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García-Jiménez S, Paz-Artal E, Trujillo H, Polanco N, Castro MJ, Del Rey MJ, Alfocea Á, Morales E, González E, Andrés A, Mancebo E. A personalised delisting strategy enables successful kidney transplantation in highly sensitised patients with preformed donor-specific anti HLA antibodies. HLA 2024; 103:e15572. [PMID: 38923242 DOI: 10.1111/tan.15572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/13/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
This study investigates kidney transplant outcomes in highly sensitised patients after implementing a delisting strategy aimed at enabling transplantation despite preformed donor-specific antibodies (preDSA), with the goal of reducing acute antibody-mediated rejection (aAMR) risk. Fifty-three sensitised recipients underwent kidney transplant after delisting prohibited HLA antigens, focusing initially in low MFI antibodies (<5000), except for anti-HLA-DQ. If insufficient, higher MFI antibodies were permitted, especially for those without an immunogenic eplet pattern assigned. Delisting of Complement-fixing antibodies (C1q+) was consistently avoided. Comparison cohorts included 53 sensitised recipients without DSA (SwoDSA) and 53 non-sensitised (NS). The average waiting time prior to delisting was 4.4 ± 1.8 years, with a reduction in cPRA from 99.7 ± 0.5 to 98.1 ± 0.7, followed by transplantation within 7.2 ± 8.0 months (analysed in 34 patients). Rejection rates were similar among preDSA, SwoDSA, and NS groups (16%, 8%, and 11%, respectively; p = 0.46). However, aAMR was higher in the preDSA group (12%, 4%, and 2%, respectively; p = 0.073), only presented in recipients with DSA of MFI >5000. The highest MFI DSA were against HLA-DP (Median: 10796 MFI), with 50% of preDSA aAMR cases due to anti-DP antibodies (n = 3). Graft survival rates at 1 and 5 years in preDSA group were 94%, and 67%, comparable to SwoDSA (94%, and 70%; p = 0.69), being significantly higher in the NS group (p = 0.002). The five-year recipient survival rate was 89%, comparable to SwoDSA and NS groups (p = 0.79). A delisting strategy enables safe kidney transplant in highly sensitised patients with preDSA, with a slight increase in aAMR and comparable graft and patient survivals to non-DSA cohorts.
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Affiliation(s)
- Sandra García-Jiménez
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Estela Paz-Artal
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Natalia Polanco
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - María J Castro
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Manuel J Del Rey
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Ángel Alfocea
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Enrique Morales
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Esther González
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Amado Andrés
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Esther Mancebo
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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Li F, Gragert L, Giovanni Biagini D, Patel JK, Kobashigawa JA, Trück J, Rodriguez O, Watson CT, Gibb DR, Zhang X, Kransdorf EP. IgM marks persistent IgG anti-human leukocyte antigen antibodies in highly sensitized heart transplant patients. J Heart Lung Transplant 2024; 43:314-323. [PMID: 37793509 DOI: 10.1016/j.healun.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sensitization to human leukocyte antigens (HLA) is a persistent problem in heart transplant (HT) candidates. We sought to characterize the anti-HLA antibody and circulating B cell repertoire in a cohort of highly sensitized HT candidates. METHODS We assessed immunoglobulin G (IgG) and immunoglobulin M (IgM) anti-HLA antibodies using Luminex single antigen bead assays in a cohort of 11 highly sensitized (HS; calculated panel reactive antibody ≥ 90%) and 3 mildly sensitized (MS) candidates. We also performed B cell receptor repertoire sequencing (BCRseq) in HS candidates and 33 non-candidate controls. HLA antibody strength was measured by mean fluorescence intensity (MFI). RESULTS We found that IgM anti-HLA antibodies were present in all HS candidates, but with a lower breadth and strength as compared to IgG. When anti-HLA IgG specificities intersected with IgM, binding strength was higher. In contrast, there were IgM but no intersecting IgG specificities for the MS group. In four candidates in the HS group, IgG anti-HLA antibodies decreased in both breadth and strength after HT, but the decrease in strength was smaller if the IgG possessed a specificity that intersected with pre-transplant IgM. BCRseq revealed larger B cell clonotypes in HS candidates but similar diversity as compared to controls. CONCLUSIONS IgM marks IgG anti-HLA antibodies with higher strength before HT and persistence after HT. The presence of IgM intersecting IgG for an anti-HLA specificity may be a useful approach to determine which donor HLA should be avoided for a sensitized candidate.
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Affiliation(s)
- Fang Li
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - D Giovanni Biagini
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jignesh K Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Johannes Trück
- Division of Immunology, University Children's Hospital and Children's Research Center, University of Zurich (UZH), Zurich, Switzerland
| | - Oscar Rodriguez
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - Corey T Watson
- Department of Biochemistry and Molecular Genetics, University of Louisville, Louisville, Kentucky
| | - David R Gibb
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Charreau B. Cellular and Molecular Crosstalk of Graft Endothelial Cells During AMR: Effector Functions and Mechanisms. Transplantation 2021; 105:e156-e167. [PMID: 33724240 DOI: 10.1097/tp.0000000000003741] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Graft endothelial cell (EC) injury is central to the pathogenesis of antibody-mediated rejection (AMR). The ability of donor-specific antibodies (DSA) to bind C1q and activate the classical complement pathway is an efficient predictor of graft rejection highlighting complement-dependent cytotoxicity as a key process operating during AMR. In the past 5 y, clinical studies further established the cellular and molecular signatures of AMR revealing the key contribution of other, IgG-dependent and -independent, effector mechanisms mediated by infiltrating NK cells and macrophages. Beyond binding to alloantigens, DSA IgG can activate NK cells and mediate antibody-dependent cell cytotoxicity through interacting with Fcγ receptors (FcγRs) such as FcγRIIIa (CD16a). FcRn, a nonconventional FcγR that allows IgG recycling, is highly expressed on ECs and may contribute to the long-term persistence of DSA in blood. Activation of NK cells and macrophages results in the production of proinflammatory cytokines such as TNF and IFNγ that induce transient and reversible changes in the EC phenotype and functions promoting coagulation, inflammation, vascular permeability, leukocyte trafficking. MHC class I mismatch between transplant donor and recipient can create a situation of "missing self" allowing NK cells to kill graft ECs. Depending on the microenvironment, cellular proximity with ECs may participate in macrophage polarization toward an M1 proinflammatory or an M2 phenotype favoring inflammation or vascular repair. Monocytes/macrophages participate in the loss of endothelial specificity in the process of endothelial-to-mesenchymal transition involved in renal and cardiac fibrosis and AMR and may differentiate into ECs enabling vessel and graft (re)-endothelialization.
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Affiliation(s)
- Béatrice Charreau
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et en Immunologie, UMR 1064, ITUN, Nantes, France
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Pelletier RP, Balazs I, Adams P, Rajab A, DiPaola NR, Henry ML. Clinical utility of C3d binding donor-specific anti-human leukocyte antigen antibody detection by single antigen beads after kidney transplantation-a retrospective study. Transpl Int 2018; 31:424-435. [DOI: 10.1111/tri.13106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/20/2017] [Accepted: 12/13/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Ronald P Pelletier
- Department of Surgery; Division of Transplantation; The Ohio State University; Columbus OH USA
| | - Ivan Balazs
- Discovery Research; Immucor Inc.; Norcross GA USA
| | - Pat Adams
- Tissue Typing Laboratory; The Ohio State University; Columbus OH USA
| | - Amer Rajab
- Department of Surgery; Division of Transplantation; The Ohio State University; Columbus OH USA
| | | | - Mitchell L Henry
- Department of Surgery; Division of Transplantation; The Ohio State University; Columbus OH USA
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Diagnostic Contribution of Donor-Specific Antibody Characteristics to Uncover Late Silent Antibody-Mediated Rejection-Results of a Cross-Sectional Screening Study. Transplantation 2017; 101:631-641. [PMID: 27120452 DOI: 10.1097/tp.0000000000001195] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Circulating donor-specific antibodies (DSA) detected on bead arrays may not inevitably indicate ongoing antibody-mediated rejection (AMR). Here, we investigated whether detection of complement-fixation, in parallel to IgG mean fluorescence intensity (MFI), allows for improved prediction of AMR. METHODS Our study included 86 DSA+ kidney transplant recipients subjected to protocol biopsy, who were identified upon cross-sectional antibody screening of 741 recipients with stable graft function at 6 months or longer after transplantation. IgG MFI was analyzed after elimination of prozone effect, and complement-fixation was determined using C1q, C4d, or C3d assays. RESULTS Among DSA+ study patients, 44 recipients (51%) had AMR, 24 of them showing C4d-positive rejection. Although DSA number or HLA class specificity were not different, patients with AMR or C4d + AMR showed significantly higher IgG, C1q, and C3d DSA MFI than nonrejecting or C4d-negative patients, respectively. Overall, the predictive value of DSA characteristics was moderate, whereby the highest accuracy was computed for peak IgG MFI (AMR, 0.73; C4d + AMR, 0.71). Combined analysis of antibody characteristics in multivariate models did not improve AMR prediction. CONCLUSIONS We estimate a 50% prevalence of silent AMR in DSA+ long-term recipients and conclude that assessment of IgG MFI may add predictive accuracy, without an independent diagnostic advantage of detecting complement-fixation.
