Renal target structures in acute allograft rejection: a histochemical study

On a Long and Winding Road: Alloantibodies in Organ Transplantation

Today we know that both the humoral and the cellular arm of the immune system are engaged in severe immunological challenges. A close interaction between B and T cells can be observed in most "natural" challenges, including infections, malignancies, and autoimmune diseases. The importance and power of humoral immunity are impressively demonstrated by the current coronavirus disease 2019 pandemic. Organ transplant rejection is a normal immune response to a completely "artificial" challenge. It took a long time before the multifaceted action of different immunological forces was recognized and a unified, generally accepted opinion could be formed. Here, we address prominent paradigms and paradigm shifts in the field of transplantation immunology. We identify several instances in which the transplant community missed a timely paradigm shift because essential, available knowledge was ignored. Moreover, we discuss key findings that critically contributed to our understanding of transplant immunology but sometimes developed with delay and in a roundabout way, as was the case with antibody-mediated rejection-a main focus of this article. These include the discovery of the molecular principles of histocompatibility, the recognition of the microcirculation as a key interface of immune damage, the refinement of alloantibody detection, the description of C4d as a footmark of endothelium-bound antibody, and last but not least, the developments in biopsy-based diagnostics beyond conventional morphology, which only now give us a glimpse of the enormous complexity and pathogenetic diversity of rejection.

The role of microvascular injury on steroid and OKT3 response in renal allograft rejection

BACKGROUND

The authors' aim is to understand the influence of human leukocyte antigen-DR positive microvascular (MV)-DR destruction on steroid and OKT3 response in acute rejection (AR).

METHODS

Twenty of 40 patients had steroid-resistant AR (group 1) and received OKT3 treatment, and the other 20 patients had AR that responded to steroid treatment (group 2). A renal biopsy specimen was obtained from each subject during the AR episode. The degree of MV-DR destruction and the peritubular capillary (PTC) leukocyte infiltration were recorded in each case, using three-tiered scales. The follow-up biopsy specimens of all cases were evaluated for the development of interstitial fibrosis (IF).

RESULTS

Seventy-eight percent of the cases with severe MV destruction and 45% of those with moderate MV destruction did not show response to steroid therapy, whereas 74% of the cases with mild MV destruction responded to steroid therapy. Group 1 patients showed higher frequencies of vascular rejection (80%) and high-grade PTC leukocyte infiltration (85%) than the group 2 cases (P<0.01 for both). Seventy percent of the patients in group 1 responded to OKT3 therapy. The biopsy specimens from the six individuals who were resistant to OKT3 had shown severe MV destruction, vascular rejection, and high-grade PTC leukocyte infiltration. Severity of MV destruction in the initial AR diagnostic biopsy was positively correlated with development of diffuse IF and chronic allograft nephropathy in the follow-up biopsy specimens (P<0.001)

CONCLUSIONS

Analysis of MV destruction may be helpful for diagnosing rejection and predicting graft prognosis. This type of assessment may be useful for determining the immune response and thus identifying the most appropriate treatment.

A novel mechanism of liver allograft rejection facilitated by antibodies to liver sinusoidal endothelial cells

Liver sinusoidal endothelial cells (LSECs) may be implicated in the induction of liver allograft rejections. We studied the clinical consequences of LSEC-reactive antibodies and their functional capacity in modulating T-cell responses during acute rejections. Pre- and posttransplant sera and T lymphocytes from 95 liver transplant patients were used in this study. LSECs were isolated from normal healthy liver. Binding of antibodies to LSECs was detected using flow cytometry. To study whether LSEC antibodies facilitated cell-mediated immunity, a mixed cell culture (MCC) assay was used. Cytokines in the supernatants of MCC were measured by enzyme-linked immunosorbent assay. Liver biopsy sections were stained to detect the deposition of immunoglobulins in LSECs during rejections. The 2-year patient survival was 86.3%. A significantly higher number of patients with rejections had LSEC antibodies (35/50; 70%) than those without rejections (8/45; 18%) (P < .0001). Purified fractions of LSEC antibodies induced the expression of the costimulatory molecule CD86 on LSECs. A significantly higher number of patients with LSEC antibodies and rejections had an increased proliferation of T cells and markedly decreased levels of transforming growth factor beta (TGF-beta) in the MCC than those without antibodies and rejections (P < .0001, P < .0001, respectively). Deposition of antibodies in LSECs during rejection episodes was observed in the biopsies of patients with LSEC antibodies but not in those without LSEC antibodies. In conclusion, antibodies to LSECs may facilitate acute liver allograft rejections by down-regulating the immune modulating cytokine TGF-beta and thus up-regulating alloreactive T-cell proliferation.

