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Zhang J, Zhang H, Wang Z, Yang H, Chen H, Cheng H, Zhou J, Zheng M, Tan R, Gu M. BTLA suppress acute rejection via regulating TCR downstream signals and cytokines production in kidney transplantation and prolonged allografts survival. Sci Rep 2019; 9:12154. [PMID: 31434927 PMCID: PMC6704067 DOI: 10.1038/s41598-019-48520-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 08/01/2019] [Indexed: 12/23/2022] Open
Abstract
Acute rejection is a major risk for renal transplant failure. During this adverse process, activated T cells are considered the main effectors. Recently, B and T lymphocyte attenuator (BTLA), a member of the CD28 family receptor, was reported to be a novel inhibitory regulator of T cell activation in heart and pancreatic allograft rejection. Due to the similarity of acute rejection pathways among different organs, we hypothesized that BTLA might play a role in acute rejection of kidney transplant. In renal transplant patients, we observed that BTLA expression was significantly decreased in peripheral CD3+ T lymphocytes of biopsy-proven acute rejection (BPAR) recipients compared with control patients with stable transplanted kidney functions. Remarkably, overexpression of BTLA in the rat model was found to significantly inhibit the process of acute rejection, regulate the postoperative immune status, and prolong allograft survival. BTLA overexpression significantly suppressed IL-2 and IFN-γ production and increased IL-4 and IL-10 production both in vivo and in vitro. Moreover, vital factors in T-cell signaling pathways, including mitogen-associated protein kinases (MAPK), nuclear factor-kappa B (NF-κB) and nuclear factor of activated T cells (NFAT), were also significantly repressed by BTLA overexpression. Therefore, BTLA can suppress acute rejection and regulate allogeneic responses of kidney transplant by regulating TCR downstream signals and inflammatory cytokines production to improve allografts outcomes.
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Affiliation(s)
- Jiayi Zhang
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hengcheng Zhang
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zijie Wang
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Haiwei Yang
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hao Chen
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hong Cheng
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jiajun Zhou
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ming Zheng
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ruoyun Tan
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Min Gu
- Department of Urology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Palchevskiy V, Xue YY, Kern R, Weigt SS, Gregson AL, Song SX, Fishbein MC, Hogaboam CM, Sayah DM, Lynch JP, Keane MP, Brooks DG, Belperio JA. CCR4 expression on host T cells is a driver for alloreactive responses and lung rejection. JCI Insight 2019; 5:121782. [PMID: 31085832 PMCID: PMC6629140 DOI: 10.1172/jci.insight.121782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/08/2019] [Indexed: 12/16/2022] Open
Abstract
Despite current immunosuppressive strategies, long-term lung transplant outcomes remain poor due to rapid allogenic responses. Using a stringent mouse model of allo-airway transplantation, we identify the CCR4-ligand axis as a central node driving secondary lymphoid tissue homing and activation of the allogeneic T cells that prevent long-term allograft survival. CCR4 deficiency on transplant recipient T cells diminishes allograft injury and when combined with CTLA4-Ig leads to an unprecedented long-term lung allograft accommodation. Thus, we identify CCR4-ligand interactions as a central mechanism driving allogeneic transplant rejection and suggest it as a potential target to enhance long-term lung transplant survival.
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Affiliation(s)
- Vyacheslav Palchevskiy
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Ying Ying Xue
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Rita Kern
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Stephen S. Weigt
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Aric L. Gregson
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Sophie X. Song
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Michael C. Fishbein
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Cory M. Hogaboam
- Pulmonary & Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David M. Sayah
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Joseph P. Lynch
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Michael P. Keane
- University College Dublin School of Medicine, Respiratory Medicine, St Vincent’s University Hospital, Dublin, Ireland
| | - David G. Brooks
- Princess Margaret Cancer Center, University Health Network and Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - John A. Belperio
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
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Aktas S, Colak T, Baskin E, Sevmis S, Ozdemir H, Moray G, Karakayali H, Haberal M. Comparison of Basiliximab and Daclizumab With Triple Immunosuppression in Renal Transplantation. Transplant Proc 2011; 43:453-7. [DOI: 10.1016/j.transproceed.2011.01.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pourmand G, Saraji A, Salem S, Mehrsai A, Nikoobakht MR, Taherimahmoudi M, Rezaeidanesh M, Asadpour A. Could prophylactic monoclonal antibody improve kidney graft survival? Transplant Proc 2009; 41:2794-6. [PMID: 19765437 DOI: 10.1016/j.transproceed.2009.07.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study was designed to evaluate the impact of daclizumab monoclonal antibody on early and late kidney graft survival. MATERIALS AND METHODS From 2007 to 2008, 57 kidney transplant recipients were followed for a mean of 9.3 months. Twenty-three patients received 1 mg/kg daclizumab 24 hours before and 14 days after transplantation. In contrast, 34 patients (controls) did not receive daclizumab. The same immunosuppressive protocol was administered to all participants: oral prednisolone, mycophenolate mofetil, and cyclosporine. Delayed graft function (DGF), acute rejection, prednisolone pulses and/or antithymoglobulin (ATG), cytomegalovirus (CMV) infection, urinary tract infection (UTI), as well as early and late graft function were compared between the two groups. RESULTS The mean age in cases and controls was 39.7 and 37.1 years, respectively. The occurrence of DGF was 4% versus 3%; reversible acute rejection, 16% versus 14.5%, and irreversible acute rejection 0% versus 9% (P < .05) for treated versus control groups, respectively. ATG was used in 21% versus 23%, and pulse prednisolone 26% versus 20%, respectively. In case and control groups, the mean creatinine levels were 1.4 mg/dL versus 1.35 mg/dL at discharge. At last follow-up, it was 1.35 mg/dL versus 1.2 mg/dL, respectively. CMV infection occurred in 30% versus 35%, and UTI in 17% versus 19% of treated versus controls, respectively. CONCLUSION The prophylactic administration of daclizumab improved early graft survival and prevented irreversible acute rejection.
