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Fayyaz A, Raja M, Natori Y. Prevention and Management of Infections in Lung Transplant Recipients. J Clin Med 2023; 13:11. [PMID: 38202018 PMCID: PMC10779253 DOI: 10.3390/jcm13010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024] Open
Abstract
Anti-rejection medications are essential in preventing organ rejection amongst solid organ transplant recipients; however, these agents also cause profound immunosuppression, predisposing lung transplant recipients (LTRs) to infectious complications. The timely management including prevention, diagnosis, and treatment of such infectious complications is vital to prevent significant morbidity and mortality in solid organ transplant recipients and allograft dysfunction. LTRs are inundated with microbes that may be recognized as commensals in hosts with intact immune systems. Bacterial infections are the most common ones, followed by viral pathogens. Indications of a brewing infectious process may be subtle. Hence, the importance of adapting vigilance around isolated hints through symptomatology and signs is pivotal. Signals to suggest an infectious process, such as fever and leukocytosis, may be dampened by immunosuppressive agents. One must also be vigilant about drug interactions of antibiotics and immunosuppressive agents. Treatment of infections can become challenging, as antimicrobials can interact with immunosuppressive agents, and antimicrobial resistance can surge under antimicrobial pressure. Transplant infectious disease physicians work in concert with transplant teams to obtain specimens for diagnostic testing and follow through with source control when possible. This heavily impacts medical decisions and fosters a multidisciplinary approach in management. Furthermore, the reduction of immunosuppression, although it augments the risk of allograft rejection, is as crucial as the initiation of appropriate antimicrobials when it comes to the management of infections.
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Affiliation(s)
| | | | - Yoichiro Natori
- Miami Transplant Institute, Jackson Health System, Division of Infectious Disease, Department of Clinical Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.F.); (M.R.)
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2
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Bidgoli A, DePriest BP, Saatloo MV, Jiang H, Fu D, Paczesny S. Current Definitions and Clinical Implications of Biomarkers in Graft-versus-Host Disease. Transplant Cell Ther 2022; 28:657-666. [PMID: 35830932 PMCID: PMC9547856 DOI: 10.1016/j.jtct.2022.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a potentially curative treatment for many hematologic and nonhematologic disorders. Graft-versus-host-disease (GVHD) in its acute or chronic form remains the most important nonrelapse post-HCT complication. Biomarkers offer objective, unbiased information on systemic disorders, and significant attention has focused on identifying biomarkers for GVHD. Ideally, a GVHD biomarker is actionable, with the results of biomarker testing used to guide clinical management of disease and clinical trial design. Although many GVHD biomarkers have been identified, none have been properly qualified for clinical use. The National Institutes of Health (NIH) and Food and Drug Administration (FDA) have provided biomarker subtype definitions; however, confusion remains about the proper definition and application of these subtypes in the HCT field. The 2014 NIH consensus development project provided a framework for the development of biomarkers for clinical practice. This review aims to clarify the biomarker subtype definitions and reemphasize the developmental framework. Armed with this knowledge, clinicians can properly translate GVHD biomarkers for clinical use.
