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Leckie-Harre A, Silverman I, Wu H, Humphreys BD, Malone AF. Sequencing of Physically Interacting Cells in Human Kidney Allograft Rejection to Infer Contact-dependent Immune Cell Transcription. Transplantation 2024; 108:421-429. [PMID: 37638864 PMCID: PMC10798591 DOI: 10.1097/tp.0000000000004762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/05/2023] [Accepted: 06/25/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Rejection requires cell-cell contact involving immune cells. Inferring the transcriptional programs of cell-cell interactions from single-cell RNA-sequencing (scRNA-seq) data is challenging as spatial information is lost. METHODS We combined a CD45 pos enrichment strategy with Cellular Indexing of Transcriptomes and Epitopes by sequencing based quantification of leukocyte surface proteins to analyze cell-cell interactions in 11 human kidney transplant biopsies encompassing a spectrum of rejection diagnoses. scRNA-seq was performed using the 10X Genomics platform. We applied the sequencing physically interacting cells computational method to deconvolute the transcriptional profiles of heterotypic physically interacting cells. RESULTS The 11 human allograft biopsies generated 31 203 high-quality single-cell libraries. Clustering was further refined by combining Cellular Indexing of Transcriptomes and Epitopes by sequencing data from 6 different leukocyte-specific surface proteins. Three of 6 doublet clusters were identified as physically interacting cell complexes; macrophages or dendritic cells bound to B cells or plasma cells; natural killer (NK) or T cells bound to macrophages or dendritic cells and NK or T cells bound to endothelial cells. Myeloid-lymphocyte physically interacting cell complexes expressed activated and proinflammatory genes. Lymphocytes physically interacting with endothelial cells were enriched for NK and CD4 T cells. NK cell-endothelial cell contact caused increased expression of endothelial proinflammatory genes CXCL9 and CXCL10 and NK cell proinflammatory genes CCL3 , CCL4 , and GNLY . CONCLUSIONS The transcriptional profiles of physically interacting cells from human kidney transplant biopsies can be inferred from scRNA-seq data using the sequencing physically interacting cells method. This approach complements previous methods that estimate cell-cell physical contact from scRNA-seq data.
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Affiliation(s)
- Aidan Leckie-Harre
- Division of Nephrology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Isabel Silverman
- Division of Nephrology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Haojia Wu
- Division of Nephrology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Benjamin D. Humphreys
- Division of Nephrology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
- Department of Developmental Biology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Andrew F. Malone
- Division of Nephrology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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2
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Ahuja HK, Azim S, Maluf D, Mas VR. Immune landscape of the kidney allograft in response to rejection. Clin Sci (Lond) 2023; 137:1823-1838. [PMID: 38126208 DOI: 10.1042/cs20230493] [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: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
Preventing kidney graft dysfunction and rejection is a critical step in addressing the nationwide organ shortage and improving patient outcomes. While kidney transplants (KT) are performed more frequently, the overall number of patients on the waitlist consistently exceeds organ availability. Despite improved short-term outcomes in KT, comparable progress in long-term allograft survival has not been achieved. Major cause of graft loss at 5 years post-KT is chronic allograft dysfunction (CAD) characterized by interstitial fibrosis and tubular atrophy (IFTA). Accordingly, proactive prevention of CAD requires a comprehensive understanding of the immune mechanisms associated with either further dysfunction or impaired repair. Allograft rejection is primed by innate immune cells and carried out by adaptive immune cells. The rejection process is primarily facilitated by antibody-mediated rejection (ABMR) and T cell-mediated rejection (TCMR). It is essential to better elucidate the actions of individual immune cell subclasses (e.g. B memory, Tregs, Macrophage type 1 and 2) throughout the rejection process, rather than limiting our understanding to broad classes of immune cells. Embracing multi-omic approaches may be the solution in acknowledging these intricacies and decoding these enigmatic pathways. A transition alongside advancing technology will better allow organ biology to find its place in this era of precision and personalized medicine.
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Affiliation(s)
- Harsimar Kaur Ahuja
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, U.S.A
| | - Shafquat Azim
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, U.S.A
| | - Daniel Maluf
- Program of Transplantation, School of Medicine, 29S Greene St, University of Maryland, Baltimore, MD 21201, U.S.A
| | - Valeria R Mas
- Surgical Sciences Division, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, U.S.A
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3
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Bansal S, Arjuna A, Franz B, Guerrero-Alba A, Canez J, Fleming T, Rahman M, Hachem R, Mohanakumar T. Extracellular vesicles: a potential new player in antibody-mediated rejection in lung allograft recipients. FRONTIERS IN TRANSPLANTATION 2023; 2:1248987. [PMID: 38993876 PMCID: PMC11235353 DOI: 10.3389/frtra.2023.1248987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/22/2023] [Indexed: 07/13/2024]
Abstract
Identification of recipients with pre-existing antibodies and cross-matching of recipient sera with donor lymphocytes have reduced the incidence of antibody-mediated rejection (AMR) after human lung transplantation. However, AMR is still common and requires not only immediate intervention but also has long-term consequences including an increased risk of chronic lung allograft dysfunction (CLAD). The mechanisms resulting in AMR remain largely unknown due to the variation in clinical and histopathological features among lung transplant recipients; however, several reports have demonstrated a strong association between the development of antibodies against mismatched donor human leucocyte antigens [donor-specific antibodies (DSAs)] and AMR. In addition, the development of antibodies against lung self-antigens (K alpha1 tubulin and collagen V) also plays a vital role in AMR pathogenesis, either alone or in combination with DSAs. In the current article, we will review the existing literature regarding the association of DSAs with AMR, along with clinical diagnostic features and current treatment options for AMR. We will also discuss the role of extracellular vesicles (EVs) in the immune-related pathogenesis of AMR, which can lead to CLAD.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Brian Franz
- HLA Laboratory, Vitalant, Phoenix, AZ, United States
| | - Alexa Guerrero-Alba
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Jesse Canez
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohammad Rahman
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Ramsey Hachem
- Department of Surgery, Washington University, St. Louis, MO, United States
| | - T. Mohanakumar
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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4
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Riddell P, Juvet SC. Natural killer cells, CMV infection, and antibody-mediated rejection. J Heart Lung Transplant 2023; 42:315-316. [PMID: 36804059 DOI: 10.1016/j.healun.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- P Riddell
- Irish Lung Transplant Program, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - S C Juvet
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Canada
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5
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Johnson AC, Silva JAF, Kim SC, Larsen CP. Progress in kidney transplantation: The role for systems immunology. Front Med (Lausanne) 2022; 9:1070385. [PMID: 36590970 PMCID: PMC9800623 DOI: 10.3389/fmed.2022.1070385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
The development of systems biology represents an immense breakthrough in our ability to perform translational research and deliver personalized and precision medicine. A multidisciplinary approach in combination with use of novel techniques allows for the extraction and analysis of vast quantities of data even from the volume and source limited samples that can be obtained from human subjects. Continued advances in microfluidics, scalability and affordability of sequencing technologies, and development of data analysis tools have made the application of a multi-omics, or systems, approach more accessible for use outside of specialized centers. The study of alloimmune and protective immune responses after solid organ transplant offers innumerable opportunities for a multi-omics approach, however, transplant immunology labs are only just beginning to adopt the systems methodology. In this review, we focus on advances in biological techniques and how they are improving our understanding of the immune system and its interactions, highlighting potential applications in transplant immunology. First, we describe the techniques that are available, with emphasis on major advances that allow for increased scalability. Then, we review initial applications in the field of transplantation with a focus on topics that are nearing clinical integration. Finally, we examine major barriers to adapting these methods and discuss potential future developments.