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Affiliation(s)
- G Pourmand
- Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Lerut J, Bonaccorsi-Riani E, Finet P, Gianello P. Minimization of steroids in liver transplantation. Transpl Int 2009; 22:2-19. [PMID: 19121145 DOI: 10.1111/j.1432-2277.2008.00758.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Because of the markedly improved short-term results of liver transplantation (LT) and persistently high number of long-term complications, the attention of transplant physicians should be focused on minimizing immunosuppressive therapy as much as possible. Steroid-based immunosuppression is responsible for a substantial post-LT morbidity and mortality, hence, minimization of its use is of utmost importance to improve the quality of life of the successfully transplanted liver recipient. This literature review shows that LT can be performed safely with steroid-minimal immunosuppression without compromising graft and patient survival. The tendency in clinical practice is to move more and more from steroid withdrawal to steroid avoidance protocols.
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Affiliation(s)
- Jan Lerut
- Department of Abdominal and Transplantation Surgery, Université catholique de Louvain, Brussels, Belgium.
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Park JB, Kim SJ, Oh HY, Han YS, Kim DJ, Park JW, Kwon CH, Joh JW, Lee SK. Steroid withdrawal in living donor renal transplant recipients using tacrolimus and cyclosporine: a randomized prospective study*. Transpl Int 2006; 19:478-84. [PMID: 16771869 DOI: 10.1111/j.1432-2277.2006.00303.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Steroids have been a mainstay of immunosuppressive regimens in renal transplantation despite their adverse effects. The introduction of new immunosuppressant has improved the survival rates and prompted trials of steroid withdrawal. We conducted a randomized prospective study to compare steroid withdrawal at 6 months post-transplant between tacrolimus + mycophenolate mofetil (MMF) (FK group) versus cyclosporine A + MMF (CsA group). Steroid was withdrawn at 6 months post-transplant under the condition of no rejection episode proven by biopsy and maintenance of serum creatinine level <2.0 mg/dl. Fourteen recipients were excluded because of acute rejection within 6 months or protocol violation. Steroid could be tapered off in 62 in FK group and 55 in CsA. Three cases in FK group and five in CsA had acute rejection within another 6 months after steroid withdrawal (P > 0.05). At 12 months, the incidence of post-transplant diabetes was 18.6% vs. 8.0% in FK and CsA group. And hypercholesterolemia was presented in 8.5% vs. 2.0%, hypertension in 47.5% vs. 56.0%, and serum creatinine level 1.18 +/- 0.24 mg/dl vs. 1.18 +/- 0.20 mg/dl, respectively (P > 0.05). Steroid withdrawal may be carried out successfully using both FK and CsA with MMF, but long-term follow-up is necessary.
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Affiliation(s)
- Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
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Kumar MSA, Xiao SG, Fyfe B, Sierka D, Heifets M, Moritz MJ, Saeed MI, Kumar A. Steroid avoidance in renal transplantation using basiliximab induction, cyclosporine-based immunosuppression and protocol biopsies. Clin Transplant 2005; 19:61-9. [PMID: 15659136 DOI: 10.1111/j.1399-0012.2004.00298.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Reducing chronic steroid exposure is important to minimize steroid-related morbidity, particularly for susceptible renal transplant recipients. Steroid-free and steroid-sparing protocols have shown benefits, but safety has not been established for all populations. We investigated the safety of steroid avoidance (SA) in a population including African-Americans, using modern immunosuppression with protocol biopsy monitoring. METHODS A randomized-controlled SA trial (early discontinuation, days 2-7) was conducted in a population (n = 77) including African-Americans and cadaveric kidney recipients. Patients received basiliximab, cyclosporine (CsA), and mycophenolate mofetil (MMF). In controls, steroids were tapered to 5 mg prednisone/d by day 30. Protocol biopsies were performed (1, 6, 12 and 24 months) to evaluate subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). RESULTS The SA did not result in significantly higher incidences of graft loss, AR, SCAR, CAN, or renal fibrosis. SA patients experienced similar renal function, comparable serum lipid levels, and a trend toward fewer cases of new-onset diabetes. Clinical outcomes of African-American and non-African-American patients did not significantly differ. CONCLUSIONS The SA is safe in the context of basiliximab induction and CsA-based immunosuppression. This protocol could minimize steroid-related side effects in susceptible groups, including African-Americans, without increasing the risk of AR or graft failure.
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Affiliation(s)
- Mysore S Anil Kumar
- Department of Surgery, Hahnemann University Hospital and Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Abstract
This review of immunosuppression in renal transplantation has allowed us to highlight the deleterious effect of calcineurin inhibitor nephrotoxicity and to emphasise the importance of sirolimus. Now, a whole new set of possibilities has opened up in immunosuppression: sirolimus-based immunosuppression without calcineurin inhibitors; sirolimus in combination with calcineurin inhibitors in reduced doses; early calcineurin inhibitor withdrawal from a regimen that combines sirolimus, calcineurin inhibitors and steroids; and calcineurin inhibitor conversion to sirolimus when the first signs of graft nephrotoxicity appear. These new strategies in immunosuppression in renal transplantation are associated with good results in graft and patient survival in year 1, and with better renal function. Therefore, we can hope for better long-term results in transplantation, with a significant increase in the graft half-life and in the patient survival.
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Affiliation(s)
- Alfredo Mota
- Hospitais da Universidade de Coimbra, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal.
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Pawlik A, Florczak M, Bak L, Dabrowska-Zamojcin E, Rozanski J, Domanski L, Gawronska-Szklarz B. The FcgammaRIIa polymorphism in patients with chronic kidney graft rejection. Transplant Proc 2005; 36:1311-3. [PMID: 15251320 DOI: 10.1016/j.transproceed.2004.05.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The FcgammaRIIa receptors, which provide a crucial link between cellular and humoral components of the immune response, display allelic polymorphism. Individuals are homozygous for either arginine 131 (RR131) or histidine 131 (HH131) or are heterozygous for these two alleles (RH131). The HH131 genotype binds human IgG2 with high RR131 with low, and RH131 with intermediate affinity. The aim of the study was to evaluate the FcgammaRIIa polymorphism in patients with chronic kidney graft rejection. The study included 121 renal transplant recipients: 53 patients with long-term stable graft function and 68 with chronic allograft rejection. The distribution of FcgammaRIIa genotypes in patients with chronic kidney graft rejection did not differ significantly from that in patients with stable graft function. The results suggest that the FcgammaRIIa polymorphism is not an important genetic risk factor for chronic rejection of kidney allografts.
