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Mubarak M, Raza A, Rashid R, Shakeel S. Evolution of human kidney allograft pathology diagnostics through 30 years of the Banff classification process. World J Transplant 2023; 13:221-238. [PMID: 37746037 PMCID: PMC10514746 DOI: 10.5500/wjt.v13.i5.221] [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: 04/10/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 09/15/2023] Open
Abstract
The second half of the previous century witnessed a tremendous rise in the number of clinical kidney transplants worldwide. This activity was, however, accompanied by many issues and challenges. An accurate diagnosis and appropriate management of causes of graft dysfunction were and still are, a big challenge. Kidney allograft biopsy played a vital role in addressing the above challenge. However, its interpretation was not standardized for many years until, in 1991, the Banff process was started to fill this void. Thereafter, regular Banff meetings took place every 2 years for the past 30 years. Marked changes have taken place in the interpretation of kidney allograft biopsies, diagnosis, and classification of rejection and other non-rejection pathologies from the original Banff 93 classification. This review attempts to summarize those changes for increasing the awareness and understanding of kidney allograft pathology through the eyes of the Banff process. It will interest the transplant surgeons, physicians, pathologists, and allied professionals associated with the care of kidney transplant patients.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Amber Raza
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Rahma Rashid
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Shaheera Shakeel
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
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Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
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The Histological Spectrum and Clinical Significance of T Cell-mediated Rejection of Kidney Allografts. Transplantation 2022; 107:1042-1055. [PMID: 36584369 DOI: 10.1097/tp.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
T cell-mediated rejection (TCMR) remains a significant cause of long-term kidney allograft loss, either indirectly through induction of donor-specific anti-HLA alloantibodies or directly through chronic active TCMR. Whether found by indication or protocol biopsy, Banff defined acute TCMR should be treated with antirejection therapy and maximized maintenance immunosuppression. Neither isolated interstitial inflammation in the absence of tubulitis nor isolated tubulitis in the absence of interstitial inflammation results in adverse outcomes, and neither requires antirejection treatment. RNA gene expression analysis of biopsy material may supplement conventional histology, especially in ambiguous cases. Lesser degrees of tubular and interstitial inflammation (Banff borderline) may portend adverse outcomes and should be treated when found on an indication biopsy. Borderline lesions on protocol biopsies may resolve spontaneously but require close follow-up if untreated. Following antirejection therapy of acute TCMR, surveillance protocol biopsies should be considered. Minimally invasive blood-borne assays (donor-derived cell-free DNA and gene expression profiling) are being increasingly studied as a means of following stable patients in lieu of biopsy. The clinical benefit and cost-effectiveness require confirmation in randomized controlled trials. Treatment of acute TCMR is not standardized but involves bolus corticosteroids with lymphocyte depleting antibodies for severe, refractory, or relapsing cases. Arteritis may be found with acute TCMR, active antibody-mediated rejection, or mixed rejections and should be treated accordingly. The optimal treatment ofchronic active TCMR is uncertain. Randomized controlled trials are necessary to optimally define therapy.
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Seron D, Rabant M, Becker JU, Roufosse C, Bellini MI, Böhmig GA, Budde K, Diekmann F, Glotz D, Hilbrands L, Loupy A, Oberbauer R, Pengel L, Schneeberger S, Naesens M. Proposed Definitions of T Cell-Mediated Rejection and Tubulointerstitial Inflammation as Clinical Trial Endpoints in Kidney Transplantation. Transpl Int 2022; 35:10135. [PMID: 35669975 PMCID: PMC9163314 DOI: 10.3389/ti.2022.10135] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
The diagnosis of acute T cell-mediated rejection (aTCMR) after kidney transplantation has considerable relevance for research purposes. Its definition is primarily based on tubulointerstitial inflammation and has changed little over time; aTCMR is therefore a suitable parameter for longitudinal data comparisons. In addition, because aTCMR is managed with antirejection therapies that carry additional risks, anxieties, and costs, it is a clinically meaningful endpoint for studies. This paper reviews the history and classifications of TCMR and characterizes its potential role in clinical trials: a role that largely depends on the nature of the biopsy taken (indication vs protocol), the level of inflammation observed (e.g., borderline changes vs full TCMR), concomitant chronic lesions (chronic active TCMR), and the therapeutic intervention planned. There is ongoing variability—and ambiguity—in clinical monitoring and management of TCMR. More research, to investigate the clinical relevance of borderline changes (especially in protocol biopsies) and effective therapeutic strategies that improve graft survival rates with minimal patient morbidity, is urgently required. The present paper was developed from documentation produced by the European Society for Organ Transplantation (ESOT) as part of a Broad Scientific Advice request that ESOT submitted to the European Medicines Agency for discussion in 2020. This paper proposes to move toward refined definitions of aTCMR and borderline changes to be included as primary endpoints in clinical trials of kidney transplantation.
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Affiliation(s)
- Daniel Seron
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Marion Rabant
- Department of Pathology, Hôpital Necker–Enfants Malades, Paris, France
| | - Jan Ulrich Becker
- Institute of Pathology, University Hospital Cologne, Cologne, Germany
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | | | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
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Loupy A, Mengel M, Haas M. 30 years of the International Banff Classification for Allograft Pathology: The Past, Present and Future of Kidney Transplant Diagnostics. Kidney Int 2021; 101:678-691. [DOI: 10.1016/j.kint.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
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Borderline Changes in Renal Transplantation: Are We Aware of the Real Impact in Graft Survival? Transplant Proc 2021; 53:1514-1518. [PMID: 33994188 DOI: 10.1016/j.transproceed.2021.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Borderline changes suspicious for acute T-cell-mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell-mediated rejection (aTCMR) and the influence of treating BC on graft outcomes. METHODS A retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded. RESULTS We included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m2, P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087). CONCLUSION Our study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.
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Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection. BMC Nephrol 2019; 20:373. [PMID: 31623566 PMCID: PMC6796330 DOI: 10.1186/s12882-019-1563-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background Medication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown. Methods We conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome. Results A total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012]. Conclusions After adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.
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8
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Vazquez Martul E. [The pathology of renal transplants]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:110-123. [PMID: 29602372 DOI: 10.1016/j.patol.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 11/15/2022]
Abstract
In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.
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Affiliation(s)
- Eduardo Vazquez Martul
- Ex Jefe de Servicio de Anatomía Patológica, Hospital Universitario A Coruña (retirado), A Coruña, España; Ex profesor asociado de la Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Miembro del Club de Nefropatología (Sociedad Española de Nefrología), España.
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The Effect of Histological CD20-Positive B Cell Infiltration in Acute Cellular Rejection on Kidney Transplant Allograft Survival. J Immunol Res 2017; 2016:7473239. [PMID: 28058267 PMCID: PMC5183773 DOI: 10.1155/2016/7473239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/16/2016] [Indexed: 11/23/2022] Open
Abstract
Background. It is controversial whether lymphocyte infiltration exhibited in biopsy specimens is associated with transplant outcomes. This study focused on the effect of CD20-positive B cell infiltration in biopsy specimens from allografts with acute cellular rejection (ACR) in a Chinese population. Methods. Altogether, 216 patients transplanted from Sep. 2001 to Dec. 2014 with biopsy-proved ACR (Banff I or Banff II) were included in the analysis. Biopsies were immunostained for CD20 and C4d. Baseline information, serum creatinine and GFR before and after treatment, steroid resistance, response to treatment, graft loss, and survival were analyzed. Results. Eighty-three patients were classified into CD20-negative group, and 133 patients were classified into CD20-positive group. Significantly more CD20-negative patients (49/83, 59.0%) received steroid plus antibody therapy compared with the CD20-positive group (52/133, 39.1%) (P = 0.004). The response to treatment for ACR did not differ between these two groups. The CD20-positive group had less graft loss (18.8% versus 32.5%, P = 0.022) and a better graft survival rate. Further exploration of the infiltration degree suggested that it tended to be positively related to graft survival, but this did not reach statistical significance. Conclusion. CD20-positive B cell infiltration in renal allograft biopsies with ACR is associated with less steroid resistance and better graft survival. The presence of CD20-positive B cells is protective for renal allografts.