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6
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Szentimrei R, Lőrincz H, Szentpéteri A, E Varga V, Harangi M, Seres I, P Szabó R, Nemes B, Paragh G. Changes in serum pigment epithelium-derived factor levels after kidney transplantation in patients with end-stage renal disease. Ren Fail 2022; 44:1649-1659. [PMID: 36217673 PMCID: PMC9559055 DOI: 10.1080/0886022x.2022.2106243] [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] [Indexed: 11/11/2022] Open
Abstract
Background Pigment epithelium-derived factor (PEDF) is a serin protease inhibitor and a potent inhibitor of angiogenesis. Its serum level has significant associations with metabolic parameters. However, little is known about the association between PEDF levels and lipid parameters in renal transplanted (TX) patients. Therefore, our aim was to investigate the relationship between PEDF level and lipid parameters in TX patients. Methods Seventy TX patients (47 males, 23 females, mean age 51.7 ± 12.4 years) and 34 healthy controls were enrolled. We examined the serum creatinine, C-reactive protein, fasting glucose and lipid parameters right before, then 1 and 6 months after TX. High-density lipoprotein (HDL)-associated paraoxonase-1 (PON1) activities were measured spectrophotometrically. Lipoprotein subfractions were determined by Lipoprint. PEDF and oxidized low-density liporotein (oxLDL) levels were measured by ELISA. Results Before transplantation, patients had had a significantly higher PEDF level compared to control subjects (p < 0.001). One month after transplantation, their PEDF level decreased significantly reaching the healthy controls’ level, and this lower level was maintained during the 6 months follow-up period as well. The initial oxLDL level was significantly higher, while PON1 activities were significantly lower in the patient group compared to the control group. We found a significant positive correlation between PEDF and total cholesterol, low-density lipoprotein (LDL)-cholesterol, triglyceride, oxLDL and small HDL subfraction; while negative correlations were found between PEDF and mean LDL size and large HDL subfraction during the entire follow-up period. Conclusion PEDF may play an important role in the increased oxidative stress and enhanced atherogenesis in renal transplant patients.
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Affiliation(s)
- Réka Szentimrei
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Doctoral School of Health Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Hajnalka Lőrincz
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anita Szentpéteri
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Viktória E Varga
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mariann Harangi
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ildikó Seres
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Réka P Szabó
- Department of Nephrology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Nemes
- Department of Organ Transplantation, Faculty of Medicine, Institute of Surgery, University of Debrecen, Debrecen, Hungary
| | - György Paragh
- Division of Metabolic Disorders, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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7
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Bräsen JH. [Current insights on monitoring of renal transplants-Banff and beyond]. PATHOLOGIE (HEIDELBERG, GERMANY) 2022; 43:134-136. [PMID: 36378289 DOI: 10.1007/s00292-022-01148-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Renal transplantation represents the best treatment for end-stage renal disease. Much effort has been invested in improvement of longevity of the transplanted organ including a comprehensive and regularly updated histological scoring system (Banff classification) for surveillance; however, survival of transplanted kidneys is still limited to median 15 years. Molecular analyses have increased the understanding of damaging mechanisms within the transplant, especially antibody-mediated rejection, which can be difficult to identify using histological methods. Changes in the Banff classification necessitate to reclassify biopsies included in studies according to current consensus. Digital and molecular innovations as well as new immunologic mechanisms are anticipated.
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Affiliation(s)
- Jan Hinrich Bräsen
- Bereichsleitung Nephropathologie, Institut für Pathologie, OE 5110, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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8
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McCloskey C, Zubrycki M, Lawrence C. The Molecular Microscope Diagnostic System (MMDx) interpretation of solid organ allograft biopsies: Restoring the perspective. Clin Transplant 2022; 36:e14711. [PMID: 35668041 DOI: 10.1111/ctr.14711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Chris McCloskey
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
| | - Michelle Zubrycki
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
| | - Christopher Lawrence
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
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9
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Jethwani P, Rao A, Bow L, Menon MC. Donor–Recipient Non-HLA Variants, Mismatches and Renal Allograft Outcomes: Evolving Paradigms. Front Immunol 2022; 13:822353. [PMID: 35432337 PMCID: PMC9012490 DOI: 10.3389/fimmu.2022.822353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/03/2022] [Indexed: 12/22/2022] Open
Abstract
Despite significant improvement in the rates of acute allograft rejection, proportionate improvements in kidney allograft longevity have not been realized, and are a source of intense research efforts. Emerging translational data and natural history studies suggest a role for anti-donor immune mechanisms in a majority of cases of allograft loss without patient death, even when overt evidence of acute rejection is not identified. At the level of the donor and recipient genome, differences in highly polymorphic HLA genes are routinely evaluated between donor and recipient pairs as part of organ allocation process, and utilized for patient-tailored induction and maintenance immunosuppression. However, a growing body of data have characterized specific variants in donor and recipient genes, outside of HLA loci, that induce phenotypic changes in donor organs or the recipient immune system, impacting transplant outcomes. Newer mechanisms for “mismatches” in these non-HLA loci have also been proposed during donor–recipient genome interactions with transplantation. Here, we review important recent data evaluating the role of non-HLA genetic loci and genome-wide donor-recipient mismatches in kidney allograft outcomes.