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Affiliation(s)
- Alan Bidgoli
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Brittany Paige DePriest
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Maedeh Vakili Saatloo
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Hua Jiang
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Denggang Fu
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Sophie Paczesny
- Departments of (1)Microbiology and Immunology and (2)Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
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3
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Dynamics of Inflammatory and Neurodegenerative Biomarkers after Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis. Int J Mol Sci 2022; 23:ijms231810946. [PMID: 36142860 PMCID: PMC9503241 DOI: 10.3390/ijms231810946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (aHSCT) is a highly efficient treatment of multiple sclerosis (MS), and hence it likely normalizes pathological and/or enhances beneficial processes in MS. The disease pathomechanisms include neuroinflammation, glial cell activation and neuronal damage. We studied biomarkers that in part reflect these, like markers for neuroinflammation (C-X-C motif chemokine ligand (CXCL) 9, CXCL10, CXCL13, and chitinase 3-like 1 (CHI3L1)), glial perturbations (glial fibrillary acidic protein (GFAP) and in part CHI3L1), and neurodegeneration (neurofilament light chain (NfL)) by enzyme-linked immunosorbent assays (ELISA) and single-molecule array assay (SIMOA) in the serum and cerebrospinal fluid (CSF) of 32 MS patients that underwent aHSCT. We sampled before and at 1, 3, 6, 12, 24 and 36 months after aHSCT for serum, as well as before and 24 months after aHSCT for CSF. We found a strong increase of serum CXCL10, NfL and GFAP one month after the transplantation, which normalized one and two years post-aHSCT. CXCL10 was particularly increased in patients that experienced reactivation of cytomegalovirus (CMV) infection, but not those with Epstein-Barr virus (EBV) reactivation. Furthermore, patients with CMV reactivation showed increased Th1 phenotype in effector memory CD4+ T cells. Changes of the other serum markers were more subtle with a trend for an increase in serum CXCL9 early post-aHSCT. In CSF, GFAP levels were increased 24 months after aHSCT, which may indicate sustained astroglia activation 24 months post-aHSCT. Other CSF markers remained largely stable. We conclude that MS-related biomarkers indicate neurotoxicity early after aHSCT that normalizes after one year while astrocyte activation appears increased beyond that, and increased serum CXCL10 likely does not reflect inflammation within the central nervous system (CNS) but rather occurs in the context of CMV reactivation or other infections post-aHSCT.
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Pidala J, Kitko C, Lee SJ, Carpenter P, Cuvelier GDE, Holtan S, Flowers ME, Cutler C, Jagasia M, Gooley T, Palmer J, Randolph T, Levine JE, Ayuk F, Dignan F, Schoemans H, Tkaczyk E, Farhadfar N, Lawitschka A, Schultz KR, Martin PJ, Sarantopoulos S, Inamoto Y, Socie G, Wolff D, Blazar B, Greinix H, Paczesny S, Pavletic S, Hill G. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IIb. The 2020 Preemptive Therapy Working Group Report. Transplant Cell Ther 2021; 27:632-641. [PMID: 33836313 DOI: 10.1016/j.jtct.2021.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022]
Abstract
Chronic graft-versus-host disease (GVHD) commonly occurs after allogeneic hematopoietic cell transplantation (HCT) despite standard prophylactic immune suppression. Intensified universal prophylaxis approaches are effective but risk possible overtreatment and may interfere with the graft-versus-malignancy immune response. Here we summarize conceptual and practical considerations regarding preemptive therapy of chronic GVHD, namely interventions applied after HCT based on evidence that the risk of developing chronic GVHD is higher than previously appreciated. This risk may be anticipated by clinical factors or risk assignment biomarkers or may be indicated by early signs and symptoms of chronic GVHD that do not fully meet National Institutes of Health diagnostic criteria. However, truly preemptive, individualized, and targeted chronic GVHD therapies currently do not exist. In this report, we (1) review current knowledge regarding clinical risk factors for chronic GVHD, (2) review what is known about chronic GVHD risk assignment biomarkers, (3) examine how chronic GVHD pathogenesis intersects with available targeted therapeutic agents, and (4) summarize considerations for preemptive therapy for chronic GVHD, emphasizing trial development, including trial design and statistical considerations. We conclude that robust risk assignment models that accurately predict chronic GVHD after HCT and early-phase preemptive therapy trials represent the most urgent priorities for advancing this novel area of research.