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Rabbit antithymocyte globulin and donor-specific antibodies in kidney transplantation — A review. Transplant Rev (Orlando) 2016; 30:85-91. [DOI: 10.1016/j.trre.2015.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/22/2015] [Indexed: 01/28/2023]
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Vallin P, Désy O, Béland S, Wagner E, De Serres SA. Clinical relevance of circulating antibodies and B lymphocyte markers in allograft rejection. Clin Biochem 2016; 49:385-93. [PMID: 26721422 DOI: 10.1016/j.clinbiochem.2015.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/27/2015] [Accepted: 12/06/2015] [Indexed: 01/08/2023]
Abstract
The main challenge in solid organ transplantation remains to tackle antibody-mediated rejection. Our understanding of the antibody-mediated response and the capacity to detect it has improved in the last decade. However, the sensitivity and specificity of the current clinical tools to monitor B cell activation are perfectible. New strategies, including the refinement in the characterization of HLA and non-HLA antibodies, as well as a better understanding of the circulating B cell phenotype will hopefully help to non-invasively identify patients at risk or undergoing antibody-mediated allograft damage. The current review discusses the current knowledge of the B cell biomarkers in solid organ transplantation, with a focus on circulating antibodies and peripheral B cells.
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Affiliation(s)
- Patrice Vallin
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Olivier Désy
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Stéphanie Béland
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Eric Wagner
- Immunology and Histocompatibility Laboratory, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Sacha A De Serres
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada.
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Lefaucheur C, Viglietti D, Bentlejewski C, Duong van Huyen JP, Vernerey D, Aubert O, Verine J, Jouven X, Legendre C, Glotz D, Loupy A, Zeevi A. IgG Donor-Specific Anti-Human HLA Antibody Subclasses and Kidney Allograft Antibody-Mediated Injury. J Am Soc Nephrol 2015; 27:293-304. [PMID: 26293822 DOI: 10.1681/asn.2014111120] [Citation(s) in RCA: 218] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/27/2015] [Indexed: 12/24/2022] Open
Abstract
Antibodies may have different pathogenicities according to IgG subclass. We investigated the association between IgG subclasses of circulating anti-human HLA antibodies and antibody-mediated kidney allograft injury. Among 635 consecutive kidney transplantations performed between 2008 and 2010, we enrolled 125 patients with donor-specific anti-human HLA antibodies (DSA) detected in the first year post-transplant. We assessed DSA characteristics, including specificity, HLA class specificity, mean fluorescence intensity (MFI), C1q-binding, and IgG subclass, and graft injury phenotype at the time of sera evaluation. Overall, 51 (40.8%) patients had acute antibody-mediated rejection (aABMR), 36 (28.8%) patients had subclinical ABMR (sABMR), and 38 (30.4%) patients were ABMR-free. The MFI of the immunodominant DSA (iDSA, the DSA with the highest MFI level) was 6724±464, and 41.6% of patients had iDSA showing C1q positivity. The distribution of iDSA IgG1-4 subclasses among the population was 75.2%, 44.0%, 28.0%, and 26.4%, respectively. An unsupervised principal component analysis integrating iDSA IgG subclasses revealed aABMR was mainly driven by IgG3 iDSA, whereas sABMR was driven by IgG4 iDSA. IgG3 iDSA was associated with a shorter time to rejection (P<0.001), increased microcirculation injury (P=0.002), and C4d capillary deposition (P<0.001). IgG4 iDSA was associated with later allograft injury with increased allograft glomerulopathy and interstitial fibrosis/tubular atrophy lesions (P<0.001 for all comparisons). Integrating iDSA HLA class specificity, MFI level, C1q-binding status, and IgG subclasses in a Cox survival model revealed IgG3 iDSA and C1q-binding iDSA were strongly and independently associated with allograft failure. These results suggest IgG iDSA subclasses identify distinct phenotypes of kidney allograft antibody-mediated injury.
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Affiliation(s)
- Carmen Lefaucheur
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France;
| | - Denis Viglietti
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | | | - Jean-Paul Duong van Huyen
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France; Department of Pathology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dewi Vernerey
- Methodology Unit (Research team 3181), University Hospital de Besançon, Besançon, France
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | - Jérôme Verine
- Department of Pathology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | - Christophe Legendre
- Department of Kidney Transplantation, Necker Hospital, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Denis Glotz
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France; Department of Kidney Transplantation, Necker Hospital, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Adriana Zeevi
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Messina M, Ariaudo C, Praticò Barbato L, Beltramo S, Mazzucco G, Amoroso A, Ranghino A, Cantaluppi V, Fop F, Segoloni GP, Biancone L. Relationship among C1q-fixing de novo donor specific antibodies, C4d deposition and renal outcome in transplant glomerulopathy. Transpl Immunol 2015; 33:7-12. [PMID: 26160049 DOI: 10.1016/j.trim.2015.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND The C1q-binding properties of donor specific antibodies (DSA) may be related to antibody-mediated rejection and poor outcome. METHODS We retrospectively studied 35 kidney transplant recipients with transplant glomerulopathy (TG) and de novo DSA (dnDSA). C1q dnDSA were measured in the serum stored at renal biopsy and the association among C1q-fixing dnDSA, C4d deposition and graft loss was examined. RESULTS Of the 35 patients with dnDSA and TG, 15 (42.9%) had C1q-positive dnDSA and 20 (57.1%) had C1q-negative dnDSA. Ten out of 15 patients with C1q-positive dnDSA (66.6%) and 5 with C1q-negative dnDSA (25%) had C4d positive staining renal biopsies (P=0.02), being the C1q-negative dnDSA/C4d-negative TG 42.9% of the total. The C1q-positive dnDSA group has significantly higher IgG DSA Class II MFI than the C1q-negative dnDSA group (P=0.004). Patients with C4d deposits have significantly higher IgG DSA MFI for both Class I and Class II than those without C4d deposits (P=0.02). We found a trend toward higher graft loss in the C1q-positive dnDSA group (60%) versus the C1q-negative dnDSA group (40%) without a statistical significance (P=0.31). CONCLUSION Our study provides further characterization of TG associated with dnDSA. The major part of dnDSA-associated TG was C1q-negative and the presence of C1q-fixing dnDSA did not significantly correlate with graft outcome.
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Affiliation(s)
- Maria Messina
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Claudia Ariaudo
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Loredana Praticò Barbato
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Silvia Beltramo
- Center for Experimental Medical Research (CeRMS), University of Turin, Italy
| | - Gianna Mazzucco
- Division of Pathology Transplantation, Department of Medical Sciences, University of Turin, Italy
| | - Antonio Amoroso
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Andrea Ranghino
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Vincenzo Cantaluppi
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy; Center for Experimental Medical Research (CeRMS), University of Turin, Italy
| | - Fabrizio Fop
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Giuseppe Paolo Segoloni
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy
| | - Luigi Biancone
- Renal Transplantation Unit 'A. Vercellone', Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Italy; Center for Experimental Medical Research (CeRMS), University of Turin, Italy.
