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Resse M, Maiello C, Cacciatore F, Romano G, Sabia C, Picascia A, Ursomando F, Napoli C. Heart Transplant with Donor-Specific Antibody after Immunoadsorption plus Rituximab: A Case Report. Prog Transplant 2013; 23:128-31. [DOI: 10.7182/pit2013454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Different desensitization strategies are available for treating patients with preformed human leukocyte antigen (HLA) antibodies. A highly presensitized heart recipient received immunoadsorption and rituximab therapy. The patient, with end-stage heart failure, was positive only for antibodies of HLA class I (anti-A2, A10, B17), and Luminex platform (One Lambda kit) showed a panel-reactive antibody score of 64%. The patient's serum was tested repeatedly in both complement-dependent cytotoxicity and flow-cytometry crossmatches against cells from different potential organ donors. The results of these crossmatches were positive on flow cytometry when tested with HLA-A2, A10, and B17 but were still negative on cytotoxicity. The patient was treated with a desensitization regimen; this treatment immediately decreased antibody levels of 70% and the patient subsequently received a transplant with donor-specific HLA antibody (HLA-A2). After more than 2 years, graft function remains normal and the clinical status of the patient is stable.
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Affiliation(s)
- Marianna Resse
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Ciro Maiello
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Francesco Cacciatore
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Gianpaolo Romano
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Chiara Sabia
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Antonietta Picascia
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Fabio Ursomando
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
| | - Claudio Napoli
- Second University of Naples, Italy (MR, CM, GR, CS, AP, FU, CN), Institute of Telese, Benevento, Italy (FC)
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Mechanism of accommodation in a sensitized human leukocyte antigen transgenic murine cardiac transplant model. Transplantation 2012; 93:364-72. [PMID: 22273841 DOI: 10.1097/tp.0b013e3182406a6b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Presence of donor-specific antibodies (Abs) is detrimental to posttransplant allograft function. Some sensitized recipients have successfully undergone transplantation after pretransplant conditioning regimen using plasmapheresis and/or intravenous immunoglobulin therapy, but underlying mechanisms that confer such allograft protection are undefined. METHODS We developed a single human leukocyte antigen (HLA)-mismatched heterotopic murine heart transplant model (HLA-A2 into HLA-A2-sensitized-C57BL/6) to determine whether pretreatment of donors with low concentration of HLA class I (W6/32) or control Ab (C1.18.4) will confer protection. Expression levels of survival genes, Bcl-2 and heme oxygenase-1, were analyzed by gene array analysis and quantitative real-time polymerase chain reaction. Expression levels of cytokine panel were analyzed by Luminex. Role of Bcl-2 in the induction of allograft protection was analyzed by silencing the Bcl-2 expression in the donor hearts using a small hairpin (shRNA) specific for Bcl-2. RESULTS Control Ab-pretreated hearts were rejected in less than 5 days demonstrating hemorrhage, Ab, and C4 deposition. In contrast, W6/32-pretreated hearts were rejected at 15 days (P<0.05) that was prolonged to 25 days with antilymphocyte serum treatment. W6/32-pretreated hearts on day 5 exhibited increased expression of Bcl-2 (5.5-folds), Bcl-xl (5.5-folds), and heme oxygenase-1 (4.4-folds); decreased expression of ICAM-1, VCAM-1 (3.2-fold), along with reduced levels of cytokines interleukin (IL)-1β (4.4-folds), tumor necrosis factor α (3.7-folds), IL-6 (7.5-folds), IL-12 (2.3-folds) and chemokines monocyte chemotactic protein 1 (4.5-folds), MIG (4.4-folds), MIP-1α (3.4-folds), and IL-8 (3.1-folds). Silencing of Bcl-2 in accommodated hearts before transplant resulted in loss of protection with rejection (9±3 vs. 15±2days, P<0.05). CONCLUSION Pretreatment of hearts with low levels of anti-HLA Abs increases expression of antiapoptotic genes that inhibits caspases, leading to decreased inflammatory cytokines and chemokines, which promote allograft survival.
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Abstract
Highly sensitised children have markedly reduced chances of receiving a successful deceased donor renal transplant, increased risk of rejection, and decreased graft survival. There is limited experience with the long-term followup of children who have undergone desensitization. Following 2 failed transplants, our patient was highly sensitised. She had some immunological response to intravenous immunoglobulin (IVIg) but this was not sustained. We developed a protocol involving sequential therapies with rituximab, IVIg, and plasma exchange. Immunosuppressant therapy at transplantation consisted of basiliximab, tacrolimus, mycophenolate mofetil, and steroids. At the time of transplantation, historical crossmatch was ignored. Current CDC crossmatch was negative, but T and B cell flow crossmatch was positive, due to donor-specific HLA Class I antibodies. Further plasma exchange and immunoglobulin therapy were given pre- and postoperatively. Our patient received a deceased donor-kidney-bearing HLA antigens to which she originally had antibodies, which would have precluded transplant. The graft kidney continues to function well 8 years posttransplant.
