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de Rougemont O, Deng Y, Frischknecht L, Wehmeier C, Villard J, Ferrari-Lacraz S, Golshayan D, Gannagé M, Binet I, Wirthmueller U, Sidler D, Schachtner T, Schaub S, Nilsson J. Donation type and the effect of pre-transplant donor specific antibodies - Data from the Swiss Transplant Cohort Study. Front Immunol 2023; 14:1104371. [PMID: 36875145 PMCID: PMC9974644 DOI: 10.3389/fimmu.2023.1104371] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Introduction The type of donation may affect how susceptible a donor kidney is to injury from pre-existing alloimmunity. Many centers are, therefore, reluctant to perform donor specific antibody (DSA) positive transplantations in the setting of donation after circulatory death (DCD). There are, however, no large studies comparing the impact of pre-transplant DSA stratified on donation type in a cohort with a complete virtual cross-match and long-term follow-up of transplant outcome. Methods We investigated the effect of pre-transplant DSA on the risk of rejection, graft loss, and the rate of eGFR decline in 1282 donation after brain death (DBD) transplants and compared it to 130 (DCD) and 803 living donor (LD) transplants. Results There was a significant worse outcome associated with pre-transplant DSA in all of the studied donation types. DSA directed against Class II HLA antigens as well as a high cumulative mean fluorescent intensity (MFI) of the detected DSA showed the strongest association with worse transplant outcome. We could not detect a significant additive negative effect of DSA in DCD transplantations in our cohort. Conversely, DSA positive DCD transplants appeared to have a slightly better outcome, possibly in part due to the lower mean fluorescent intensity (MFI) of the pre-transplant DSA. Indeed when DCD transplants were compared to DBD transplants with similar MFI (<6.5k), graft survival was not significantly different. Discussion Our results suggest that the negative impact of pre-transplant DSA on graft outcome could be similar between all donation types. This suggests that immunological risk assessment could be performed in a similar way regardless of the type of donor kidney transplantation.
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Affiliation(s)
- Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Yun Deng
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Lukas Frischknecht
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jean Villard
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Department of Diagnostic, Geneva University Hospitals, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Department of Diagnostic, Geneva University Hospitals, Geneva, Switzerland
| | - Déla Golshayan
- Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Monique Gannagé
- Service of Immunology and Allergy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Isabelle Binet
- Nephrology & Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Urs Wirthmueller
- Department of Laboratory Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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Frischknecht L, Deng Y, Wehmeier C, de Rougemont O, Villard J, Ferrari-Lacraz S, Golshayan D, Gannagé M, Binet I, Wirthmueller U, Sidler D, Schachtner T, Schaub S, Nilsson J. The impact of pre-transplant donor specific antibodies on the outcome of kidney transplantation – Data from the Swiss transplant cohort study. Front Immunol 2022; 13:1005790. [PMID: 36211367 PMCID: PMC9532952 DOI: 10.3389/fimmu.2022.1005790] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pre-transplant donor specific antibodies (DSA), directed at non-self human leukocyte antigen (HLA) protein variants present in the donor organ, have been associated with worse outcomes in kidney transplantation. The impact of the mean fluorescence intensity (MFI) and the target HLA antigen of the detected DSA has, however, not been conclusively studied in a large cohort with a complete virtual cross-match (vXM). Methods We investigated the effect of pre-transplant DSA on the risk of antibody-mediated rejection (ABMR), graft loss, and the rate of eGFR decline in 411 DSA positive transplants and 1804 DSA negative controls. Results Pre-transplant DSA were associated with a significantly increased risk of ABMR, graft loss, and accelerated eGFR decline. DSA directed at Class I and Class II HLA antigens were strongly associated with increased risk of ABMR, but only DSA directed at Class II associated with graft loss. DSA MFI markedly affected outcome, and Class II DSA were associated with ABMR already at 500-1000 MFI, whereas Class I DSA did not affect outcome at similar low MFI values. Furthermore, isolated DSA against HLA-DP carried comparable risks for ABMR, accelerated eGFR decline, and graft loss as DSA against HLA-DR. Conclusion Our results have important implications for the construction and optimization of vXM algorithms used within organ allocation systems. Our data suggest that both the HLA antigen target of the detected DSA as well as the cumulative MFI should be considered and that different MFI cut-offs could be considered for Class I and Class II directed DSA.
