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Pradère P, Zajacova A, Bos S, Le Pavec J, Fisher A. Molecular monitoring of lung allograft health: is it ready for routine clinical use? Eur Respir Rev 2023; 32:230125. [PMID: 37993125 PMCID: PMC10663940 DOI: 10.1183/16000617.0125-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
Maintenance of long-term lung allograft health in lung transplant recipients (LTRs) requires a fine balancing act between providing sufficient immunosuppression to reduce the risk of rejection whilst at the same time not over-immunosuppressing individuals and exposing them to the myriad of immunosuppressant drug side-effects that can cause morbidity and mortality. At present, lung transplant physicians only have limited and rather blunt tools available to assist them with this task. Although therapeutic drug monitoring provides clinically useful information about single time point and longitudinal exposure of LTRs to immunosuppressants, it lacks precision in determining the functional level of immunosuppression that an individual is experiencing. There is a significant gap in our ability to monitor lung allograft health and therefore tailor optimal personalised immunosuppression regimens. Molecular diagnostics performed on blood, bronchoalveolar lavage or lung tissue that can detect early signs of subclinical allograft injury, differentiate rejection from infection or distinguish cellular from humoral rejection could offer clinicians powerful tools in protecting lung allograft health. In this review, we look at the current evidence behind molecular monitoring in lung transplantation and ask if it is ready for routine clinical use. Although donor-derived cell-free DNA and tissue transcriptomics appear to be the techniques with the most immediate clinical potential, more robust data are required on their performance and additional clinical value beyond standard of care.
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Affiliation(s)
- Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrea Zajacova
- Prague Lung Transplant Program, Department of Pneumology, Motol University Hospital and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Jérôme Le Pavec
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrew Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
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2
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Yang W, Lecuona E, Wu Q, Liu X, Sun H, Alam H, Nadig SN, Bharat A. The role of lung-restricted autoantibodies in the development of primary and chronic graft dysfunction. FRONTIERS IN TRANSPLANTATION 2023; 2:1237671. [PMID: 38993924 PMCID: PMC11235341 DOI: 10.3389/frtra.2023.1237671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/18/2023] [Indexed: 07/13/2024]
Abstract
Lung transplantation is a life-saving treatment for both chronic end-stage lung diseases and acute respiratory distress syndrome, including those caused by infectious agents like COVID-19. Despite its increasing utilization, outcomes post-lung transplantation are worse than other solid organ transplants. Primary graft dysfunction (PGD)-a condition affecting more than half of the recipients post-transplantation-is the chief risk factor for post-operative mortality, transplant-associated multi-organ dysfunction, and long-term graft loss due to chronic rejection. While donor-specific antibodies targeting allogenic human leukocyte antigens have been linked to transplant rejection, the role of recipient's pre-existing immunoglobulin G autoantibodies against lung-restricted self-antigens (LRA), like collagen type V and k-alpha1 tubulin, is less understood in the context of lung transplantation. Recent studies have found an increased risk of PGD development in lung transplant recipients with LRA. This review will synthesize past and ongoing research-utilizing both mouse models and human subjects-aimed at unraveling the mechanisms by which LRA heightens the risk of PGD. Furthermore, it will explore prospective approaches designed to mitigate the impact of LRA on lung transplant patients.
