection of HLA antibody-triggered complement activation reflected by C1q, C4 or C3 split product deposition to the bead surface. Establishing such assays it was recognized that deposition of complement products to SAB, which critically depends on antibody binding strength, may be a cardinal trigger of the prozone effect, a troublesome in vitro artifact caused by a steric interference with IgG detection reagents. False-low IgG results, especially on SAB with extensive antibody binding, have to be considered when interpreting studies analyzing the diagnostic value of complement in relation to standard IgG detection. Levels of complement-fixing donor-specific antibodies (DSA) were shown to correlate with the results of standard crossmatch tests, suggesting potential application for crossmatch prediction. Moreover, while the utility of pre-transplant complement detection, at least in crossmatch-negative transplant recipients, is controversially discussed, a series of studies have shown that the appearance of post-transplant complement-fixing DSA may be associated with C4d deposition in transplant capillaries and a particular risk of graft failure. CONCLUSIONS The independent value of modified single antigen bead assays, as compared to a careful analysis of standard IgG detection, which may be affected considerably by complement dependent artifacts, needs to be clarified. Whether they have the potential to improve the predictive accuracy of our current diagnostic repertoire warrants further study.
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Affiliation(s)
- Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Zeljko Kikic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Arezu Z Aliabadi
- Department of Cardiac Surgery, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Gerhard J Zlabinger
- Institute of Immunology, Medical University Vienna, Lazarettgasse 19, A-1090 Vienna, Austria
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Helmut E Feucht
- Department of Organ Transplantation/Nephrology, Fachklinik Bad Heilbrunn, Wörnerweg 30, 83670 Bad Heilbrunn, Germany
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27
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Rascio F, Pontrelli P, Accetturo M, Oranger A, Gigante M, Castellano G, Gigante M, Zito A, Zaza G, Lupo A, Ranieri E, Stallone G, Gesualdo L, Grandaliano G. A type I interferon signature characterizes chronic antibody-mediated rejection in kidney transplantation. J Pathol 2015; 237:72-84. [DOI: 10.1002/path.4553] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/13/2015] [Accepted: 04/22/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Federica Rascio
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences; University of Foggia; Viale L Pinto 1 Foggia Italy
| | - Paola Pontrelli
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Matteo Accetturo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Annarita Oranger
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Margherita Gigante
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Maddalena Gigante
- Clinical Pathology, Department of Medical and Surgical Sciences; University of Foggia; Italy, Viale L Pinto 1 Foggia Italy
| | - Anna Zito
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine; University of Verona; Piazzale A Stefani 1 Verona Italy
| | - Antonio Lupo
- Renal Unit, Department of Medicine; University of Verona; Piazzale A Stefani 1 Verona Italy
| | - Elena Ranieri
- Clinical Pathology, Department of Medical and Surgical Sciences; University of Foggia; Italy, Viale L Pinto 1 Foggia Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences; University of Foggia; Viale L Pinto 1 Foggia Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation; University of Bari; Piazza G Cesare 11 Bari Italy
| | - Giuseppe Grandaliano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences; University of Foggia; Viale L Pinto 1 Foggia Italy
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28
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Jordan SC, Choi J, Vo A. Achieving incompatible transplantation through desensitization: current perspectives and future directions. Immunotherapy 2015; 7:377-98. [DOI: 10.2217/imt.15.10] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The application of life-saving transplantation is severely limited by the shortage of organs, and histoincompatibility. To increase transplant rates in sensitized patients, new protocols for HLA and blood type incompatible (ABOi) desensitization have emerged. These approaches require significant desensitization using intravenous immunoglobulin, rituximab and plasma exchange. In addition, the development of donor-specific antibody responses post transplant is the major cause of allograft failure with return to dialysis. This increases patient morbidity/mortality and cost. Immunotherapeutic agents used for desensitization evolved from drug development in oncology and autoimmune diseases. Currently, there is a renaissance in development of novel drugs likely to improve antibody reduction in transplantation. These include agents that inactivate IgG molecules, anticytokine antibodies, costimulatory molecule blockade, anticomplement agents and therapies aimed at the plasma cell.