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Affiliation(s)
- Lukas Frischknecht
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Yun Deng
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jean Villard
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Department of Diagnostic, Geneva University Hospitals, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Department of Diagnostic, Geneva University Hospitals, Geneva, Switzerland
| | - Déla Golshayan
- Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Monique Gannagé
- Service of Immunology and Allergy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Isabelle Binet
- Nephrology & Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Urs Wirthmueller
- Department of Laboratory Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich (USZ), Zurich, Switzerland
- *Correspondence: Jakob Nilsson,
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Naesens M, Budde K, Hilbrands L, Oberbauer R, Bellini MI, Glotz D, Grinyó J, Heemann U, Jochmans I, Pengel L, Reinders M, Schneeberger S, Loupy A. Surrogate Endpoints for Late Kidney Transplantation Failure. Transpl Int 2022; 35:10136. [PMID: 35669974 PMCID: PMC9163814 DOI: 10.3389/ti.2022.10136] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022]
Abstract
In kidney transplant recipients, late graft failure is often multifactorial. In addition, primary endpoints in kidney transplantation studies seek to demonstrate the short-term efficacy and safety of clinical interventions. Although such endpoints might demonstrate short-term improvement in specific aspects of graft function or incidence of rejection, such findings do not automatically translate into meaningful long-term graft survival benefits. Combining many factors into a well-validated model is therefore more likely to predict long-term outcome and better reflect the complexity of late graft failure than using single endpoints. If conditional marketing authorization could be considered for therapies that aim to improve long-term outcomes following kidney transplantation, then the surrogate endpoint for graft failure in clinical trial settings needs clearer definition. This Consensus Report considers the potential benefits and drawbacks of several candidate surrogate endpoints (including estimated glomerular filtration rate, proteinuria, histological lesions, and donor-specific anti-human leukocyte antigen antibodies) and composite scoring systems. The content was created from information prepared by a working group within the European Society for Organ Transplantation (ESOT). The group submitted a Broad Scientific Advice request to the European Medicines Agency (EMA), June 2020: the request focused on clinical trial design and endpoints in kidney transplantation. Following discussion and refinement, the EMA made final recommendations to ESOT in December 2020 regarding the potential to use surrogate endpoints in clinical studies that aim to improving late graft failure.
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Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | | | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
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Ziemann M, Suwelack B, Banas B, Budde K, Einecke G, Hauser I, Heinemann FM, Kauke T, Kelsch R, Koch M, Lachmann N, Reuter S, Seidl C, Sester U, Zecher D. Determination of unacceptable HLA antigen mismatches in kidney transplant recipients. HLA 2021; 100:3-17. [PMID: 34951119 DOI: 10.1111/tan.14521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022]
Abstract
With the introduction of the virtual allocation crossmatch in the Eurotransplant (ET) region in 2023, the determination of unacceptable antigen mismatches (UAM) in kidney transplant recipients is of utmost importance for histocompatibility laboratories and transplant centers. Therefore, a joined working group of members from the German Society for Immunogenetics (Deutsche Gesellschaft für Immungenetik, DGI) and the German Transplantation Society (Deutsche Transplantationsgesellschaft, DTG) revised and updated the previous recommendations from 2015 in light of recently published evidence. Like in the previous version, a wide range of topics is covered from technical issues to clinical risk factors. This review summarizes the evidence about the prognostic value