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Affiliation(s)
- Wenbin Yang
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Emilia Lecuona
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Qiang Wu
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Xianpeng Liu
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Haiying Sun
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Hasan Alam
- Division of Trauma & Acute Care Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Satish N. Nadig
- Division of Abdominal Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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McGinniss JE, Whiteside SA, Deek RA, Simon-Soro A, Graham-Wooten J, Oyster M, Brown MD, Cantu E, Diamond JM, Li H, Christie JD, Bushman FD, Collman RG. The Lung Allograft Microbiome Associates with Pepsin, Inflammation, and Primary Graft Dysfunction. Am J Respir Crit Care Med 2022; 206:1508-1521. [PMID: 36103583 PMCID: PMC9757091 DOI: 10.1164/rccm.202112-2786oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 09/14/2022] [Indexed: 12/24/2022] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the principal cause of early morbidity and mortality after lung transplantation. The lung microbiome has been implicated in later transplantation outcomes but has not been investigated in PGD. Objectives: To define the peritransplant bacterial lung microbiome and relationship to host response and PGD. Methods: This was a single-center prospective cohort study. Airway lavage samples from donor lungs before organ procurement and recipient allografts immediately after implantation underwent bacterial 16S ribosomal ribonucleic acid gene sequencing. Recipient allograft samples were analyzed for cytokines by multiplex array and pepsin by ELISA. Measurements and Main Results: We enrolled 139 transplant subjects and obtained donor lung (n = 109) and recipient allograft (n = 136) samples. Severe PGD (persistent grade 3) developed in 15 subjects over the first 72 hours, and 40 remained without PGD (persistent grade 0). The microbiome of donor lungs differed from healthy lungs, and recipient allograft microbiomes differed from donor lungs. Development of severe PGD was associated with enrichment in the immediate postimplantation lung of oropharyngeal anaerobic taxa, particularly Prevotella. Elevated pepsin, a gastric biomarker, and a hyperinflammatory cytokine profile were present in recipient allografts in severe PGD and strongly correlated with microbiome composition. Together, immediate postimplantation allograft Prevotella/Streptococcus ratio, pepsin, and indicator cytokines were associated with development of severe PGD during the 72-hour post-transplantation period (area under the curve = 0.81). Conclusions: Lung allografts that develop PGD have a microbiome enriched in anaerobic oropharyngeal taxa, elevated gastric pepsin, and hyperinflammatory phenotype. These findings suggest a possible role for peritransplant aspiration in PGD, a potentially actionable mechanism that warrants further investigation.
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Affiliation(s)
- John E. McGinniss
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | | | - Aurea Simon-Soro
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Melanie D. Brown
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | | | - Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Hongzhe Li
- Department of Epidemiology, Biostatistics, and Informatics
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Frederic D. Bushman
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald G. Collman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Microbiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Yang W, Cerier EJ, Núñez-Santana FL, Wu Q, Yan Y, Kurihara C, Liu X, Yeldandi A, Khurram N, Avella-Patino D, Sun H, Budinger GS, Kreisel D, Mohanakumar T, Lecuona E, Bharat A. IL-1β-dependent extravasation of preexisting lung-restricted autoantibodies during lung transplantation activates complement and mediates primary graft dysfunction. J Clin Invest 2022; 132:157975. [PMID: 36250462 PMCID: PMC9566897 DOI: 10.1172/jci157975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Preexisting lung-restricted autoantibodies (LRAs) are associated with a higher incidence of primary graft dysfunction (PGD), although it remains unclear whether LRAs can drive its pathogenesis. In syngeneic murine left lung transplant recipients, preexisting LRAs worsened graft dysfunction, which was evident by impaired gas exchange, increased pulmonary edema, and activation of damage-associated pathways in lung epithelial cells. LRA-mediated injury was distinct from ischemia-reperfusion injury since deletion of donor nonclassical monocytes and host neutrophils could not prevent graft dysfunction in LRA-pretreated recipients. Whole LRA IgG molecules were necessary for lung injury, which was mediated by the classical and alternative complement pathways and reversed by complement inhibition. However, deletion of Fc receptors in donor macrophages or mannose-binding lectin in recipient mice failed to rescue lung function. LRA-mediated injury was localized to the transplanted lung and dependent on IL-1β-mediated permeabilization of pulmonary vascular endothelium, which allowed extravasation of antibodies. Genetic deletion or pharmacological inhibition of IL-1R in the donor lungs prevented LRA-induced graft injury. In humans, preexisting LRAs were an independent risk factor for severe PGD and could be treated with plasmapheresis and complement blockade. We conclude that preexisting LRAs can compound ischemia-reperfusion injury to worsen PGD for which complement inhibition may be effective.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - G.R. Scott Budinger