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10
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Efficacy of Acute Cellular Rejection Treatment According to Banff Score in Kidney Transplant Recipients: A Systematic Review. Transplant Direct 2016; 2:e115. [PMID: 27990480 PMCID: PMC5142362 DOI: 10.1097/txd.0000000000000626] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/25/2022] Open
Abstract
Supplemental digital content is available in the text. Background The poor prognosis classically associated with Banff grade 2 acute cell-mediated rejection (CMR) may be due to unrecognized antibody-mediated damage. We thus performed a systematic review of the literature to determine the rate of response to treatment in kidney transplant recipients with pure CMR, stratified by Banff class. Methods In addition to a manual search, databases interrogated included Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), Evidence-Based Medicine (EBM) databases, Central, PubMed and CINAHL. Studies providing functional and/or histological response rates to the treatment of CMR rejection by Banff class (1997 or more recent) were included. Results Among the 746 articles identified, 5 articles were included in the final review. Two studies excluded some, and 2 excluded all features of antibody-mediated rejection, while providing data on functional recovery. The absence of functional recovery was reported in 4% of borderline, 15% for Banff grade 1A and IB pooled, 0% to 25% of Banff grade 1B alone, 11% to 20% of Banff grade 2A, and 38% of Banff grade 2B rejections. Conclusions The rate of functional recovery of pure Banff IIA CMR overlapped with that of Banff grade 1 CMR, whereas Banff grade 2B showed worse prognosis. There was important heterogeneity in the definition of response to treatment and paucity of data describing the histological response to treatment stratified by Banff class. There is a pressing need to standardize outcome metrics for the reversibility of rejection in kidney transplant recipients in order to design high-quality trials for novel therapeutic alternatives.
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11
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Becker JU, Chang A, Nickeleit V, Randhawa P, Roufosse C. Banff Borderline Changes Suspicious for Acute T Cell-Mediated Rejection: Where Do We Stand? Am J Transplant 2016; 16:2654-60. [PMID: 26988137 DOI: 10.1111/ajt.13784] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
The definition of Banff Borderline became ambiguous when the Banff 2005 consensus modified the lower threshold from i1t1 (10-25% interstitial inflammation with mild tubulitis) to i0t1 (0-10% interstitial inflammation with mild tubulitis). We conducted a worldwide survey among members of the Renal Pathology Society about their approach to this diagnostic category. A web-based survey was sent out to all 503 current members (153 respondents). A database search yielded which threshold for Banff i was applied in the most influential manuscripts about Borderline. Among the 139 nephropathologists using the Borderline category, 67% use the Banff 1997 definition, requiring Banff i1. Thirty-seven percent admitted to sometimes exaggerating Banff i in the presence of tubulitis, to reach a diagnosis of Borderline. Forty-eight percent were dissatisfied with the definition of Borderline. The majority of the most influential manuscripts used the 1997 definition, contrary to the current one. There is considerable dissatisfaction with Borderline, and practice in Banff i thresholds is variable. Until additional studies inform a revision, we suggest leaving it to each pathologist's discretion whether to use i0 or i1 as the minimal threshold. In order to avoid future ambiguity, a web-based synopsis of all scattered current Banff definitions and rules should be created.
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Affiliation(s)
- J U Becker
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - A Chang
- The University of Chicago Medicine, Chicago, IL
| | - V Nickeleit
- Division of Nephropathology, Department of Pathology, The University of North Carolina, Chapel Hill, NC
| | - P Randhawa
- Department of Pathology, Thomas E Starzl Txn Institute, University of Pittsburgh, UPMC-Montefiore, Pittsburgh, PA
| | - C Roufosse
- Department of Cellular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Schneider M, Cardones ARG, Selim MA, Cendales LC. Vascularized composite allotransplantation: a closer look at the banff working classification. Transpl Int 2016; 29:663-71. [DOI: 10.1111/tri.12750] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/15/2015] [Accepted: 01/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - M. Angelica Selim
- Pathology and Dermatology; Department of Pathology; Duke University Medical Center; Durham NC USA
| | - Linda C. Cendales
- Department of Surgery; Duke University Medical Center; Durham NC USA
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13
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Abrahimi P, Qin L, Chang WG, Bothwell ALM, Tellides G, Saltzman WM, Pober JS. Blocking MHC class II on human endothelium mitigates acute rejection. JCI Insight 2016; 1. [PMID: 26900601 DOI: 10.1172/jci.insight.85293] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Acute allograft rejection is mediated by host CD8+ cytotoxic T lymphocytes (CTL) targeting graft class I major histocompatibility complex (MHC) molecules. In experimental rodent models, rejection requires differentiation of naive CD8+ T cells into alloreactive CTL within secondary lymphoid organs, whereas in humans, CTL may alternatively develop within the graft from circulating CD8+ effector memory T cells (TEM) that recognize class I MHC molecules on graft endothelial cells (EC). This latter pathway is poorly understood. Here, we show that host CD4+ TEM, activated by EC class II MHC molecules, provide critical help for this process. First, blocking HLA-DR on EC lining human artery grafts in immunodeficient mice reduces CD8+ CTL development within and acute rejection of the artery by adoptively transferred allogeneic human lymphocytes. Second, siRNA knockdown or CRISPR/Cas9 ablation of class II MHC molecules on EC prevents CD4+ TEM from helping CD8+ TEM to develop into CTL in vitro. Finally, implanted synthetic microvessels, formed from CRISPR/Cas9-modified EC lacking class II MHC molecules, are significantly protected from CD8+ T cell-mediated destruction in vivo. We conclude that human CD8+ TEM-mediated rejection targeting graft EC class I MHC molecules requires help from CD4+ TEM cells activated by recognition of class II MHC molecules.
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Affiliation(s)
- Parwiz Abrahimi
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lingfeng Qin
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William G Chang
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alfred L M Bothwell
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - George Tellides
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - W Mark Saltzman
- Department of Biomedical Engineering, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jordan S Pober
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
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14
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Wu K, Budde K, Schmidt D, Neumayer HH, Lehner L, Bamoulid J, Rudolph B. The inferior impact of antibody-mediated rejection on the clinical outcome of kidney allografts that develop de novo thrombotic microangiopathy. Clin Transplant 2016; 30:105-17. [PMID: 26448478 DOI: 10.1111/ctr.12645] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) can induce and develop thrombotic microangiopathy (TMA) in renal allografts. A definitive AMR (dAMR) co-presents three diagnostic features. A suspicious AMR (sAMR) is designated when one of the three features is missing. METHODS Thirty-two TMA cases overlapping with AMR (AMR+ TMA) were studied, which involved 14 cases of sAMR+ TMA and 18 cases of dAMR+ TMA. Thirty TMA cases free of AMR features (AMR- TMA) were enrolled as control group. RESULTS The ratio of complete response to treatment was similar between AMR- TMA and AMR+ TMA group (23.3% vs. 12.5%, p = 0.33), or between sAMR+ TMA and dAMR+ TMA group (14.3% vs. 11.1%, p = 0.79). At eight yr post-transplantation, the death-censored graft survival (DCGS) rate of AMR- TMA group was 62.8%, which was significantly higher than 28.0% of AMR+ TMA group (p = 0.01), but similar between sAMR+ TMA and dAMR+ TMA group (30.0% vs. 26.7%, p = 0.92). Overall, the intimal arteritis and the broad HLA (Human leukocyte antigens) mismatches were closely associated with over time renal allograft failure. CONCLUSION The AMR+ TMA has inferior long-term graft survival, but grafts with sAMR+ TMA or dAMR+ TMA have similar characteristics and clinical courses.