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Affiliation(s)
- A Pawlik
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Pomeranian Medical University, Szczecin, Poland
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10
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Pawlik A, Domanski L, Rozanski J, Florczak M, Wrzesniewska J, Dutkiewicz G, Dabrowska-Zamojcin E, Gawronska-Szklarz B. The cytokine gene polymorphisms in patients with chronic kidney graft rejection. Transpl Immunol 2005; 14:49-52. [PMID: 15814282 DOI: 10.1016/j.trim.2004.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 12/01/2004] [Accepted: 12/01/2004] [Indexed: 11/24/2022]
Abstract
Chronic allograft rejection remains an important cause of morbidity after kidney transplantation. The aim of the study was to examine the association between IL-2, IL-6 and TNF-alpha promoter polymorphisms and chronic kidney allograft rejection. The study included 64 patients with long-term stable graft function and 62 with chronic allograft nephropathy. Among patients with chronic allograft nephropathy a statistically significant prevalence of the IL-6 CC genotype associated with low IL-6 expression was observed (p < 0.01, OR 3.18; 95% CI 1.27-8.15). There were no statistically significant differences in distribution of IL-2 and TNF-alpha genotypes between patients with stable graft function and chronic allograft rejection. The results of present study suggest that the genetically determined low IL-6 production may be the risk factor of chronic allograft nephropathy development.
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Affiliation(s)
- A Pawlik
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Pomeranian Medical University, 70-111 Szczecin, Powst. Wielkopolskich 72, Poland.
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11
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Pawlik A, Florczak M, Masiuk M, Dutkiewicz G, Machalinski B, Rozanski J, Domanski L, Gawrońska-Szklarz B. The expansion of CD4+CD28- T cells in patients with chronic kidney graft rejection. Transplant Proc 2004; 35:2902-4. [PMID: 14697933 DOI: 10.1016/j.transproceed.2003.10.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
CD4+CD28- T cells are oligoclonal lymphocytes rarely found in healthy subjects, but are present in high frequencies in patients with inflammatory diseases. Contrary to paradigm, they are functionally active and produce interferon gamma and cytolytic proteins, are cytotoxic in vessels and may contribute to tissue damage. The size of the peripheral blood CD4+CD28- T cell compartments was determined in 20 healthy individuals, 20 patients after renal transplantation with stable graft function, and 20 with chronic graft rejection by two-color FACS analysis. In patients with stable graft function, the median frequency of CD4+CD28- T cells was 3.1% and was significantly higher in comparison to the control group (1.4%) (P <.01). The highest subset CD4+CD28- cells was detected in patients with chronic graft rejection (10.65%). The amount of CD4+CD28- cells was significantly higher in this group in comparison to patients with stable graft function (P <.01). The evaluated number of CD4+CD28- cells in patients after renal transplantation, especially in graft recipients with chronic graft rejection, suggests a role of these cells in chronic graft destruction.
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Affiliation(s)
- A Pawlik
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Pomeranian University of Medicine, Al Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland.
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12
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Aiello FB, Calabrese F, Rigotti P, Furian L, Marino S, Cusinato R, Valente M. Acute rejection and graft survival in renal transplanted patients with viral diseases. Mod Pathol 2004; 17:189-96. [PMID: 14657951 DOI: 10.1038/modpathol.3800033] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Transplanted patients are susceptible to viral infections; thus, the aim of this study was to evaluate the features of acute rejections and the outcome of the renal graft in transplanted patients with herpes virus diseases. Renal biopsies from 30 renal transplanted patients undergoing early acute rejection (type IA and IB according to the Banff 97 classification) were evaluated. In total, 15 of these patients experienced cytomegalovirus (CMV) or Epstein-Barr virus disease within the first year following transplantation (group I) and 15 patients showed no evidence of viral infection (group II). No significant differences between the groups in terms of age, male/female ratio, living/cadaveric donor ratio, cold ischemia time, HLA A-B matching, pretransplant panel reactive antibody test, occurrence of post-transplant tubular necrosis, plasma levels of cyclosporin A and mean percent increase of serum creatinine at the time of the biopsy were observed. In group I biopsies, the mean number of interstitial plasma cells, as well as the mean number of CD79a-positive cells (B lymphocytes and plasma cells) was significantly higher than in group II (P<0.01 and <0.01, respectively). There was a positive correlation between the number of infections and the number of plasma cells (P<0.05). In transplanted patients, CMV can trigger the formation of anti-endothelial cell antibodies, which have been proposed to play a role in antibody-mediated rejections. We investigated whether a deposition of C4d, a marker of antibody-mediated reactions, was present in renal peritubular capillaries. In group I C4d deposition was found in five cases, while in group II it was not observed (P<0.05). In group I, 7/15 patients developed chronic allograft nephropathy vs 1/15 patients in group II (P<0.05). The estimated 1-, 5- and 8-year cumulative graft survival rates were 80, 66 and 57%, respectively, in group I, while in group II the estimated 8-year cumulative survival rate was 100% (P<0.05). In conclusion, acute rejection biopsies of patients with viral infections displayed plasma cell infiltrates and, in several cases, C4d deposition. Our study suggests a role of B lymphocytes in the pathology of these rejections and confirms the association between viral infections and poor graft survival.
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Affiliation(s)
- Francesca B Aiello
- Department of Oncology and Neuroscience, University of Chieti, Chieti, Italy
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Jurewicz WA, Miles A. Strategies for ensuring effective surveillance in post-transplant patients: practical organization and clinical evaluation. J Eval Clin Pract 2004; 10:37-56. [PMID: 14731150 DOI: 10.1111/j.1365-2753.2003.00408.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Results of renal transplantation have improved steadily over the years. This article reviews the current status of patient and graft survival and discusses major causes of mortality and renal allograft failure. Review of recent literature demonstrates that the traditional enemies of transplantation, acute rejection and opportunistic infections are no longer major problems facing transplantation. Chronic graft nephropathy and death with functioning graft due to cardiovascular disease are the main challenges in the current era. An impact of an early graft thrombosis, recurrent renal disease and post-transplant malignancies are also reviewed. Chronic graft nephropathy is examined in a context of differences between two calcineurin inhibitors, cyclosporin microemulsion and tacrolimus. Strategies of post-transplant surveillance are suggested.