IL-11 protects human microvascular endothelium from alloinjury in vivo by induction of survivin expression

IL-11 can reduce tissue injury in animal models of inflammation but the mechanism(s) is unknown. When C.B-17 SCID/beige mice bearing human skin grafts are injected i.p. with human PBMC allogeneic to the donor skin, infiltrating T cells destroy human microvessels by day 21. Intradermal injection of human IL-11 (500 ng/day) delays the time course of graft microvessel loss without reducing the extent of T cell infiltration. Protective actions of IL-11 are most pronounced on day 15. IL-11 has no effect on T cell activation marker, effector molecule, cytokine expression, or endothelial ICAM-1 expression. IL-11 up-regulates the expression of survivin, a cytoprotective protein, in graft keratinocytes and endothelial cells. Topical application of survivin antisense oligonucleotide down-regulates survivin expression in both cell types and largely abrogates the protective effect of IL-11. We conclude that in this human transplant model, IL-11 exerts a cytoprotective rather than anti-inflammatory or immunomodulatory effect mediated through induction of survivin.

Perfusion quantitation in transplanted rat kidney by MRI with arterial spin labeling

The purpose of this study was to determine the feasibility of using quantitative magnetic resonance imaging (MRI) with non-invasive arterial spin labeling to assess perfusion of transplanted kidneys in rats. MRI studies were performed on five groups of rats: normal Fisher 344 rats, Fisher 344 rats that had received a syngeneic kidney transplant either 3 or seven days prior to study, and Fisher 344 rats that had received an allogeneic kidney (ACI rat as the donor) either three or seven days prior to study. The contralateral native kidney remained in place for comparison. Cortical perfusion was quantitated from a slice through the center of each kidney in anesthetized rats at 4.7 Tesla with a fast gradient-echo MRI sequence following the arterial spin labeling. The spin-lattice relaxation time was measured within the cortex, and the cross sectional area of the kidney was also determined within the same MRI plane. Immediately after the perfusion imaging measurement, transplanted kidneys were removed and scored for rejection using the Banff histological criteria. Renal cortical perfusion in normal kidneys was 7.5 +/- 0.8 ml/g/min (N = 12 rats, 24 kidneys). At the third day post-transplantation, that is, before marked acute rejection, the renal cortical perfusion rate was similar in both syngeneic and allogeneic kidneys [3.3 +/- 1.7 (N = 6) and 3.0 +/- 2.4 ml/g/min (N = 6), respectively]. In contrast, at the seventh day post-transplantation, that is, during severe rejection, the renal cortical perfusion rate in allogeneic kidneys was very low (undetectable) compared to the value in syngeneic kidneys [that is, < or = 0.3 (N = 6) versus 5.2 +/- 2.0 ml/g/min (N = 6), respectively]. Moreover, the renal cortical perfusion rate determined by MRI was significantly (P < 0.05, r = -0.82) correlated with histological rejection. We conclude that the quantitative measurement of renal cortical perfusion by MRI with arterial spin-labeling could provide a non-invasive diagnostic method for monitoring the status of renal transplants without requiring the administration of a contrast agent.