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Affiliation(s)
- Kaiyin Wu
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Klemens Budde
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Danilo Schmidt
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Hans-Hellmut Neumayer
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Lukas Lehner
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Jamal Bamoulid
- Medizinische Klinik mit Schwerpunkt Nephrologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
| | - Birgit Rudolph
- Institut für Pathologie, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany
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15
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The Relationship of the Severity and Category of Acute Rejection With Intimal Arteritis Defined in Banff Classification to Clinical Outcomes. Transplantation 2015; 99:e105-14. [PMID: 25719260 DOI: 10.1097/tp.0000000000000640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear if the category of acute rejection with intimal arteritis (ARV) is relevant to short- and long-term clinical outcomes and if the graft outcomes are affected by the severity of intimal arteritis. METHODS One hundred forty-eight ARV episodes were reviewed and categorized according to the 2013 Banff criteria of AMR: T cell-mediated rejection with intimal arteritis (v) lesion (TCMRV; n = 78), total antibody-mediated rejection with v lesion (AMRV), which were further divided into suspicious AMRV (n = 37) and AMRV (n = 33). The Banff scores of intimal arteritis (v1, v2 and v3) represented low, moderate, and high ARV severity. RESULTS The grafts with TCMRV, suspicious AMRV (sAMRV), and AMRV showed similar responses to antirejection therapy, whereas the grafts with v2- or v3-ARV responded significantly poorer compared to those with v1-ARV. The 8-year death-censored graft survival (DCGS) rate was 56.8% of TCMRV versus 34.1% of total AMRV (Log rank, P = 0.03), but the 1- and 5-year DCGS rates were comparable between the 2 groups; moreover, the 1-, 5-, and 8-year DCGS rates of v1-ARV were evidently higher than v2- and v3-ARV (each pairwise comparison to v1-AVR yields P < 0.01); in contrast, the DCGS rates were similar between sAMRV and AMRV. The existing donor-specific antibodies or moderate microvascular inflammation or C4d-positive staining or intensive tubulointerstitial inflammation played a less significant role on the long-term graft survival. CONCLUSIONS Compared to the category, the ARV severity is more closely associated with the initial response to antirejection therapy and long-term graft failure. The sAMRV and AMRV might represent a spectrum of the same disorder.
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Sentís A, Kers J, Yapici U, Claessen N, Roelofs JJTH, Bemelman FJ, Ten Berge IJM, Florquin S. The prognostic significance of glomerular infiltrating leukocytes during acute renal allograft rejection. Transpl Immunol 2015; 33:168-75. [PMID: 26494157 DOI: 10.1016/j.trim.2015.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 10/16/2015] [Accepted: 10/19/2015] [Indexed: 11/19/2022]
Abstract
Transplant glomerulitis, observed in T cell-mediated and antibody-mediated rejection, is histologically characterized by intracapillary mononuclear cell infiltration. However, the prognostic value of counting various glomerular inflammatory cells during rejection has not been elucidated, which is a key step for the introduction of novel biomarkers in the clinics. We immunophenotyped glomerulitis during episodes of acute rejection in order to investigate their predictive value for transplant outcomes. To do so, we included 57 transplant biopsies of 57 renal transplant recipients with biopsy-proven acute rejection with a median follow-up of 4.2 years. We determined average glomerular cell counts for T cells, B cells, Tregs, IL-17(+) cells, neutrophils and macrophages. Logistic and Cox regression models were used to investigate the association of glomerular inflammatory cells with response to therapy and graft failure on a population level. We used novel time-dependent ROC curve analyses to investigate the value of glomerular inflammatory cell infiltrates for the prediction of transplant outcomes, applicable to the individual patient. We identified three cell types that were responsible for glomerulitis during rejection: macrophages, T cells and neutrophils. By quantification of glomerular macrophages, an emerging cell type associated with antibody-mediated rejection, we were able to predict the progression towards death-censored graft failure within the first 500 days after the initial episode of rejection. With the use of novel time-dependent ROC analyses, we propose dynamic sensitivities, specificities, and positive and negative predictive values with their corresponding cut-off values for the average amount of glomerular macrophages, depending on what time after rejection death-censored graft failure needs prediction.
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Affiliation(s)
- Alexis Sentís
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; Department of Nephrology and Renal Transplantation, Hospital Clinic i Provincial de Barcelona, Universitat de Barcelona, Carrer Villaroel 170, 08036 Barcelona, Spain
| | - Jesper Kers
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Unsal Yapici
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Nike Claessen
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Frederike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ineke J M Ten Berge
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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17
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Abstract
PURPOSE OF REVIEW Inflammation of the arterial wall has been recognized as a key element of rejection since the early studies of pathologic changes in transplanted organs. Better elucidation of the mechanisms involved in endothelial injury has brought increasing complexity to the diagnostic classification of this lesion in the context of transplantation, and has affected the clinical management of patients with allograft rejection. Here, we examine how our understanding of the significance of intimal arteritis in renal graft biopsies has evolved in the past decades. RECENT FINDINGS Recognition that antidonor antibody may cause intimal arteritis has prompted revision of histologic classifications of transplant rejection. Although molecular signatures/biomarkers are being developed and proposed as new tools for aiding in the identification of cell-mediated and antibody-mediated types of rejection, histological examination is still needed to identify intimal arteritis in allograft biopsies. Outcome studies are contributing to clarify the prognostic significance of intimal arteritis in transplant rejection. SUMMARY Intimal arteritis remains an important histologic feature of allograft rejection, which comes in different nuances requiring tailored therapeutic approaches.
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Gentile G, Somma C, Gennarini A, Mastroluca D, Rota G, Lacanna F, Locatelli B, Remuzzi G, Ruggenenti P. Low-dose RATG with or without basiliximab in renal transplantation: a matched-cohort observational study. Am J Nephrol 2015; 41:16-27. [PMID: 25612603 DOI: 10.1159/000371728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/18/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS In renal transplantation, peri-operative low-dose rabbit-antithymocyte-globulin (RATG) plus basiliximab induction prevented acute allograft rejection more effectively than post-operative RATG plus basiliximab induction. We investigated the specific antirejection contribution of basiliximab in this context. METHODS This single-center, observational, matched-cohort study evaluated allograft rejections (primary outcome), steroid exposure and side effects, GFR (iohexol plasma clearance) and treatment costs in 16 deceased-donor renal transplant recipients induced with RATG (0.5 mg/kg/day) and 32 age-, gender- and treatment-matched reference-patients given RATG plus basiliximab (20 mg on days 0 and 4). RESULTS Induction was well tolerated. At 18 months, 8 patients (50%) vs. 3 reference-patients (9.4%) rejected the graft [HR (95% CI): 6.53 (1.73-24.70), p = 0.006]. Difference was significant (p < 0.01) even after adjusting for recipient/donor age and gender, cold ischemia time and HLA mismatches. There were 1 antibody-mediated rejection and 2 moderate cellular rejections in patients vs. none in reference-patients (p = 0.032). The median (interquartile range) prednisone cumulative dose was remarkably higher in patients than reference-patients [4.78 (1.12-6.10) vs. 0.19 (0.18-3.81) grams, p = 0.002]. Three patients vs. 24 reference-patients were off-steroid at study end (p < 0.001). Three patients vs. no reference-patient developed new-onset diabetes (p = 0.003). Both inductions similarly depleted B-cells. Outcomes of AZA- vs. MMF-treated participants were similar. GFR was similar in all groups. Compared to MMF, AZA therapy saved ≈ EUR 2,500/year and by month 14.3 post-transplant compensated basiliximab costs. CONCLUSION In renal transplantation, basiliximab plus peri-operative low-dose RATG more efficiently prevented allograft rejection than RATG monotherapy, and minimized steroid exposure and toxicity. AZA- vs MMF-based maintenance immunosuppression largely compensated the extra costs of basiliximab.