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel Kreisel
- Departments of Surgery, Pathology & Immunology, Washington University, St. Louis, Missouri, USA
| | | | | | - Ankit Bharat
- Division of Thoracic Surgery
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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5
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Clausen E, Cantu E. Primary graft dysfunction: what we know. J Thorac Dis 2022; 13:6618-6627. [PMID: 34992840 PMCID: PMC8662499 DOI: 10.21037/jtd-2021-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/21/2021] [Indexed: 12/19/2022]
Abstract
Many advances in lung transplant have occurred over the last few decades in the understanding of primary graft dysfunction (PGD) though effective prevention and treatment remain elusive. This review will cover prior understanding of PGD, recent findings, and directions for future research. A consensus statement updating the definition of PGD in 2016 highlights the growing complexity of lung transplant perioperative care taking into account the increasing use of high flow oxygen delivery and pulmonary vasodilators in the current era. PGD, particularly more severe grades, is associated with worse short- and long-term outcomes after transplant such as chronic lung allograft dysfunction. Growing experience have helped identify recipient, donor, and intraoperative risk factors for PGD. Understanding the pathophysiology of PGD has advanced with increasing knowledge of the role of innate immune response, humoral cell immunity, and epithelial cell injury. Supportive care post-transplant with technological advances in extracorporeal membranous oxygenation (ECMO) remain the mainstay of treatment for severe PGD. Future directions include the evolving utility of ex vivo lung perfusion (EVLP) both in PGD research and potential pre-transplant treatment applications. PGD remains an important outcome in lung transplant and the future holds a lot of potential for improvement in understanding its pathophysiology as well as development of preventative therapies and treatment.
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Affiliation(s)
- Emily Clausen
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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6
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McQuiston A, Emtiazjoo A, Angel P, Machuca T, Christie J, Atkinson C. Set Up for Failure: Pre-Existing Autoantibodies in Lung Transplant. Front Immunol 2021; 12:711102. [PMID: 34456920 PMCID: PMC8385565 DOI: 10.3389/fimmu.2021.711102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Lung transplant patients have the lowest long-term survival rates compared to other solid organ transplants. The complications after lung transplantation such as primary graft dysfunction (PGD) and ultimately chronic lung allograft dysfunction (CLAD) are the main reasons for this limited survival. In recent years, lung-specific autoantibodies that recognize non-HLA antigens have been hypothesized to contribute to graft injury and have been correlated with PGD, CLAD, and survival. Mounting evidence suggests that autoantibodies can develop during pulmonary disease progression before lung transplant, termed pre-existing autoantibodies, and may participate in allograft injury after transplantation. In this review, we summarize what is known about pulmonary disease autoantibodies, the relationship between pre-existing autoantibodies and lung transplantation, and potential mechanisms through which pre-existing autoantibodies contribute to graft injury and rejection.
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Affiliation(s)
- Alexander McQuiston
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States.,Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, United States
| | - Amir Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, United States
| | - Peggi Angel
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, United States
| | - Tiago Machuca
- Department of Surgery, University of Florida, Gainesville, FL, United States
| | - Jason Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Carl Atkinson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, United States
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7
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COMP: A Potential Early Biomarker of RAS After Lung Transplantation. Transplant Direct 2021; 7:e730. [PMID: 34291152 PMCID: PMC8291357 DOI: 10.1097/txd.0000000000001189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022] Open
Abstract
Chronic rejection, defined as chronic lung allograft dysfunction (CLAD), is the major factor limiting long-term survival after lung transplantation (LTx). A specific subgroup of CLAD is restrictive allograft syndrome (RAS). CLAD’s pathogenesis is largely unknown, but previous findings suggest that it is associated with increased fibrosis in the transplanted lung. Cartilage oligomeric matrix protein (COMP) has been associated with multiple fibrotic conditions. The current study aimed to explore the relation between COMP serum levels and development of CLAD, and RAS in particular, in a retrospective cohort of LTx patients.