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Affiliation(s)
- W Adam Jurewicz
- Department of Surgery, University of Wales College of Medicine, Cardiff, UK.
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14
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Abstract
Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.
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Affiliation(s)
- Mark R Benfield
- Division of Pediatric Nephrology, University of Alabama at Birmingham, 1600 7th Avenue S-ACC 516, Birmingham, AL 35233, USA.
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15
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Humar A, Khwaja K, Ramcharan T, Asolati M, Kandaswamy R, Gruessner RWG, Sutherland DER, Gruessner AC. Chronic rejection: the next major challenge for pancreas transplant recipients. Transplantation 2003; 76:918-23. [PMID: 14508354 DOI: 10.1097/01.tp.0000079457.43199.76] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE With newer immunosuppressive agents, acute rejection and graft loss resulting from acute rejection have become less common for pancreas transplant recipients. As long-term graft survival rates have improved, an increasing number of grafts are being lost to chronic rejection (CR). We studied the incidence of CR and identified risk factors. METHODS We retrospectively analyzed all cadaver pancreas transplants performed at the University of Minnesota between June 19, 1994, and December 31, 2002. We determined the causes of graft loss, the incidence of graft loss to CR and, using multivariate techniques, the major risk factors for CR. RESULTS A total of 914 cadaver pancreas transplants were performed in the following three categories: simultaneous pancreas-kidney (SPK) (n=321), pancreas after kidney (PAK) (n=389), and pancreas transplant alone (PTA) (n=204). The mean recipient age was 41.3 years and the mean donor age was 30.1 years. Of the 914 pancreas grafts, 643 (70.3%) continue to function (mean length of follow-up, 39 months). The most common cause of graft loss was technical failure, accounting for 118 (12.9%) of the failed grafts. The second most common cause was CR, accounting for 80 (8.8%) of the failed grafts. The incidence of graft loss to CR was highest for PTA (n=23 [11.3%]) and PAK (n=45 [11.6%]) recipients and lowest for SPK recipients (n=12 [3.7%]) (P=0.002). By multivariate analysis, the most significant risk factors for graft loss to CR were a previous episode of acute rejection (relative risk [RR]=4.41, P<0.0001), an isolated (vs. simultaneous) transplant (PAK or PTA [vs. SPK], RR=3.02, P=0.002), cytomegalovirus infection posttransplant (RR=2.41, P=0.001), a retransplant (versus primary transplant) (RR=2.27, P=0.004), and one or two (vs. zero) antigen mismatches at the B loci (RR=1.68, P=0.04). CONCLUSIONS As short-term pancreas transplant results improve and as isolated (PAK or PTA) pancreas transplants gain in popularity, CR will become increasingly common as a cause of pancreas graft loss.
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Affiliation(s)
- Abhinav Humar
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA.
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16
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Mota A, Figueiredo A, Cunha MF, Bastos M, Pratas J, Furtado L. Risk factors for acute rejection in 806 cyclosporine-treated renal transplants: a multivariate analysis. Transplant Proc 2003; 35:1061-3. [PMID: 12947856 DOI: 10.1016/s0041-1345(03)00306-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A Mota
- Department of Urology and Transplantation, Coimbra University Hospital, 3049 Coimbra, Portugal
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18
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Park YH, Lee JN, Min SK, Lee WK, Joo KW, Cha MK, Lee YD. Clinical outcome of living unrelated donor kidney transplantation. Transplant Proc 2003; 35:152-3. [PMID: 12591344 DOI: 10.1016/s0041-1345(02)03965-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Y H Park
- Department of Surgery, Gachon Medical School, Gil Medical Center, Inchon, South Korea
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Pawlik A, Florczak M, Bak L, Dutkiewicz G, Pudlo A, Gawronska-Szklarz B. The correlation between FcgammaRIIA polymorphism and renal allograft survival. Transplant Proc 2002; 34:3138-9. [PMID: 12493400 DOI: 10.1016/s0041-1345(02)03584-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A Pawlik
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Szczecin, Poland.
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Cainelli F, Vento S. Infections and solid organ transplant rejection: a cause-and-effect relationship? THE LANCET. INFECTIOUS DISEASES 2002; 2:539-49. [PMID: 12206970 DOI: 10.1016/s1473-3099(02)00370-5] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although evidence is far from being conclusive, several studies have suggested that infections could trigger rejection in different transplant settings. In this review we examine the evidence linking cytomegalovirus (CMV), adenovirus, enterovirus, parvovirus, and herpes simplex virus infections to the vasculopathy leading to cardiac allograft rejection, the association between CMV and chronic kidney, lung, and liver graft rejection, and the association of human herpesvirus 6 reactivation with CMV-related disease in kidney and liver transplant recipients. We also review the numerous antiviral prophylactic or pre-emptive treatments in use to control CMV infection, and suggest that they do not limit immune reactions leading to graft rejection or lower the risk of developing post-transplantation atherosclerosis in allograft recipients. Finally, we emphasise the need for prospective, international studies to clarify the role of infections in transplant rejection, to look at virus-to-virus interactions, and to establish specific therapeutic strategies. Such strategies must not rely exclusively on expensive antiviral agents but also on vaccination or other, innovative approaches, such as the use of agents able to inhibit the activity of natural killer cells, which might have an important role in acute allograft rejection.
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Affiliation(s)
- Francesca Cainelli
- Section of Infectious Diseases, Department of Pathology, University of Verona, Verona, Italy.
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Matas AJ, Humar A, Gillingham KJ, Payne WD, Gruessner RWG, Kandaswamy R, Dunn DL, Najarian JS, Sutherland DER. Five preventable causes of kidney graft loss in the 1990s: a single-center analysis. Kidney Int 2002; 62:704-14. [PMID: 12110036 DOI: 10.1046/j.1523-1755.2002.00491.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite improvements in immunosuppressive protocols and patient care, kidney allografts continue to fail. We studied causes of graft loss for primary kidney transplants in the 1990s to determine major causes and potential interventions. METHODS Causes of graft loss were reviewed for 1467 primary kidney transplants done at our institution between January 1, 1990, and December 31, 1999. Graft loss for that entire population was studied and then the causes of loss selectively examined at <1 year, 1 to 5 years, and>5 years post-transplant. Finally, causes of loss in the 1990s versus the 1980s were compared. RESULTS Five major causes of graft loss were noted in the 1990s: thrombosis, acute rejection (either alone or combined with delayed graft function or infection), chronic rejection, death with function, and noncompliance. In the first year post-transplant, thrombosis (25%) and death with function (41%) were the major causes of graft loss. After the first year, chronic rejection and death with function predominated. For recipients dying with graft function, cardiovascular disease was the major cause of death. CONCLUSIONS This study identified the five major causes of kidney graft loss in the 1990s. Different interventions are required to decrease loss from each of these causes. Future research needs to be directed at such interventions.