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Affiliation(s)
- Giorgio Gentile
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Bergamo, Italy
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Brown KL, Palyvoda OY, Auner GW, Gruber SA. Raman spectroscopic modeling of early versus late T-lymphocyte activation via differential spectral detection of receptor expression. J Immunol Methods 2014; 415:31-5. [DOI: 10.1016/j.jim.2014.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 10/07/2014] [Accepted: 10/13/2014] [Indexed: 11/25/2022]
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20
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. EXP CLIN TRANSPLANT 2014; 12. [DOI: 10.6002/ect.2014.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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The severity of acute cellular rejection defined by Banff classification is associated with kidney allograft outcomes. Transplantation 2014; 97:1146-54. [PMID: 24892962 DOI: 10.1097/01.tp.0000441094.32217.05] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear if the severity or the timing of acute cellular rejection (ACR) defined by Banff classification 2009 is associated with graft survival. METHODS Borderline changes, TCMR I (interstitial rejection), and TCMR II/III (vascular rejection) were defined as low, moderate, and high ACR severity, respectively. Approximately 270 patients who had at least one episode of ACR were enrolled, 270 biopsies were chosen which showed the highest ACR severity of each patient and were negative for donor-specific antibodies (DSA), C4d, and microcirculation changes (MC). Six months were used as the cutoff to define early and late ACR; 370 patients without biopsy posttransplantation were recruited in the control group. RESULTS Up to 8-year posttransplantation, death-censored graft survival (DCGS) rates of control, borderline, TCMR I, and TCMR II/III groups were 97.6%, 93.3%, 79.6%, and 73.6% (log rank test, P<0.001); the control group had significantly higher DCGS rate than the three ACR groups (each pairwise comparison yields P<0.05). The DCGS rate of late ACR was significantly lower compared with early ACR (63.6% vs. 87.4%, P<0.001). Intimal arteritis (Banff v-lesion) was an independent histologic risk factor correlated with long-term graft loss regardless of the timing of ACR. The v-lesions with minimal or high-grade tubulitis displayed similar graft survival (72.7% vs. 72.9%, P=0.96). CONCLUSION All types of ACR affect long-term graft survival. Vascular or late ACR predict poorer graft survival; the extent of tubulointerstitial inflammation (TI) is of no prognostic significance for vascular rejection.
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22
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Wu KY, Budde K, Schmidt D, Neumayer HH, Rudolph B. Acute cellular rejection with isolated v-lesions is not associated with more favorable outcomes than vascular rejection with more tubulointerstitial inflammations. Clin Transplant 2014; 28:410-8. [DOI: 10.1111/ctr.12333] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- K. Y. Wu
- Medizinische Klinik mit Schwerpunkt Nephrologie; Charité Campus Mitte; Universitätsmedizin Berlin; Berlin Germany
| | - K. Budde
- Medizinische Klinik mit Schwerpunkt Nephrologie; Charité Campus Mitte; Universitätsmedizin Berlin; Berlin Germany
| | - D. Schmidt
- Medizinische Klinik mit Schwerpunkt Nephrologie; Charité Campus Mitte; Universitätsmedizin Berlin; Berlin Germany
| | - H. H. Neumayer
- Medizinische Klinik mit Schwerpunkt Nephrologie; Charité Campus Mitte; Universitätsmedizin Berlin; Berlin Germany
| | - B. Rudolph
- Institut für Pathologie; Charité Campus Mitte; Universitätsmedizin Berlin; Berlin Germany
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23
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24
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van de Berg PJEJ, Yong SL, Koch SD, Lardy N, van Donselaar-van der Pant KAMI, Florquin S, Bemelman FJ, van Lier RAW, ten Berge IJM. Characteristics of alloreactive T cells measured before renal transplantation. Clin Exp Immunol 2012; 168:241-50. [PMID: 22471286 DOI: 10.1111/j.1365-2249.2011.04551.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Several assays to measure pre-existing allospecific T cell immunity in renal transplant candidates have been developed in the past years. In 46 patients, we used flow cytometry-based mixed lymphocyte culture to measure the precursor frequency and phenotype of alloreactive T cells before renal transplantation, using donor-specific or third-party cells for allostimulation. Allostimulation induced up-regulation of co-stimulatory molecules, chemokine receptors relevant for migration of T cells into the graft and effector proteins. Recipients prone for acute rejection had a higher precursor frequency of alloreactive CD8(+) T cells and a lower percentage of interleukin (IL)-7Rα expressing alloreactive CD8(+) T cells than non-rejectors. These data point to quantitative and qualitative differences between T cells of patients who will experience acute cellular rejection episodes from those who will not.
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Affiliation(s)
- P J E J van de Berg
- Renal Transplant Unit, Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands.
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25
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Yapici Ü, Kers J, Bemelman FJ, Roelofs JJTH, Groothoff JW, van der Loos CM, van Donselaar-van der Pant KAMI, Idu MM, Claessen N, ten Berge IJM, Florquin S. Interleukin-17 positive cells accumulate in renal allografts during acute rejection and are independent predictors of worse graft outcome. Transpl Int 2011; 24:1008-17. [DOI: 10.1111/j.1432-2277.2011.01302.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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26
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Einecke G, Reeve J, Sis B, Mengel M, Hidalgo L, Famulski KS, Matas A, Kasiske B, Kaplan B, Halloran PF. A molecular classifier for predicting future graft loss in late kidney transplant biopsies. J Clin Invest 2010; 120:1862-72. [PMID: 20501945 DOI: 10.1172/jci41789] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 04/26/2010] [Indexed: 01/05/2023] Open
Abstract
Kidney transplant recipients that develop signs of renal dysfunction or proteinuria one or more years after transplantation are at considerable risk for progression to renal failure. To assess the kidney at this time, a "for-cause" biopsy is performed, but this provides little indication as to which recipients will go on to organ failure. In an attempt to identify molecules that could provide this information, we used microarrays to analyze gene expression in 105 for-cause biopsies taken between 1 and 31 years after transplantation. Using supervised principal components analysis, we derived a molecular classifier to predict graft loss. The genes associated with graft failure were related to tissue injury, epithelial dedifferentiation, matrix remodeling, and TGF-beta effects and showed little overlap with rejection-associated genes. We assigned a prognostic molecular risk score to each patient, identifying those at high or low risk for graft loss. The molecular risk score was correlated with interstitial fibrosis, tubular atrophy, tubulitis, interstitial inflammation, proteinuria, and glomerular filtration rate. In multivariate analysis, molecular risk score, peritubular capillary basement membrane multilayering, arteriolar hyalinosis, and proteinuria were independent predictors of graft loss. In an independent validation set, the molecular risk score was the only predictor of graft loss. Thus, the molecular risk score reflects active injury and is superior to either scarring or function in predicting graft failure.
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Affiliation(s)
- Gunilla Einecke
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
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27
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Beimler J, Zeier M. Borderline rejection after renal transplantation--to treat or not to treat. Clin Transplant 2010; 23 Suppl 21:19-25. [PMID: 19930312 DOI: 10.1111/j.1399-0012.2009.01105.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
According to the Banff classification of renal allograft pathology, the category borderline changes defines changes insufficient for a diagnosis of acute rejection. The relationship between borderline changes and acute renal allograft rejection still remains unclear. The appropriate clinical management for patients showing such changes is controversial. One possible interpretation of the high incidence of subacute tubulitis is that these changes in the absence of graft dysfunction are of no consequence and that treatment with intensified immunosuppression is unnecessary and perhaps harmful. Another view, consistent with the high incidence of CAN in late protocol biopsy studies, is that immunosuppression has become so powerful, that rejection may not even be manifested by a rising serum creatinine. Borderline changes should be used as part of an algorithm, but not as the only criterion, for therapeutic decision making. Based on the weak evidence of existing studies, in our patients with clinical borderline rejection, we have to weigh the individual immunological risk against the potential side effects of increased immunosuppression. Even in the knowledge that a majority of patients with borderline infiltrates will not progress into rejection, in many transplant centers, borderline rejection is treated with additional steroids or augmentation of maintenance immunosuppression.
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Affiliation(s)
- J Beimler
- Department of Medicine, Division of Nephrology, University of Heidelberg, 69120 Heidelberg, Germany.