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8
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Li C, Patel K, Tu Z, Yang X, Kulik L, Alawieh A, Allen P, Cheng Q, Wallace C, Kilkenny J, Kwon J, Gibney B, Cantu E, Sharma A, Pipkin M, Machuca T, Emtiazjoo A, Goddard M, Holers VM, Nadig S, Christie J, Tomlinson S, Atkinson C. A novel injury site-natural antibody targeted complement inhibitor protects against lung transplant injury. Am J Transplant 2021; 21:2067-2078. [PMID: 33210808 PMCID: PMC8246004 DOI: 10.1111/ajt.16404] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
Complement is known to play a role in ischemia and reperfusion injury (IRI). A general paradigm is that complement is activated by self-reactive natural IgM antibodies (nAbs), after they engage postischemic neoepitopes. However, a role for nAbs in lung transplantation (LTx) has not been explored. Using mouse models of LTx, we investigated the role of two postischemic neoepitopes, modified annexin IV (B4) and a subset of phospholipids (C2), in LTx. Antibody deficient Rag1-/- recipient mice were protected from LTx IRI. Reconstitution with either B4 or C2nAb restored IRI, with C2 significantly more effective than B4 nAb. Based on these information, we developed/characterized a novel complement inhibitor composed of single-chain antibody (scFv) derived from the C2 nAb linked to Crry (C2scFv-Crry), a murine inhibitor of C3 activation. Using an allogeneic LTx, in which recipients contain a full nAb repertoire, C2scFv-Crry targeted to the LTx, inhibited IRI, and delayed acute rejection. Finally, we demonstrate the expression of the C2 neoepitope in human donor lungs, highlighting the translational potential of this approach.
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Affiliation(s)
- Changhai Li
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Kunal Patel
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Zhenxiao Tu
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Hepatic and Vascular Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofeng Yang
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Liudmila Kulik
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
| | - Ali Alawieh
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Patterson Allen
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Qi Cheng
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
| | - Caroline Wallace
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jane Kilkenny
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jennie Kwon
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Barry Gibney
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Ashish Sharma
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Mauricio Pipkin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tiago Machuca
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Amir Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Martin Goddard
- Pathology Department, Papworth Hospital, NHS Trust, Papworth Everard, Cambridge, UK
| | - V Michael Holers
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Satish Nadig
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jason Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, University of Florida, Gainesville, Florida, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Carl Atkinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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9
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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10
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Keller M, Bush E, Diamond JM, Shah P, Matthew J, Brown AW, Sun J, Timofte I, Kong H, Tunc I, Luikart H, Iacono A, Nathan SD, Khush KK, Orens J, Jang M, Agbor-Enoh S. Use of donor-derived-cell-free DNA as a marker of early allograft injury in primary graft dysfunction (PGD) to predict the risk of chronic lung allograft dysfunction (CLAD). J Heart Lung Transplant 2021; 40:488-493. [PMID: 33814284 DOI: 10.1016/j.healun.2021.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a risk factor for chronic lung allograft dysfunction (CLAD). However, the association between PGD and degree of allograft injury remains poorly defined. In this study, we leverage a novel biomarker for allograft injury, percentage donor-derived cell-free DNA (%ddcfDNA), to study the association between PGD, degree of allograft injury, and the development of CLAD. METHODS This prospective cohort study recruited 99 lung transplant recipients and collected plasma samples on days 1, 3, and 7 for %ddcfDNA measurements. Clinical data on day 3 was used to adjudicate for PGD. %ddcfDNA levels were compared between PGD grades. In PGD patients, %ddcfDNA was compared between those who developed CLAD and those who did not. RESULTS On posttransplant day 3, %ddcfDNA was higher in PGD than in non-PGD patients (median [IQR]: 12.2% [8.2, 22.0] vs 8.5% [5.6, 13.2] p = 0.01). %ddcfDNA correlated with the severity grade of PGD (r = 0.24, p = 0.02). Within the PGD group, higher levels of %ddcfDNA correlated with increased risk of developing CLAD (log OR(SE) 1.38 (0.53), p = 0.009). PGD patients who developed CLAD showed ∼2-times higher %ddcfDNA levels than patients who did not develop CLAD (median [IQR]: 22.4% [11.8, 27.6] vs 9.9% [6.7, 14.9], p = 0.007). CONCLUSION PGD patients demonstrated increased early posttransplant allograft injury, as measured by %ddcfDNA, in comparison to non-PGD patients, and these high %ddcfDNA levels were associated with subsequent development of CLAD. This study suggests that %ddcfDNA identifies PGD patients at greater risk of CLAD than PGD alone.