Antibody-mediated rejection of human renal allografts: an electron microscopic study of peritubular capillaries

The role of humoral rejection in acute and chronic rejection of human renal allografts other than in hyperacute rejection has not been well established, and its importance may be underestimated. Recently, a specific histological pattern of antibody-mediated rejection of renal allografts has been recognized. The antigens targeted by this mode of rejection are not well defined but are likely located on the endothelium of small vessels (arterioles and glomerular and peritubular capillaries). In both cellular and humoral rejection, the microvasculature of transplanted organs appears to be a main target of injury. This study describes the ultrastructural changes of peritubular capillaries, over a period of up to 8 months, in 14 biopsy specimens obtained from 5 renal allograft recipients diagnosed with "pure" antibody-mediated rejection. In peritubular capillaries, there is progression of injury from necrosis of endothelial cells with lifting and denudation of basement membrane to complete disappearance of capillaries. Acutely, acute tubular necrosis is a constant finding. At 2 to 3 months post-transplantation, the remaining capillaries are dilated, misshapen, and distorted, and are surrounded by a reduplicated and thickened basement membrane. These changes are associated with increased interstitial fibrosis and tubular atrophy, comparable to a sort of renal "asphyxial" death. The author concludes that in "pure" antibody-mediated rejection, the endothelium of peritubular capillaries is a main target of injury. The potential role of antibody-mediated rejection in acute and chronic rejection of renal allografts needs to be explored further.

Presensitization accelerates allograft arteriosclerosis

Transplant arteriosclerosis is the major factor influencing allograft survival after the first year posttransplantation. The host's immunologic response is one of the principal effectors responsible for the constitution of this vascular wall lesion, but the effector pathway and the factors influencing the immune injury are not clear. In a rat abdominal aortic allograft model, we used a skin priming method to study the influence of sensitization on the occurrence of vascular wall lesions. Primed rats developed transplant arteriosclerosis lesions involving medial decellularization and intimal proliferation before the 21st day, whereas naive animals had the same lesions at 2 months posttransplantation. A significant difference between primed and naive rats was found for medial thickness (48.00 +/- 2.85 microm versus 79.34 +/- 2.55 microm, P<0.001) and smooth muscle cell content (160 +/- 28 cell/mm versus 466 +/- 19 cell/mm, P<0.001) at 21 days posttransplantation, and intimal hyperplasia was seen in primed animals at that time, whereas it was not observed in naive rats until the 60th day. The immune profile in naive and primed animals was different. The immune cells infiltrating the arterial wall in naive rats, were principally macrophages and CD8+ T-lymphocytes. No Ig or complement deposition was detected. IgG and complement activated fraction were present in the media of primed animals as early as the fifth day posttransplantation and CD4+ T lymphocytes were the dominant immune cell population. In conclusion, sensitization influences the immune mechanisms responsible for the development of transplant arteriosclerosis and alters the rate of its evolution.

Early renal graft dysfunction. The role of preformed antibodies to DR-typed lymphoblastoid cell lines

Diverse pathogenetic factors may lead to the complex syndrome of early graft dysfunction, an important determinant of later renal graft outcome. That humoral factors could play a prominent role in the development of the syndrome was suggested by the capillary deposition of complement fragment C4d in about 50% of graft biopsies. This study investigates whether the presumed classical activation of complement is derived from preformed antibodies that would possibly react against endothelial HLA-class II molecules. Such antibodies were detectable by flow cytometry using a representative collection of 11 DR-typed lymphoblastoid cell lines (LCL) as targets. Simultaneous discrimination between complement-activating and -nonactivating antibodies was achieved by two-color FACS analysis. Using this method, 44 out of 86 pretransplant serum samples from recipients with early dysfunction showed reactivity against LCL (18 complement-activating, 14 nonactivating, 12 complement-activating non-IgG). Conventional panel-reactivity was observed in 20 sera only (14 also LCL-reactive). Evaluation of corresponding graft biopsies revealed that capillary C4d was associated with LCL (P = 0.018) and panel reactivity (P = 0.015) alone and in combination (P = 0.001; Pearson's chi-square test). Thirteen subsequent graft losses within one year were observed in the LCL-reactive group as compared with seven losses in the nonreactive group (panel-reactive: 7; nonreactive: 13). Thus, measurement of LCL-reactive antibodies in prospective transplant recipients improves the assessment of an individual immunological risk. The results further demonstrate that performed antibodies do not simply reflect the enhanced overall immune reactivity of certain recipients but rather act locally in vivo, thus emphasizing the role of humoral factors in the development of early graft dysfunction.