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Böhmig GA, Kikic Z, Wahrmann M, Eskandary F, Aliabadi AZ, Zlabinger GJ, Regele H, Feucht HE. Detection of alloantibody-mediated complement activation: A diagnostic advance in monitoring kidney transplant rejection? Clin Biochem 2015; 49:394-403. [PMID: 26118475 DOI: 10.1016/j.clinbiochem.2015.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 05/23/2015] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Antibody-mediated rejection (ABMR) is an important cause of kidney allograft injury. In the last two decades, detection of complement split product C4d along transplant capillaries, a footprint of antibody-mediated classical complement activation, has evolved as a useful diagnostic marker of ABMR. While it was recognized that ABMR may occur also in the absence of C4d, numerous studies have shown that C4d deposition may indicate a more severe rejection phenotype associated with poor graft survival. Such studies suggest a possible diagnostic benefit of ex vivo monitoring the complement-activating capability of circulating alloantibodies. DESIGN AND METHODS We reviewed the literature between 1993 and 2015, focusing on in vivo (biopsy work-up) and in vitro detection (modified bead array technology) of HLA antibody-triggered classical complement activation in kidney transplantation. RESULTS Precise HLA antibody detection methods, in particular Luminex-based single antigen bead (SAB) assays, have provided a valuable basis for the design of techniques for in vitro detection of HLA antibody-triggered complement activation reflected by C1q, C4 or C3 split product deposition to the bead surface. Establishing such assays it was recognized that deposition of complement products to SAB, which critically depends on antibody binding strength, may be a cardinal trigger of the prozone effect, a troublesome in vitro artifact caused by a steric interference with IgG detection reagents. False-low IgG results, especially on SAB with extensive antibody binding, have to be considered when interpreting studies analyzing the diagnostic value of complement in relation to standard IgG detection. Levels of complement-fixing donor-specific antibodies (DSA) were shown to correlate with the results of standard crossmatch tests, suggesting potential application for crossmatch prediction. Moreover, while the utility of pre-transplant complement detection, at least in crossmatch-negative transplant recipients, is controversially discussed, a series of studies have shown that the appearance of post-transplant complement-fixing DSA may be associated with C4d deposition in transplant capillaries and a particular risk of graft failure. CONCLUSIONS The independent value of modified single antigen bead assays, as compared to a careful analysis of standard IgG detection, which may be affected considerably by complement dependent artifacts, needs to be clarified. Whether they have the potential to improve the predictive accuracy of our current diagnostic repertoire warrants further study.
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Affiliation(s)
- Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Zeljko Kikic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Arezu Z Aliabadi
- Department of Cardiac Surgery, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Gerhard J Zlabinger
- Institute of Immunology, Medical University Vienna, Lazarettgasse 19, A-1090 Vienna, Austria
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Helmut E Feucht
- Department of Organ Transplantation/Nephrology, Fachklinik Bad Heilbrunn, Wörnerweg 30, 83670 Bad Heilbrunn, Germany
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11
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Valenzuela NM, Trinh KR, Mulder A, Morrison SL, Reed EF. Monocyte recruitment by HLA IgG-activated endothelium: the relationship between IgG subclass and FcγRIIa polymorphisms. Am J Transplant 2015; 15:1502-18. [PMID: 25648976 PMCID: PMC4439339 DOI: 10.1111/ajt.13174] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/01/2014] [Accepted: 12/15/2014] [Indexed: 01/25/2023]
Abstract
It is currently unclear which donor specific HLA antibodies confer the highest risk of antibody-mediated rejection (AMR) and allograft loss. In this study, we hypothesized that two distinct features (HLA IgG subclass and Fcγ receptor [FcγR] polymorphisms) which vary from patient to patient, influence the process of monocyte trafficking to and macrophage accumulation in the allograft during AMR in an interrelated fashion. Here, we investigated the contribution of human IgG subclass and FcγR polymorphisms in monocyte recruitment in vitro by primary human aortic endothelium activated with chimeric anti-HLA I human IgG1 and IgG2. Both subclasses triggered monocyte adhesion to endothelial cells, via a two-step process. First, HLA I crosslinking by antibodies stimulated upregulation of P-selectin on endothelium irrespective of IgG subclass. P-selectin-induced monocyte adhesion was enhanced by secondary interactions of IgG with FcγRs, which was highly dependent upon subclass. IgG1 was more potent than IgG2 through differential engagement of FcγRs. Monocytes homozygous for FcγRIIa-H131 adhered more readily to HLA antibody-activated endothelium compared with FcγRIIa-R131 homozygous. Finally, direct modification of HLA I antibodies with immunomodulatory enzymes EndoS and IdeS dampened recruitment by eliminating antibody-FcγR binding, an approach that may have clinical utility in reducing AMR and other forms of antibody-induced inflammation.
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Affiliation(s)
- Nicole M. Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - K. Ryan Trinh
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA
| | - Arend Mulder
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Sherie L. Morrison
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
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Lobashevsky AL. Methodological aspects of anti-human leukocyte antigen antibody analysis in solid organ transplantation. World J Transplant 2014; 4:153-67. [PMID: 25346888 PMCID: PMC4208078 DOI: 10.5500/wjt.v4.i3.153] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/16/2014] [Accepted: 07/25/2014] [Indexed: 02/05/2023] Open
Abstract
Donor human leukocyte antigen (HLA)-specific antibodies (DSA) play an important role in solid organ transplantation. Preexisting IgG isotype DSA are considered a risk factor for antibody mediated rejection, graft failure or graft loss. The post-transplant development of DSA depends on multiple factors including immunogenicity of mismatched antigens, HLA class II typing of the recipient, cytokine gene polymorphisms, and cellular immunoregulatory mechanisms. De novo developed antibodies require special attention because not all DSA have equal clinical significance. Therefore, it is important for transplant clinicians and transplant immunologists to accurately characterize DSA. In this review, the contemporary immunological techniques for detection and characterization of anti-HLA antibodies and their pitfalls are described.
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Sicard A, Ducreux S, Rabeyrin M, Couzi L, McGregor B, Badet L, Scoazec JY, Bachelet T, Lepreux S, Visentin J, Merville P, Fremeaux-Bacchi V, Morelon E, Taupin JL, Dubois V, Thaunat O. Detection of C3d-binding donor-specific anti-HLA antibodies at diagnosis of humoral rejection predicts renal graft loss. J Am Soc Nephrol 2014; 26:457-67. [PMID: 25125383 DOI: 10.1681/asn.2013101144] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Antibody-mediated rejection (AMR) is a major cause of kidney graft loss, yet assessment of individual risk at diagnosis is impeded by the lack of a reliable prognosis assay. Here, we tested whether the capacity of anti-HLA antibodies to bind complement components allows accurate risk stratification at the time of AMR diagnosis. Among 938 kidney transplant recipients for whom a graft biopsy was performed between 2004 and 2012 at the Lyon University Hospitals, 69 fulfilled the diagnosis criteria for AMR and were enrolled. Sera banked at the time of the biopsy were screened for the presence of donor-specific anti-HLA antibodies (DSAs) and their ability to bind C1q and C3d using flow bead assays. In contrast with C4d graft deposition, the presence of C3d-binding DSA was associated with a higher risk of graft loss (P<0.001). Despite similar trend, the difference did not reach significance with a C1q-binding assay (P=0.06). The prognostic value of a C3d-binding assay was further confirmed in an independent cohort of 39 patients with AMR (P=0.04). Patients with C3d-binding antibodies had worse eGFR and higher DSA mean fluorescence intensity. In a multivariate analysis, only eGFR <30 ml/min per 1.73 m(2) (hazard ratio [HR], 3.56; 95% confidence interval [CI], 1.46 to 8.70; P=0.005) and the presence of circulating C3d-binding DSA (HR, 2.80; 95% CI, 1.12 to 6.95; P=0.03) were independent predictors for allograft loss at AMR diagnosis. We conclude that assessment of the C3d-binding capacity of DSA at the time of AMR diagnosis allows for identification of patients at risk for allograft loss.