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Affiliation(s)
- Priyanka Jethwani
- Department of Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Arundati Rao
- Department of Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Laurine Bow
- Department of Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Madhav C. Menon
- Department of Medicine, Yale University School of Medicine, New Haven, CT, United States
- *Correspondence: Madhav C. Menon,
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10
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Nankivell BJ, P’Ng CH, Shingde M. Glomerular C4d Immunoperoxidase in Chronic Antibody-Mediated Rejection and Transplant Glomerulopathy. Kidney Int Rep 2022; 7:1594-1607. [PMID: 35812271 PMCID: PMC9263257 DOI: 10.1016/j.ekir.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The diagnosis of late antibody-mediated rejection (AMR) is compromised by frequent absence of C4d in peritubular capillaries (C4dptc), termed “C4d-negative” AMR. We hypothesized that glomerular capillary C4d (C4dglom) reflected endothelial interaction with antibody and could improve immunologic classification of transplant glomerulopathy (TG). Methods We evaluated C4d using immunoperoxidase in 3524 consecutive, kidney transplant biopsies from a single center. Results C4dglom was detected in 16.5% and C4dptc in 9.9% of biopsies. C4dglom occurred in 60.3% of TG (n = 174) and was absent in normal glomeruli. Epidemiologic risk factors for C4dglom were younger, female, living-donor recipients with early AMR, prior treated rejection, and late presentation using multivariable analysis. Semiquantitative C4dglom score correlated with donor specific antibody (DSA) level, C4dptc, microvascular inflammation (MVI), Banff cg scores, renal dysfunction, and proteinuria. Principal component analysis colocalized C4dglom with histologic AMR. Multivariable analysis of TG found DSA, C4dptc, and post-transplant time associated with C4dglom. Addition of C4dglom into Banff chronic AMR schema improved its diagnostic sensitivity for TG (verified by electron microscopy [EM]) from 22.2% to 82.4% and accuracy from 59.6% to 93.9%, compared with Banff 2019 using only C4dptc. Tissue C4dglom and chronic AMR diagnosis incorporating C4dglom were associated with death-censored allograft failure in TG (P < 0.001), independent of the severity of glomerulopathy and chronic interstitial fibrosis. Conclusion C4dglom is a promising diagnostic biomarker of endothelial interaction with antibody which substantially improved test performance of the Banff schema to correctly classify TG by pathophysiology and prognosticate graft loss. We recommend routine C4d immunoperoxidase to minimize underdiagnosis of late AMR in TG.
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Affiliation(s)
- Brian J. Nankivell
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Correspondence: Brian J. Nankivell, Department of Renal Medicine, Westmead Hospital, Westmead, Sydney, 2145 New South Wales, Australia.
| | - Chow H. P’Ng
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| | - Meena Shingde
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
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11
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The Proteome of Antibody-Mediated Rejection: From Glomerulitis to Transplant Glomerulopathy. Biomedicines 2022; 10:biomedicines10030569. [PMID: 35327371 PMCID: PMC8945687 DOI: 10.3390/biomedicines10030569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 01/11/2023] Open
Abstract
Antibody-mediated rejection (ABMR) is the leading cause of allograft failure in kidney transplantation. Its histological hallmark is represented by lesions of glomerulitis i.e., inflammatory cells within glomeruli. Current therapies for ABMR fail to prevent chronic allograft damage i.e., transplant glomerulopathy, leading to allograft loss. We used laser microdissection of glomeruli from formalin-fixed allograft biopsies combined with mass spectrometry-based proteomics to describe the proteome modification of 11 active and 10 chronic active ABMR cases compared to 8 stable graft controls. Of 1335 detected proteins, 77 were deregulated in glomerulitis compared to stable grafts, particularly involved in cellular stress mediated by interferons type I and II, leukocyte activation and microcirculation remodeling. Three proteins extracted from this protein profile, TYMP, WARS1 and GBP1, showed a consistent overexpression by immunohistochemistry in glomerular endothelial cells that may represent relevant markers of endothelial stress during active ABMR. In transplant glomerulopathy, 137 proteins were deregulated, which favor a complement-mediated mechanism, wound healing processes through coagulation activation and ultimately a remodeling of the glomerular extracellular matrix, as observed by light microscopy. This study brings novel information on glomerular proteomics of ABMR in kidney transplantation, and highlights potential targets of diagnostic and therapeutic interest.
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12
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Lee BT, Fiel MI, Schiano TD. Antibody-mediated rejection of the liver allograft: An update and a clinico-pathological perspective. J Hepatol 2021; 75:1203-1216. [PMID: 34343613 DOI: 10.1016/j.jhep.2021.07.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Antibody-mediated rejection after liver transplantation is an under-recognised cause of allograft injury. While definitions of acute and chronic antibody-mediated rejection have increased clinical awareness, timely identification and management of antibody-mediated rejection remain difficult because of complexities in diagnosis and histopathology, lack of treatment protocols, and unclear long-term outcomes. While recent cohort studies assessing the importance of donor-specific antibodies have aided in its diagnosis, literature on the treatment of antibody-mediated rejection in liver transplantation remain limited to case reports and small series. Further increasing the awareness and timely recognition of antibody-mediated rejection post-liver transplantation is crucial in order to stimulate future research and the development of protocols for its diagnosis and treatment. This review will summarise recent advances in the clinical diagnosis and treatment of antibody-mediated rejection in liver transplantation, as well as some of the histopathologic features (on liver biopsy tissue) of acute and chronic antibody-mediated rejection.
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Affiliation(s)
- Brian T Lee
- Division of Gastroenterology and Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas D Schiano
- Division of Liver Diseases, Department of Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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13
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Cornell LD. Histopathologic Features of Antibody Mediated Rejection: The Banff Classification and Beyond. Front Immunol 2021; 12:718122. [PMID: 34646262 PMCID: PMC8503253 DOI: 10.3389/fimmu.2021.718122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/07/2021] [Indexed: 01/27/2023] Open
Abstract
Antibody mediated rejection (ABMR) in the kidney can show a wide range of clinical presentations and histopathologic patterns. The Banff 2019 classification currently recognizes four diagnostic categories: 1. Active ABMR, 2. Chronic active ABMR, 3. Chronic (inactive) ABMR, and 4. C4d staining without evidence of rejection. This categorization is limited in that it does not adequately represent the spectrum of antibody associated injury in allograft, it is based on biopsy findings without incorporating clinical features (e.g., time post-transplant, de novo versus preformed DSA, protocol versus indication biopsy, complement inhibitor drugs), the scoring is not adequately reproducible, and the terminology is confusing. These limitations are particularly relevant in patients undergoing desensitization or positive crossmatch kidney transplantation. In this article, I discuss Banff criteria for these ABMR categories, with a focus on patients with pre-transplant DSA, and offer a framework for considering the continuum of allograft injury associated with donor specific antibody in these patients.
