Serotyping for homotransplantation. V. Evaluation of a matching scheme

Significance of HLA-DQ in kidney transplantation: time to reevaluate human leukocyte antigen matching priorities to improve transplant outcomes? An expert review and recommendations

The weight of human leukocyte antigen (HLA) matching in kidney allocation algorithms, especially in the United States, has been devalued in a stepwise manner, supported by the introduction of modern immunosuppression. The intent was further to reduce the observed ethnic/racial disparity, as data emerged associating HLA matching with decreased access to transplantation for African American patients. In recent years, it has been increasingly recognized that a leading cause of graft loss is chronic antibody-mediated rejection, attributed to the development of de novo antibodies against mismatched donor HLA expressed on the graft. These antibodies are most frequently against donor HLA-DQ molecules. Beyond their impact on graft survival, generation of de novo donor-specific HLA antibodies also leads to increased sensitization, as measured by panel-reactive antibody metrics. Consequently, access to transplantation for patients returning to the waitlist in need of a second transplant is compromised. Herein, we address the implications of reduced HLA matching policies in kidney allocation. We highlight the observed diminished outcome data, the significant financial burden, the long-term health consequences, and, more important, the unintended consequences. We further provide recommendations to examine the impact of donor-recipient HLA class II and specifically HLA-DQα₁β₁ mismatching, focusing on collection of appropriate data, application of creative simulation approaches, and reconsideration of best practices to reduce inequalities while optimizing patient outcomes.

Human leukocyte antigen matching in organ transplantation: what we know and how can we make it better (Revisiting the past, improving the future)

PURPOSE OF REVIEW

A renaissance for human leukocyte antigen (HLA) testing emerged with the understanding that donor-specific HLA antibodies play a significant role in long-term allograft survival. This renewed focus on donor/recipient histocompatibility led to a recent quest to decipher antibody responses or, as introduced into the transplantation lexicon, 'HLA-epitope matching'.

RECENT FINDINGS

Whether matching is at the antigen or the epitope level, in-depth understanding of how histo-incompatibility leads to activation of an immune response is required. HLA-DQ donor-specific antibody (DSA) has the highest association with poor graft survival. However, HLA-DQ antigens and antibodies are understudied and significant gaps still exist in understanding the function of HLA-DQ in immune activation. Much of our knowledge about HLA class-II molecules is derived from studies performed on HLA-DR, whether it is crystallography, antigen processing and presentation analysis, or activation of T-cell signal-transduction pathways. Indeed, HLA-DQ molecules are less amenable for laboratory testing, but the limited studies that were performed indicate that HLA-DQ might have, at least to some extent, a different role compared with HLA-DR.

SUMMARY

This review highlights qualities of HLA-DQ that may be associated with different pathways of activating an immune response. Understanding the consequences of such differences may lead to better appreciation and significance of HLA-DQ for matching purposes.

HLA Epitope Matching in Kidney Transplantation: An Overview for the General Nephrologist

Rapid changes in tissue-typing technology, including the widespread availability of highly specific molecular typing methods and solid-phase assays for the detection of allele-specific anti-HLA antibodies, make it increasingly challenging to remain up to date with developments in organ matching. Terms such as epitopes and eplets abound in the transplantation literature, but often it can be difficult to see what they might mean for the patient awaiting transplantation. In this review, we provide the historical context for current practice in tissue typing and explore the potential role of HLA epitopes in kidney transplantation. Despite impressive gains in preventing and managing T-cell-mediated rejection and the associated improvements in graft survival, the challenge of the humoral alloresponse remains largely unmet and is the major cause of late graft loss. Describing HLA antigens as a series of antibody targets, or epitopes, rather than based on broad seroreactivity patterns or precise amino acid sequences may provide a more practical and clinically relevant system to help avoid antibody-mediated rejection, reduce sensitization, and select the most appropriate organs in the setting of pre-existing alloantibodies. We explain the systems proposed to define HLA epitopes, summarize the evidence to date for their role in transplantation, and explore the potential benefits of incorporating HLA epitopes into clinical practice as this field continues to evolve toward everyday practice.