of contemporary methods for HLA antibody detection and identification, as well as the impact of UAM on waiting time, on which these recommendations are based. As no clear criteria could be determined to differentiate potentially harmful from harmless HLA antibodies, the general recommendation is to assign all HLA against which plausible antibodies are found as UAM. There is, however, a need for individualized solutions for highly immunized patients. These revised recommendations provide a list of aspects that need to be considered when assigning UAM to enable a fair and comprehensible procedure and to harmonize risk stratification prior to kidney transplantation between transplant centers. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Malte Ziemann
- Institute of Transfusion Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Barbara Suwelack
- Medizinische Klinik D, University Hospital Münster, Münster, Germany
| | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Klemens Budde
- Medizinische Klinik m. S. Nephrologie, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Gunilla Einecke
- Clinic for Renal and Hypertensive Disorders, Medizinische Hochschule Hannover, Hannover, Germany
| | - Ingeborg Hauser
- Department of Nephrology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Teresa Kauke
- Division of Thoracic Surgery, Hospital of the Ludwig-Maximilians-University München, München, Germany and Transplantation Center, Hospital of the Ludwig-Maximilians-University München, München, Germany
| | - Reinhard Kelsch
- Institute of Transfusion Medicine and Transplantation Immunology, University Hospital Münster, Münster, Germany
| | - Martina Koch
- General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Nils Lachmann
- Institute for Transfusion Medicine, H&I Laboratory, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Reuter
- Medizinische Klinik D, University Hospital Münster, Münster, Germany
| | - Christian Seidl
- Institute for Transfusion Medicine and Immunohaematology, German Red Cross Baden-Württemberg-Hessen, Frankfurt am Main, Germany
| | - Urban Sester
- Transplant center, University Hospital of Saarland, Homburg/Saar, Germany
| | - Daniel Zecher
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
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Rejection-associated Phenotype of De Novo Thrombotic Microangiopathy Represents a Risk for Premature Graft Loss. Transplant Direct 2021; 7:e779. [PMID: 34712779 PMCID: PMC8547913 DOI: 10.1097/txd.0000000000001239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Thrombotic microangiopathy (TMA) significantly affects kidney graft survival, but its pathophysiology remains poorly understood. Methods. In this multicenter, retrospective, case–control paired study designed to control for donor-associated risks, we assessed the recipients’ risk factors for de novo TMA development and its effects on graft survival. The study group consists of patients with TMA found in case biopsies from 2000 to 2019 (n = 93), and the control group consists of recipients of paired kidney grafts (n = 93). Graft follow-up was initiated at the time of TMA diagnosis and at the same time in the corresponding paired kidney graft. Results. The TMA group displayed higher peak panel-reactive antibodies, more frequent retransplantation status, and longer cold ischemia time in univariable analysis. In the multivariable regression model, longer cold ischemia times (odds ratio, 1.18; 95% confidence interval [CI], 1.01-1.39; P = 0.043) and higher peak pretransplant panel-reactive antibodies (odds ratio, 1.03; 95% CI, 1.01-1.06; P = 0.005) were found to be associated with increased risk of de novo TMA. The risk of graft failure was higher in the TMA group at 5 y (hazard ratio [HR], 3.99; 95% CI, 2.04-7.84; P < 0.0001). Concomitant rejection significantly affected graft prognosis at 5 y (HR, 6.36; 95% CI, 2.92-13.87; P < 0.001). De novo TMA associated with the active antibody-mediated rejection was associated with higher risk of graft failure at 5 y (HR, 3.43; 95% CI, 1.69-6.98; P < 0.001) compared with other TMA. Conclusions. Longer cold ischemia and allosensitization play a role in de novo TMA development, whereas TMA as a part of active antibody-mediated rejection was associated with the highest risk for premature graft loss.