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Affiliation(s)
- Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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14
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Caveolin-1 in Kidney Chronic Antibody-Mediated Rejection: An Integrated Immunohistochemical and Transcriptomic Analysis Based on the Banff Human Organ Transplant (B-HOT) Gene Panel. Biomedicines 2021; 9:biomedicines9101318. [PMID: 34680435 PMCID: PMC8533527 DOI: 10.3390/biomedicines9101318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023] Open
Abstract
Caveolin-1 overexpression has previously been reported as a marker of endothelial injury in kidney chronic antibody-mediated rejection (c-ABMR), but conclusive evidence supporting its use for daily diagnostic practice is missing. This study aims to evaluate if Caveolin-1 can be considered an immunohistochemical surrogate marker of c-ABMR. Caveolin-1 expression was analyzed in a selected series of 22 c-ABMR samples and 11 controls. Caveolin-1 immunohistochemistry proved positive in peritubular and glomerular capillaries of c-ABMR specimens, irrespective of C4d status whereas all controls were negative. Multiplex gene expression profiling in c-ABMR cases confirmed Caveolin-1 overexpression and identified additional genes (n = 220) and pathways, including MHC Class II antigen presentation and Type II interferon signaling. No differences in terms of gene expression (including Caveolin-1 gene) were observed according to C4d status. Conversely, immune cell signatures showed a NK-cell prevalence in C4d-negative samples compared with a B-cell predominance in C4d-positive cases, a finding confirmed by immunohistochemical assessment. Finally, differentially expressed genes were observed between c-ABMR and controls in pathways associated with Caveolin-1 functions (angiogenesis, cell metabolism and cell–ECM interaction). Based on our findings, Caveolin-1 resulted as a key player in c-ABMR, supporting its role as a marker of this condition irrespective of C4d status.
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15
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Malone AF. Transplant Biopsy Assessment in 21st Century. J Am Soc Nephrol 2021; 32:1827-1828. [PMID: 34281960 PMCID: PMC8455280 DOI: 10.1681/asn.2021060804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andrew F Malone
- Division of Nephrology, Department of Medicine, Washington University at St. Louis, St. Louis, Missouri
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Kielar M, Gala-Błądzińska A, Dumnicka P, Ceranowicz P, Kapusta M, Naumnik B, Kubiak G, Kuźniewski M, Kuśnierz-Cabala B. Complement Components in the Diagnosis and Treatment after Kidney Transplantation-Is There a Missing Link? Biomolecules 2021; 11:biom11060773. [PMID: 34064132 PMCID: PMC8224281 DOI: 10.3390/biom11060773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022] Open
Abstract
Currently, kidney transplantation is widely accepted as the renal replacement therapy allowing for the best quality of life and longest survival of patients developing end-stage renal disease. However, chronic transplant rejection, recurrence of previous kidney disease or newly acquired conditions, or immunosuppressive drug toxicity often lead to a deterioration of kidney allograft function over time. Complement components play an important role in the pathogenesis of kidney allograft impairment. Most studies on the role of complement in kidney graft function focus on humoral rejection; however, complement has also been associated with cell mediated rejection, post-transplant thrombotic microangiopathy, the recurrence of several glomerulopathies in the transplanted kidney, and transplant tolerance. Better understanding of the complement involvement in the transplanted kidney damage has led to the development of novel therapies that inhibit complement components and improve graft survival. The analysis of functional complotypes, based on the genotype of both graft recipient and donor, may become a valuable tool for assessing the risk of acute transplant rejection. The review summarizes current knowledge on the pathomechanisms of complement activation following kidney transplantation and the resulting diagnostic and therapeutic possibilities.
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Affiliation(s)
- Małgorzata Kielar
- St. Louis Regional Children’s Hospital, Medical Diagnostic Laboratory with a Bacteriology Laboratory, Strzelecka 2 St., 31-503 Kraków, Poland;
| | - Agnieszka Gala-Błądzińska
- Medical College of Rzeszów University, Institute of Medical Sciences, Kopisto 2A Avn., 35-310 Rzeszów, Poland;
| | - Paulina Dumnicka
- Jagiellonian University Medical College, Faculty of Pharmacy, Department of Medical Diagnostics, Medyczna 9 St., 30-688 Kraków, Poland;
| | - Piotr Ceranowicz
- Jagiellonian University Medical College, Faculty of Medicine, Department of Physiology, Grzegórzecka 16 St., 31-531 Kraków, Poland;
| | - Maria Kapusta
- Jagiellonian University Medical College, Faculty of Medicine, Chair of Clinical Biochemistry, Department of Diagnostics, Kopernika 15A St., 31-501 Kraków, Poland;
| | - Beata Naumnik
- Medical University of Białystok, Faculty of Medicine, 1st Department of Nephrology and Transplantation with Dialysis Unit, Żurawia 14 St., 15-540 Białystok, Poland;
| | - Grzegorz Kubiak
- Catholic University of Leuven, Department of Cardiovascular Diseases, 3000 Leuven, Belgium;
| | - Marek Kuźniewski
- Jagiellonian University Medical College, Faculty of Medicine, Chair and Department of Nephrology, Jakubowskiego 2 St., 30-688 Kraków, Poland;
| | - Beata Kuśnierz-Cabala
- Jagiellonian University Medical College, Faculty of Medicine, Chair of Clinical Biochemistry, Department of Diagnostics, Kopernika 15A St., 31-501 Kraków, Poland;
- Correspondence: ; Tel.: +48-12-424-83-65
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The FCGR3A 158 V/V-genotype is associated with decreased survival of renal allografts with chronic active antibody-mediated rejection. Sci Rep 2021; 11:7903. [PMID: 33846428 PMCID: PMC8041758 DOI: 10.1038/s41598-021-86943-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/19/2021] [Indexed: 01/24/2023] Open
Abstract
Natural killer (NK) cells express the Fc-gamma receptor CD16 (FCGR3A) and could therefore mediate renal endothelial cell damage in cases of chronic-active antibody mediated rejection (c-aABMR). The V/V-genotype of the FCGR3A 158 F/V polymorphism is associated with increased CD16 expression and cytotoxicity by NK cells. This study evaluated whether this genotype is associated with the diagnosis of c-aABMR and renal allograft loss. The distribution of the FGCR3A 158 F/V-genotypes was not different for c-aABMR cases (N = 133) compared to control kidney transplant recipients (N = 116, P = 0.65). The V-allele was associated with increased median fluorescence intensity (MFI) of CD16 by NK cells (MFI 3.5 × 104 versus 1.3 × 104 for V/V and F/F-genotype, P < 0.001). Increased expression of CD16 correlated with CD16-dependent degranulation of NK cells (R = 0.4; P = 0.02). Moreover, the V/V-genotype was significantly associated with a higher glomerulitis score and an independent risk factor (HR 1.98; P = 0.04) for decreased allograft survival. Death-censored graft survival in c-aABMR cases at 3 years follow-up was 33% for the FCGR3A 158 V/V-genotype versus 62% for the F/F-genotype. In conclusion, the FCGR3A V/V-genotype increases CD16-mediated NK cell cytotoxicity and is associated with a higher glomerulitis score and decreased graft survival in cases with c-aABMR.