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Abstract
The rate of access to transplantation of hyperimmunized patients has improved thanks to a modification of the organ allocation rule in 2002 and the initiation of the Acceptable Mismatch program. Transplantation of immunized patients must be now preceded by a fine description of the characteristics of pretransplantation immunization using sensitive techniques and by an indispensable clinical and biological discussion to choose the best transplantation strategy, taking into account the risk/benefit balance for the patient of each strategy. Whichever transplantation strategy is adopted, immunosuppression should be adapted to the immunological status of the patient, often using the new therapeutic strategies (IVIg, rituximab, plasma exchange) with a specific follow-up, notably for anti-HLA antibodies, checking their evolution post treatment.
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Affiliation(s)
- C Antoine
- Service de Néphrologie et de transplantation rénale, Hôpital Saint-Louis, 1, avenue Claude Vellefaux, 75010 Paris, France.
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Tools for human leukocyte antigen antibody detection and their application to transplanting sensitized patients. Transplantation 2008; 86:384-90. [PMID: 18698240 DOI: 10.1097/tp.0b013e31817c90f5] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In recent years there have been major advances in the technology for the detection and definition of human leukocyte antigen antibodies. In this overview we describe the evolution in laboratory technology, the techniques currently available and consider their application in antibody specificity definition and in understanding a patient's sensitization profile. We discuss the importance of antibody specificity definition in facilitating efficient national organ allocation and informing clinical discussion regarding the appropriate pathway for sensitized patients awaiting renal transplantation.
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Matignon M, Tagnaouti M, Audard V, Dahan K, Lang P, Grimbert P. Failure of Anti-CD20 Monoclonal Antibody Therapy to Prevent Antibody-Mediated Rejection in Three Crossmatch-Positive Renal Transplant Recipients. Transplant Proc 2007; 39:2565-7. [DOI: 10.1016/j.transproceed.2007.08.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Pescovitz MD. B cells: a rational target in alloantibody-mediated solid organ transplantation rejection. Clin Transplant 2006; 20:48-54. [PMID: 16556153 DOI: 10.1111/j.1399-0012.2005.00439.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Loss of allografts over time remains a barrier to achieving successful outcomes in solid organ transplantation. Although the role of donor-specific alloantibody-mediated mechanisms in hyperacute rejection is well known, research and management of early and late post-transplant rejection have traditionally focused on T cell-mediated mechanisms. However, available agents that affect T-cell pathways have minimal impact on long-term graft survival, suggesting that other effector mechanisms are involved. A growing body of evidence now supports a role for alloantibody-mediated mechanisms in early and late graft rejection, which can significantly impact on long-term graft survival. The important role of B cells in generating and perpetuating alloantibody production provides a rationale for B-cell depletion therapy as an approach to prevent or reduce alloantibody formation before transplantation and to treat or prevent early and late alloantibody-mediated rejection. The use of monoclonal antibodies that directly target B cells, in combination with standard alloantibody-depleting therapies and/or immunosuppression, has been investigated in several small non-controlled studies. Promising results suggest that this strategy warrants further investigation in larger controlled studies.
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Affiliation(s)
- Mark D Pescovitz
- Department of Surgery, Indiana University, Indianapolis, IN 46202, USA.