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8
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Kolonko A, Więcek A. Safety of Antithymocyte Globulin Use in Kidney Graft Recipients During the COVID-19 Pandemic. Ann Transplant 2021; 26:e933001. [PMID: 34697282 PMCID: PMC8556699 DOI: 10.12659/aot.933001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background There are many safety concerns regarding the use of antithymocyte globulin (ATG) in kidney transplant recipients (KTRs) during the ongoing COVID-19 pandemic. Hereby, we present our recent experience with ATG administration both as induction therapy and as an anti-rejection treatment. Material/Methods We retrospectively analyzed all patients transplanted during the first 12 months of the COVID-19 pandemic who were treated with thymoglobulin. The ATG dosing, lymphocyte number and percentage in blood smear, adverse effects (thrombocytopenia and infectious complications), and kidney graft function up to 12 months and patients’ outcomes were analyzed and compared to KTRs who received basiliximab induction. Results During pandemic, a total of 31 patients were treated with ATG and 59 received basiliximab. The median cumulative ATG doses were 275 (175–325) mg in the induction subgroup and 263 (200–275) mg in the anti-rejection treatment subgroup. Mild thrombocytopenia was noted in 7 (22.6%) and 13 (29.5%) patients, respectively. There were more infectious complications among patients treated with ATG as compared with the basiliximab subgroup (32.3 vs 10.2%, P<0.01), but there were similar incidence rates of thrombocytopenia. Kidney graft function up to 12 months after transplant was comparable (1.1 [1.0–1.9] vs 1.1 [1.0–1.4] mg/dl, respectively). Conclusions 1. ATG use in the induction protocol or as the anti-rejection treatment during the COVID-19 pandemic appears to be safe and the risk of adverse events is acceptable. 2. During the COVID-19 pandemic the necessary use of ATG should not be postponed, especially in KTRs with increased immunologic risk.
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Affiliation(s)
- Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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9
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Hart A, Schladt DP, Matas AJ, Itzler R, Israni AK, Kasiske BL. Incidence, risk factors, and long-term outcomes associated with antibody-mediated rejection - The long-term Deterioration of Kidney Allograft Function (DeKAF) prospective cohort study. Clin Transplant 2021; 35:e14337. [PMID: 33955070 DOI: 10.1111/ctr.14337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 01/03/2023]
Abstract
Major gaps remain in our understanding of antibody-mediated rejection (AMR) after kidney transplant. We examined the incidence, risk factors, response to treatment, and effects on outcomes of AMR at seven transplant programs in the long-term Deterioration of Kidney Allograft Function prospective study cohort. Among 3131 kidney recipients, there were 194 observed AMR cases (6.2%) during (mean ± SD) 4.85 ± 1.86 years of follow-up. Time to AMR was 0.97 ± 1.17 (median, 0.48) years. Risk factors for AMR included younger recipient age, human leukocyte antigen DR mismatches, panel-reactive antibody >0%, positive T- or B-cell cross-match, and delayed graft function. Compared with no AMR, the adjusted time-dependent hazard ratio for death-censored graft failure is 10.1 (95% confidence interval, 6.5-15.7) for all AMR patients, 4.0 (2.5, 9.1) for early AMR (<90 days after transplant), and 24.0 (14.0-41.1) for late AMR (≥90 days after transplant). Patients were treated with different therapeutic combinations. Of 194 kidney transplant recipients with AMR, 50 (25.8%) did not respond to treatment, defined as second AMR within 100 days or no improvement in estimated glomerular filtration rate by 42 days. Long-term outcomes after AMR are poor, regardless of the initial response to treatment. Better prevention and new therapeutic strategies are needed to improve long-term allograft survival.