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Affiliation(s)
- Antoine Sicard
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Transplantation, Néphrologie et Immunologie Clinique, Lyon, France; Institut National de la Santé et de la Recherche Médicale U1111, Lyon, France; Unité de Formation et de Recherche Lyon Est, Université de Lyon, Lyon, France
| | - Stéphanie Ducreux
- Laboratoire d'Histocompatibilité, Etablissement Français du Sang, Lyon, France
| | - Maud Rabeyrin
- Laboratoire d'anatomopathologie, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Lionel Couzi
- Service de Néphrologie Transplantation Dialyse, Université de Bordeaux, Bordeaux, France
| | - Brigitte McGregor
- Laboratoire d'anatomopathologie, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Lionel Badet
- Unité de Formation et de Recherche Lyon Est, Université de Lyon, Lyon, France; Service d'Urologie et Transplantation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Jean Yves Scoazec
- Unité de Formation et de Recherche Lyon Est, Université de Lyon, Lyon, France; Laboratoire d'anatomopathologie, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Bachelet
- Service de Néphrologie Transplantation Dialyse, Université de Bordeaux, Bordeaux, France
| | | | - Jonathan Visentin
- Laboratoire d'immunologie et immunogénétique, Centre Hospitalier Universitaire, Hôpital Pellegrin, Bordeaux, France
| | - Pierre Merville
- Service de Néphrologie Transplantation Dialyse, Université de Bordeaux, Bordeaux, France
| | - Véronique Fremeaux-Bacchi
- Service d'Immunologie Biologique, Assistance Publique-Hopitaux de Paris, Hopital Europeen Georges Pompidou, Paris, France; and Centre de Recherche des Cordeliers, Paris, France
| | - Emmanuel Morelon
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Transplantation, Néphrologie et Immunologie Clinique, Lyon, France; Institut National de la Santé et de la Recherche Médicale U1111, Lyon, France; Unité de Formation et de Recherche Lyon Est, Université de Lyon, Lyon, France
| | - Jean-Luc Taupin
- Laboratoire d'immunologie et immunogénétique, Centre Hospitalier Universitaire, Hôpital Pellegrin, Bordeaux, France
| | - Valérie Dubois
- Laboratoire d'Histocompatibilité, Etablissement Français du Sang, Lyon, France
| | - Olivier Thaunat
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Transplantation, Néphrologie et Immunologie Clinique, Lyon, France; Institut National de la Santé et de la Recherche Médicale U1111, Lyon, France; Unité de Formation et de Recherche Lyon Est, Université de Lyon, Lyon, France;
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Transplant glomerulopathy: the interaction of HLA antibodies and endothelium. J Immunol Res 2014; 2014:549315. [PMID: 24741606 PMCID: PMC3987972 DOI: 10.1155/2014/549315] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 01/15/2023] Open
Abstract
Transplant glomerulopathy (TG) is a major cause of chronic graft dysfunction without effective therapy. Although the histological definition of TG is well characterized, the pathophysiological pathways leading to TG development are still poorly understood. Electron microscopy suggests an earlier appearance of TG and suggests that endothelial cell injury is the first sign of the disease. The pathogenic role of human leukocyte antigen (HLA) antibodies in endothelial cells has been described in acute vascular and humoral rejection. However the mechanisms and pathways of endothelial cell injury by HLA antibodies remain unclear. Despite the description of different causes of the morphological lesion of TG (hepatitis, thrombotic microangiopathy), the strong link between TG and chronic antibody mediated rejection suggests a major role for HLA antibodies in TG formation. In this review, we describe the effect of classes I or II HLA-antibodies in TG and especially the implication of donor specific antibodies (DSA). We update recent studies about endothelial cells and try to explain the different signals and intracellular pathways involved in the progression of TG.
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Lee J, Romero R, Xu Y, Miranda J, Yoo W, Chaemsaithong P, Kusanovic JP, Chaiworapongsa T, Tarca AL, Korzeniewski SJ, Hassan SS, Than NG, Yoon BH, Kim CJ. Detection of anti-HLA antibodies in maternal blood in the second trimester to identify patients at risk of antibody-mediated maternal anti-fetal rejection and spontaneous preterm delivery. Am J Reprod Immunol 2013; 70:162-75. [PMID: 23841577 PMCID: PMC4154511 DOI: 10.1111/aji.12141] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 04/30/2013] [Indexed: 02/04/2023] Open
Abstract
PROBLEM Maternal anti-fetal rejection is a mechanism of disease in spontaneous preterm labor. The objective of this study was to determine whether the presence of human leukocyte antigen (HLA) panel-reactive antibodies (PRA) during the second trimester increases the risk of spontaneous preterm delivery. METHODS OF STUDY This longitudinal case-control study included pregnant women with spontaneous preterm deliveries (n = 310) and control patients with normal term pregnancies (n = 620), matched for maternal age and gravidity. Maternal plasma samples obtained at 14-16, 16-20, 20-24, and 24-28 weeks of gestation were analyzed for HLA class I and class II PRA positivity using flow cytometry. The fetal HLA genotype and maternal HLA alloantibody epitope were determined for a subset of patients with positive HLA PRA. RESULTS (i) Patients with spontaneous preterm delivery were more likely to exhibit HLA class I (adjusted OR = 2.54, P < 0.0001) and class II (adjusted OR = 1.98, P = 0.002) PRA positivity than those delivering at term; (ii) HLA class I PRA positivity for patients with spontaneous preterm delivery between 28 and 34 weeks (adjusted OR = 2.88; P = 0.001) and after 34 weeks of gestation (adjusted OR = 2.53; P < 0.0001) was higher than for those delivering at term; (iii) HLA class II PRA positivity for patients with spontaneous preterm delivery after 34 weeks of gestation was higher than for those delivering at term (adjusted OR = 2.04; P = 0.002); (iv) multiparous women were at a higher risk for HLA class I PRA positivity than nulliparous women (adjusted OR = 0.097, P < 0.0001 for nulliparity); (v) nulliparous women had a higher rate of HLA class I PRA positivity with advancing gestational age (P = 0.001); and (vi) 78% of women whose fetuses were genotyped had alloantibodies specific against fetal HLA class I antigens. CONCLUSION Pregnant women with positive HLA class I or class II PRA during the second trimester are at an increased risk of spontaneous preterm delivery due to antibody-mediated maternal anti-fetal rejection.