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28
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Reeve J, Einecke G, Mengel M, Sis B, Kayser N, Kaplan B, Halloran PF. Diagnosing rejection in renal transplants: a comparison of molecular- and histopathology-based approaches. Am J Transplant 2009; 9:1802-10. [PMID: 19519809 DOI: 10.1111/j.1600-6143.2009.02694.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The transcriptome has considerable potential for improving biopsy diagnoses. However, to realize this potential the relationship between the molecular phenotype of disease and histopathology must be established. We assessed 186 consecutive clinically indicated kidney transplant biopsies using microarrays, and built a classifier to distinguish rejection from nonrejection using predictive analysis of microarrays (PAM). Most genes selected by PAM were interferon-gamma-inducible or cytotoxic T-cell associated, for example, CXCL9, CXCL11, GBP1 and INDO. We then compared the PAM diagnoses to those from histopathology, which are based on the Banff diagnostic criteria. Disagreement occurred in approximately 20% of diagnoses, principally because of idiosyncratic limitations in the histopathology scoring system. The problematic diagnosis of 'borderline rejection' was resolved by PAM into two distinct classes, rejection and nonrejection. The diagnostic discrepancies between Banff and PAM in these cases were largely due to the Banff system's requirement for a tubulitis threshold in defining rejection. By examining the discrepancies between gene expression and histopathology, we provide external validation of the main features of the histopathology diagnostic criteria (the Banff consensus system), recommend improvements and outline a pathway for introducing molecular measurements.
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Affiliation(s)
- J Reeve
- Department of Laboratory Medicine and Pathology, Arizona Health Science Centre, University of Arizona, Tucson, AZ, USA
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29
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Brown KL, Palyvoda OY, Thakur JS, Nehlsen-Cannarella SL, Fagoaga OR, Gruber SA, Auner GW. Raman spectroscopic differentiation of activated versus non-activated T lymphocytes: an in vitro study of an acute allograft rejection model. J Immunol Methods 2008; 340:48-54. [PMID: 18996128 DOI: 10.1016/j.jim.2008.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 10/06/2008] [Indexed: 10/21/2022]
Abstract
Acute rejection (AR) remains a significant complication in renal transplant patients. Using serum creatinine for AR screening has proven problematic, and thus a noninvasive, highly sensitive and specific test is needed. T cells from human peripheral blood were analyzed using Raman spectroscopy. Fifty-one Mixed Lymphocyte Culture (MLC) activated T cells (ATC), 28 Mitomycin C inactivated T cells (ITC), and 35 resting T cells (RTC), were studied utilizing 785 and 514.5 nm wavelengths. Statistical analysis following subtraction of fluorescence used Student's t test to quantify peak ratio differences and discriminant function analysis (DFA), with three distinct sectors assigned for grouping purposes: Sector I, ITC; Sector II, ATC; Sector III, RTC. Differences between ATC and non-activated T cells (ITC and RTC) were found at 1182 and 1195 cm-1 peak positions for both wavelengths. Significant differences in peak ratios for 785 and 514.5 nm wavelengths existed between ATC and RTC (p=0.001 and p=0.006, respectively) and ATC and ITC (p=0.001 and p=0.001, respectively), with a trend in differences observed between ITC and RTC (p=0.07 and p=0.08, respectively). Analysis of the DFA-derived sector distribution for the 785 and 514.5 nm wavelengths revealed a sensitivity of 95.7% and 89.3%, respectively, and a specificity of 100% and 93.8%, respectively. This data suggests that Raman spectroscopy can detect significant differences between activated and nonactivated T cells based upon cell-surface receptor expression, thereby establishing unique signatures that can aid in the development of a noninvasive AR screening tool with high sensitivity and specificity.
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Affiliation(s)
- Kristian L Brown
- Department of Surgery, Section of Transplant Surgery, Wayne State University, Detroit, MI, USA.
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30
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Mansour H, Homs S, Desvaux D, Badoual C, Dahan K, Matignon M, Audard V, Lang P, Grimbert P. Intragraft levels of Foxp3 mRNA predict progression in renal transplants with borderline change. J Am Soc Nephrol 2008; 19:2277-81. [PMID: 18667728 DOI: 10.1681/asn.2008030254] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The optimal therapeutic management of borderline lymphocytic infiltrates in renal allografts, described by Banff criteria, is unknown, largely because of the inability to predict clinical outcome in these cases. For determination of molecular factors that may predict outcome in cases of borderline change histology, mRNA levels of Foxp3, Granzyme B, IFN-gamma, IL-23, and RORgammat were measured in renal tissue from 46 untreated patients. Twenty-five patients were considered "nonprogressive," defined by a serum creatinine that remained <110% of baseline during the 40 d after biopsy. Twenty-one patients were considered "progressive," defined by an increase in serum creatinine >110% from baseline and by repeat histologic examination within 40 d showing progression toward acute rejection. Only Foxp3 mRNA levels were significantly higher in nonprogressors than in progressors (P = 0.001). Analysis of receiver operating characteristic curves demonstrated that the outcome for patients with biopsies showing borderline change could be predicted with 90% sensitivity and 79.1% specificity using the optimal Foxp3 mRNA cutoff value. Our findings suggest that the measurement of Foxp3 mRNA offers a means of improving prediction of outcome of borderline change.
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Affiliation(s)
- Hicham Mansour
- Department of Nephrology and Transplantation, Centre de Recherche INSERM 841, CHU Henri Mondor and Université Paris XII, Créteil, Association pour l'Utilisation du Rein Artificiel, Paris, France
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31
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Mueller TF, Einecke G, Reeve J, Sis B, Mengel M, Jhangri GS, Bunnag S, Cruz J, Wishart D, Meng C, Broderick G, Kaplan B, Halloran PF. Microarray analysis of rejection in human kidney transplants using pathogenesis-based transcript sets. Am J Transplant 2007; 7:2712-22. [PMID: 17941957 DOI: 10.1111/j.1600-6143.2007.02005.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Microarrays offer potential for objective diagnosis and insights into pathogenesis of allograft rejection. We used mouse transplants to annotate pathogenesis-based transcript sets (PBTs) that reflect major biologic events in allograft rejection-cytotoxic T-cell infiltration, interferon-gamma effects and parenchymal deterioration. We examined the relationship between PBT expression, histopathologic lesions and clinical diagnoses in 143 consecutive human kidney transplant biopsies for cause. PBTs correlated strongly with one another, indicating that transcriptome disturbances in renal transplants have a stereotyped internal structure. This disturbance was continuous, not dichotomous, across rejection and nonrejection. PBTs correlated with histopathologic lesions and were the highest in biopsies with clinically apparent rejection episodes. Surprisingly, antibody-mediated rejection had changes similar to T-cell mediated rejection. Biopsies lacking PBT disturbances did not have rejection. PBTs suggested that some current Banff histopathology criteria are unreliable, particularly at the cut-off between borderline and rejection. Results were validated in 51 additional biopsies. Thus many transcriptome changes previously described in rejection are features of a large-scale disturbance characteristic of rejection but occurring at lower levels in many forms of injury. PBTs represent a quantitative measure of the inflammatory disturbances in organ transplants, and a new window on the mechanisms of these changes.
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Affiliation(s)
- T F Mueller
- Department of Medicine, Division of Nephrology and Immunology, University of Alberta, Edmonton, AB, Canada
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32
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Dahan K, Audard V, Roudot-Thoraval F, Desvaux D, Abtahi M, Mansour H, Kumal M, Lang P, Grimbert P. Renal allograft biopsies with borderline changes: predictive factors of clinical outcome. Am J Transplant 2006; 6:1725-30. [PMID: 16827877 DOI: 10.1111/j.1600-6143.2006.01348.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The clinical outcome and appropriate management for patients showing 'borderline changes' on allograft biopsy after renal transplantation is still controversial. In an attempt to identify predictive factors of clinical outcome of patients with such lesions, we reviewed the clinical course of 91 patients with borderline changes. Multivariate analysis revealed significant and independent effects of histological stage (i + t < or = or > 2) and time to borderline changes (< or = or > 3 months after transplant) on serum creatinine levels at 1 year from borderline changes episodes (respectively, p = 0.04 and p = 0.02) and only a significant effect of time to borderline changes on serum creatinine levels at 2 years (p = 0.005). Renal function at 1 year and 2 years as 5- and 8-year graft survival were not significantly different in the group of patients treated with antirejection therapy (T group, n = 49) compared with the untreated group (UT group, n = 42). This study strongly suggests that borderline changes with histological score (i + t) > 2 and late episodes of borderline changes should be considered to be of poor prognosis.