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Molecular Analysis of Renal Allograft Biopsies: Where Do We Stand and Where Are We Going? Transplantation 2021; 104:2478-2486. [PMID: 32150035 DOI: 10.1097/tp.0000000000003220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A renal core biopsy for histological evaluation is the gold standard for diagnosing renal transplant pathology. However, renal biopsy interpretation is subjective and can render insufficient precision, making it difficult to apply a targeted therapeutic regimen for the individual patient. This warrants a need for additional methods assessing disease state in the renal transplant. Significant research activity has been focused on the role of molecular analysis in the diagnosis of renal allograft rejection. The identification of specific molecular expression patterns in allograft biopsies related to different types of allograft injury could provide valuable information about the processes underlying renal transplant dysfunction and can be used for the development of molecular classifier scores, which could improve our diagnostic and prognostic ability and could guide treatment. Molecular profiling has the potential to be more precise and objective than histological evaluation and may identify injury even before it becomes visible on histology, making it possible to start treatment at the earliest time possible. Combining conventional diagnostics (histology, serology, and clinical data) and molecular evaluation will most likely offer the best diagnostic approach. We believe that the use of state-of-the-art molecular analysis will have a significant impact in diagnostics after renal transplantation. In this review, we elaborate on the molecular phenotype of both acute and chronic T cell-mediated rejection and antibody-mediated rejection and discuss the additive value of molecular profiling in the setting of diagnosing renal allograft rejection and how this will improve transplant patient care.
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Teixeira AC, Távora F, de Deus E Silva MLF, Prado RMG, de Matos Esmeraldo R, de Sandes-Freitas TV. The immunohistochemical expression of von Willebrand factor, T-cadherin, and Caveolin-1 is increased in kidney allograft biopsies with antibody-mediated injury. Clin Exp Nephrol 2020; 25:305-314. [PMID: 33242156 DOI: 10.1007/s10157-020-01994-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/08/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND There are only a few reports evaluating the applicability of endothelial-damage markers analysis by immunohistochemistry (IHC) in kidney allograft samples. This study analyzed the expression of Caveolin-1 (Cav), von Willebrand factor (Vwf), and T-cadherin (Cad) in kidney biopsies and their association with antibody-mediated injury. METHODS In this retrospective study, 114 cases with antibody-mediated changes (Banff, 2020) and 72 with interstitial fibrosis/tubular atrophy were selected. IHC for Cav, Vwf and Cad was performed and evaluated according to their qualitative expression in peritubular capillaries. The cases were grouped according to the presence of microvascular inflammation (MVI), donor-specific antibodies (DSA), C4d positivity and antibody-mediated rejection (AMR). A level of significance < 0.05 was adopted. RESULTS Vwf expression was associated with MVI (p < 0.001), DSA (p = 0.016), C4d (p < 0.001) and AMR (p < 0.001), and was higher in DSA+/C4d+ cases despite MVI (p < 0.001). The expression of Cad correlated with MVI (p = 0.015), C4d (p = 0.005) and AMR (p = < 0.001). Cad was more expressed in chronic AMR compared with acute/active cases (p = 0.001). Cav expression was associated with MVI (p = 0.029) and AMR (p = 0.016) and was also higher in chronic AMR (p = 0.049). A combined score of Vwf and Cad was higher in AMR when compared with C4d without rejection and IF/TA cases (p < 0.001). CONCLUSION Vwf, Cad and Cav expression shows association with antibody-mediated injury and may be helpful to support AMR diagnosis.
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Affiliation(s)
- André Costa Teixeira
- Medical Sciences Postgraduation Program, Department of Clinical Medicine, Faculty of Medicine of the Federal University of Ceará, Monsenhor Furtado St, s/n, Fortaleza, CE, 60430-275, Brazil. .,ARGOS Patologia, 5753 Santos Dumont av, Room 1604, Office Tower, Fortaleza, Ceará, 60175047, Brazil.
| | - Fábio Távora
- Medical Sciences Postgraduation Program, Department of Clinical Medicine, Faculty of Medicine of the Federal University of Ceará, Monsenhor Furtado St, s/n, Fortaleza, CE, 60430-275, Brazil.,ARGOS Patologia, 5753 Santos Dumont av, Room 1604, Office Tower, Fortaleza, Ceará, 60175047, Brazil
| | | | - Renan Martins Gomes Prado
- Faculty of Medicine of State University of Ceará, 1700 Silas Munguba St, Itaperi, Fortaleza, CE, 60441-750, Brazil
| | - Ronaldo de Matos Esmeraldo
- Division of Transplantation, General Hospital of Fortaleza, 900 Ávila Goulart St, Papicu, Fortaleza, CE, 60165-160, Brazil
| | - Tainá Veras de Sandes-Freitas
- Medical Sciences Postgraduation Program, Department of Clinical Medicine, Faculty of Medicine of the Federal University of Ceará, Monsenhor Furtado St, s/n, Fortaleza, CE, 60430-275, Brazil.,Division of Transplantation, General Hospital of Fortaleza, 900 Ávila Goulart St, Papicu, Fortaleza, CE, 60165-160, Brazil
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Immunological follow-up of patients with renal transplants: A proposal for clinical practice in Colombia. ACTA ACUST UNITED AC 2020; 40:479-486. [PMID: 33030826 PMCID: PMC7666855 DOI: 10.7705/biomedica.5092] [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: 06/05/2019] [Indexed: 11/21/2022]
Abstract
Graft damage is a process that starts at the moment of transplantation, due to comorbidities of receptor, donor status, ischemia time, ischemia-reperfusion phenomenon, among others, those induce metabolic and immune factors that ultimately trigger clinical manifestations of graft dysfunction. However, the preclinical progression between the time of transplantation and the appearance of signs and symptoms of graft damage can take weeks to years.
Therefore, the implementation of rational monitoring approaches during the post-transplantation period is critical and should include not only the clinical follow-up but also anticipate immunological graft damage. In the present essay, we propose an immunological monitoring algorithm for the post-renal transplantation period.