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Affiliation(s)
- Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Carrie Kitko
- Division of Pediatric Hematology/Oncology, Dpeartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Shernan Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Madan Jagasia
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joycelynne Palmer
- Division of Biostatistics, Department of Computational and Quantitative Medicine, City of Hope, Duarte, California
| | - Tim Randolph
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Dignan
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven and Department of Public Health, KU Leuven, Leuven, Belgium
| | - Eric Tkaczyk
- Department of Veterans Affairs and Departments of Dermatology and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nosha Farhadfar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St Anna Children's Hospital, Medical University of Vienna, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | - Kirk R Schultz
- Pediatric Hematology/Oncology/BMT, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University Department of Medicine, Durham, North Carolina
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Gerard Socie
- Hematology and Bone Marrow Transplant Department, AP-HP Saint Louis Hospital and University of Paris, Paris, France
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - Bruce Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Hildegard Greinix
- Clinical Division of Hematology, Medical University of Graz, Graz, Austria
| | - Sophie Paczesny
- Department of Microbiology and Immunology and Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Geoffrey Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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5
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Werlein C, Seidel A, Warnecke G, Gottlieb J, Laenger F, Jonigk D. Lung Transplant Pathology: An Overview on Current Entities and Procedures. Surg Pathol Clin 2020; 13:119-140. [PMID: 32005428 DOI: 10.1016/j.path.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alloimmune reactions are, besides various infections, the major cause for impaired lung allograft function following transplant. Acute cellular rejection is not only a major trigger of acute allograft failure but also contributes to development of chronic lung allograft dysfunction. Analogous to other solid organ transplants, acute antibody-mediated rejection has become a recognized entity in lung transplant pathology. Adequate sensitivity and specificity in the diagnosis of alloimmune reactions in the lung can only be achieved by synoptic analysis of histopathologic, clinical, and radiological findings together with serologic and microbiologic findings.
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Affiliation(s)
- Christopher Werlein
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
| | - Allison Seidel
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Gregor Warnecke
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Jens Gottlieb
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Pneumology, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Florian Laenger
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Danny Jonigk
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
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6
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Wohlschlaeger J, Laenger F, Gottlieb J, Hager T, Seidel A, Jonigk D. Lungentransplantation. DER PATHOLOGE 2019; 40:281-291. [DOI: 10.1007/s00292-019-0598-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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7
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Patrucco F, Gavelli F, Ravanini P, Daverio M, Statti G, Castello LM, Andreoni S, Balbo PE. Use of an innovative and non-invasive device for virologic sampling of cough aerosols in patients with community and hospital acquired pneumonia: a pilot study. J Breath Res 2019; 13:021001. [PMID: 30523983 PMCID: PMC7106764 DOI: 10.1088/1752-7163/aaf010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/06/2018] [Accepted: 11/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aetiology of lower respiratory tract infections is challenging to investigate. Despite the wide array of diagnostic tools, invasive techniques, such as bronchoalveolar lavage (BAL), are often required to obtain adequate specimens. PneumoniaCheckTM is a new device that collects aerosol particles from cough, allowing microbiological analyses. Up to now it has been tested only for bacteria detection, but no study has investigated its usefulness for virus identification. METHODS In this pilot study we included 12 consecutive patients with pneumonia. After testing cough adequacy via a peak flow meter, a sampling with PneumoniaCheckTM was collected and a BAL was performed in each patient. Microbiological analyses for virus identification were performed on each sample and concordance between the two techniques was tested (sensitivity, specificity and positive/negative predictive values), taking BAL results as reference. RESULTS BAL was considered adequate in 10 patients. Among them, a viral pathogen was identified by PneumoniaCheckTM 6 times, each on different samples, whereas BAL allowed to detect the presence of a virus on 7 patients (14 positivities). Overall, the specificity for PneumoniaCheckTM to detect a virus was 100%, whereas the sensitivity was 66%. When considering only herpes viruses, PneumoniaCheckTM showed a lower sensitivity, detecting a virus in 1/4 of infected patients (25%). CONCLUSIONS In this pilot study PneumoniaCheckTM showed a good correlation with BAL for non-herpes virologic identification in pneumonia patients, providing excellent specificity. Further studies on larger population are needed to confirm these results and define its place in the panorama of rapid diagnostic tests for lower respiratory tract infections.