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Affiliation(s)
- Stanley C Jordan
- Comprehensive Transplant Center, Kidney Transplant Program & Transplant Immunotherapy Program, Cedars-Sinai Medical Center, 8900 Beverly Blvd, Los Angeles, CA 90048, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Nephrology & Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jua Choi
- Comprehensive Transplant Center, Kidney Transplant Program & Transplant Immunotherapy Program, Cedars-Sinai Medical Center, 8900 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Kidney Transplant Program & Transplant Immunotherapy Program, Cedars-Sinai Medical Center, 8900 Beverly Blvd, Los Angeles, CA 90048, USA
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29
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Banham GD, Clatworthy MR. B-cell biomarkers in transplantation - from genes to therapy. ACTA ACUST UNITED AC 2015; 85:82-92. [DOI: 10.1111/tan.12520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- G. D. Banham
- Department of Medicine; University of Cambridge School of Clinical Medicine; Cambridge UK
| | - M. R. Clatworthy
- Department of Medicine; University of Cambridge School of Clinical Medicine; Cambridge UK
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30
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Masterson R, Hughes P, Walker RG, Hogan C, Haeusler M, Robertson AR, Millar R, Suh N, Cohney SJ. ABO incompatible renal transplantation without antibody removal using conventional immunosuppression alone. Am J Transplant 2014; 14:2807-13. [PMID: 25389083 DOI: 10.1111/ajt.12920] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/23/2014] [Accepted: 06/25/2014] [Indexed: 01/25/2023]
Abstract
ABO incompatible living donor renal transplantation (ABOi) can achieve outcomes comparable to ABO compatible transplantation (ABOc). However, with the exception of blood group A2 kidneys transplanted into recipients with low titer anti-A antibody, regimens generally include antibody removal, intensified immunosuppression and splenectomy or rituximab. We now report a series of 20 successful renal transplants across a range of blood group incompatibilities using conventional immunosuppression alone in recipients with low baseline anti-blood group antibody (ABGAb) titers. Incompatibilities were A1 to O (3), A1 to B (2), A2 to O (2), AB to A (2), AB to B (1), B to A1 (9), B to O (1); titers 1:1 to 1:16 by Ortho. At 36 months, patient and graft survival are 100%. Antibody-mediated rejection (AbMR) occurred in one patient with thrombophilia and low level donor-specific anti-HLA antibody. Four patients experienced cellular rejection (two subclinical), which responded to oral prednisolone. This series demonstrates that selected patients with low titer ABGAb can undergo ABOi with standard immunosuppression alone, suggesting baseline titer as a reliable predictor of AbMR. This reduces morbidity and cost of ABOi for patients with low titer ABGAb and increases the possibility of ABOi from deceased donors.
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Affiliation(s)
- R Masterson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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31
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Kim MG, Kim YJ, Kwon HY, Park HC, Koo TY, Jeong JC, Jeon HJ, Han M, Ahn C, Yang J. Outcomes of combination therapy for chronic antibody-mediated rejection in renal transplantation. Nephrology (Carlton) 2014; 18:820-6. [PMID: 24033843 DOI: 10.1111/nep.12157] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 12/28/2022]
Abstract
AIM Chronic antibody-mediated rejection (CAMR) in renal transplant patients has poor allograft outcomes. However, treatment strategy has not been established yet. Herein, we present short-term outcomes of combination therapy for CAMR. METHODS We identified nine patients with CAMR or suspicious CAMR who were treated with antihumoral therapy from 2010 to 2011 and analyzed their medical records retrospectively. RESULTS Five patients had CAMR, and four patients had suspicious CAMR. Severe transplant glomerulopathy (TG) was observed in seven patients. The estimated glomerular filtration rate (eGFR) was decreased in all patients before treatment. We used three different treatment regimens: (i) high-dose intravenous immunoglobulin (IVIG) and rituximab; (ii) high-dose IVIG, rituximab, and bortezomib; and (iii) plasmapheresis with low-dose IVIG, rituximab and bortezomib. After treatment with one of these three regimens, graft function improved or stabilized in six patients, whereas three patients showed further deterioration of eGFR. The third regimen suppressed deterioration of renal function in all patients. Most patients showed no progression of proteinuria. Infectious complications due to Pneumocystis jirovecii pneumonia and herpes zoster occurred in two patients. CONCLUSION Combination therapy for CAMR might be effective, even in patients with relatively late-stage CAMR.
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Affiliation(s)
- Myung-Gyu Kim
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea; Transplantation Center, Seoul National University Hospital, Seoul, Korea
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32
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Jiang X, Sung YK, Tian W, Qian J, Semenza GL, Nicolls MR. Graft microvascular disease in solid organ transplantation. J Mol Med (Berl) 2014; 92:797-810. [PMID: 24880953 PMCID: PMC4118041 DOI: 10.1007/s00109-014-1173-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 04/29/2014] [Accepted: 05/14/2014] [Indexed: 02/07/2023]
Abstract
Alloimmune inflammation damages the microvasculature of solid organ transplants during acute rejection. Although immunosuppressive drugs diminish the inflammatory response, they do not directly promote vascular repair. Repetitive microvascular injury with insufficient regeneration results in prolonged tissue hypoxia and fibrotic remodeling. While clinical studies show that a loss of the microvascular circulation precedes and may act as an initiating factor for the development of chronic rejection, preclinical studies demonstrate that improved microvascular perfusion during acute rejection delays and attenuates tissue fibrosis. Therefore, preservation of a functional microvasculature may represent an effective therapeutic strategy for preventing chronic rejection. Here, we review recent advances in our understanding of the role of the microvasculature in the long-term survival of transplanted solid organs. We also highlight microvessel-centered therapeutic strategies for prolonging the survival of solid organ transplants.