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Bery AI, Hachem RR. Antibody-mediated rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:411. [PMID: 32355855 PMCID: PMC7186640 DOI: 10.21037/atm.2019.11.86] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibody-mediated rejection (AMR) has been identified as a significant form of acute allograft dysfunction in lung transplantation. The development of consensus diagnostic criteria has created a uniform definition of AMR; however, significant limitations of these criteria have been identified. Treatment modalities for AMR have been adapted from other areas of medicine and data on the effectiveness of these therapies in AMR are limited. AMR is often refractory to these therapies, and graft failure and death are common. AMR is associated with increased rates of chronic lung allograft dysfunction (CLAD) and poor long-term survival. In this review, we discuss the history of AMR and describe known mechanisms, application of the consensus diagnostic criteria, data for current treatment strategies, and long-term outcomes. In addition, we highlight current gaps in knowledge, ongoing research, and future directions to address these gaps. Promising diagnostic techniques are actively being investigated that may allow for early detection and treatment of AMR. We conclude that further investigation is required to identify and define chronic and subclinical AMR, and head-to-head comparisons of currently used treatment protocols are necessary to identify an optimal treatment approach. Gaps in knowledge regarding the epidemiology, mechanisms, diagnosis, and treatment of AMR continue to exist and future research should focus on these aspects.
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Affiliation(s)
- Amit I Bery
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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22
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Khairwa A. The relevance of complement C4d staining in renal allograft biopsies. INDIAN JOURNAL OF TRANSPLANTATION 2020. [DOI: 10.4103/ijot.ijot_60_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Thurman JM, Panzer SE, Le Quintrec M. The role of complement in antibody mediated transplant rejection. Mol Immunol 2019; 112:240-246. [PMID: 31195225 PMCID: PMC6646053 DOI: 10.1016/j.molimm.2019.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/23/2019] [Accepted: 06/02/2019] [Indexed: 12/26/2022]
Abstract
Antibody mediated transplant rejection (AMR) is a major cause of long-term allograft failure, and currently available treatments are of limited efficacy for treating the disease. AMR is caused by donor specific antibodies (DSA) that bind to antigens within the transplanted organ. DSA usually activate the classical pathway of complement within the allograft, and complement activation is believed to be an important cause of tissue injury in AMR. Several new clinical assays may improve our ability to identify patients at risk of AMR. Complement inhibitory drugs have also been tested in selected patients and in small series. Better understanding of the role of complement activation in the pathogenesis of AMR will likely improve our ability to diagnose the disease and to develop novel treatments.
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Affiliation(s)
- Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Sarah E Panzer
- Department of Medicine, University of Wisconsin Madison, Madison, WI, USA
| | - Moglie Le Quintrec
- Department of Nephrology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
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24
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Abstract
The complement system may contribute in many ways to transplant injury, being a promising target for specific therapeutic interventions. There is evidence that the monoclonal anti-C5 antibody eculizumab is effective in the prevention and treatment of early antibody-mediated rejection, but terminal complement blockade might be of limited efficiency in chronic rejection. Given the diversity of immunological events triggered by activation steps upstream to C5, in particular, opsonin and anaphylatoxin formation through C3 cleavage, one may argue that, in the specific context of antibody-mediated rejection, inhibition of antibody-triggered classical pathway (CP) activation might be beneficial. Strategies to interfere with key CP component C1 are currently under clinical evaluation and include the therapeutic use of purified C1-inhibitor, which, besides targeting the integrity and function of the C1 complex, also affects components of the LP, the contact system, the coagulation cascade or surface molecules mediating leukocyte-endothelial interactions. In addition, a monoclonal anti-C1s antibody (BIVV009) has now entered clinical evaluation and was shown to effectively block antibody-triggered CP activation in rejecting kidney allografts. Moreover, modified apheresis techniques for preferential removal of macromolecules, including C1q, may allow for efficient complement depletion, in addition to antibody removal. The availability of effective strategies to interfere with the CP, as well as innovative approaches targeting other pathways, some of them already being tested in clinical trials, will help us figure out how complement contributes to acute and chronic graft injury, and hopefully provide us with new ways to more efficiently counteract rejection.
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25
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Is Skin the Most Allogenic Tissue in Vascularized Composite Allotransplantation and a Valid Monitor of the Deeper Tissues? Plast Reconstr Surg 2019; 143:880e-886e. [DOI: 10.1097/prs.0000000000005436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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26
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McCaughan J, Xu Q, Tinckam K. Detecting donor-specific antibodies: the importance of sorting the wheat from the chaff. Hepatobiliary Surg Nutr 2019; 8:37-52. [PMID: 30881964 DOI: 10.21037/hbsn.2019.01.01] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Human leukocyte antigen (HLA) compatibility is very important for successful transplantation of solid organs. In this paper, we focused on the humoral arm of immunity in the clinical setting of organ transplantation: how HLA antibodies develop, how they can be detected, and what they can do to injure organ transplants. Specifically, we explore the technical perspectives of detecting donor-specific antibodies (DSA) in HLA laboratories, and use real-life clinical cases to explain the principles. Currently there are many tools in our HLA antibody detection toolbox: conventional cytotoxicity cross match, flow cross match, and solid phase assays using beads conjugated with single or multiple HLA antigens. Single antigen bead (SAB) assay is the most sensitive tool available for detecting HLA antibodies and assessing the immunological risk for organ transplant. However, there are intrinsic limitations to solid-phase assays and they are prone to both false negativity and importantly, false positivity. Denatured antigens on single antigen beads might be the most prominent source of false positive reactivity, and may have been underestimated by many HLA experts. No single assay is perfect and therefore multiple methods, including the less sensitive assays, should be employed to determine the clinical relevance of detected HLA antibodies. Thoughtful process, including knowledge of HLA systems, cross reactivity, epitopes, and the patient's clinical history should be employed to correctly interpret data. The clinical team should work closely with HLA laboratories to ensure accurate interpretation of information and optimal management of patients before and after organ transplantation.
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Affiliation(s)
- Jennifer McCaughan
- Regional Histocompatibility Laboratory, University Health Network, Toronto, ON, Canada
| | - Qingyong Xu
- Transplant Immunology Lab, London Health Sciences Centre, London, ON, Canada
| | - Kathryn Tinckam
- Regional Histocompatibility Laboratory, University Health Network, Toronto, ON, Canada
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Solar-Cafaggi D, Marino L, Uribe-Uribe N, Morales-Buenrostro LE. Antibody-mediated rejection in the Banff classifications of 2007 and 2017: A comparison of renal graft loss prediction capability. Transpl Immunol 2018; 51:40-44. [DOI: 10.1016/j.trim.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/19/2018] [Accepted: 08/26/2018] [Indexed: 10/28/2022]
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Doreille A, Dieudé M, Cardinal H. The determinants, biomarkers, and consequences of microvascular injury in kidney transplant recipients. Am J Physiol Renal Physiol 2018; 316:F9-F19. [PMID: 30379097 DOI: 10.1152/ajprenal.00163.2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Independent of the initial cause of kidney disease, microvascular injury to the peritubular capillary network appears to play a central role in the development of interstitial fibrosis in both native and transplanted kidney disease. This association is explained by mechanisms such as the upregulation of profibrotic genes and epigenetic changes induced by hypoxia, capillary leakage, endothelial and pericyte transition to interstitial fibroblasts, as well as modifications in the secretome of endothelial cells. Alloimmune injury due to antibody-mediated rejection and ischemia-reperfusion injury are the two main etiologies of microvascular damage in kidney transplant recipients. The presence of circulating donor-specific anti-human leukocyte antigen (HLA) antibodies, histological findings, such as diffuse C4d staining in peritubular capillaries, and the extent and severity of peritubular capillaritis, are commonly used clinically to provide both diagnostic and prognostic information. Complement-dependent assays, circulating non-HLA antibodies, or evaluation of the microvasculature with novel imaging techniques are the subject of ongoing studies.