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Affiliation(s)
- K Dahan
- Department of Nephrology and Renal Transplantation, Hopital Henri Mondor and Universite Paris XII, Creteil, France
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33
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Miyagi M, Ishikawa Y, Mizuiri S, Aikawa A, Ohara T, Hasegawa A. Significance of subclinical rejection in early renal allograft biopsies for chronic allograft dysfunction. Clin Transplant 2005; 19:456-65. [PMID: 16008588 DOI: 10.1111/j.1399-0012.2005.00303.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To determine the significance of early subclinical rejection of renal allografts, we reviewed 127 biopsy specimens obtained soon after transplantation. Histological finding was categorized according to a modification of the Banff scheme as: acute rejection (AR), borderline changes (BL); non-specific inflammatory changes, (NI) and no rejection (NR). Subclinical rejection was defined as AR, BL or NI. Patients with BL or NI were divided into two groups; one was treated with high-dose methylprednisolone (MP), the other remained untreated. Freedom from chronic allograft dysfunction (defined as non-doubling of serum creatinine 5 yr after transplantation) was significantly more frequent in the NR group (89%) than in the BL (70%) and AR (64%) groups. At 1 yr after transplantation, mean serum creatinine had increased significantly only in the untreated group (p < 0.05), and re-biopsy showed that interstitial fibrosis had developed to a significantly greater extent in the untreated group than in the treated group (p < 0.01). Subclinical rejection in the early protocol biopsies correlated closely with subsequent allograft dysfunction. High-dose MP treatment for early subclinical rejection may be effective in suppressing the development of interstitial fibrosis at 1 yr after transplantation.
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De Cock HEV, Kyles AE, Griffey SM, Bernsteen L, Gregory CR. Histopathologic findings and classification of feline renal transplants. Vet Pathol 2004; 41:244-56. [PMID: 15133173 DOI: 10.1354/vp.41-3-244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Seventy-seven feline transplant kidney specimens, obtained from 1 to 3,183 days (9 years) after transplantation, were reevaluated histologically and classified on the basis of the Banff '97 guidelines for human renal transplant kidneys. Overall, this classification system appeared useful in detecting rejection reactions and confirmed the finding in humans that biopsies can diagnose subclinical rejection and therefore are an important diagnostic tool for the follow up of renal transplants. However, on the basis of serum creatinine values, the severity of the acute or active and chronic lesions was not accurately reflected by this scoring system. This is thought to be due to the significant differences in histologic rejection patterns, especially in acute or active rejection, in cats when compared with humans. Tubulitis, lymphocytic glomerulitis, and vasculitis, which are the main pillars of the Banff '97 acute or active rejection scoring system, are either rare or not found in cats. The presence of significant necrotizing glomerulitis and vasculitis in feline renal transplants might imply that the rejection is complicated by acute antibody-mediated rejection. Alternatively, cyclosporine toxicity also should be considered because some of these kidneys show other signs of cyclosporine toxicity. Finally, the significance of subcapsular and interlobular phlebitis, rarely described in human rejection reactions but a distinct entity in cats, is unknown. From this study, it is clear that there are significant differences in the histology of acute or active rejection between humans and cats and that a better understanding of the histologic appearance of renal allografts will be especially beneficial for treatment and prognostic purposes.
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Affiliation(s)
- H E V De Cock
- Department of Pathology, Microbiology, and Immunology, University of California-Davis, One Shields Avenue, Davis, CA 95616-8739, USA.
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Halloran PF, Urmson J, Ramassar V, Melk A, Zhu LF, Halloran BP, Bleackley RC. Lesions of T-cell-mediated kidney allograft rejection in mice do not require perforin or granzymes A and B. Am J Transplant 2004; 4:705-12. [PMID: 15084164 DOI: 10.1111/j.1600-6143.2004.00421.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organ allograft rejection is strongly associated with the presence of alloreactive cytotoxic T cells but the role of cytotoxicity in the pathologic lesions is unclear. Previous studies showed that the principal lesions of kidney rejection - interstitial infiltration, tubulitis, and endothelial arteritis - are T-cell-dependent and antibody-independent. We studied the role of cytotoxic granule components perforin and granzymes A and B in the evolution of the T-cell-mediated lesions of mouse kidney transplant rejection. By real-time RT-PCR, allografts rejecting in wild-type hosts at days 5, 7, 21, and 42 showed massively elevated and persistent expression of perforin and granzymes A and B, but evolution of tubulitis and arteritis did not correlate with increasing granzyme or perforin expression. Allografts transplanted into hosts with disrupted genes for perforin or granzymes A and B showed no change in tubulitis, arteritis, or MHC induction. Thus the development of the histologic lesions diagnostic of T-cell-mediated kidney transplant rejection are associated with but not mediated by perforin or granzyme A or B. Together with previous graft survival studies, these results indicate that the granule-associated cytotoxic mechanisms of T cells are not the effectors of T-cell-mediated allograft rejection.
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Affiliation(s)
- Philip F Halloran
- Department of Medicine, Division of Nephrology & Transplantation Immunology, University of Alberta, Edmonton, Alberta, Canada.
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Srinivas TR, Kubilis PS, Croker BP. Macrophage index predicts short-term renal allograft function and graft survival. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00428.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The relationship between acute renal allograft rejection and histopathologic biopsy alterations recognized by the Banff Schema as "borderline changes" is not clear. Some evidence supports the contention that about one third of patients with borderline infiltrates and clinical evidence of graft dysfunction do indeed have acute rejection, which, if left untreated, progresses to a histologically more advanced stage of rejection. Several investigators recognize that not all patients with mild tubulitis respond clinically to antirejection therapy; a significant number of these biopsy specimens display additional histological alterations. The most common concurrent lesions are chronic allograft nephropathy, arteriolar lesions consistent with calcineurin inhibitor toxicity, acute tubular necrosis, and obstructive nephropathy. Management of patients with borderline changes must tightly correlate the pathologic features and the clinical information.
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Affiliation(s)
- L W Gaber
- Department of Pathology, University of Tennesee Health Science Center, Memphis, Tennesee, USA
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Desvaux D, Le Gouvello S, Pastural M, Abtahi M, Suberbielle C, Boeri N, Rémy P, Salomon L, Lang P, Baron C. Acute renal allograft rejections with major interstitial oedema and plasma cell-rich infiltrates: high -interferon expression and poor clinical outcome. Nephrol Dial Transplant 2004; 19:933-9. [PMID: 15031352 DOI: 10.1093/ndt/gfh027] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute rejections are scored according to three main criteria: vasculitis, tubulitis and interstitial infiltration as defined in the Banff classification. Typically, B cells account for <8% of the infiltrates and oedema is limited. The clinical significance of severe interstitial oedema and plasma cell-rich infiltrates (OPcR) are still a matter of debate. METHODS Kidney graft biopsies performed between 1991 and 1998 were retrospectively evaluated for these two criteria. RESULTS Among the 826 biopsies performed during the study period, 14 samples in 12 patients met these criteria; 11 were of Banff type I acute rejection and three were borderline. Based on clinical data, all were treated as acute rejections. OPcR occurred at a median of 187 days post-transplantation. All episodes were steroid resistant. Graft survival was 40% at 1 year following the rejection. Circulating antibodies reactive either to donor HLA or to endothelial cells were present in eight of 12 patients and widespread C4d deposit in peritubular capillary were present in three out of five patients studied. Level of gamma-interferon mRNA within the graft was significantly higher than in standard acute cellular rejection (ACR). CONCLUSION This study showed that OPcR rejections portend a poor outcome irrespective of the Banff score. Our data strongly support the hypothesis that a humoral component participated in the graft injuries. Altogether, the data suggest that OPcR rejection might represent a late and attenuated variant of acute humoral rejection that should be classified separately from ACR.