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Affiliation(s)
- Allyson Hart
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - David P Schladt
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Arthur J Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Ajay K Israni
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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10
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Cioni M, Comoli P, Tagliamacco A, Innocente A, Basso S, Fontana I, Magnasco A, Trivelli A, Nocco A, Macchiagodena M, Catenacci L, Klersy C, Verrina E, Garibotto G, Ghiggeri GM, Cardillo M, Ginevri F, Nocera A. Post-transplant de novo non donor-specific HLA antibodies are not associated with poor graft outcome in non-sensitized pediatric recipients of kidney transplantation. Transpl Immunol 2021; 65:101375. [PMID: 33610675 DOI: 10.1016/j.trim.2021.101375] [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: 11/27/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
While de novo donor-specific HLA antibodies (dnDSAs) have a detrimental impact on kidney graft outcome, the clinical significance of de novo non donor-specific antibodies (dnNDSAs) is more controversial. We retrospectively evaluated for Ab development and characteristics of dnNDSAs serially collected post-transplant sera and, when available, graft biopsy eluates, from 144 non-sensitized, primary pediatric kidney recipients, consecutively transplanted at a single center between 2003 and 2017, using HLA class I and class II single-antigen flow-bead assays (SAB). The results were compared with clinical-pathologic data from HLA antibody negative and HLA dnDSA-positive patients. Forty-five out of 144 patients developed dnNDSAs (31%). Among the dnNDSA-positive patients, 86% displayed one or more class I/II antibodies recognizing antigens included in the CREG/shared epitope groups that also comprise the mismatched donor HLA antigens. Despite potential pathogenicity, as suggested by their occasional presence within the graft, dnNDSAs displayed significantly lower MFI, and limited complement binding and graft homing properties, when compared with dnDSAs. In parallel, the graft survival probability was significantly lower in patients with dnDSA than in those with dnNDSA or without HLA antibodies (p < 0.005). Indeed, the dnNDSA-positive patients remaining dnDSA-negative throughout the posttransplant period did not develop clinical antibody mediated rejection and graft loss, and maintained good graft function at a median follow-up of 9 years. The biological characteristics of dnNDSAs may account for the low graft damaging capability when compared to dnDSAs.
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Affiliation(s)
- Michela Cioni
- Laboratory of Molecular Nephrology, IRCCS Giannina Gaslini, Genova, Italy
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Augusto Tagliamacco
- Clinical Nephrology Unit and Transplant Coordination Unit, Policlinico San Martino, Genova, Italy
| | - Annalisa Innocente
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Sabrina Basso
- Cell Factory and Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Iris Fontana
- Vascular and Endovascular Unit and Kidney Transplant Surgery Unit, Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Magnasco
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Antonella Trivelli
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Angela Nocco
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Mario Macchiagodena
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Laura Catenacci
- Cell Factory and Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Catherine Klersy
- Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Enrico Verrina
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Giacomo Garibotto
- Clinical Nephrology Unit, University of Genova and Policlinico San Martino Genova, Italy
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy
| | - Massimo Cardillo
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy; Italian National Transplant Centre, Italian National Institute of Health (ISS), Rome, Italy
| | - Fabrizio Ginevri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy.
| | - Arcangelo Nocera
- Nephrology, Dialysis, Transplantation Unit, IRCCS Giannina Gaslini, Genova, Italy
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11
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Duygu B, Matern BM, Wieten L, Voorter CEM, Tilanus MGJ. Specific amino acid patterns define split specificities of HLA-B15 antigens enabling conversion from DNA-based typing to serological equivalents. Immunogenetics 2020; 72:339-346. [PMID: 32561995 PMCID: PMC7456404 DOI: 10.1007/s00251-020-01172-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/10/2020] [Indexed: 12/02/2022]
Abstract
The HLA-B15 typing by serological approaches defined the serological subgroups (or splits) B62, B63, B75, B76, B77 and B70 (B71 and B72). The scarcity of sera with specific anti-HLA antibodies makes the serological typing method difficult to discriminate a high variety of HLA antigens, especially between the B15 antigen subgroups. Advancements in DNA-based technologies have led to a switch from serological typing to high-resolution DNA typing methods. DNA sequencing techniques assign B15 specificity to all alleles in the HLA-B*15 allele group, without distinction of the serological split equivalents. However, the presence of antibodies in the patient defined as split B15 antigens urges the identification of HLA-B*15 allele subtypes of the donor, since the presence of donor-specific antibodies is an important contraindication for organ transplantation. Although the HLA dictionary comprises information regarding the serological subtypes of HLA alleles, there are currently 394 B15 antigens out of 516 in the IPD-IMGT/HLA database (3.38.0) without any assigned serological subtype. In this regard, we aimed to identify specific amino acid patterns for each B*15 serological split, in order to facilitate the assignment of B*15 alleles to serological equivalents after high-resolution molecular typing. As a result, serological specificities of 372/394 not yet assigned alleles could be predicted based on amino acid motifs. Furthermore, two new serological types were identified and added, B62-Bw4 and B71-Bw4.