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Affiliation(s)
- Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Sun H, Woodward JE, Subbotin VM, Kuddus R, Logar AJ, Schaefer AT, Aitouche A, Rao AS. Use of recombinase activation gene-2 deficient mice to ascertain the role of cellular and humoral immune responses in the development of chronic rejection. J Heart Lung Transplant 2002; 21:738-50. [PMID: 12100900 DOI: 10.1016/s1053-2498(02)00393-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Given its multifactorial etiology, the relative contribution of anti-donor cellular and humoral immune responses in the pathogenesis of chronic rejection is as yet ambiguous. We hypothesized that alloreactive T and B cells play a seminal role in the development of this lesion. METHODS To address this hypothesis, RAG-2(-/-) mice were used as donors and recipients in a well-established murine model of aortic transplantation. Grafts were transplanted across the following groups: Group I: C3H --> C3H; Group II: Wild-type [WT] 129Sv (H-2(b)) --> C3H (H-2(k)); Group III: C3H --> WT 129Sv; Group IV: 129SvEv RAG-2(-/-) --> C3H; and Group V: C3H --> 129SvEv RAG-2(-/-). Grafts were harvested at d40 to 146 post-transplantation for morphologic and immunohistochemical analyses and semi-quantitative RT-PCR was employed to evaluate the intragraft mRNA expression of various immune mediators. Mixed lymphocyte reaction and complement-mediated alloantibody cytotoxicity assays were performed to determine anti-donor proliferative and humoral responses, respectively. RESULTS Unlike that across the syngeneic combination (Group I), marked intimal thickening with corresponding luminal narrowing was observed in the majority of the aortic allografts (Groups II-IV). On the contrary, the morphology of C3H aortic allografts harvested from the majority of the RAG-2(-/-) was remarkably preserved. Correspondingly, anti-donor proliferative and humoral immune responses were undetectable in C3H --> RAG-2(-/-) recipients as was the intragraft mRNA expression of the Th(1) and the Th(2)-type cytokines. CONCLUSIONS Taken together, these data suggest that in this murine model of aortic allotransplantation, donor-specific cellular and humoral responses play a dominant role in the initiation and perpetuation of chronic rejection.
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Affiliation(s)
- Hong Sun
- Department of Surgery, Section of Cellular Transplantation, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA
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Tejani A, Ho PL, Emmett L, Stablein DM. Reduction in acute rejections decreases chronic rejection graft failure in children: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Am J Transplant 2002; 2:142-7. [PMID: 12099516 DOI: 10.1034/j.1600-6143.2002.020205.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chronic rejection accounted for 32% of all graft losses in 7123 pediatric transplants. In a previous study acute, multiple acute and late acute rejections were risk factors for the development of chronic rejection. We postulated that the recent decrease in acute rejections would translate into a lower risk for chronic rejection among patients with recent transplants. We reviewed our data on patients transplanted from 1995 to 2000, and using multivariate analysis and a proportional hazards model developed risk factors for patients whose grafts had failed due to chronic rejection. A late initial rejection increased the risk of chronic rejection graft failure 3.6-fold (p < 0.001), while a second rejection resulted in further increase of 4.2-fold (p < 0.001). Recipients who received less than 5 mg/kg of cyclosporine at 30 days post-transplant had a relative risk (RR) of 1.9 (p = 0.02). Patients transplanted from 1995 to 2000 had a significantly lower risk (RR = 0.54, p < 0.001) of graft failure from chronic rejection than those who received their transplants earlier (1987-94). Since we were able to demonstrate that there is a decreased risk of chronic rejection graft failure in our study cohort, we would conclude that the goal of future transplants should be to minimize acute rejections.
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Affiliation(s)
- Amir Tejani
- Department of Pediatrics and Surgery, New York Medical College, Valhalla, USA.
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Serón D, Moreso F. Protocol biopsies and risk factors associated with chronic allograft nephropathy. Transplant Proc 2002; 34:331-2. [PMID: 11959311 DOI: 10.1016/s0041-1345(01)02786-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- D Serón
- Nephrology Department, Ciutat Sanitària i Universitària de Bellvitge, L'Hospitalet, Barcelona, Spain
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Matas AJ, Ramcharan T, Paraskevas S, Gillingham KJ, Dunn DL, Gruessner RW, Humar A, Kandaswamy R, Najarian JS, Payne WD, Sutherland DE. Rapid discontinuation of steroids in living donor kidney transplantation: a pilot study. Am J Transplant 2001; 1:278-83. [PMID: 12102262 DOI: 10.1034/j.1600-6143.2001.001003278.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED Steroids are associated with significant postoperative complications (hypertension, cosmetic changes, bone loss, hyperlipidemia, diabetes, and cataracts). Most develop early; in addition, late post-transplant steroid withdrawal in kidney transplant recipients has been associated with increased acute rejection (AR). To obviate these problems, we studied outcome of a protocol of rapid discontinuation of prednisone (RDS) (steroids stopped on POD6). Between November 1, 1999 and October 31, 2000, 51 adult living donor (LD) first transplant recipients (2 HLA-id, 28 non-id relative, 21 LURD) were immunosuppressed with thymoglobulin (1.25 mg/kg intraoperatively and then qdx4); prednisone (P) (500 mg methylprednisolone intraoperatively, 1 mg/kg x 1 day, 0.5 mg/kg x 2 days, 0.25 mg/kg x 2 days, then d/c); MMF, 1 g b.i.d.; and CSA, 4 mg/kg b.i.d. adjusted to achieve levels of 150-200 ng/mL (by HPLC). Exclusion criteria were delayed graft function or primary disease requiring P. Minimum follow-up was 5.5 months (range 5.5 to 17.5 months). Outcome was compared vs. previous cohorts of LD recipients immunosuppressed with P/AZA/CSA (n = 171) or P/MMF/CSA (n = 43) (both without antibody induction). RESULTS For the RDS group, average CSA level (+/- S.E.) at 3 and 6 months was 190 +/- 12 and 180 +/- 9; avg. MMF dose, 1.7 +/- 0.1 g and 1.7 +/- 0.1 g. There was no significant difference in 6- and 12-month actuarial patient survival, graft survival and rejection-free graft survival between recipients on the RDS protocol vs. historical controls. For RDS recipients, actuarial 6- and 12-month rejection-free graft survival was 87%. Of the 51 RDS recipients, five (10%) have had AR (at 20 days, 1 month, 3 months, 3 months, and 3.5 months post-transplant). After treatment, all five were maintained on 5 mg P; there have been no second AR episodes. Two additional recipients were started on 5 mg P due to low white blood count (WBC) and low/no MMF. Of the 51 grafts, one has failed (death with function). Average serum Cr level (+/- S.E.) at 3 and 6 months for RDS recipients was 1.7 +/- 0.5 (NS vs. historical controls). CONCLUSION For low-risk LD recipients, a kidney transplant with an RDS protocol does not increase risk of AR or graft loss. Future studies will need to be done to assess AR rates with an RDS protocol in cadaver transplant recipients and in recipients with delayed graft function.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA.
