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Kosuta I, Kelava T, Ostojic A, Sesa V, Mrzljak A, Lalic H. Immunology demystified: A guide for transplant hepatologists. World J Transplant 2024; 14:89772. [PMID: 38576757 PMCID: PMC10989464 DOI: 10.5500/wjt.v14.i1.89772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/24/2024] [Accepted: 02/29/2024] [Indexed: 03/15/2024] Open
Abstract
Liver transplantation has become standard practice for treating end-stage liver disease. The success of the procedure relies on effective immunosuppressive medications to control the host's immune response. Despite the liver's inherent capacity to foster tolerance, the early post-transplant period is marked by significant immune reactivity. To ensure favorable outcomes, it is imperative to identify and manage various rejection types, encompassing T-cell-mediated, antibody-mediated, and chronic rejection. However, the approach to prescribing immunosuppressants relies heavily on clinical judgment rather than evidence-based criteria. Given that the majority of patients will require lifelong immuno suppression as the mechanisms underlying operational tolerance are still being investigated, healthcare providers must possess an understanding of immune responses, rejection mechanisms, and the pathways targeted by immunosuppressive drugs. This knowledge enables customization of treatments and improved patient care, even though a consensus on an optimal immunosuppressive regimen remains elusive.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Tomislav Kelava
- Department of Physiology, School of Medicine, Univeristy of Zagreb, Zagreb 10000, Croatia
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, Zagreb 10000, Croatia
| | - Ana Ostojic
- Department of Gastroenterology and Hepatology, Liver Transplant Center, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Vibor Sesa
- Department of Gastroenterology and Hepatology, Liver Transplant Center, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Centre Zagreb, Zagreb 10000, Croatia
- Department of Medicine, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Hrvoje Lalic
- Department of Physiology, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Laboratory for Cell Biology, Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Department of Laboratory Immunology, Clinical Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb 10000, Croatia
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Kok G, Ilcken EF, Houwen RH, Lindemans CA, Nieuwenhuis EE, Spierings E, Fuchs SA. The Effect of Genetic HLA Matching on Liver Transplantation Outcome: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2023; 4:e334. [PMID: 37746594 PMCID: PMC10513352 DOI: 10.1097/as9.0000000000000334] [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: 11/21/2022] [Accepted: 08/11/2023] [Indexed: 09/26/2023] Open
Abstract
Objective We aim to investigate the effects of genetically based HLA matching on patient and graft survival, and acute and chronic rejection after liver transplantation. Background Liver transplantation is a common treatment for patients with end-stage liver disease. In contrast to most other solid organ transplantations, there is no conclusive evidence supporting human leukocyte antigen (HLA) matching for liver transplantations. With emerging alternatives such as transplantation of bankable (stem) cells, HLA matching becomes feasible, which may decrease the need for immunosuppressive therapy and improve transplantation outcomes. Methods We systematically searched the PubMed, Embase, and Cochrane databases and performed a meta-analysis investigating the effect of genetic HLA matching on liver transplantation outcomes (acute/chronic rejection, graft failure, and mortality). Results We included 14 studies with 2682 patients. HLA-C mismatching significantly increased the risk of acute rejection (full mismatching: risk ratio = 1.90, 95% confidence interval = 1.08 to 3.33, P = 0.03; partial mismatching: risk ratio = 1.33, 95% confidence interval = 1.07 to 1.66, P = 0.01). We did not discern any significant effect of HLA mismatching per locus on acute rejection for HLA-A, -B, -DR, and -DQ, nor on chronic rejection, graft failure, or mortality for HLA-DR, and -DQ. Conclusions We found evidence that genetic HLA-C matching reduces the risk of acute rejection after liver transplantation while matching for other loci does not reduce the risk of acute rejection, chronic rejection, graft failure, or mortality.