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Affiliation(s)
- Filippo Patrucco
- Medical Department, Division of Respiratory Diseases, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Francesco Gavelli
- Department of Translational Medicine, Emergency Medicine Unit, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Paolo Ravanini
- Laboratory Medicine Department, Microbiology and Virology Unit, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Matteo Daverio
- Medical Department, Division of Respiratory Diseases, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Giulia Statti
- Department of Translational Medicine, Emergency Medicine Unit, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Luigi Mario Castello
- Department of Translational Medicine, Emergency Medicine Unit, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Stefano Andreoni
- Laboratory Medicine Department, Microbiology and Virology Unit, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
| | - Piero Emilio Balbo
- Medical Department, Division of Respiratory Diseases, University of Piemonte Orientale, Maggiore della Carità Hospital, Novara, Italy
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8
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Wolff D, Greinix H, Lee SJ, Gooley T, Paczesny S, Pavletic S, Hakim F, Malard F, Jagasia M, Lawitschka A, Hansen JA, Pulanic D, Holler E, Dickinson A, Weissinger E, Edinger M, Sarantopoulos S, Schultz KR. Biomarkers in chronic graft-versus-host disease: quo vadis? Bone Marrow Transplant 2018; 53:832-837. [PMID: 29367715 PMCID: PMC6041126 DOI: 10.1038/s41409-018-0092-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 12/11/2022]
Abstract
Biomarkers are increasingly used for diagnosis and treatment of transplant-related complications including the first biomarker-driven interventional trials of acute graft-versus-host disease (GvHD). In contrast, the development of biomarkers of chronic GvHD (cGvHD) has lagged behind due to a broader variety of manifestations, overlap with acute GvHD, a greater variation in time to onset and maximum severity, and lack of sufficient patient numbers within prospective trials. An international workshop organized by a North-American and European consortium was held in Marseille in March 2017 with the goal to discuss strategies for future biomarker development to guide cGvHD therapy. As a result of this meeting, two areas were prioritized: the development of prognostic biomarkers for subsequent onset of moderate/severe cGvHD, and in parallel, the development of qualified clinical-grade assays for biomarker quantification. The most promising prognostic serum biomarkers are CXCL9, ST2, matrix metalloproteinase-3, osteopontin, CXCL10, CXCL11, and CD163. Urine-proteomics and cellular subsets (CD4+ T-cell subsets, NK cell subsets, and CD19+CD21low B cells) represent additional potential prognostic biomarkers of cGvHD. A joint effort is required to verify the results of numerous exploratory trials before any of the potential candidates is ready for validation and subsequent clinical application.
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Affiliation(s)
- D Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany.
| | - H Greinix
- Division of Haematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - S J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - T Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S Paczesny
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Pavletic
- Experimental Transplantation and Immunology Branch, Center of Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - F Hakim
- Experimental Transplantation and Immunology Branch, Center of Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - F Malard
- Hematology Department, Hôpital Saint-Antoine; Université Pierre & Marie Curie; and INSERM, Centre de Recherche Saint-Antoine, UMRS U938, Paris, France
| | - M Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A Lawitschka
- St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - J A Hansen
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - D Pulanic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, and Medical School University of Zagreb, Zagreb, Croatia
- Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - E Holler
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - A Dickinson
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - E Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - M Edinger
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - S Sarantopoulos
- Department of Medicine, Division of Hematological Malignancies & Cellular Therapy, Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - K R Schultz
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital/University of British Columbia, Vancouver, BC, Canada
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9
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Abstract
Despite induction immunosuppression and the use of aggressive maintenance immunosuppressive regimens, acute allograft rejection following lung transplantation is still a problem with important diagnostic and therapeutic challenges. As well as causing early graft loss and mortality, acute rejection also initiates the chronic alloimmune responses and airway-centred inflammation that predispose to bronchiolitis obliterans syndrome (BOS), also known as chronic lung allograft dysfunction (CLAD), which is a major source of morbidity and mortality after lung transplantation. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, but the influence of humoral immunity is increasingly recognised. As with other several other solid organ transplants, antibody-mediated rejection (AMR) is now a well-accepted and distinct clinical entity in lung transplantation. While acute cellular rejection (ACR) has defined histopathological criteria, transbronchial biopsy is less useful in AMR and its diagnosis is complicated by challenges in the measurement of antibodies directed against donor HLA, and a determination of their significance. Increasing awareness of the importance of non-HLA antigens further clouds this issue. Here, we review the pathophysiology, diagnosis, clinical presentation and treatment of ACR and AMR in lung transplantation, and discuss future potential biomarkers of both processes that may forward our understanding of these conditions.