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de Haan A, van den Berg AP, van der Bij W, Hepkema BG, Bruin-van Dijk E, van der Gun I, Lems SP, Slooff MJ, Haagsma EB, de Leij LF, Prop J. Rapid decreases in donor-specific cytotoxic T lymphocyte precursor frequencies and graft outcome after liver and lung transplantation. Transplantation 2001; 71:785-91. [PMID: 11330543 DOI: 10.1097/00007890-200103270-00017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A decrease in donor-specific T cell precursor frequencies as seen late, one or more years, after transplantation is assumed to reflect transplantation tolerance, a condition important for long term acceptance of the allograft. However, such late decreases also occur in recipients that developed chronic transplant dysfunction questioning its relevance in transplantation tolerance. We investigated whether early, i.e., the first 6 months, decreases in donor-specific T cell precursor frequencies reflect transplantation tolerance and predict graft outcome after liver and lung transplantation. METHODS Donor and third party specific cytotoxic (CTLp) and helper T lymphocyte precursor (HTLp) frequencies were analyzed in pretransplant and 1 (or 2) and 6-month blood samples taken from liver and lung recipients and were correlated with graft outcome. RESULTS In liver allograft recipients with good graft function (n=7), mean donor-specific CTLp frequencies decreased as early as 1 month after transplantation and remained low thereafter. In contrast, mean CTLp frequencies did not decrease in liver allograft recipients with chronic transplant dysfunction (n=6). In lung allograft recipients, donor-specific CTLp frequencies remained relatively high and frequencies were not different between recipients without (n=6) or with (n=6) chronic transplant dysfunction. Donor-specific HTLp frequencies did not change significantly after liver or lung transplantation and did not differ between recipients without or with chronic transplant dysfunction. CONCLUSIONS An early decrease in donor-specific CTLp correlates with good graft outcome after liver transplantation. Such rapid decreases in alloreactivity do not occur after lung transplantation illustrating the unique capacity of liver allografts to induce transplantation tolerance.
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Affiliation(s)
- A de Haan
- Department of Gastroenterology and Hepatology, University Hospital Groningen, and Groningen University, The Netherlands
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Humar A, Payne WD, Sutherland DE, Matas AJ. Clinical determinants of multiple acute rejection episodes in kidney transplant recipients. Transplantation 2000; 69:2357-60. [PMID: 10868640 DOI: 10.1097/00007890-200006150-00024] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recipients with multiple (more than one) acute rejection (AR) episodes have significantly lower graft survival rates than those with no AR or only one treated episode. However, fewer than 50% of recipients treated for one AR episode will have another episode. METHODS We studied recipients with at least one AR episode to determine whether any clinical features could identify risk factors for multiple AR. RESULTS Between January 1, 1984, and June 30, 1997, a total of 1793 recipients underwent a kidney transplant at our institution. Of these, 354 were treated for one AR episode, 307 for more than one. By multivariate analysis, recipients at highest risk for multiple AR episodes were those with initial delayed or slow graft function (relative risk=1.5, P=0.05), those with initially severe AR (as judged by vascular involvement or steroid resistance), and those with an initial early AR episode (<6 months posttransplant). The remaining variables tested were not significant. Graft survival in recipients with more than one AR episode was significantly lower than in those with only one AR episode. Graft survival at 5 years posttransplant was 52.5% in recipients with more than one AR episode and 85.1% in recipients with one AR episode (P=0.0001). Chronic rejection as a cause of graft loss was significantly more common in recipients with more than one vs. only one AR episode (34.8% vs. 8.9%, P=0.001). CONCLUSION Clinical features may be used to identify recipients at higher risk for multiple AR episodes. These recipients can then be targeted with more aggressive or novel immunosuppressive regimens in an attempt to reduce the likelihood of another AR episode.