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Affiliation(s)
- Alice Doreille
- Research Centre, Centre Hospitalier de l'Université de Montréal , Montreal, Quebec , Canada.,Université Paris-Sud , Paris , France
| | - Mélanie Dieudé
- Research Centre, Centre Hospitalier de l'Université de Montréal , Montreal, Quebec , Canada.,Canadian Donation and Transplantation Research Program, Montreal, Quebec, Canada
| | - Heloise Cardinal
- Research Centre, Centre Hospitalier de l'Université de Montréal , Montreal, Quebec , Canada.,Canadian Donation and Transplantation Research Program, Montreal, Quebec, Canada
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Molecular Assessment of C4d-Positive Renal Transplant Biopsies Without Evidence of Rejection. Kidney Int Rep 2018; 4:148-158. [PMID: 30596178 PMCID: PMC6308373 DOI: 10.1016/j.ekir.2018.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/17/2018] [Accepted: 09/10/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Immunohistochemical staining for C4d in peritubular capillaries has been part of antibody-mediated rejection (AbMR) definition in the Banff Classification for Allograft Pathology since 2003. However, it has limited sensitivity and specificity, therefore the clinical significance of C4d-positive biopsies without evidence of rejection (C4d+ WER) is unknown. We investigated the transcript levels of genes associated with AbMR in C4d+ WER biopsies from both ABO-compatible and incompatible renal transplant patients. Methods RNA was extracted from formalin-fixed paraffin-embedded renal transplant biopsies (n = 125) and gene expression analysis of 35 AbMR-associated transcripts carried out using the NanoString nCounter system. Results AbMR-associated transcripts were significantly increased in samples with AbMR or suspicious AbMR. A subgroup of 17 of 35 transcripts that best distinguished AbMR from C4d-negative biopsies without evidence of rejection was used to study C4d+ WER samples. There was no differential expression between C4d-negative and C4d+ WER from both ABO-incompatible and -compatible transplants. The geometric mean of 17 differentially expressed genes was used to assign the C4d+ WER biopsies a high- or low-AbMR transcript score. Follow-up biopsies showed AbMR within 1 year of initial biopsy in 5 of 7 high-AbMR transcript patients but only 2 of 46 low-AbMR transcript patients. In multivariate logistic regression analysis, elevated transcript levels in a C4d+ WER biopsy were associated with increased odds for biopsy-proven AbMR on follow-up (P = 0.032, odds ratio 16.318), whereas factors including donor-specific antibody (DSA) status and time since transplantation were not. Conclusion Gene expression analysis in C4d+ WER samples has the potential to identify patients at higher risk of developing AbMR.
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30
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Cardinal H, Dieudé M, Hébert MJ. Endothelial Dysfunction in Kidney Transplantation. Front Immunol 2018; 9:1130. [PMID: 29875776 PMCID: PMC5974048 DOI: 10.3389/fimmu.2018.01130] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/04/2018] [Indexed: 12/17/2022] Open
Abstract
Kidney transplantation entails a high likelihood of endothelial injury. The endothelium is a target of choice for injury by ischemia-reperfusion, alloantibodies, and autoantibodies. A certain degree of ischemia-reperfusion injury inevitably occurs in the immediate posttransplant setting and can manifest as delayed graft function. Acute rejection episodes, whether T-cell or antibody-mediated, can involve the graft micro- and macrovasculature, leading to endothelial injury and adverse long-term consequences on graft function and survival. In turn, caspase-3 activation in injured and dying endothelial cells favors the release of extracellular vesicles (apoptotic bodies and apoptotic exosome-like vesicles) that further enhance autoantibody production, complement deposition, and microvascular rarefaction. In this review, we present the evidence for endothelial injury, its causes and long-term consequences on graft outcomes in the field of kidney transplantation.
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Affiliation(s)
- Héloïse Cardinal
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada
| | - Mélanie Dieudé
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Montreal, QC, Canada
| | - Marie-Josée Hébert
- Research Centre, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Canadian National Transplant Research Program, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada
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31
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Polyomavirus BK Nephropathy-Associated Transcriptomic Signatures: A Critical Reevaluation. Transplant Direct 2018; 4:e339. [PMID: 29464200 PMCID: PMC5811268 DOI: 10.1097/txd.0000000000000752] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/07/2017] [Indexed: 12/29/2022] Open
Abstract
Background Recent work using DNA microarrays has suggested that genes related to DNA replication, RNA polymerase assembly, and pathogen recognition receptors can serve as surrogate tissue biomarkers for polyomavirus BK nephropathy (BKPyVN). Methods We have examined this premise by looking for differential regulation of these genes using a different technology platform (RNA-seq) and an independent set 25 biopsies covering a wide spectrum of diagnoses. Results RNA-seq could discriminate T cell–mediated rejection from other common lesions seen in formalin fixed biopsy material. However, overlapping RNA-seq signatures were found among all disease processes investigated. Specifically, genes previously reported as being specific for the diagnosis of BKPyVN were found to be significantly upregulated in T cell–mediated rejection, inflamed areas of fibrosis/tubular atrophy, as well as acute tubular injury. Conclusions In conclusion, the search for virus specific molecular signatures is confounded by substantial overlap in pathogenetic mechanisms between BKPyVN and nonviral forms of allograft injury. Clinical heterogeneity, overlapping exposures, and different morphologic patterns and stage of disease are a source of substantial variability in “Omics” experiments. These variables should be better controlled in future biomarker studies on BKPyVN, T cell–mediated rejection, and other forms of allograft injury, before widespread implementation of these tests in the transplant clinic.