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Affiliation(s)
- JoonHo Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Yi Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Jezid Miranda
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Wonsuk Yoo
- Biostatistics and Epidemiology Division, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Sótero del Río Hospital, Santiago, Chile
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Adi L. Tarca
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Computer Science, Wayne State University, Detroit, Michigan, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nandor Gabor Than
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Chong Jai Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pathology, Wayne State University School of Medicine, Hutzel Women's Hospital, Detroit, Michigan, USA
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Lee J, Romero R, Chaiworapongsa T, Dong Z, Tarca AL, Xu Y, Chiang PJ, Kusanovic JP, Hassan SS, Yeo L, Yoon BH, Than NG, Kim CJ. Characterization of the fetal blood transcriptome and proteome in maternal anti-fetal rejection: evidence of a distinct and novel type of human fetal systemic inflammatory response. Am J Reprod Immunol 2013; 70:265-84. [PMID: 23905683 DOI: 10.1111/aji.12142] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/07/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The human fetus is able to mount a systemic inflammatory response when exposed to microorganisms. This stereotypic response has been termed the 'fetal inflammatory response syndrome' (FIRS), defined as an elevation of fetal plasma interleukin-6 (IL-6). FIRS is frequently observed in patients whose preterm deliveries are associated with intra-amniotic infection, acute inflammatory lesions of the placenta, and a high rate of neonatal morbidity. Recently, a novel form of fetal systemic inflammation, characterized by an elevation of fetal plasma CXCL10, has been identified in patients with placental lesions consistent with 'maternal anti-fetal rejection'. These lesions include chronic chorioamnionitis, plasma cell deciduitis, and villitis of unknown etiology. In addition, positivity for human leukocyte antigen (HLA) panel-reactive antibodies (PRA) in maternal sera can also be used to increase the index of suspicion for maternal anti-fetal rejection. The purpose of this study was to determine (i) the frequency of pathologic lesions consistent with maternal anti-fetal rejection in term and spontaneous preterm births; (ii) the fetal serum concentration of CXCL10 in patients with and without evidence of maternal anti-fetal rejection; and (iii) the fetal blood transcriptome and proteome in cases with a fetal inflammatory response associated with maternal anti-fetal rejection. METHOD OF STUDY Maternal and fetal sera were obtained from normal term (n = 150) and spontaneous preterm births (n = 150). A fetal inflammatory response associated with maternal anti-fetal rejection was diagnosed when the patients met two or more of the following criteria: (i) presence of chronic placental inflammation; (ii) ≥80% of maternal HLA class I PRA positivity; and (iii) fetal serum CXCL10 concentration >75th percentile. Maternal HLA PRA was analyzed by flow cytometry. The concentrations of fetal CXCL10 and IL-6 were determined by ELISA. Transcriptome analysis was undertaken after the extraction of total RNA from white blood cells with a whole-genome DASL assay. Proteomic analysis of fetal serum was conducted by two-dimensional difference gel electrophoresis. Differential gene expression was considered significant when there was a P < 0.01 and a fold-change >1.5. RESULTS (i) The frequency of placental lesions consistent with maternal anti-fetal rejection was higher in patients with preterm deliveries than in those with term deliveries (56% versus 32%; P < 0.001); (ii) patients with spontaneous preterm births had a higher rate of maternal HLA PRA class I positivity than those who delivered at term (50% versus 32%; P = 0.002); (iii) fetuses born to mothers with positive maternal HLA PRA results had a higher median serum CXCL10 concentration than those with negative HLA PRA results (P < 0.001); (iv) the median serum CXCL10 concentration (but not IL-6) was higher in fetuses with placental lesions associated with maternal anti-fetal rejection than those without such lesions (P < 0.001); (v) a whole-genome DASL assay of fetal blood RNA demonstrated differential expression of 128 genes between fetuses with and without lesions associated with maternal anti-fetal rejection; and (vi) comparison of the fetal serum proteome demonstrated 20 proteins whose abundance differed between fetuses with and without lesions associated with maternal anti-fetal rejection. CONCLUSION We describe a systemic inflammatory response in human fetuses born to mothers with evidence of maternal anti-fetal rejection. The transcriptome and proteome of this novel type of fetal inflammatory response were different from that of FIRS type I (which is associated with acute infection/inflammation).
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Affiliation(s)
- Joonho Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, Detroit, MI, USA
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Dragun D, Hegner B. Detection of C4d-fixing HLA antibodies in serum - a glass half full and half empty. Transpl Int 2013; 26:119-20. [PMID: 23317108 DOI: 10.1111/tri.12045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 11/26/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Duska Dragun
- Clinic for Nephrology and Intensive Care Medicine, Charité University Hospital, Berlin, Germany.
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Preformed complement-activating low-level donor-specific antibody predicts early antibody-mediated rejection in renal allografts. Transplantation 2013. [PMID: 23197178 DOI: 10.1097/tp.0b013e3182743cfa] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND.: Donor-specific anti-HLA antibodies (DSA) are a major cause of alloimmune injury. Transplant recipients with negative complement-dependent cytotoxic crossmatch (CDC-XM) and donor cell-based flow cytometric crossmatch (flow-XM) but low level DSA (i.e., by Luminex) have worse outcomes compared with nonsensitized patients. The aim of this study was to establish whether complement-activating ability in this low-level DSA, present before transplantation, as determined by this technique is important in dictating pathogenicity. METHODS.: We retrospectively studied 52 patients with preformed DSA detected by single-antigen flow cytometric fluorescent beads (SAFBs). Patients were transplanted using a steroid-sparing regimen consisting of alemtuzumab induction, 1 week of corticosteroids and tacrolimus monotherapy.Fifteen (29%) of 52 patients experienced antibody-mediated rejection (AMR), whereas 37 (71%) patients did not. There were no demographic differences between patients with AMR and those without. Pretransplant sera were retested using a modified (SAFB) assay, which detects the presence of the complement fragment C4d as a result of DSA-induced complement activation. RESULTS.: C4d+DSA were detected in 10 (19%) of 52 patients. Biopsy-proven AMR occurred in 7 (70%) of the 10 patients with C4d+DSA and in 8 (19%) of 42 patients with C4d-DSA. AMR-free survival was worse in patients with C4d+DSA (P<0.001). CONCLUSIONS.: The ability of preformed, low-level, DSA to trigger C4d fixation in vitro in patients with negative conventional crossmatch tests is predictive for AMR. C4d SAFB is potentially a powerful tool for risk stratification prior to transplantation and may allow identification of unacceptable donor antigens, or patients who may require enhanced immunosuppression.
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Wahrmann M, Hlavin G, Fischer G, Marinova L, Schwaiger E, Hörl WH, Zlabinger GJ, Körmöczi GF, König F, Böhmig GA. Modified solid-phase alloantibody detection for improved crossmatch prediction. Hum Immunol 2013; 74:32-40. [DOI: 10.1016/j.humimm.2012.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/17/2012] [Accepted: 10/03/2012] [Indexed: 11/17/2022]
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Bartel G, Wahrmann M, Schwaiger E, Kikić Ž, Winzer C, Hörl WH, Mühlbacher F, Hoke M, Zlabinger GJ, Regele H, Böhmig GA. Solid phase detection of C4d-fixing HLA antibodies to predict rejection in high immunological risk kidney transplant recipients. Transpl Int 2012; 26:121-30. [PMID: 23145861 DOI: 10.1111/tri.12000] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/21/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023]
Abstract
Protocols for recipient desensitization may allow for successful kidney transplantation across major immunological barriers. Desensitized recipients, however, still face a considerable risk of antibody-mediated rejection (AMR), which underscores the need for risk stratification tools to individually tailor treatment. Here, we investigated whether solid phase detection of complement-fixing donor-specific antibodies (DSA) has the potential to improve AMR prediction in high-risk transplants. The study included 68 sensitized recipients of deceased donor kidney allografts who underwent peritransplant immunoadsorption for alloantibody depletion (median cytotoxic panel reactivity: 73%; crossmatch conversion: n = 21). Pre and post-transplant sera were subjected to detection of DSA-triggered C4d deposition ([C4d]DSA) applying single-antigen bead (SAB) technology. While standard crossmatch and [IgG]SAB testing failed to predict outcomes in our desensitized patients, detection of preformed [C4d]DSA (n = 44) was tightly associated with C4d-positive AMR [36% vs. 8%, P = 0.01; binary logistic regression: odds ratio: 10.1 (95% confidence interval: 1.6-64.2), P = 0.01]. Moreover, long-term death-censored graft survival tended to be worse among [C4d]DSA-positive recipients (P = 0.07). There were no associations with C4d-negative AMR or cellular rejection. [C4d]DSA detected 6 months post-transplantation were not related to clinical outcomes. Our data suggest that pretransplant SAB-based detection of complement-fixing DSA may be a valuable tool for risk stratification.
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Affiliation(s)
- Gregor Bartel
- Department of Medicine III, Medical University Vienna, Vienna, Austria
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22
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Zachary AA, Vega RM, Lucas DP, Leffell MS. HLA antibody detection and characterization by solid phase immunoassays: methods and pitfalls. Methods Mol Biol 2012; 882:289-308. [PMID: 22665241 DOI: 10.1007/978-1-61779-842-9_17] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Solid phase immunoassays for the detection and characterization of HLA-specific antibodies provide greatly increased sensitivity, specificity, and time and reagent efficiency, compared to the traditionally used cell-based methods. Testing is performed using commercially available test kits. The assays are of two general types: enzyme-linked immunosorbent assays and multianalyte bead. The types vary in both sensitivity and equipment requirements.While these assays afford great improvement over the cell-based assays, they can be confounded by interference from substances within the serum that result in high background reactivity. The high sensitivity of the assays also makes them more susceptible to environmental factors and operator variability. The user must be aware of the capabilities of the various formats, the factors that can affect test results, and lot to lot variability of any single product. Knowledge of the characteristics of each product and thorough and accurate analysis of the results are essential to the utility of these assays.