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Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Humar A, Durand B, Gillingham K, Payne WD, Sutherland DE, Matas AJ. Living unrelated donors in kidney transplants: better long-term results than with non-HLA-identical living related donors? Transplantation 2000; 69:1942-5. [PMID: 10830235 DOI: 10.1097/00007890-200005150-00033] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Given the severe organ shortage and the documented superior results obtained with living (vs. cadaver) donor kidney transplants, we have adopted a very aggressive policy for the use of living donors. Currently, we make thorough attempts to locate a living related donor (LRD) or a living unrelated donor (LURD) before proceeding with a cadaver transplant. METHODS We compared the results of our LURD versus LRD transplants to determine any significant difference in outcome. RESULTS Between 1/1/84 and 6/30/98, we performed 711 adult kidney transplants with non-HLA-identical living donors. Of these, 595 procedures used LRDs and 116 used LURDs. Immunosuppression for both groups was cyclosporine-based, although LURD recipients received 5-7 days of induction therapy (antilymphocyte globulin or antithymocyte globulin), whereas LRD recipients did not. LURD recipients tended to be older, to have inferior HLA matching, and to have older donors than did the LRD recipients (all factors potentially associated with decreased graft survival). Short-term results, including initial graft function and incidence of acute rejection, were similar in the two groups. LURD recipients had a slightly higher incidence of cytomegalovirus disease (P=NS). We found no difference in patient and graft survival rates. However, the incidence of biopsy-proven chronic rejection was significantly lower among LURD recipients (16.7% for LRD recipients and 10.0% for LURD recipients at 5 years posttransplant; P=0.05). LRD recipients also had a greater incidence of late (>6 months posttransplant) acute rejection episodes than did the LURD recipients (8.6% vs. 2.6%, P=0.04). The exact reason for these findings is unknown. CONCLUSION Although LURD recipients have poorer HLA matching and older donors, their patient and graft survival rates are equivalent to those of non-HLA-identical LRD recipients. The incidence of biopsy-proven chronic rejection is lower in LURD transplants. Given this finding and the superior results of living donor (vs. cadaver) transplants, a thorough search should be made for a living donor-LRD or LURD-before proceeding with a cadaver transplant.
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Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Abstract
For pediatric kidney transplant recipients, chronic rejection has become the predominant cause of graft loss. This article reviews risk factors for chronic rejection and what can be done to lower the risk of chronic rejection for future transplant recipients.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Matas AJ, Gillingham K, Payne WD, Humar A, Dunn DL, Sutherland DE, Najarian JS. Should I accept this kidney? Clin Transplant 2000; 14:90-5. [PMID: 10693643 DOI: 10.1034/j.1399-0012.2000.140117.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transplant candidates frequently ask whether they should, based on information available at the time, accept a cadaver kidney or wait for a potentially better one. METHODS We analyzed 937 first and second cadaver transplants done between January 1, 1984 and December 31, 1997 to determine if information available at the time an offer is made could be used to predict long-term graft survival. RESULTS By Cox regression, risk factors for worse long-term graft survival were older donor age, cardiovascular or cerebrovascular cause of donor death, and delayed graft function (DGF). HLA-ABDR mismatch was marginally significant. Whether DGF will occur is not known at the time of an offer, but risk factors can be determined; we found these to be older donor age and > 10% panel-reactive antibodies (PRA) at transplantation (by Cox regression). Using these variables (PRA, ABDR mismatch, donor age, and donor cause of death) known at the time of an offer, we calculated the relative risk of worse long-term graft survival for each subgroup (Table 3 in manuscript). In general, older age and donor death from cardiovascular or cerebrovascular disease were associated with worse outcome. Kidneys from donors of < 50 yr had the best outcome, irrespective of match. CONCLUSION The data provided can be used to help guide patients as to whether they are better off accepting an offered kidney or waiting for a potentially better one. If an offer is declined, the next kidney may have a potentially worse outcome.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota Medical School, Minneapolis 55455, USA
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Matas AJ, Gillingham KJ, Humar A, Dunn DL, Sutherland DE, Najarian JS. Immunologic and nonimmunologic factors: different risks for cadaver and living donor transplantation. Transplantation 2000; 69:54-8. [PMID: 10653380 DOI: 10.1097/00007890-200001150-00011] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a debate about the relative contribution of immunologic (rejection) and nonimmunologic (limited nephron mass) factors in long-term graft survival. METHODS Using multivariate analysis, we studied the association of the following variables with outcome: delayed graft function (DGF), acute rejection, recipient race (black vs. nonblack), donor age (<50 vs. > or =50), donor race, and donor and recipient gender. Because of the association between DGF and rejection, recipients were grouped as follows: DGF, rejection; DGF, no rejection; no DGF, rejection; no DGF, no rejection. Data were analyzed on 1199 first kidney transplants in adults (752 living donor, 447 cadaver donor) done between January 1, 1985 and December 31, 1996. Two analyses were done: first, all transplants; second, only those with > or =1 year survival. For both, there was no difference in risk factors if death with function was or was not censored. RESULTS For all cadaver transplant recipients, risk factors were acute rejection, DGF plus rejection, black recipient race, and donor age > or =50. For living donor recipients, only acute rejection was a risk factor. When only 1-year graft survivors were considered, risk factors were the same: for cadaver recipients, risk factors were acute rejection, DGF plus rejection, black recipient race, and donor age > or =50; for living donor recipients the risk factor was rejection. CONCLUSION We found immunologic factors (rejection with or without DGF) to be significant in both living donor and cadaver donor transplants. Nonim. munologic factors (donor age, recipient race) were significant only in cadaver donor transplants.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota Medical School, Minneapolis 55455, USA
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Humar A, Gillingham KJ, Payne WD, Dunn DL, Sutherland DE, Matas AJ. Association between cytomegalovirus disease and chronic rejection in kidney transplant recipients. Transplantation 1999; 68:1879-83. [PMID: 10628768 DOI: 10.1097/00007890-199912270-00011] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND It has long been suggested that cytomegalovirus (CMV) disease plays a role in the pathogenesis of chronic rejection (CR). However, its role has been difficult to prove, given the strong association between acute rejection and CMV, and the even stronger association between acute rejection and CR. To try to isolate the relative contribution of CMV infection in the pathogenesis of CR, we used multivariate techniques to examine risk factors for CR, including CMV disease. METHODS Our study population consisted of adult recipients of a first kidney graft who underwent transplantation at a single center between 1/1/85 and 6/30/97 (n = 1339). RESULTS Multivariate analysis using time to CR as the dependent variable demonstrated acute rejection to be the strongest risk factor (relative risk [RR] = 17.8, P = 0.0001), followed by older donor age (RR = 1.46, P = 0.01). The presence of CMV disease showed a trend toward increased risk for CR (RR = 1.30, P = 0.10), although the association was not as strong as with the other two variables. Comparing only those recipients with acute rejection and CMV disease versus those with acute rejection but no CMV disease, the relative risk of developing CR was 1.37 times higher in the former group. Recipients with acute rejection and CMV developed CR sooner and with a higher incidence versus those with acute rejection but no CMV (P = 0.002). It is interesting, however, that CMV disease was only a risk factor for CR in the presence of acute rejection. Recipients with no acute rejection and CMV disease did not have a higher incidence of CR versus those with no acute rejection and no CMV (P = NS). CONCLUSION CMV disease seems to play some role in the pathogenesis of CR but only in the presence of acute rejection. Reasons may include (i) the inability to adequately treat acute rejection due to the presence of CMV disease or (ii) the increased virulence of latent CMV virus in recipients being treated for acute rejection. Our data may suggest a role for more aggressive prophylaxis against CMV disease, especially at the time of treatment for acute rejection.