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Affiliation(s)
- Gautam Kok
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Eveline F. Ilcken
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Roderick H.J. Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Caroline A. Lindemans
- Department of Immunology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Hematopoietic Cell Transplantation, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Edward E.S. Nieuwenhuis
- Department of Pediatric Gastroenterology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Eric Spierings
- Center of Translational Immunology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Sabine A. Fuchs
- From the Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
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Bricogne C, Halliday N, Fernando R, Tsochatzis EA, Davidson BR, Harber M, Westbrook RH. Donor-recipient human leukocyte antigen A mismatching is associated with hepatic artery thrombosis, sepsis, graft loss, and reduced survival after liver transplant. Liver Transpl 2022; 28:1306-1320. [PMID: 35313059 PMCID: PMC9541857 DOI: 10.1002/lt.26458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 01/13/2023]
Abstract
Human leukocyte antigen (HLA) matching is not routinely performed for liver transplantation as there is no consistent evidence of benefit; however, the impact of HLA mismatching remains uncertain. We explored the effect of class I and II HLA mismatching on graft failure and mortality. A total of 1042 liver transplants performed at a single center between 1999 and 2016 with available HLA typing data were included. The median follow-up period was 9.38 years (interquartile range 4.9-14) and 350/1042 (33.6%) transplants resulted in graft loss and 280/1042 (26.9%) in death. Graft loss and mortality were not associated with the overall number of mismatches at HLA-A, HLA-B, HLA-C, HLA-DR, and HLA-DQ loci. However, graft failure and mortality were both increased in HLA mismatching on graft failure and mortality the presence of one (p = 0.004 and p = 0.01, respectively) and two (p = 0.01 and p = 0.04, respectively) HLA-A mismatches. Elevated hazard ratios for graft failure and death were observed with HLA-A mismatches in univariate and multivariate Cox proportional hazard models. Excess graft loss with HLA-A mismatch (138/940 [14.7%] mismatched compared with 6/102 [5.9%] matched transplants) occurred within the first year following transplantation (odds ratio 2.75; p = 0.02). Strikingly, transplants performed at a single all grafts lost due to hepatic artery thrombosis were in HLA-A-mismatched transplants (31/940 vs. 0/102), as were those lost due to sepsis (35/940 vs. 0/102). In conclusion, HLA-A mismatching was associated with increased graft loss and mortality. The poorer outcome for the HLA-mismatched group was due to hepatic artery thrombosis and sepsis, and these complications occurred exclusively with HLA-A-mismatched transplants. These data suggest that HLA-A mismatching is important for outcomes following liver transplant. Therefore, knowledge of HLA-A matching status may potentially allow for enhanced surveillance, clinical interventions in high-risk transplants or stratified HLA-A matching in high-risk recipients.
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Affiliation(s)
- Christopher Bricogne
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Neil Halliday
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Raymond Fernando
- The Anthony Nolan Research InstituteRoyal Free London NHS Foundation TrustLondonUK
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Brian R. Davidson
- UCL Division of Surgery and Interventional SciencesRoyal Free HospitalLondonUK
| | - Mark Harber
- Kidney UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Rachel H. Westbrook
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
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Rai V, Dietz NE, Agrawal DK. Immunological basis for treatment of graft versus host disease after liver transplant. Expert Rev Clin Immunol 2016; 12:583-93. [PMID: 26795873 DOI: 10.1586/1744666x.2016.1145056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Graft versus host disease (GVHD) after liver transplant, although a rare disease, has a very high mortality rate. GVHD occurs due to immunoreactions caused by donor T lymphocytes and host cell surface antigens resulting in proliferation and clonal expansion of T lymphocyte. Migration of effector cells, including macrophages, NK cells and cytotoxic T lymphocyte, to the target organs such as skin, intestine and bone marrow results in skin rashes, diarrhea and bone marrow depression. GVHD is diagnosed by clinical symptoms, histopathological findings and by the presence of chimerism. The delayed diagnosis, opportunistic infections and lack of definitive treatment of post orthotopic liver transplant (OLT)-GVHD results in sepsis and multi-organ failure leading to very low survival rates. In this review, we have focused on early diagnosis and critically discuss novel treatment modalities to decrease the incidence of GVHD.
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Affiliation(s)
- Vikrant Rai
- a Department of Clinical and Translational Science , Creighton University School of Medicine , Omaha , NE , USA
| | - Nicholas Edward Dietz
- b Department of Pathology , Creighton University School of Medicine , Omaha , NE , USA
| | - Devendra K Agrawal
- a Department of Clinical and Translational Science , Creighton University School of Medicine , Omaha , NE , USA