Strain combination-dependent genesis of necrotizing arteritis in anti-ICAM-1 antibody-perfused renal allografts in the rat

Rat kidneys were perfused with anti-intercellular adhesion molecule-1 (anti-ICAM-1) monoclonal antibody prior to allotransplantation. In the two strain combinations examined, LEF-to-WKAH transplants resulted in accelerated graft loss, and no prolongation of graft survival. The accelerated graft loss was the result of frequent occurrence of necrotizing arteritis within the grafts. In contrast, TO-to-WKAH transplants resulted in no change in graft survival and no arteritis. Necrotizing vasculitis in the LEJ-to-WKAH grafts was characterized by fibrinoid necrosis, collection of cellular infiltrates and serum macromolecular protein entrapment. The F(ab1)2 form of anti-ICAM-1 antibody partially preserved the antibody's capacity to accelerate graft loss. Therefore, although endothelial injury by Fc-mediated cytotoxicity may be involved in vascular damage, other mechanisms also come into play. The amount and distribution pattern of ICAM-1 antigen were identical in both TO and LEJ strains. Intravenous anti-ICAM-1 antibody administration combined with lipopolysaccharide, Poly(I)-Poly(C), warm ischemia to the kidney, or subcutaneous immunization with allogeneic spleen cells, but without renal transplantation, did not generate necrotizing vasculitis or proteinuria. These observations plus our previous data on the rat liver transplantation model clearly show that graft perfusion with anti-ICAM-1 monoclonal antibody invokes extensive vascular damage within allografts by Fc-mediated and Fc-independent mechanisms, depending on the donor-to-host combination.

Human T-cell-mediated destruction of allogeneic dermal microvessels in a severe combined immunodeficient mouse

We developed a chimeric human-severe combined immunodeficient mouse model to study human allograft rejection. Mice received first partial thickness human skin grafts and then, after anastomosis of the mouse with graft human microvessels, human lymphocytes allogeneic to the skin. By 2 weeks, the skin grafts uniformly developed changes that resemble first-set skin rejection in humans. Vascular cell adhesion molecule 1 and major histocompatibility complex class II molecules were induced on the human vascular endothelium at day 6, prior to significant T-cell infiltration. Perivascular human CD4+ and CD8+ T-cell infiltrates were marked by day 11. Some T cells, adjacent to injured human vessels, expressed the cytolytic granule protein perforin. The human microvessels were destroyed by day 16 without significant damage to human keratinocytes or adjacent mouse microvessels. This small animal model may permit evaluation of potential therapeutic reagents that inhibit human T-cell-mediated injury.

Intimal thickening and medial necrosis in allograft arteriosclerosis (chronic rejection) are independently regulated

Rat aortic allografts from the DA (RT1a) to the WF (RT1v) strain but not syngeneic DA-to-DA control grafts develop arteriosclerotic changes in the vascular wall that are virtually identical to human allografts during chronic rejection. A more prominent medial cell destruction in the rat aorta, leading ultimately to complete medial necrosis, is the major difference between rat and human allografts. If the adventitia of syngeneic grafts is exposed to starch before transplantation, these grafts also develop an inflammatory reaction in the adventitia and an extensive intimal thickening at the site of the granulomas, but the medial smooth muscle cells are preserved. In both types of transplants with an intact endothelium as determined by light microscopy, adventitial inflammatory cell proliferation was accompanied by smooth muscle cell replication in the media and thickening of the intima. We therefore propose that an adventitial proliferative response is a prerequisite for intimal thickening to occur. In the allograft but not in starch-exposed syngeneic grafts there was also a notable lymphoid activation in the adventitia, which was accompanied by medial necrosis. We suggest that the medial necrosis in the allograft is linked to a toxic effect of activated lymphoid cells on medial myocytes and is not a prerequisite for intimal proliferation. Instead, intimal proliferation and medial necrosis in the allograft seem to be independently regulated.