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Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA
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Humar A, Hassoun A, Kandaswamy R, Payne WD, Sutherland DE, Matas AJ. Immunologic factors: the major risk for decreased long-term renal allograft survival. Transplantation 1999; 68:1842-6. [PMID: 10628761 DOI: 10.1097/00007890-199912270-00004] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both antigen-dependent (immunologic) and non-antigen-dependent (nonimmunologic) factors have been implicated in long-term renal allograft loss. Differentiating between these two factors is important because prevention strategies differ. METHODS To isolate the importance of these 2 factors, we studied long-term actuarial graft survival in a cohort of adult kidney recipients who underwent transplants at a single institution between January 1, 1984 and October 31, 1998. Excluded were recipients with graft loss as a result of death with function, technical failure, primary nonfunction, and recurrent disease, leaving 1587 recipients (757 cadaver [CAD], 830 living donor [LD]) who would be at risk for graft loss secondary to both immunologic and nonimmunologic factors. These recipients were analyzed in the following 2 groups: those treated for a previous episode of acute rejection (AR) (Group1; n = 588; 328 CAD, 260 LD) and those with no AR (Group 2: n = 999; 429 CAD, 570 LD). Actuarial graft survival and causes of graft loss were determined for each group. Presumably, graft loss in Group 1 would be caused by immunologic and nonimmunologic factors; graft loss in Group 2 would be caused primarily by nonimmunologic factors. RESULTS The 10-year graft survival rate (censored for death with function, technical failure, primary nonfunction, and recurrent disease) in Group 2 was 91%. In contrast, the 10-year graft survival rate in Group 1 was 45% (P<0.001 vs. Group 2). Causes of graft loss in Group 2 were chronic rejection in 1.8% (3.0% CAD, 0.9% LD), de novo disease, 0.4%; sepsis, 0.2%; discontinuation of immunosuppressive therapy, 0.3%; and unknown, 0.6%. In contrast, 23.8% (29.9% CAD, 16.2% LD) of recipients in Group 1 had graft loss caused by chronic rejection (P = 0.001 vs. Group 2). CONCLUSIONS This very low incidence of chronic rejection in recipients without previous AR suggests that immunologic factors are the main determinants of long-term kidney transplant outcome; nonimmunologic factors in isolation may have only a minimal impact on long-term graft survival.
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Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA.
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Matas AJ, Humar A, Payne WD, Gillingham KJ, Dunn DL, Sutherland DE, Najarian JS. Decreased acute rejection in kidney transplant recipients is associated with decreased chronic rejection. Ann Surg 1999; 230:493-8; discussion 498-500. [PMID: 10522719 PMCID: PMC1420898 DOI: 10.1097/00000658-199910000-00005] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether a recent decrease in the rate of acute rejection after kidney transplantation was associated with a decrease in the rate of chronic rejection. SUMMARY BACKGROUND DATA Single-institution and multicenter retrospective analyses have identified acute rejection episodes as the major risk factor for chronic rejection after kidney transplantation. However, to date, no study has shown that a decrease in the rate of acute rejection leads to a decrease in the rate of chronic rejection. METHODS The authors studied patient populations who underwent transplants at a single center during two eras (1984-1987 and 1991-1994) to determine the rate of biopsy-proven acute rejection, the rate of biopsy-proven chronic rejection, and the graft half-life. RESULTS Recipients who underwent transplantation in era 2 had a decreased rate of biopsy-proven acute rejection compared with era 1 (p < 0.05). This decrease was associated with a decreased rate of biopsy-proven chronic rejection for both cadaver (p = 0.0001) and living donor (p = 0.08) recipients. A trend was observed toward increased graft half-life in era 2 (p = NS). CONCLUSIONS Development of immunosuppressive protocols that decrease the rate of acute rejection should lower the rate of chronic rejection and improve long-term graft survival.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA
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Zhu S, Dekaris I, Duncker G, Dana MR. Early expression of proinflammatory cytokines interleukin-1 and tumor necrosis factor-alpha after corneal transplantation. J Interferon Cytokine Res 1999; 19:661-9. [PMID: 10433368 DOI: 10.1089/107999099313811] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study's aim was to determine the early postoperative expression of proinflammatory cytokines interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNF-alpha) by corneal grafts. BALB/c (n = 90) and C57BL/6 (n = 90) murine recipients were grafted with donor corneas from either syngeneic or allogeneic mice. At 7 and 14 days after surgery, corneal grafts were excised and the recipient rims separated from the donor tissue. Corneal segments were cultured and assayed for cytokines by enzyme-linked immunosorbent assay (ELISA). There was profound upregulation in expression of both IL-1alpha and TNF-alpha after corneal transplantation. Among both low-rejecting BALB/c and high-rejecting C57BL/6 hosts, levels of IL-1alpha were significantly (p < 0.01) more marked in allogeneic as compared to syngeneic grafts. TNF-alpha overexpression was similarly more marked in allogeneic as compared to syngeneic grafts in both BALB/c and C57BL/6 hosts, although the difference was generally more marked among high-rejecting C57BL/6 recipients. In the case of both IL-1alpha and TNF-alpha, the principal source of cytokine expression in the transplanted tissue was the recipient rim. There is significant overexpression of both IL-1alpha and TNF-alpha during the first 2 weeks after transplantation in both syngeneic and allogeneic orthotopic corneal grafts. However, whereas in syngeneic grafts cytokine expression generally decreases after the first postoperative week, significantly elevated cytokine levels are sustained in allogeneic grafts, implicating IL-1 and TNF-alpha as mediators of the alloimmune response in corneal transplantation.
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Affiliation(s)
- S Zhu
- Laboratory of Immunology, Schepens Eye Research Institute, Harvard Medical School, Boston, MA 02114, USA
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