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Affiliation(s)
- Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA,
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33
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Salvadori M, Bertoni E. Impact of donor-specific antibodies on the outcomes of kidney graft: Pathophysiology, clinical, therapy. World J Transplant 2014; 4:1-17. [PMID: 24669363 PMCID: PMC3964192 DOI: 10.5500/wjt.v4.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
Allo-antibodies, particularly when donor specific, are one of the most important factors that cause both early and late graft dysfunction. The authors review the current state of the art concerning this important issue in renal transplantation. Many antibodies have been recognized as mediators of renal injury. In particular donor-specific-Human Leukocyte Antigens antibodies appear to play a major role. New techniques, such as solid phase techniques and Luminex, have revealed these antibodies from patient sera. Other new techniques have uncovered alloantibodies and signs of complement activation in renal biopsy specimens. It has been acknowledged that the old concept of chronic renal injury caused by calcineurine inhibitors toxicity should be replaced in many cases by alloantibodies acting against the graft. In addition, the number of patients on waiting lists with preformed anti-human leukocyte antigens (HLA) antibodies is increasing, primarily from patients with a history of renal transplant failure already been sensitized. We should distinguish early and late acute antibody-mediated rejection from chronic antibody-mediated rejection. The latter often manifets late during the course of the post-transplant period and may be difficult to recognize if specific techniques are not applied. Different therapeutic strategies are used to control antibody-induced damage. These strategies may be applied prior to transplantation or, in the case of acute antibody-mediated rejection, after transplantation. Many new drugs are appearing at the horizon; however, these drugs are far from the clinic because they are in phase I-II of clinical trials. Thus the pipeline for the near future appears almost empty.
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34
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Serre JE, Michonneau D, Bachy E, Noël LH, Dubois V, Suberbielle C, Kreis H, Legendre C, Mamzer-Bruneel MF, Morelon E, Thaunat O. Maintaining calcineurin inhibition after the diagnosis of post-transplant lymphoproliferative disorder improves renal graft survival. Kidney Int 2014; 85:182-90. [DOI: 10.1038/ki.2013.253] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 04/15/2013] [Accepted: 05/09/2013] [Indexed: 12/28/2022]
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35
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Banasik M, Boratyńska M, Kościelska-Kasprzak K, Mazanowska O, Krajewska M, Zabińska M, Bartoszek D, Myszka M, Nowakowska B, Dawiskiba T, Lepiesza A, Chudoba P, Klinger M. The impact of de novo donor-specific anti-human leukocyte antigen antibodies on 5-year renal transplant outcome. Transplant Proc 2013; 45:1449-52. [PMID: 23726594 DOI: 10.1016/j.transproceed.2012.12.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 12/31/2012] [Indexed: 02/08/2023]
Abstract
Numerous studies have shown that circulating donor-specific antibodies targeting human leukocyte antigen (HLA) are associated with accelerated renal transplant failure, but many patients with these antibodies have good graft function. The aim of our study was to investigate the long-term graft function and survival in patients with de novo post-transplant donor-specific anti-HLA antibodies (DSA). Our prospective study included 78 consecutive recipients with a negative crossmatch before transplantation. Recipient serum samples were assayed for DSA in week 2 and 1, 3, 6, 9, 12 months after transplantation using a complement-dependent lymphocytotoxic technique with donor lymphocytes. Additionally, patients with DSA and stable renal function in the first year were tested with a more sensitive flow-panel-reactive antibody. DSA were present in 34 (44%) of our patients during the first 12 months after transplantation. Biopsy-proved acute rejection occurred in 11 DSA-positive and 10 DSA-negative patients. Seven DSA-positive patients had antibody-mediated rejection and no DSA-negative ones developed humoral rejection. The serum creatinine level in DSA-positive patients was significantly higher (2.48 vs 1.43 mg/dL) in year 5. The 13 (38%) DSA-positive patients with good graft function in month 12 were stable during a 5-year follow-up: their serum creatinine was 1.46 ± 0.4 in year 1 and 1.56 ± 0.4 mg/dL in year 5 and nobody lost their allograft. One- and 5- year graft survivals were appropriately 85% and 59% in DSA-positive patients compared to 93% and 93% in DSA-negative patients. To sum up, post-transplant DSA had a significant influence on kidney function and graft survival but in 38% of patients the presence of DSA did not decrease a 5-year renal function. A good renal allograft function in the presence of DSA in the first year after transplantation and cessation of their production in the subsequent years may be a good prognostic marker for a long-term allograft function and survival.