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Affiliation(s)
- Michael Keller
- Laborarory of Applied Precision Omics (APO), Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Errol Bush
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Inova Fairfax Hospital, Falls Church, Virginia
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - Pali Shah
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joby Matthew
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Anne W Brown
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Bioinformatics and Computation Core, NHLBI, Bethesda, Maryland
| | - Junfeng Sun
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Irina Timofte
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Hyesik Kong
- Laborarory of Applied Precision Omics (APO), Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Ilker Tunc
- Laborarory of Applied Precision Omics (APO), Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Helen Luikart
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Aldo Iacono
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Bioinformatics and Computation Core, NHLBI, Bethesda, Maryland
| | - Kiran K Khush
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jonathan Orens
- Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Moon Jang
- Laborarory of Applied Precision Omics (APO), Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Sean Agbor-Enoh
- Laborarory of Applied Precision Omics (APO), Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland; Genomic Research Alliance for Transplantation (GRAfT), National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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11
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Sharma M, Gunasekaran M, Ravichandran R, Fisher CE, Limaye AP, Hu C, McDyer J, Kaza V, Bharat A, Tokman S, Omar A, Arjuna A, Walia R, Bremner RM, Smith MA, Hachem RR, Mohanakumar T. Circulating exosomes with lung self-antigens as a biomarker for chronic lung allograft dysfunction: A retrospective analysis. J Heart Lung Transplant 2020; 39:1210-1219. [PMID: 32713614 DOI: 10.1016/j.healun.2020.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Exosomes isolated from plasma of lung transplant recipients (LTxRs) with bronchiolitis obliterans syndrome (BOS) contain human leukocyte antigens and lung self-antigens (SAgs), K-alpha 1 tubulin (Kα1T) and collagen type V (Col-V). The aim was to determine the use of circulating exosomes with lung SAgs as a biomarker for BOS. METHODS Circulating exosomes were isolated retrospectively from plasma from LTxRs at diagnosis of BOS and at 6 and 12 months before the diagnosis (n = 41) and from stable time-matched controls (n = 30) at 2 transplant centers by ultracentrifugation. Exosomes were validated using Nanosight, and lung SAgs (Kα1T and Col-V) were detected by immunoblot and semiquantitated using ImageJ software. RESULTS Circulating exosomes from BOS and stable LTxRs demonstrated 61- to 181-nm vesicles with markers Alix and CD9. Exosomes from LTxRs with BOS (n = 21) showed increased levels of lung SAgs compared with stable (n = 10). A validation study using 2 separate cohorts of LTxRs with BOS and stable time-matched controls from 2 centers also demonstrated significantly increased lung SAgs-containing exosomes at 6 and 12 months before BOS. CONCLUSIONS Circulating exosomes isolated from LTxRs with BOS demonstrated increased levels of lung SAgs (Kα1T and Col-V) 12 months before the diagnosis (100% specificity and 90% sensitivity), indicating that circulating exosomes with lung SAgs can be used as a non-invasive biomarker for identifying LTxRs at risk for BOS.
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Affiliation(s)
- Monal Sharma
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | | | - Cynthia E Fisher
- Deparment of Medicine, University of Washington, Seattle, Washington
| | - Ajit P Limaye
- Deparment of Medicine, University of Washington, Seattle, Washington
| | - Chengcheng Hu
- Department of Epidemiology and Biostatistics, University of Arizona, Phoenix, Arizona
| | - John McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vaidehi Kaza
- Internal Medicine-Pulmonary Disease, University of Texas Southwestern, Dallas, Texas
| | - Ankit Bharat
- Department of Surgery-Thoracic, Northwestern University, Chicago, Illinois
| | - Sofya Tokman
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashraf Omar
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashwini Arjuna
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ramsey R Hachem
- Department of Internal Medicine, Washington University Medical School, St Louis, Missouri
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