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Bućin D, Johansson S, Lindberg LO. Heart transplantation across antibodies against human leukocyte antigens and blood group A1 antigen. Post-transplant follow-up of donor reactive antibodies. Xenotransplantation 2006; 13:101-4. [PMID: 16623800 DOI: 10.1111/j.1399-3089.2006.00276.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have successfully performed heart transplantation despite the most unfavourable risk factors for graft and patient survival: the presence of a high level of antibodies (Abs) against the donor's human leukocyte antigens (HLA) class I/II and blood group A1 antigens. The present study concerns post-transplant follow-up and characterization of donor reactive antibodies (DRA). METHODS Pre-transplant treatment consisted of mycophenolate mofetil (MMF), prednisolone, tacrolimus, intravenous immunoglobulin (IVIG), rituximab, protein-A immunoadsorption (PAIA) and per-operative plasma exchange. A standard triple-drug immunosuppressive protocol was used post-operatively. Abs were analyzed by the complement dependent cytotoxicity (CDC) test against donor and panel B/T cells and by flow cytometry (FlowPRA tests detecting isolated HLA class I/II antigens). Abs against the donor's erythrocytes were analyzed using a standard direct agglutination test for immunoglobulin M (IgM) Abs and a Bio-Rad AHG gel card test detecting IgG Abs and C3d. RESULTS Pre-transplant treatment reduced Ab titers against the donor's lymphocytes from 128 to 16 and against the donor's blood group A1 antigen from 256 to 0. The patient was emergently transplanted with a heart from a blood group incompatible donor (A1 secretor to O). No hyperacute rejection was seen. DRA were present against all mismatched HLA class I and class II antigens at the time of transplantation; two of these DRA Abs disappeared within the first year post-transplant (anti-B62 and anti-DR4), one showed weakened reactivity (anti-A24) and one is still strongly reactive (anti-DQ3). The donor-specific CDC cross-match is still positive (titers 2 to 8). The level of panel reactive antibodies (PRA) remained unchanged from 6 months on post-transplant. Rising anti-A1 blood group Abs preceded the second rejection and were adsorbed by two blood group specific immunoadsorptions (Glycosorb)-ABO) and remained at a low level. IgM anti-A1 blood group Abs disappeared at 1 yr post-transplant and IgG Abs are still reactive with blood group A1 erythrocytes but at low titers (1 to 2). CONCLUSIONS The patient is clinically well 2 years after heart transplantation despite the constant persistence of donor reactive IgG Abs against blood group A1 and HLA-DQ antigens. The reactivity of DRA against other mismatched HLA antigens disappeared or weakened during the follow-up period.
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Affiliation(s)
- Dragan Bućin
- Blood Centre, Department of Pediatrics, University Hospital, Lund, Sweden.
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Bucin D, Johansson S, Malm T, Jögi P, Johansson J, Westrin P, Lindberg LO, Olsson AK, Gelberg J, Peres V, Harling S, Bennhagen R, Kornhall B, Ekmehag B, Kurkus J, Otto G. Heart transplantation across the antibodies against HLA and ABO. Transpl Int 2006; 19:239-44. [PMID: 16441774 DOI: 10.1111/j.1432-2277.2005.00260.x] [Citation(s) in RCA: 23] [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
We have intentionally performed heart transplantation in a 5-year-old child, despite the most unfavourable risk factors for patient survival; the presence of high level of antibodies against donor's human leucocyte antigen (HLA) class I/II and blood group antigens. Pretransplant treatment by mycophenolate mofetil, prednisolone, tacrolimus, intravenous immunoglobulin, rituximab, protein-A immunoadsorption (IA) and plasma exchange reduced antibody titres against the donor's lymphocytes from 128 to 16 and against the donor's blood group antigen from 256 to 0. The patient was urgently transplanted with a heart from an ABO incompatible donor (A(1) to O). A standard triple-drug immunosuppressive protocol was used. No hyperacute rejection was seen. Antibodies against the donor's HLA antigens remained at a low level despite three acute rejections. Rising anti-A(1) blood group antibodies preceded the second rejection and were reduced by two blood group-specific IAs and remained at a low level. The patient is doing well despite the persistence of donor-reactive antibodies.
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Affiliation(s)
- Dragan Bucin
- Transplantation Laboratory, University Hospital Blood Centre, Lund, Sweden.
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Doxiadis IIN, Duquesnoy RJ, Claas FHJ. Extending options for highly sensitized patients to receive a suitable kidney graft. Curr Opin Immunol 2005; 17:536-40. [PMID: 16084709 DOI: 10.1016/j.coi.2005.07.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Accepted: 07/21/2005] [Indexed: 11/20/2022]
Abstract
Highly sensitized patients (anti-HLA) on the kidney waiting list wait longer for a suitable crossmatch negative organ. At the moment there are two strategies to enhance transplantation of these patients. One approach is the determination of acceptable HLA mismatches and application of this knowledge for the selection of crossmatch negative donors, and the second is the desensitization of patients with intravenous immunoglobulin-based protocols to enable transplantation of an organ from a donor towards which antibodies were originally present. Both approaches have advantages and disadvantages and are only successful in a proportion of the patients. The optimal solution is an integrated strategy whereby desensitization is used for those patients for whom the acceptable mismatch approach is not successful.
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Affiliation(s)
- Ilias I N Doxiadis
- Section Immunogenetics and Transplantation Immunology, Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, The Netherlands.
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