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Affiliation(s)
- Mark Benzimra
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - Greg L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Allan R Glanville
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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10
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Saman S, Henes JC, Niepel D, Bosmüller H, Werner CR, Lauer UM, Malek NP, Xenitidis T. [Varicella gastritis under immunosuppression : Case report of a woman after lung transplantation due to granulomatosis with polyangiitis]. Internist (Berl) 2017; 58:855-858. [PMID: 28405696 DOI: 10.1007/s00108-017-0231-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 35-year-old woman who had previously undergone a lung transplantation presented with severe abdominal pain and vomiting. The gastroscopy showed diffuse ulcerative gastric lesions. Tests for varicella zoster virus and Epstein-Barr virus via polymerase chain reactions (PCR) on endoscopically obtained gastric biopsies were found to be positive and confirmed varicella gastritis. Intravenous antiviral therapy with acyclovir was administered resulting in a normalization of all clinical symptoms, especially of abdominal pain and inflammation parameters.
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Affiliation(s)
- S Saman
- Abteilung Innere Medizin I (Hepatologie, Gastroenterologie, Infektiologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
| | - J-C Henes
- Abteilung Innere Medizin II (Onkologie, Hämatologie, Rheumatologie, Immunologie, Pulmonologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
| | - D Niepel
- Abteilung Innere Medizin I (Hepatologie, Gastroenterologie, Infektiologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
| | - H Bosmüller
- Abteilung Allgemeine Pathologie, Institut für Pathologie und Neuropathologie, Liebermeisterstr. 8, 72076, Tübingen, Deutschland
| | - C R Werner
- Abteilung Innere Medizin I (Hepatologie, Gastroenterologie, Infektiologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
| | - U M Lauer
- Abteilung Innere Medizin I (Hepatologie, Gastroenterologie, Infektiologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
| | - N P Malek
- Abteilung Innere Medizin I (Hepatologie, Gastroenterologie, Infektiologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
| | - T Xenitidis
- Abteilung Innere Medizin II (Onkologie, Hämatologie, Rheumatologie, Immunologie, Pulmonologie), Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
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11
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Immune Responses to Tissue-Restricted Nonmajor Histocompatibility Complex Antigens in Allograft Rejection. J Immunol Res 2017; 2017:6312514. [PMID: 28164137 PMCID: PMC5253484 DOI: 10.1155/2017/6312514] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/06/2016] [Indexed: 01/02/2023] Open
Abstract
Chronic diseases that result in end-stage organ damage cause inflammation, which can reveal sequestered self-antigens (SAgs) in that organ and trigger autoimmunity. The thymus gland deletes self-reactive T-cells against ubiquitously expressed SAgs, while regulatory mechanisms in the periphery control immune responses to tissue-restricted SAgs. It is now established that T-cells reactive to SAgs present in certain organs (e.g., lungs, pancreas, and intestine) are incompletely eliminated, and the dysregulation of peripheral immuneregulation can generate immune responses to SAgs. Therefore, chronic diseases can activate self-reactive lymphocytes, inducing tissue-restricted autoimmunity. During organ transplantation, donor lymphocytes are tested against recipient serum (i.e., cross-matching) to detect antibodies (Abs) against donor human leukocyte antigens, which has been shown to reduce Ab-mediated hyperacute rejection. However, primary allograft dysfunction and rejection still occur frequently. Because donor lymphocytes do not express tissue-restricted SAgs, preexisting Abs against SAgs are undetectable during conventional cross-matching. Preexisting and de novo immune responses to tissue-restricted SAgs (i.e., autoimmunity) play a major role in rejection. In this review, we discuss the evidence that supports autoimmunity as a contributor to rejection. Testing for preexisting and de novo immune responses to tissue-restricted SAgs and treatment based on immune responses after organ transplantation may improve short- and long-term outcomes after transplantation.