Chronic rejection in rat aortic allografts. An experimental model for transplant arteriosclerosis

Chronic rejection has several histological appearances, depending on the type of organ graft. Common to all of them is transplant arteriosclerosis associated with an ongoing inflammatory response in the transplanted graft. To the contrary of classical atherosclerosis, in which the manifestations are mostly focal, proximal, and asymmetric, transplant arteriosclerosis is generalized, and the intimal thickening is concentric. In this article, we describe an experimental animal model whereby transplant arteriosclerosis may be investigated in the inbred rat. Aortic allografts were transplanted from DA (RTIa) to major histocompatibility complex-incompatible WF (RTIv) rats or, for control, to rats of the DA strain. Transplantation was followed by an acute inflammation episode in the aortic adventitia of the allograft, largely lacking in the syngeneic graft, with a prominence of lymphoid activation markers (Cd25) in the cells of the inflammatory infiltrate. The inflammation episode peaked at 2 months after transplantation, became attenuated, and was followed by a proliferative response of myocytes in the allograft media. An increase in the migration of myocytes to the subendothelial space (presumably through small breaks generated in the internal elastic lamina) was observed thereafter, and myocyte proliferation continued in the intima with some intermingled macrophages. Finally, necrosis and disappearance of myocytes and their replacement by fibrous tissue were observed in the media. These alterations are virtually identical with the vascular lesion of chronically rejecting parenchymal organ transplants in human subjects. We suggest that aortic allografts exchanged between histoincompatible rat strains may be used as an experimental model for transplant arteriosclerosis.

Cultured rat kidney parenchymal components are damaged by cytotoxic lymphocytes produced in MLC

Donor-specific cytotoxic lymphocytes (CTL) can be recovered from rejecting allografts both in animal models and in humans. These allograft infiltrating CTL expressing specific cytotoxicity to relevant MHC-restricted target cells in vitro most likely constitute the major effector arm during rejection. Effector cells with similar phenotype, specificity and function can be produced in mixed lymphocyte cultures (MLC). Despite the pivotal importance of CTL in allograft rejection, there is limited information about the susceptibility of different parenchymal graft cells to CTL-mediated damage. We used cultured rat glomerular epithelial cells (GEPC), glomerular mesangial cells (GMC), tubular cells (TC) and heart endothelial cells (HEC) as distinct parenchymal target components in 4 h Chromium release assays. All of these graft components were damaged by CTL produced in 6-day MLC (specific release: 10-25%). Three-day gamma-interferon (IFN-G) treatment enhanced MHC class I and II surface expression on all our targets and increased their susceptibility for CTL-mediated lysis in our experiments (specific release: 20-60%).

Expression of leucocyte and lymphocyte adhesion molecules in the human kidney

Leucocyte interaction with other cells is facilitated by the adhesion molecules, leucocyte function-associated antigen-1 (LFA-1)-binding to intercellular adhesion molecule-1 (ICAM-1) and for T cells and natural killer (NK) cells the binding of LFA-2 (CD2) to LFA-3. As these interactions are critical for the mediation of graft destruction by effector T cells, we examined whether there was a change in the expression of these molecules during rejection compared to normal kidneys. In normal kidneys, peritubular and glomerular capillaries and large vessel endothelium expressed ICAM-1 and LFA-3, but tubular cells expressed only low levels of LFA-3. LFA-1-expressing cells, which were probably macrophages, were observed in the glomerulus. A few scattered LFA-1-expressing cells in the interstitium were probably tissue macrophages or dendritic cells, and only occasional interstitial mononuclear cells expressed LFA-2. During rejection, there was an infiltrate of mononuclear cells expressing LFA-1 and the T cell and NK cell component of the infiltrate expressed LFA-2. Neither of these markers was expressed by kidney parenchymal cells except for one allograft with severe rejection which showed LFA-1 beta chain expression by some tubular cells. Tubular cells had increased expression of ICAM-1 during rejection but there was no increase in LFA-3. The importance of LFA-2 and ICAM-1 expression on kidney tubular cells for adhesion of activated T cells was also examined in an in vitro system.(ABSTRACT TRUNCATED AT 250 WORDS)