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Affiliation(s)
- Dominique Desvaux
- Service de Néphrologie, Hôpital Henri Mondor, 51 Avenue du Marechal de Lattre Tassigny, F-94000 Créteil, France
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Jabs WJ, Sedlmeyer A, Ramassar V, Hidalgo LG, Urmson J, Afrouzian M, Zhu LF, Halloran PF. Heterogeneity in the evolution and mechanisms of the lesions of kidney allograft rejection in mice. Am J Transplant 2003; 3:1501-9. [PMID: 14629280 DOI: 10.1046/j.1600-6135.2003.00269.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The natural history and pathogenesis of the pathologic lesions that define rejection of kidney transplants have not been well characterized. We studied the evolution of the pathology of rejection in mouse kidney allografts, using four strain combinations across full major histocompatibility complex (MHC) plus nonMHC disparities, to permit more general conclusions. Interstitial infiltrate, MHC induction, and venulitis appeared by day 5, peaked at day 7-10, then stabilized or regressed by day 21. In contrast, tubulitis, arteritis, and glomerulitis were absent or mild at days 5 and 7, but progressed through day 21, indicating separate regulation and homeostatic control of these lesions. Edema, hemorrhage, and necrosis also increased through day 21. All lesions were T-dependent, failing to develop in T-cell-deficient hosts. Allografts into immunoglobulin-deficient hosts manifested typical infiltration, MHC induction, and tubulitis at days 7 and 21, indicating that these lesions are alloantibody-independent. However at day 21 kidneys rejecting in immunoglobulin-deficient hosts showed decreased edema, arteritis, venulitis, and necrosis. Thus the three groups of lesions are: T-cell-mediated interstitial infiltration, MHC induction, and venulitis, which develops rapidly then stabilizes; slower but progressive T-cell-mediated tubulitis and arteritis; and late antibody-mediated endothelial injury, which contributes to late edema, arteritis, and venulitis.
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Affiliation(s)
- Wolfram J Jabs
- 1st Department of Internal Medicine, University of Luebeck School of Medicine, Luebeck, Germany
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Meijer RT, Surachno S, Yong SL, Bemelman FJ, Florquin S, Ten Berge IJM, Schellekens PTA. Treatment of acute kidney allograft rejection with a non-mitogenic CD3 antibody. Clin Exp Immunol 2003; 133:485-92. [PMID: 12930378 PMCID: PMC1808785 DOI: 10.1046/j.1365-2249.2003.02200.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
T3/4.A is a non-mitogenic murine IgA mAb to human CD3 that was selected for clinical studies to provide an alternative for the mitogenic, T cell-activating, therapeutic mAb OKT3. Previously, we reported that T3/4.A is better tolerated in humans than the IgG2a-CD3 mAb T3/4.2a. Here we report the results of a phase II clinical trial to assess the immunosuppressive potential of T3/4.A. Eighteen first kidney transplant recipients with a first rejection episode were included. Baseline immunosuppression consisted of cyclosporin and prednisolone. Rejection treatment consisted of 5 mg mAb per day during 10 days. Fourteen patients responded, of whom four experienced a second rejection within 2 weeks, one experienced chronic rejection after 2.5 years, whereas the others remained rejection-free after treatment (median duration of follow-up 42 months). Four patients did not respond and eventually lost their graft. These results are similar to treatment results with OKT3, as reported in the literature. Following the first dose of T3/4.A, side effects were limited, and reduced compared to OKT3-treated controls. On the second day, 15 patients developed transient vomiting and/or diarrhoea, which coincided with elevated serum levels of proinflammatory cytokines. Minimal or even no side effects occurred during the remaining days, which is in sharp contrast to that seen generally during OKT3 treatment. Both T cell numbers and TCR expression were reduced during the therapy. We conclude that T3/4.A is a good alternative for OKT3 to treat rejection episodes in renal transplant recipients.
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Affiliation(s)
- R T Meijer
- Academic Medical Center, University of Amsterdam, Division of Clinical Immunology and Rheumatology, Amsterdam, The Netherlands.
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Sharma RK, Kumar A, Kumar J, Gupta A, Gulati S, Sharma AP, Bhandari M, Kumar A. Low-dose ATG is effective in treatment of acute rejection episodes. Transplant Proc 2003; 35:225-6. [PMID: 12591374 DOI: 10.1016/s0041-1345(02)03895-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R K Sharma
- Department of Nephrology & Urology Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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McCarthy GP, Roberts ISD. Diagnosis of acute renal allograft rejection: evaluation of the Banff 97 Guidelines for Slide Preparation. Transplantation 2002; 73:1518-21. [PMID: 12023635 DOI: 10.1097/00007890-200205150-00026] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Arteritis and tubulitis, the diagnostic features of acute renal allograft rejection, are typically focal lesions. To avoid under-diagnosis, the Banff '97 schema recommends the preparation of multiple slides, of which three should be stained with hematoxylin and eosin (H&E) and three with periodic acid-Schiff (PAS) or silver. In this study, we examine the validity of the Banff '97 recommendations and determine how widely these recommendations are applied. METHODS We reviewed 52 consecutive renal transplant biopsy specimens showing both acute tubulointerstitial and vascular rejection. Arteritis was graded for each H&E slide, and tubulitis was graded for each H&E and PAS/silver. The handling of renal allograft biopsy specimens in the U.K. was determined by means of a questionnaire. RESULTS When two, as opposed to three, H&E slides were examined, arteritis was missed in 11.4% of cases; when only one H&E slide was examined, arteritis was missed in 33.3% of cases. When only one, as opposed to three, PAS/silver slide was examined, tubulitis was under-graded in 33.3% of cases. In the U.K., 40% of laboratories stain at least three slides with H&E, and 42% stain at least three slides with PAS/silver. Only 30% of laboratories conform to all the Banff guidelines for slide preparation. CONCLUSIONS There is likely to be significant under-diagnosis and under-grading of acute rejection if the Banff '97 guidelines for slide preparation are not implemented. Most laboratories in the U.K. do not conform to these guidelines.