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Affiliation(s)
- Andrea A Zachary
- Immunogenetics Laboratory, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
PURPOSE OF REVIEW Classical complement activation is a key step in the process of antibody-mediated rejection. Emphasizing novel diagnostic strategies, this study will discuss recent studies highlighting the particular relevance of alloantibodies with complement-fixing ability. RECENT FINDINGS Reinforcing the pivotal role of complement, numerous studies have shown tight associations of capillary C4d deposition, a 'footprint' of alloantibody-triggered complement activation, with the occurrence of allograft injury. Distribution patterns of immunoglobulin isotypes or subclasses, which strongly differ in their ability to activate complement, may not adequately reflect the actual pathogenetic relevance of detected allosensitization. This fact may be explained by the finding that other variables, such as antibody-binding density or a synergism of antibodies against different epitopes of the same antigen, may contribute to complement activation. An attractive approach to distinguish between complement-fixing and presumably less harmful noncomplement-fixing alloreactivities could be the detection of C4d deposition in vitro. Applying such techniques, recent studies have shown that human leukocyte antigen reactivity with C4d-fixing ability, in contrast to noncomplement-fixing sensitization, may strongly predict antibody-mediated rejection and inferior graft survival. SUMMARY Considering the pivotal role of complement, technologies that uncover the complement-fixing ability of alloantibodies may be of particular interest for the selective detection of deleterious sensitization.
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Huber L, Lachmann N, Dürr M, Matz M, Liefeldt L, Neumayer HH, Schönemann C, Budde K. Identification and Therapeutic Management of Highly Sensitized Patients Undergoing Renal Transplantation. Drugs 2012; 72:1335-54. [DOI: 10.2165/11631110-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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25
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Profiling Posttransplant Circulating Antibodies in Kidney Transplantation Using Donor Endothelial Cells. Transplantation 2012; 93:257-64. [DOI: 10.1097/tp.0b013e31823ec0ec] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sutherland SM, Chen G, Sequeira FA, Lou CD, Alexander SR, Tyan DB. Complement-fixing donor-specific antibodies identified by a novel C1q assay are associated with allograft loss. Pediatr Transplant 2012; 16:12-7. [PMID: 22093755 DOI: 10.1111/j.1399-3046.2011.01599.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Long-term outcomes following renal transplantation remain disappointing. Recently, interest has focused on the antibody-mediated component of allograft injury and the deleterious effects of DSA. We applied a novel C1q solid-phase assay in parallel with the standard IgG SAB assay to identify DSA with the potential to activate complement by binding C1q. Among 193 consecutive renal transplants at our center, 19.2% developed de novo DSA following transplantation. Of the patients with DSA, 43% had antibodies that bound C1q in vitro [C1q+ DSA]. Patients with C1q+ DSA were more likely to develop allograft loss than patients with DSA that did not bind C1q (46.7% vs. 15%; p = 0.04); patients with C1q+ DSA were nearly six times more likely to lose their transplant than those with C1q- DSA. Additionally, patients with C1q+ DSA who underwent allograft biopsy were more likely to demonstrate C4d deposition (50% vs. 8%; p = 0.03) and meet criteria for acute rejection (60% vs. 17%; p = 0.02) when compared with patients with DSA that did not bind C1q. These data suggest that DSA with the ability to activate complement, as determined by this novel C1q assay, are associated with greater risk of acute rejection and allograft loss.
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Affiliation(s)
- Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University Medical Center, Stanford, CA 94305, USA.
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Lee J, Romero R, Xu Y, Kim JS, Park JY, Kusanovic JP, Chaiworapongsa T, Hassan SS, Kim CJ. Maternal HLA panel-reactive antibodies in early gestation positively correlate with chronic chorioamnionitis: evidence in support of the chronic nature of maternal anti-fetal rejection. Am J Reprod Immunol 2011; 66:510-26. [PMID: 21951517 PMCID: PMC3234997 DOI: 10.1111/j.1600-0897.2011.01066.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PROBLEM Maternal tolerance of the fetus is essential for viviparity, yet anti-fetal rejection occurs in several pregnancy complications. Chronic chorioamnionitis is a feature of anti-fetal cellular rejection. There is a robust association between chronic chorioamnionitis and maternal seropositivity for anti-human leukocyte antigen (HLA) panel-reactive antibodies (PRA) at the time of delivery. This longitudinal study was performed to assess maternal HLA PRA status in early gestation and the temporal evolution of maternal HLA PRA in the context of chronic chorioamnionitis and, thereby, to determine whether HLA PRA during the course of pregnancy is useful for the detection of anti-fetal rejection. METHOD OF STUDY Maternal sera obtained before 16 weeks of gestation and at delivery were analyzed for HLA PRA in cases with (N = 100) and without (N = 150) chronic chorioamnionitis. RESULTS IgG (but not IgM) HLA class I and II PRA positivity at delivery was higher in cases with chronic chorioamnionitis than in those without chronic chorioamnionitis. IgG HLA class I PRA positivity before 16 weeks of gestation was higher in cases with chronic chorioamnionitis than in those without (30.3 versus 13.3%; P = 0.001). Positive conversion (negative HLA PRA before 16 weeks of gestation but positive at delivery) of IgG HLA class I and II PRA was significantly associated with chronic chorioamnionitis. Fetal HLA class I antigen-specific antibodies were confirmed in 12 of 16 mothers tested who were sensitized to HLA class I antigens before 16 weeks of gestation. CONCLUSION Positive maternal HLA PRA before 16 weeks of gestation and the temporal evolution of maternal HLA PRA are associated with the presence of chronic chorioamnionitis at the time of delivery. Maternal IgG HLA PRA has the potential to be a monitoring tool of anti-fetal rejection. Furthermore, the findings herein indicate that subsets of fetuses are exposed to alloimmune HLA antibodies for months, especially in cases with chronic chorioamnionitis.
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Affiliation(s)
- JoonHo Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Yi Xu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Jung-Sun Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Young Park
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Sótero del Rio Hospital, Santiago, Chile
- Department of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chong Jai Kim
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Pathology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Lee J, Romero R, Dong Z, Xu Y, Qureshi F, Jacques S, Yoo W, Chaiworapongsa T, Mittal P, Hassan SS, Kim CJ. Unexplained fetal death has a biological signature of maternal anti-fetal rejection: chronic chorioamnionitis and alloimmune anti-human leucocyte antigen antibodies. Histopathology 2011; 59:928-38. [PMID: 22092404 PMCID: PMC3546834 DOI: 10.1111/j.1365-2559.2011.04038.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Chronic chorioamnionitis is a histological manifestation of maternal anti-fetal cellular rejection. As failure of graft survival is the most catastrophic event in organ transplantation, we hypothesized that fetal death could be a consequence of maternal rejection. The aim of this study was to assess whether there is evidence of cellular and antibody-mediated rejection in fetal death. METHODS AND RESULTS Placental histology was reviewed for the presence of chronic chorioamnionitis in unexplained preterm fetal death (n=30) and preterm live birth (n=103). Amniotic fluid CXCL10 concentrations were measured with a specific immunoassay. Chronic chorioamnionitis was more frequent in fetal death than in live birth (60.0% versus 37.9%; P<0.05) and fetal death had a higher median amniotic fluid CXCL10 concentration than live birth (2.0 versus 1.8 ng/ml, P<0.05), after adjusting for gestational age at amniocentesis. Maternal anti-human leucocyte antigen class II panel-reactive seropositivity determined by flow cytometry was higher in fetal death compared to live birth (35.7% versus 10.9%; P<0.05). CONCLUSIONS Chronic chorioamnionitis is a common pathologic feature in unexplained preterm fetal death. This novel finding suggests that cellular and antibody-mediated anti-fetal rejection of the mother is associated with fetal death (graft failure) in human pregnancy.