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Affiliation(s)
- Burcu Duygu
- Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
| | - Benedict M Matern
- Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Lotte Wieten
- Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Christina E M Voorter
- Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Marcel G J Tilanus
- Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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12
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Nickel RS, Horan JT, Abraham A, Qayed M, Haight A, Ngwube A, Liang H, Luban NLC, Hendrickson JE. Human leukocyte antigen (HLA) class I antibodies and transfusion support in paediatric HLA‐matched haematopoietic cell transplant for sickle cell disease. Br J Haematol 2019; 189:162-170. [DOI: 10.1111/bjh.16298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/19/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Robert S. Nickel
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Allistair Abraham
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Ann Haight
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix AZUSA
| | - Hua Liang
- Department of Statistics The George Washington University Washington DCUSA
| | - Naomi L. C. Luban
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
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Kamburova EG, Hoitsma A, Claas FH, Otten HG. Results and reflections from the PROfiling Consortium on Antibody Repertoire and Effector functions in kidney transplantation: A mini-review. HLA 2019; 94:129-140. [PMID: 31099989 PMCID: PMC6772180 DOI: 10.1111/tan.13581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/05/2019] [Accepted: 05/14/2019] [Indexed: 12/15/2022]
Abstract
Kidney transplantation is the best treatment option for patients with end-stage renal disease (ESRD). The waiting time for a deceased donor kidney in the Netherlands is approximately 3 years. Mortality among patients on the waiting list is high. The aim of the PROCARE consortium (PROfiling Consortium on Antibody Repertoire and Effector functions) was to decrease the waiting time by providing a matching algorithm yielding a prolonged graft survival and less HLA-immunization compared with the currently used Eurotransplant Kidney allocation system. In this study, 6097 kidney transplants carried out between January 1995 and December 2005 were re-examined with modern laboratory techniques and insights that were not available during that time period. In this way, we could identify potential new parameters that can be used to improve the matching algorithm and prolong graft survival. All eight University Medical Centers in the Netherlands participated in this multicenter study. To improve the matching algorithm, we used as central hypothesis that the combined presence of class-I and -II single-antigen bead (SAB)-defined donor-specific HLA antibodies (DSA) prior to transplantation, non-HLA antibodies, the number of B- and/or T-cell epitopes recognized on donor HLA, and specific polymorphisms in effector mechanisms of IgG were associated with an increased risk for graft failure. The purpose of this article is to relate the results obtained from the PROCARE consortium study to other studies published in recent years. The clinical relevance of SAB-defined DSA, complement-fixing DSA, non-HLA antibodies, and the effector functions of (non)-HLA-antibodies will be discussed.
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Affiliation(s)
- Elena G. Kamburova
- Laboratory of Translational Immunology, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Andries Hoitsma
- Dutch Organ Transplant Registry (NOTR)Dutch Transplant Foundation (NTS)LeidenThe Netherlands
| | - Frans H. Claas
- Department of Immunohematology and Blood TransfusionLeiden University Medical CenterLeidenThe Netherlands
| | - Henny G. Otten
- Laboratory of Translational Immunology, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
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