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Affiliation(s)
- Gerard P McCarthy
- Department of Histopathology, Manchester Royal Infirmary, Manchester, United Kingdom
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Haas M, Kraus ES, Samaniego-Picota M, Racusen LC, Ni W, Eustace JA. Acute renal allograft rejection with intimal arteritis: histologic predictors of response to therapy and graft survival. Kidney Int 2002; 61:1516-26. [PMID: 11918760 DOI: 10.1046/j.1523-1755.2002.00254.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute renal allograft rejection with intimal arteritis is designated by the widely used Banff 97 classification as type 2A or 2B depending on the extent of arteritis, without regard to interstitial inflammation or tubulitis. We examined whether the distinction between type 2A and 2B is relevant to short- and long-term clinical outcomes, and if outcomes in this subset of acute rejection also are affected by tubulitis, interstitial inflammation, and several additional histologic and clinical parameters. METHODS Pathology records were searched to identify cases of acute renal allograft rejection with intimal arteritis diagnosed between January 1985 and September 2000. For each case, the patient's chart was reviewed to determine the response of the rejection episode to therapy, type(s) of therapy given, and length of graft survival. All biopsies were reviewed and Banff acute and chronic indices recorded by a pathologist blinded to these data. Biopsies not showing type 2A or 2B rejection were excluded, as were repeat biopsies from the same patient and cases with recurrent glomerular disease, viral infection, donor-specific antibodies, or more than mild chronic change. RESULTS The initial response to anti-rejection therapy was significantly worse in patients with type 2B acute rejection (N = 29) than in those with type 2A (N = 102) by univariate and multivariate analyses, despite more aggressive treatment of type 2B rejection. In a Cox proportional hazards model the hazard ratio for graft failure for 2B versus 2A was 1.9 (P = 0.05), but this was not significant when adjusted for the initial response to therapy. Cases with minimal or mild tubulitis responded better to therapy than those with moderate or severe tubulitis, although graft survival was not significantly affected by the tubulitis score. CONCLUSIONS The distinction between types 2A and 2B acute rejection in the Banff 97 classification has significant prognostic value with regard to both short- and long-term clinical outcomes, although the difference in long-term graft survival is mainly related to the initial response to therapy. Reports of biopsies showing type 2A or 2B rejection also should specify the degree of tubulitis present, as the latter may significantly influence the initial response to therapy.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Herzenberg AM, Gill JS, Djurdjev O, Magil AB. C4d deposition in acute rejection: an independent long-term prognostic factor. J Am Soc Nephrol 2002; 13:234-241. [PMID: 11752043 DOI: 10.1681/asn.v131234] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Peritubular capillary deposition of C4d has been demonstrated to be associated with both acute humoral and vascular rejection and increased graft loss. Whether it is an independent predictor of long-term graft survival rates is uncertain. The biopsies (n = 126) from all patients (n = 93) with a tissue diagnosis of acute rejection that were performed between July 1, 1995, and December 31, 1997, were classified according to Cooperative Clinical Trials in Transplantation (CCTT) criteria. Fresh frozen tissue was immunostained for C4d. There were 58 patients with CCTT type I (interstitial) rejection and 35 with CCTT type II (vascular) rejection. For 34 patients, at least one biopsy exhibited peritubular C4d deposition (C4d+ group). The C4d+ group had proportionately more female patients (P = 0.003), more patients with high (>30%) panel-reactive antibody levels (P = 0.024), more patients with resistance to conventional antirejection therapy (P = 0.010), and fewer patients with postrejection hypertension (P = 0.021) and exhibited a greater rate of graft loss (38 versus 7%, P = 0.001). Peritubular C4d deposition was associated with significantly lower graft survival rates in the CCTT type I rejection group (P = 0.003) and the CCTT type II rejection group (P = 0.003). Multivariate analyses demonstrated that peritubular C4d deposition (P = 0.0002), donor age (P = 0.0002), cold ischemic time (P = 0.0211), and HLA matches (P = 0.0460) were significant independent determinants of graft survival rates. Peritubular C4d deposition is a significant predictor of graft survival rates and is independent of histologic rejection type and a variety of clinical prognostic factors.
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Affiliation(s)
- Andrew M Herzenberg
- Departments of *Pathology and Laboratory Medicine and Medicine and Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John S Gill
- Departments of *Pathology and Laboratory Medicine and Medicine and Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- Departments of *Pathology and Laboratory Medicine and Medicine and Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex B Magil
- Departments of *Pathology and Laboratory Medicine and Medicine and Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Messias NC, Eustace JA, Zachary AA, Tucker PC, Charney D, Racusen LC. Cohort study of the prognostic significance of acute transplant glomerulitis in acutely rejecting renal allografts. Transplantation 2001; 72:655-60. [PMID: 11544426 DOI: 10.1097/00007890-200108270-00016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute transplant glomerulitis is a unique lesion in renal allografts, the prognostic significance of which is controversial. We conducted this retrospective cohort study to examine the independent prognostic significance of moderate-to-severe transplant glomerulitis in acute rejection. METHODS Renal allograft survival for patients with acute rejection were studied, comparing one group with significant glomerulitis (G, n=28) with those with no glomerulitis (NG, n=35). Clinical, biopsy, and demographic data and renal graft survival were compared, and the association of G with graft failure was examined. RESULTS In the G versus NG group, a greater percentage of patients were highly sensitized (peak panel reactive antibody value >80%; P=0.009), had had a previous renal transplant (40% vs. 11%; P=0.02), or had suffered from delayed graft function (P=0.03). The G group had a trend toward earlier rejection episodes (P=0.07), a significantly higher serum creatinine at the time of index biopsy (P=0.01), a higher prevalence of vascular rejection (P=0.02), and less improvement in mean reciprocal serum creatinine at 1-2 weeks after biopsy (P=0.02). Although there was a trend toward shorter allograft survival in the G group (P=0.09), the level of significance of which increased with adjustment for transplantation time period and the duration of the transplant-biopsy interval (P=0.06), the relative risk for graft loss was no longer significant when additionally adjusted for index biopsy Banff score (relative risk, 0.97; P=0.97). CONCLUSION In this study, G was significantly more common in highly sensitized patients and was strongly associated with vascular rejection biopsies but was not an independent predictor of graft survival.
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Affiliation(s)
- N C Messias
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Robertson H, Kirby JA. Renal allograft rejection: The development and function of tubulitis. Transplant Rev (Orlando) 2001. [DOI: 10.1053/trre.2001.24499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Roberti I, Reisman L. Serial evaluation of cell surface markers for immune activation after acute renal allograft rejection by urine flow cytometry--correlation with clinical outcome. Transplantation 2001; 71:1317-20. [PMID: 11397970 DOI: 10.1097/00007890-200105150-00024] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The use of urine flow cytometry (UFC) as a noninvasive tool for the diagnosis of acute and chronic rejection of the renal allograft has been previously reported. METHODS We analyzed the expression of various cell surface antigens during a 30-day period after the diagnosis and treatment of 24 acute rejection (AR) episodes. UFC was performed on 59 urine specimens, from 17 patients meeting the diagnostic criteria for AR. UFC analysis was performed blinded to the clinical management utilizing the following fluorescinated monoclonal antibodies: anti-CD3, anti-CD14, anti-HLA-DR, anti-CD54, and anti-interleukin 2 receptor. Results were correlated with the patient's requirement for antilymphocytic drugs and increment in serum creatinine level (mg/dl) on day 30 after AR. RESULTS HLA-DR was the most prevalent antigen noted during the first 2 days of AR (91.7% of the samples), followed by CD14 (50%) and CD54 (41.7%). After day 4 the degree of expression of HLA-DR-, CD14-, and CD54-positive cells correlated with the need for antilymphocytic drugs. CD54 was the best parameter with a sensitivity=100% and specificity=90.9% (P=0.001). Those patients who had permanent graft injury after treatment of the AR had persistence of CD54- and CD14-positive cells in the urine. CONCLUSION Serial monitoring of urine sediments by UFC was predictive of the requirement for antilymphocytic therapy and irreversible graft damage.
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Affiliation(s)
- I Roberti
- Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey 07039, USA
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Ishikawa A, Flechner SM, Goldfarb DA, Myles JL, Modlin CS, Boparai N, Papajcik D, Mastroianni B, Novick AC. Significance of serum creatinine pattern and area under the creatinine versus time curve during the first acute renal transplant rejection. Transplant Proc 2000; 32:781-3. [PMID: 10856583 DOI: 10.1016/s0041-1345(00)00997-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- A Ishikawa
- Department of Urology, Section of Renal Transplantation, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Minervini MI, Torbenson M, Scantlebury V, Vivas C, Jordan M, Shapiro R, Randhawa PS. Acute renal allograft rejection with severe tubulitis (Banff 1997 grade IB). Am J Surg Pathol 2000; 24:553-8. [PMID: 10757402 DOI: 10.1097/00000478-200004000-00009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent studies have correlated renal allograft function with individual histologic lesions defined in the Banff schema of kidney transplantation pathology. The clinical significance of severe tubulitis (Banff 97 grade t3) has not been specifically examined. We compared the clinical course and response to antirejection therapy in 36 patients with t3 tubulitis, and 137 patients with milder grades of tubulitis and varying grades of intimal arteritis. Rejection associated with severe tubulitis (grade t3) was associated with graft outcome that was worse than mild to moderate tubulitis (grades t1 or t2) and approached that seen in grade v1 intimal arteritis. Rejection characterized by grade v2 or v3 intimal arteritis had worse prognosis than v1 intimal arteritis and all grades of tubulitis without coexisting intimal arteritis. These observations validate the Banff 97 recommendation that the severity of both tubulitis and intimal arteritis needs to be graded in renal allograft biopsies. In addition, grade t3 tubulitis is identified as a lesion which should be a cause for clinical concern.
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Affiliation(s)
- M I Minervini
- Division of Transplantation Pathology, University of Pittsburgh Medical Center, Pennsylvania, USA
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