HLA epitope matching in pediatric renal transplantation

Chronic graft loss due to antibody-mediated rejection (AMR) and the difficulty of re-transplanting highly sensitized patients are two of the major long-term challenges in pediatric renal transplantation. Treatments for AMR are often ineffective and desensitization protocols can be a high risk, making prevention a highly appealing strategy. Insights into the structural determinants of humoral alloantigenicity present an exciting opportunity to reassess our current paradigm of tissue matching and potentially preventing these complications. We review the theory behind human leukocyte antigen (HLA) B cell epitopes and the various systems that have been proposed to define them, including eplets. There is a growing body of clinical evidence suggesting that epitope-based tissue matching may be superior to traditional HLA antigen matching at predicting a range of clinical outcomes. However, additional studies are required to better understand the biological relevance of these systems of defining epitopes and their role in pediatric transplantation.

A novel method to quantify the turnover and release of monocytes from the bone marrow using the thymidine analog 5'-bromo-2'-deoxyuridine

The present study was designed to develop methods to study the production and release of monocytes from the bone marrow using the thymidine analog 5'-bromo-2'-deoxyuridine (BrdU). Dividing monocytes in bone marrow were labeled with BrdU (MOBrdU), and their release into the blood and disappearance from the circulation were monitored using a double immunostaining method. The first MOBrdU appeared in the circulation 4 h after labeling with BrdU and peaked at 18 h when 34.3 +/- 5.8% of monocytes were labeled. The calculated transit time of monocytes through bone marrow was 38.1 +/- 3.1 h in control rabbits with a half-life (T1/2) of 12.7 h. Instillation of Streptococcus pneumoniae into the lung accelerated the release of monocytes from bone marrow (peak at 10 h) and shortened their bone marrow transit time (27.1 +/- 1.8 vs. 22.6 +/- 0.6, vehicle vs. pneumonia; P < 0.05). We conclude that this nonradioisotope method provides a novel way to monitor monocyte kinetics and confirmed previous reports that a focal pneumonia shortens monocyte marrow transit and increases their release into the circulation.

Transplantation

The history of solid organ transplantation is traced from its beginnings in the 19th century to the beginning of the 21st century. Surgical techniques, advances in immunology, and a review of major immunosuppressive milestones are reviewed. Over the last 50 years, transplantation has moved from experimental to accepted clinical therapy. The technology of transplantation has been widely disseminated throughout the United States. This paper reviews the major ethical and social problems that still need to be addressed in regards to transplantation. These include organ supply, organ distribution, access to care, funding, and xenotransplantation.

Human histocompatibility antigens and organ transplantation

The success of organ transplantation depends not only upon the degree of skill employed in the execution of the technical procedure, but equally upon the proper antigenic matching of the donor and the recipient. Although there does not exist at the present time a perfect test for performing tissue typing-as in the case of blood transfusions-the most promising tests are those of leukocyte typing. This is possible because the histocompatibility antigens that determine the success or failure of tissue allografts are also found on the leukocytes. The problem concerns itself with developing an exact, specific, monosera test-simple and uncumbersome-that can be used to type the leukocytes and thus select a donor who corresponds antigenically to the recipient.

Alloantigens defined by cytotoxic isoantisera prepared against peripheral rabbit lymphocytes

Seven lymphocytotoxic antisera were produced in rabbits by means of isoimmunization with purified peripheral lymphocytes. The phenotypic profile of the defined lymphocyte antigens was determined in a panel of 97 rabbits. The results indicated the existence of at least two major antigenic determinants. Further typing and cross-absorptions were performed with several of the lymphocytotoxic antisera in order to demonstrate monospecificity. The anti-3 antiserum was used to determine the distribution of the respective antigens in various rabbit organs. The highest concentration of the alloantigen was contained in the spleen, followed in descending order by the lymph nodes, lung, skin, kidney, heart and liver. Fat and red blood cells (rbc) contained no detectable antigen. A two-stage physical adherence column method was used to separate T-derived from B-derived lymphocytes and each fraction was tested for the alloantigen. Alloantigen was detected on both cell types. The fact that the anti-3 antiserum never killed more than 30% of the cells suggests that it could define a subpopulation of lymphocytes.