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Affiliation(s)
- JoonHo Lee
- Perinatology Research Branch, NICHD/NIH/DHHS, USA
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Pretransplant IgG subclasses of donor-specific human leukocyte antigen antibodies and development of antibody-mediated rejection. Transplantation 2011; 92:41-7. [PMID: 21637140 DOI: 10.1097/tp.0b013e31821cdf0d] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The subclass of IgG antibodies contributes to their capability to activate complement. It is currently unknown whether the pretransplant IgG subclass composition allows distinguishing harmful from presumably irrelevant donor-specific human leukocyte antigen (HLA) antibodies (HLA-DSA) detected by single-antigen flow beads (SAFB). METHODS Seventy-four patients transplanted in the presence of HLA-DSA were investigated. HLA-DSA characteristics were not different between patients experiencing antibody-mediated rejection (AMR) (n=40) and patients who did not (n=34) experience AMR. Sera were reanalyzed using SAFB with IgG subclass-specific reporter antibodies. RESULTS The 74 patients had in total 141 HLA-DSA. IgG1 was the predominant subclass (78%), followed by IgG2 (49%), IgG3 (36%), and IgG4 (20%). When grouped according to the complement-activating capability, only 4 of 74 patients (5%) had exclusively weak/no complement-activating HLA-DSA (i.e., IgG2 and IgG4), 21 of 74 patients (28%) had isolated strong complement-activating HLA-DSA (i.e., IgG1 and IgG3), and 46 of 74 patients (62%) had a mixture of both. There was no difference between the strong complement-activating and the mixture group regarding incidence of AMR (57% vs. 54%; P=0.81), phenotypes of AMR (P=0.70), and death-censored allograft survival at 5 years (78% vs. 78%; P=0.74). Interestingly, patients with exclusively weak/no complement-activating HLA-DSA (n=4) had a numerically lower incidence of AMR (25%) and no allograft loss has occurred yet. CONCLUSION In 90% of patients, pretransplant HLA-DSA are composed of isolated strong or a mixture of strong and weak/no complement-activating IgG subclasses. Because outcomes in these two groups were similar, pretransplant IgG subclass analysis is likely not providing substantial value beyond the standard IgG SAFB assay for pretransplant risk stratification.
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C1q-fixing human leukocyte antigen antibodies are specific for predicting transplant glomerulopathy and late graft failure after kidney transplantation. Transplantation 2011; 91:342-7. [PMID: 21116220 DOI: 10.1097/tp.0b013e318203fd26] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Human leukocyte antigen (HLA) antibodies, especially those that fix complement, are associated with antibody-mediated rejection and graft failure. The C1q assay on single antigen beads detects a subset of HLA antibodies that can fix complement and precede C4d deposition. The aim of this study was to determine whether C1q-fixing antibodies distinguish de novo donor-specific antibodies (DSA) that are clinically relevant and harmful. METHODS We retrospectively studied 31 of 274 kidney transplant recipients who had pretransplant and concurrent biopsy and serum specimens, 13 with C4d-positive and 18 with C4d-negative staining. We measured IgG and C1q DSA pretransplant and at the time of biopsy using single antigen bead assays. We identified 13 recipients who developed de novo DSA by IgG or C1q and examined associations with C4d deposition, transplant glomerulopathy, and graft failure. RESULTS Testing for DSA by IgG is more sensitive for C4d deposition (IgG: 100%, 95% confidence interval [CI] 0.60-1; C1q: 75%, 95% CI 0.36-0.96). Testing for DSA by C1q is more specific for transplant glomerulopathy (C1q: 81%, 95% CI 0.57-0.94; IgG: 67%, 95% CI 0.43-0.85) and graft loss (C1q: 79%, 95% CI 0.54-0.93; IgG: 63%, 95% CI 0.39-0.83). Absence of de novo DSA by IgG and C1q has a high negative predictive value for the absence of C4d deposition (IgG: 100%, 95% CI 0.73-1; C1q: 88%, 95% CI 0.62-0.98), transplant glomerulopathy (IgG: 100%, 95% CI 0.73-1; C1q: 100%, 95% CI 0.77-1), and graft failure (IgG: 86%, 95% CI 0.56-0.97; C1q: 88%, 95% CI 0.62-0.98). CONCLUSION Monitoring patients with the C1q assay, which detects antibodies that fix complement, offers a minimally invasive means of identifying patients at risk for transplant glomerulopathy and graft loss.
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Willicombe M, Brookes P, Santos-Nunez E, Galliford J, Ballow A, Mclean A, Roufosse C, Cook HT, Dorling A, Warrens AN, Cairns T, Taube D. Outcome of patients with preformed donor-specific antibodies following alemtuzumab induction and tacrolimus monotherapy. Am J Transplant 2011; 11:470-7. [PMID: 21299828 DOI: 10.1111/j.1600-6143.2010.03421.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
It has been shown that low-level preformed donor-specific antibodies (DSAbs) detected by luminex beads in the setting of a negative CDC and flow cytometry crossmatch (CDC/FCXM) are associated with inferior allograft outcomes. The relevance of preformed DSAbs in patients receiving alemtuzumab induction and tacrolimus monotherapy has not been studied. Four hundred and eighty renal transplant recipients with a negative CDC/FCXM had their pretransplant sera retrospectively screened for DSAbs. 45/480 (9.4%) of patients were found to have preformed DSAbs. Females and patients receiving regrafts were more likely to have a DSAb (p = 0.008 and p < 0.0001, respectively). Patients with DSAbs had inferior allograft survival (p = 0.047), increased incidence of antibody-mediated rejection (p < 0.0001) and inferior allograft function at 6 months posttransplant (p = 0.017). Patients with HLA class I DSAb (alone or in combination with a Class II DSAb) with high mean fluorescence intensities (MFIs) were at highest risk. We conclude that patients with preformed DSAb are at high risk of adverse outcomes when receiving a minimal immunosuppressive regime incorporating alemtuzumab induction. Patients found to have a preformed DSAb despite a negative crossmatch might benefit from augmented immunosuppression.
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Affiliation(s)
- M Willicombe
- Imperial College Kidney and Transplant Institute, Hammersmith Hospital, London, UK.
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A signature of maternal anti-fetal rejection in spontaneous preterm birth: chronic chorioamnionitis, anti-human leukocyte antigen antibodies, and C4d. PLoS One 2011; 6:e16806. [PMID: 21326865 PMCID: PMC3033909 DOI: 10.1371/journal.pone.0016806] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/31/2010] [Indexed: 12/17/2022] Open
Abstract
Background Chronic chorioamnionitis is found in more than one-third of spontaneous preterm births. Chronic chorioamnionitis and villitis of unknown etiology represent maternal anti-fetal cellular rejection. Antibody-mediated rejection is another type of transplantation rejection. We investigated whether there was evidence for antibody-mediated rejection against the fetus in spontaneous preterm birth. Methods and Findings This cross-sectional study included women with (1) normal pregnancy and term delivery (n = 140) and (2) spontaneous preterm delivery (n = 140). We analyzed maternal and fetal sera for panel-reactive anti-HLA class I and class II antibodies, and determined C4d deposition on umbilical vein endothelium by immunohistochemistry. Maternal anti-HLA class I seropositivity in spontaneous preterm births was higher than in normal term births (48.6% vs. 32.1%, p = 0.005). Chronic chorioamnionitis was associated with a higher maternal anti-HLA class I seropositivity (p<0.01), significant in preterm and term birth. Villitis of unknown etiology was associated with increased maternal and fetal anti-HLA class I and II seropositivity (p<0.05, for each). Fetal anti-HLA seropositivity was closely related to maternal anti-HLA seropositivity in both groups (p<0.01, for each). C4d deposition on umbilical vein endothelium was more frequent in preterm labor than term labor (77.1% vs. 11.4%, p<0.001). Logistic regression analysis revealed that chronic chorioamnionitis (OR = 6.10, 95% CI 1.29–28.83), maternal anti-HLA class I seropositivity (OR = 5.90, 95% CI 1.60–21.83), and C4d deposition on umbilical vein endothelium (OR = 36.19, 95% CI 11.42–114.66) were associated with preterm labor and delivery. Conclusions A major subset of spontaneous preterm births has a signature of maternal anti-fetal cellular and antibody-mediated rejections with links to fetal graft-versus-host disease and alloimmune reactions.