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Affiliation(s)
- M Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
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36
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Abstract
Seminal studies in rabbits and rodent transplantation models by Peter Medawar revealed that cellular processes, rather than humoral antibodies, are central to the acute rejection of transplanted organs, and much of basic transplantation research continues to be focused on the biology and control of these cells, which were subsequently shown to be T cells. However, the success of current immunosuppression at controlling T-cell-mediated rejection has resulted in an increasing awareness of antibody-mediated rejection in the clinic. This, in turn, has fueled an emerging interest in the biology of allospecific antibodies, the B cells that produce these antibodies, and the development of mouse models that allow their investigation. Here we summarize some of the more widely used mouse models that have been developed to study the immunobiology of alloreactivity, transplantation rejection and tolerance, and used to identify therapeutic strategies that modulate these events.
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Affiliation(s)
- Anita S Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, Illinois 60637
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37
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Chen J, Yin H, Xu J, Wang Q, Edelblum KL, Sciammas R, Chong AS. Reversing endogenous alloreactive B cell GC responses with anti-CD154 or CTLA-4Ig. Am J Transplant 2013; 13:2280-92. [PMID: 23855587 PMCID: PMC3797532 DOI: 10.1111/ajt.12350] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/07/2013] [Accepted: 05/27/2013] [Indexed: 01/25/2023]
Abstract
Alloantibodies mediate acute antibody-mediated rejection as well as chronic allograft rejection in clinical transplantation. To better understand the cellular dynamics driving antibody production, we focused on the activation and differentiation of alloreactive B cells in the draining lymph nodes and spleen following sensitization to allogeneic cells or hearts. We used a modified staining approach with a single MHC Class I tetramer (K(d)) bound to two different fluorochromes to discriminate between the Class I-binding and fluorochrome-streptavidin-binding B cells with a high degree of specificity and binding efficiency. By Day 7-8 postsensitization, there was a 1.5- to 3.2-fold increase in the total numbers of K(d) -binding B cells. Within this K(d) -binding B cell population, approximately half were IgD(low) , MHC Class II(high) and CD86(+), 30-45% expressed a germinal center (Fas(+) GL7(+)) phenotype and 3-12% were IRF4(hi) plasma cells. Remarkably, blockade with anti-CD40 or CTLA-4Ig, starting on Day 7 postimmunization for 1 or 4 weeks, completely dissolved established GCs and halted further development of the alloantibody response. Thus MHC Class I tetramers can specifically track the in vivo fate of endogenous, Class I-specific B cells and was used to demonstrate the ability of delayed treatment with anti-CD154 or CTLA-4Ig to halt established allo-B cell responses.
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Affiliation(s)
- J Chen
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
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38
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Histopathology of Chronic Rejection in a Nonhuman Primate Model of Vascularized Composite Allotransplantation. Transplantation 2013; 95:1204-10. [DOI: 10.1097/tp.0b013e31828d1528] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Abstract
Despite improvements in outcomes of renal transplantation, kidney allograft loss remains substantial, and is associated with increased morbidity, mortality and costs. Identifying the pathologic pathways responsible for allograft loss, and the attendant development of therapeutic interventions, will be one of the guiding future objectives of transplant medicine. One of the most important advances of the past decade has been the demonstration of the destructive power of anti-HLA alloantibodies and their association with antibody-mediated rejection (ABMR). Compelling evidence exists to show that donor-specific anti-HLA antibodies (DSAs) are largely responsible for the chronic deterioration of allografts, a condition previously attributed to calcineurin inhibitor toxicity and chronic allograft nephropathy. The emergence of sensitive techniques to detect DSAs, together with advances in the assessment of graft pathology, have expanded the spectrum of what constitutes ABMR. Today, subtler forms of rejection--such as indolent ABMR, C4d-negative ABMR, and transplant arteriopathy--are seen in which DSAs exert a marked pathological effect. In addition, arteriosclerosis, previously thought to be a bystander lesion related to the vicissitudes of aging, is accelerated in ABMR. Advances in our understanding of the pathological significance of DSAs and ABMR show their primacy in the mediation of chronic allograft destruction. Therapies aimed at B cells, plasma cells and antibodies will be important therapeutic options to improve the length and quality of kidney allograft survival.
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