Urinary gamma-glutamyl transpeptidase, an indicator of renal ischaemic injury and homograft rejection

Gammaglutamyl transpeptidase is an enzyme primarily located in the brush border of the proximal convoluted tubules of the kidney. Its unique localisation in the renal cells most easily damaged by ischaemia and its ease of assay provides the rationale for its use in the measurement of renal ischaemic injury. Using a standard experimental animal model, canine urinary gamma-GT activity was shown to be increased up to 70-fold following 90 min of unilateral renal ischaemia and was significantly raised following only 5 min ischaemia. The urinary gamma-GT was used as a measure of ischaemic injury associated with renal transplantation in man and 20 consecutive patients undergoing kidney transplant were studied by daily 24-hour urinary gamma-GT estimations and excellent correlation was obtained between raised enzyme activity and the clinical diagnosis of transplant rejection.

Gamma-glutamyl transpeptidase. A sensitive indicator of renal ischaemic injury in experimental animals and renal homograft rejection in man

The sites of ischaemic injury within the kidney are reviewed and the diagnostic value of measurements of plasma and urinary enzymes in renal ischaemic injury and in renal homotransplant rejection in experimental animals and man is examined. Gamma-glutamyl transpeptidase (gamma-GT) is an enzyme primarily located in the brush border of the proximal convoluted tubule of the kidney. Its unique localization in the cells most easily damaged by ischaemia and its ease of assay provide the rationale for its use in the measurement and diagnosis of renal ischaemic injury. gamma-GT activity was measured in dogs undergoing varying periods of renal ischaemia and under conditions of local renal hypothermia and was shown to be a sensitive indicator of ischaemic injury. Twenty consecutive patients undergoing renal homotransplantation were studied by daily estimation of their 24-h urinary gamma-GT activity; excellent correlation was obtained between raised levels of this enzyme and the clinical diagnosis of transplant rejection.

Immunological investigations on patients with transplanted cornea: the role of tissue antigens in keratoplasty

After briefly describing the conceptions of the HL-A antigens and of histocompatibility, the authors give an account of their own retrospective examinations in connection with keratoplasty. Transplantations between identical groups of the ABO-system have a greater probability of ending successfully, if at least 2 HL-A antigens of donor and recipient are identical; this being chiefly important when grafting is carried out into unfavourable, vascularized surroundings.

Chronic renal homograft function: correlation with histology and lymphocyte antigen matching

Renal function was studied in twenty-nine of thirty-four surviving renal allograft recipients from an initial group of sixty-four patients two years after transplantation. Mean clearances of inulin and PAH were, respectively, greater than and equal to half the donors’ initial predicted clearances. Minimum urine osmolality during water diuresis was greater, and maximum urine osmolality during hydropenia was less than normal, an effect attributable partly to enhanced solute load in a single transplanted kidney.

Patients with compatible donor-recipient lymphocyte antigens demonstrated statistically better function than those with one or more incompatibilities, although there was a definite degree of overlap between the two groups. In contrast, little correlation could be demonstrated between the cumulative histopathology and renal clearances.

Renal function in patients with compatible donors was statistically greater than half the donors’ initial predicted function. Serial increase in renal clearances was documented in one patient with a compatible donor. Serial decreases were demonstrated in two patients with incompatible donors. These findings suggest that hypertrophy of the denervated, transplanted kidney occurs when immune reaction is minimal.

Serologic factors in human transplantation

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