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Prevalence and qualitative properties of circulating anti–human leukocyte antigen alloantibodies after pregnancy: No association with unexplained recurrent miscarriage. Hum Immunol 2011; 72:187-92. [DOI: 10.1016/j.humimm.2010.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 10/27/2010] [Accepted: 11/08/2010] [Indexed: 11/20/2022]
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Bartel G, Wahrmann M, Regele H, Kikić Z, Fischer G, Druml W, Mühlbacher F, Böhmig GA. Peritransplant immunoadsorption for positive crossmatch deceased donor kidney transplantation. Am J Transplant 2010; 10:2033-42. [PMID: 20883537 DOI: 10.1111/j.1600-6143.2010.03226.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Various desensitization protocols were shown to enable successful living donor kidney transplantation across a positive complement-dependent cytotoxicity crossmatch (CDCXM). Positive crossmatch transplantation, however, is less well established for deceased donor transplantation. We report a cohort of 68 deceased donor renal allograft recipients who, on the basis of broad sensitization (lymphocytotoxic panel reactivity ≥40%), were subjected to a protocol of peritransplant immunoadsorption (IA). Treatment consisted of a single session of immediate pretransplant IA (protein A) followed by posttransplant IA and antilymphocyte antibody therapy. Twenty-one patients had a positive CDCXM, which could be rendered negative by pretransplant apheresis. Solid phase HLA antibody detection revealed preformed donor-specific antibodies (DSA) in all 21 CDCXM-positive and in 30 CDCXM-negative recipients. At 5 years, overall graft survival, death-censored graft survival and patient survival were 63%, 76% and 87%, respectively, without any differences between CDCXM-positive, CDCXM-negative/DSA-positive and CDCXM-negative/DSA-negative recipients. Furthermore, groups did not differ regarding rates of antibody-mediated rejection (24% vs. 30% vs. 24%, p = 0.84), cellular rejection (14% vs. 23% vs. 18%, p = 0.7) or allograft function (median 5-year serum creatinine: 1.3 vs. 1.8 vs. 1.7 mg/dL, p = 0.62). Our results suggest that peritransplant IA is an effective strategy for rapid desensitization in deceased donor transplantation.
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Affiliation(s)
- G Bartel
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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C4d-fixing capability of low-level donor-specific HLA antibodies is not predictive for early antibody-mediated rejection. Transplantation 2010; 89:1471-5. [PMID: 20395886 DOI: 10.1097/tp.0b013e3181dc13e7] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Recent studies indicate that not all low-level donor-specific human leukocyte antigen (HLA) antibodies (HLA-DSA) (i.e., positive by solid-phase assays, negative by complement-dependent cytotoxic-crossmatch) have a detrimental clinical impact. The aim of this study was to investigate whether the pretransplant C4d-fixing capability allows distinguishing harmful from presumably clinically irrelevant HLA-DSA. METHODS We retrospectively investigated 64 patients with low-level HLA-DSA detected by single-antigen flow beads (SAFB). Thirty-four of 64 patients (53%) experienced early antibody-mediated rejection (AMR), whereas 30 patients (47%) did not. HLA-DSA characteristics (i.e., number, class, and strength), frequency of retransplants, and immunosuppressive regimens were not different in these two groups. Pretransplant sera were reanalyzed using a modified SAFB assay measuring C4d fixation induced by HLA antibodies. RESULTS C4d-fixing HLA-DSA were observed in 11 of 64 patients (17%). AMR occurred in 6 of 11 patients (55%) with C4d-fixing HLA-DSA and in 28 of 53 patients (53%) without C4d-fixing HLA-DSA (P=1.0). Positive C4d staining in peritubular capillaries was detected in 6 of 11 patients (55%) with C4d-fixing HLA-DSA and in 21 of 53 patients (40%) without C4d-fixing HLA-DSA (P=0.50). CONCLUSION The pretransplant capability of low-level HLA-DSA to trigger C4d fixation in vitro is not predictive for early AMR or C4d deposition in peritubular capillaries in vivo. This argues against pretransplant C4d SAFB testing to define the clinical relevance of low-level HLA-DSA.
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Tait BD, Hudson F, Brewin G, Cantwell L, Holdsworth R. Solid phase HLA antibody detection technology--challenges in interpretation. ACTA ACUST UNITED AC 2010; 76:87-95. [PMID: 20403141 DOI: 10.1111/j.1399-0039.2010.01486.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The introduction into routine diagnostic laboratories of solid phase assays for human leukocyte antigen (HLA) antibody detection has resulted in the application of new laboratory matching algorithms in clinical organ transplantation which have improved pre-transplant detection of immunization, in turn resulting in avoidance of rejection in many cases which until their introduction would not have been possible using the historical complement dependent serological techniques. There have been two generations of solid phase assays introduced into routine practice, namely, the enzyme-linked immunosorbent assay (ELISA) technique and the use of fluorescent beads with HLA molecules bound to their surface which can either be used in conventional flow cytometry or in conjunction with Luminex instrumentation, the latter having become the most popular approach. The use of the fluorescent bead techniques has raised interesting questions both with respect to technical performance and the interpretation of the results obtained. The advantages of bead technology for HLA antibody determination and the technical issues requiring resolution are the subject of this review.
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Affiliation(s)
- B D Tait
- National Transplant Services, Australian Red Cross Blood Service, Melbourne, Australia.
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Clinical relevance of complement-fixing antibodies in cardiac transplantation. Hum Immunol 2009; 70:605-9. [DOI: 10.1016/j.humimm.2009.04.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 04/09/2009] [Indexed: 11/18/2022]
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Amico P, Hönger G, Bielmann D, Lutz D, Garzoni D, Steiger J, Mihatsch MJ, Dragun D, Schaub S. Incidence and Prediction of Early Antibody-Mediated Rejection due to Non-Human Leukocyte Antigen-Antibodies. Transplantation 2008; 85:1557-63. [DOI: 10.1097/tp.0b013e31816f612a] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Bartel G, Wahrmann M, Exner M, Regele H, Huttary N, Schillinger M, Körmöczi GF, Hörl WH, Böhmig GA. In vitro detection of C4d-fixing HLA alloantibodies: associations with capillary C4d deposition in kidney allografts. Am J Transplant 2008; 8:41-9. [PMID: 17924995 DOI: 10.1111/j.1600-6143.2007.01998.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Capillary C4d deposition is a valuable marker of antibody-mediated rejection (AMR). In this analysis, flow cytometric detection of alloantibody-triggered C4d deposition to HLA antigen-coated microparticles ([C4d]FlowPRA) was evaluated for its value as a marker for C4d deposition in renal allografts. For comparative analysis, 105 first renal biopsies performed for graft dysfunction and an equal number of concurrent sera were subjected to immunohistochemistry and [C4d] plus standard [IgG]FlowPRA, respectively. C4d deposition/fixation was detected in 17 biopsies and, applying [C4d]FlowPRA HLA class I and II screening, also in a small number of corresponding sera (N = 20). IgG reactivity detected by standard [IgG]FlowPRA was more frequent (49% of sera). Comparing [C4d]FlowPRA screening with capillary C4d staining, we found a high level of specificity (0.92 [95% confidence interval: 0.86-0.98]), which far exceeded that calculated for [IgG]FlowPRA (0.60 [0.50-0.70]). [IgG]FlowPRA screening, however, turned out to be superior in terms of sensitivity (0.94 [0.83-1.05] vs. 0.76 [0.56-0.97] calculated for C4d-fixing panel reactivity). Remarkably, posttransplant single antigen testing for identification of complement-fixing donor-specific alloreactivities failed to improve the predictive value of FlowPRA-based serology. In conclusion, our results suggest that detection of complement-fixing HLA panel reactivity could provide a specific tool for monitoring of C4d-positive AMR.
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Affiliation(s)
- G Bartel
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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