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12
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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Chiu S, Fernandez R, Subramanian V, Sun H, DeCamp MM, Kreisel D, Perlman H, Budinger GRS, Mohanakumar T, Bharat A. Lung Injury Combined with Loss of Regulatory T Cells Leads to De Novo Lung-Restricted Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2016; 197:51-7. [PMID: 27194786 DOI: 10.4049/jimmunol.1502539] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/21/2016] [Indexed: 01/02/2023]
Abstract
More than one third of patients with chronic lung disease undergoing lung transplantation have pre-existing Abs against lung-restricted self-Ags, collagen type V (ColV), and k-α1 tubulin (KAT). These Abs can also develop de novo after lung transplantation and mediate allograft rejection. However, the mechanisms leading to lung-restricted autoimmunity remain unknown. Because these self-Ags are normally sequestered, tissue injury is required to expose them to the immune system. We previously showed that respiratory viruses can induce apoptosis in CD4(+)CD25(+)Foxp3(+) regulatory T cells (Tregs), the key mediators of self-tolerance. Therefore, we hypothesized that lung-tissue injury can lead to lung-restricted immunity if it occurs in a setting when Tregs are impaired. We found that human lung recipients who suffer respiratory viral infections experienced a decrease in peripheral Tregs. Pre-existing lung allograft injury from donor-directed Abs or gastroesophageal reflux led to new ColV and KAT Abs post respiratory viral infection. Similarly, murine parainfluenza (Sendai) respiratory viral infection caused a decrease in Tregs. Intratracheal instillation of anti-MHC class I Abs, but not isotype control, followed by murine Sendai virus infection led to development of Abs against ColV and KAT, but not collagen type II (ColII), a cartilaginous protein. This was associated with expansion of IFN-γ-producing CD4(+) T cells specific to ColV and KAT, but not ColII. Intratracheal anti-MHC class I Abs or hydrochloric acid in Foxp3-DTR mice induced ColV and KAT, but not ColII, immunity, only if Tregs were depleted using diphtheria toxin. We conclude that tissue injury combined with loss of Tregs can lead to lung-tissue-restricted immunity.
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Affiliation(s)
- Stephen Chiu
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Ramiro Fernandez
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | | | - Haiying Sun
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Malcolm M DeCamp
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - Daniel Kreisel
- Washington University School of Medicine, St. Louis, MO 63110
| | - Harris Perlman
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | - G R Scott Budinger
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
| | | | - Ankit Bharat
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611; and
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Hartert M, Senbaklavacin O, Gohrbandt B, Fischer BM, Buhl R, Vahld CF. Lung transplantation: a treatment option in end-stage lung disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:107-16. [PMID: 24622680 DOI: 10.3238/arztebl.2014.0107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. METHOD We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). RESULTS The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). CONCLUSION Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery at the University Medical Center of the Johannes Gutenberg University Mainz, Department of Hematology, Pneumology and Oncology at the University Medical Center of the Johannes Gutenberg University Mainz
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The Role of Infections in BOS. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7121969 DOI: 10.1007/978-1-4614-7636-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Infectious agents, particularly cytomegalovirus (CMV), have long been considered to be potential triggers for BOS, although the exact magnitude of the role of infections and the mechanisms thereof remain an area of active research. Methods: This chapter will review previous literature and newer results concerning the possible roles of CMV, other herpesviruses, community-acquired respiratory viruses, bacteria (including Pseudomonas, other gram-negative, gram-positive, and atypical organisms), and fungi, including colonization as well as invasive infection. Results: The text reviews and evaluates the body of literature supporting a role for these infectious agents as risk factors for BOS and time to BOS. Changing patterns of infection over time are taken into account, and studies that have shown an association between BOS (or lack thereof) and CMV are reviewed. Strategies for prevention or early treatment of infections are discussed as potential means of preserving allograft function long term. Immunizations, stringent infection-control practices, and antimicrobial treatment including newer therapies will be discussed. Conclusion: In addition to the classic literature that has focused on CMV, an expanding spectrum of infectious organisms has been implicated as possible risk factors for BOS. Increasing knowledge of the impact of long-term antiviral suppression, prophylaxis, and outcomes of early therapy will help guide future recipient management.
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