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Butts RJ, Savage AJ, Nietert PJ, Kavarana M, Moussa O, Burnette AL, Atz AM. Effect of human leukocyte antigen-C and -DQ matching on pediatric heart transplant graft survival. J Heart Lung Transplant 2014; 33:1282-7. [PMID: 25128416 DOI: 10.1016/j.healun.2014.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/25/2014] [Accepted: 07/16/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND A higher degree of human leukocyte antigen (HLA) matching at the A, B, and DR loci has been associated with improved long-term survival after pediatric heart transplantation in multiple International Society for Heart and Lung Transplantation registry reports. The aim of this study was to investigate the association of HLA matching at the C and DQ loci with pediatric graft survival. METHODS The United Network of Organ Sharing database was queried for isolated heart transplants that occurred from 1988 to 2012 with a recipient age of 17 or younger and at least 1 postoperative follow-up encounter. When HLA matching at the C or DQ loci were analyzed, only transplants with complete typing of donor and recipient at the respective loci were included. Transplants were divided into patients with at least 1 match at the C locus (C-match) vs no match (C-no), and at least 1 match at the DQ (DQ-match) locus vs no match (DQ-no). Primary outcome was graft loss. Univariate analysis was performed with the log-rank test. Cox regression analysis was performed with the following patient factors included in the model: recipient age, ischemic time; recipient on ventilator, extracorporeal membrane oxygenation, ventricular assist device, or inotropes at transplant; recipient serum bilirubin and creatinine closest to transplant, ratio of donor weight to recipient weight, underlying cardiac diagnosis, crossmatch results, transplant year, and HLA matching at the A, B, and DR loci. RESULTS Complete typing at the C locus occurred in 2,429 of 4,731 transplants (51%), and complete typing at the DQ locus occurred in 3,498 of 4,731 transplants (74%). Patient factors were similar in C-match and C-no, except for year of transplant (median year, 2007 [interquartile range, 1997-2010] vs year 2005 [interquartile range, 1996-2009], respectively; p = 0.03) and the degree of HLA matching at the A, B, and DR loci (high level of HLA matching in 11.9% vs 3%, respectively; p < 0.01). Matching at the C locus was not associated with a decreased risk of graft loss (median graft survival: 13.1 years [95% confidence interval {CI}, 11.5-14.8] in C-no vs 15.1 years [95% CI, 13.5-16.6) in C-match, p = 0.44 log-rank; hazard ratio, 0.93; 95% CI, 0.76-1.15; p = 0.52). DQ-match did not differ from DQ-no in any of the analyzed patient factors, except DQ-match was more likely to have high degree of matching at the A, B, and DR loci vs DQ-no (9.8% vs 3.2%, p < 0.01). Matching at the DQ locus was not associated with decreased risk of graft loss (median graft survival: DQ-no, 13.1 years [95% CI, 11.7-14.6) vs DQ-match, 13.0 years [95% CI, 11.4-14.6], p = 0.80, log-rank; hazard ratio, 0.95; 95% CI, 0.81-1.1; p = 0.51. CONCLUSIONS Complete typing at the C locus of both donor and recipient occurs less often then typing at the DQ locus. A higher degree of donor-recipient HLA matching at the C locus or the DQ locus appears not to confer any graft survival advantage.
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Affiliation(s)
- Ryan J Butts
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston South Carolina.
| | - Andrew J Savage
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston South Carolina
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston South Carolina
| | - Minoo Kavarana
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston South Carolina
| | - Omar Moussa
- Division of HLA Laboratory, Department of Pathology and Laboratory, Medical University of South Carolina, Charleston South Carolina
| | - Ali L Burnette
- Department of Transplant Services, Medical University of South Carolina, Charleston South Carolina
| | - Andrew M Atz
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston South Carolina
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Balan V, Ruppert K, Demetris AJ, Ledneva T, Duquesnoy RJ, Detre KM, Wei YL, Rakela J, Schafer DF, Roberts JP, Everhart JE, Wiesner RH. Long-term outcome of human leukocyte antigen mismatching in liver transplantation: results of the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Hepatology 2008; 48:878-88. [PMID: 18752327 DOI: 10.1002/hep.22435] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED A perfect or nearly perfect human leukocyte antigen (HLA) match has been associated with better immediate and long-term survival of diseased donor kidney transplants. However, the effect of HLA matching for hepatic allografts remains poorly defined. Using data from the National Institutes of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database, we investigated the association between HLA mismatches and hepatic allograft survival, disease recurrence, and immunosuppression interactions. A, B, and DR loci were used to calculate total mismatch scores of 0 (no mismatches in any loci) to 6 (mismatches in all loci). Seven hundred ninety-nine adults (male, 55%; female, 45%) underwent 883 liver transplants. The 10-year graft survival according to total mismatch score was as follows: 0-2, 60%; 3-4, 54%; and 5-6, 57%. There was a negative effect of mismatching at the A locus on patient survival, with shorter survival for patients with 1 or 2 mismatches compared with 0 mismatches [P = 0.05, hazard ratio (HR) = 1.6]. Patients on tacrolimus with 1 or 2 mismatches at B or DR loci appeared to have increased rates of patient and graft survival compared to patients with 0 mismatches, with the appearance of a protective effect of tacrolimus (HR = 0.67). The effect of HLA mismatching was more pronounced on certain disease recurrences. DR-locus mismatch increased recurrence of autoimmune hepatitis (P = 0.01, HR = 4.2) and primary biliary cirrhosis (P = 0.04, HR = 2). Mismatch in the A locus was associated with more recurrence of hepatitis C virus (P = 0.01, HR = 1.6) and primary sclerosing cholangitis (P = 0.03, HR = 2.9). CONCLUSION Mismatching at the A locus decreases patient survival in liver transplant recipients, and mismatching at the DR and A loci affects recurrence of autoimmune liver diseases and hepatitis C, respectively.
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Affiliation(s)
- Vijayan Balan
- Department of Transplantation Medicine, Mayo Clinic, Phoenix, AZ, USA
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Oo YH, Neuberger J. HLA and outcome in living donor liver transplantation in primary biliary cirrhosis: a new piece in the jigsaw? Liver Transpl 2007; 13:8-13. [PMID: 17192903 DOI: 10.1002/lt.20890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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