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32
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Antibody-mediated rejection in heart transplantation: new developments and old uncertainties. Curr Opin Organ Transplant 2017; 22:207-214. [PMID: 28301387 DOI: 10.1097/mot.0000000000000407] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) currently represents one of the main problems for clinical management of heart transplant because of its diagnostic complexity and poor evidences supporting treatments. RECENT FINDINGS Disorder-based diagnosis is a cornerstone in defining AMR. The limitations of the current classification have been partially overcome by novel studies improving the description of the immune-pathological graft abnormalities, and by new molecular approaches allowing a better understanding of the mechanisms behind AMR and of its relationship with cellular rejection and chronic vasculopathy. In-depth characterization of donor-specific antibodies showed to provide additional prognostic information and guide for treatment. Clinical relevance of AMR is bound to appropriate detection of graft dysfunction. In addition to traditional longitudinal evaluation by echocardiogram, cardiac magnetic resonance and detection of cell-free DNA may represent novel sensitive markers for graft injury that could prompt treatment before dysfunction becomes clinically manifest. SUMMARY Despite improvements in the diagnostic process, therapeutic strategies made little progress in addition to the consolidation of practices supported by limited evidences. Novel complement inhibitors appear promising in changing this scenario. Nevertheless, collaborative multicenter studies are needed to develop standardized approaches tailored to the highly variable clinical and laboratory features of AMR.
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33
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Dorr CR, Oetting WS, Jacobson PA, Israni AK. Genetics of acute rejection after kidney transplantation. Transpl Int 2017; 31:263-277. [PMID: 29030886 DOI: 10.1111/tri.13084] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/07/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
Abstract
Treatment of acute rejection (AR) following kidney transplantation has improved in recent years, but there are still limitations to successful outcomes. This review article covers literature in regard to recipient and donor genetics of AR kidney and secondarily of liver allografts. Many candidate gene and some genome-wide association studies (GWASs) have been conducted for AR in kidney transplantation. Genetic associations with AR in kidney and liver are mostly weak, and in most cases, the associations have not been reproducible. A limitation in the study of AR is the lack of sufficiently large populations that account for population stratification to study the AR phenotype which in this era occurs in <10% of transplants. Furthermore, the AR phenotype has been difficult to define and the definitions of classifications have evolved over time. Literature related to the pharmacogenomics of tacrolimus is robust and has been validated in many studies. Associations between gene expression and AR are emerging as markers of outcomes and AR classification. In the future, combinations of pretransplant genotype for AR risk prediction, genotype-based immune suppressant dosing, and pharmacogenomic markers to select AR maintenance or treatment and expression markers from biopsies may provide valuable clinical tools for guiding treatment.
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Affiliation(s)
- Casey R Dorr
- Department of Nephrology, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Ajay K Israni
- Department of Nephrology, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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Cheta J, Rijhwani S, Rust H. Scleroderma Renal Crisis in Mixed Connective Tissue Disease With Full Renal Recovery Within 3 Months: A Case Report With Expanding Treatment Modalities to Treat Each Clinical Sign as an Independent Entity. J Investig Med High Impact Case Rep 2017; 5:2324709617734012. [PMID: 29051891 PMCID: PMC5637966 DOI: 10.1177/2324709617734012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/12/2017] [Accepted: 08/19/2017] [Indexed: 11/15/2022] Open
Abstract
Mixed connective tissue disease (MCTD) is a rheumatologic overlap syndrome that can present with symptoms of systemic lupus erythematous, scleroderma, and polymyositis. A severe but rare complication that can occur in MCTD is scleroderma renal crisis. With multiple poor prognostic indicators, the renal outcome is usually poor. The clinical and histological picture is one of a thrombotic microangiopathy. Clinical suspicion has to be high for additional thrombotic or autoimmune processes coexisting due to associated morbidity. In this article, we report a rare case of scleroderma renal crisis in a patient with MCTD who we treated with plasma exchange for clinical suspicion for an underlying thrombotic thrombocytopenia and mycophenolate mofetil for MCTD. The patient had multiple poor prognostic indicators yet made a full renal recovery in less than 3 months.
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Affiliation(s)
| | | | - Harlan Rust
- Eastern Virginia Medical School, Norfolk, VA, USA
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35
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Moktefi A, Parisot J, Desvaux D, Canoui-Poitrine F, Brocheriou I, Peltier J, Audard V, Kofman T, Suberbielle C, Lang P, Rondeau E, Grimbert P, Matignon M. C1q binding is not an independent risk factor for kidney allograft loss after an acute antibody-mediated rejection episode: a retrospective cohort study. Transpl Int 2017; 30:277-287. [PMID: 27992962 DOI: 10.1111/tri.12905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
Abstract
After kidney transplantation, C4d is an incomplete marker of acute antibody-mediated rejection (AMR) and C1q-binding donor-specific antibodies (DSA) have been associated with allograft survival. However, the impact on allograft survival of C1q+ DSA after clinical AMR has not been studied yet. We analysed retrospectively in clinical AMR C4d staining and C1q-binding impact on allograft survival. We compared clinical, histological and serological features of C4d- and C4d+ AMR, C1q+ and C1q- DSA AMR and analysed C4d and C1q-binding impact on allograft survival. Among 500 for-cause kidney allograft biopsies, 48 fulfilled AMR criteria. C4d+ AMR [N = 18 (37.5%)] have significantly higher number class I DSA (P = 0.02), higher microvascular score (P = 0.02) and more transplant glomerulopathy (P = 0.04). C1q+ AMR [N = 20 (44%)] presented with significantly more class I and class II DSA (P = 0.005 and 0.04) and C4d+ staining (P = 0.01). Graft losses were significantly higher in the C4d+ group (P = 0.04) but similar in C1q groups. C4d+ but not C1q+ binding was an independent risk factor for graft loss [HR = 2.65; (1.11-6.34); P = 0.028]. In our cohort of clinical AMR, C4d+ staining but not C1q+ binding is an independent risk factor for graft loss. Allograft loss and patient survival were similar in C1q+ and C1q- AMR.
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Affiliation(s)
- Anissa Moktefi
- APHP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France
| | - Juliette Parisot
- AP-HP (Assistance Publique-Hôpitaux de Paris), Public Health Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Dominique Desvaux
- APHP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France
| | - Florence Canoui-Poitrine
- AP-HP (Assistance Publique-Hôpitaux de Paris), Public Health Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hositalo-Universitaire) A-TVB, IMRB (Institut Mondor de Recherche Biomédicale)- EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Université Paris-Est-Créteil, UPEC, Créteil, France
| | - Isabelle Brocheriou
- AP-HP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Tenon Hospital, Paris, France.,INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France
| | - Julie Peltier
- INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Intensive Care Nephrology and Renal Transplantation, Tenon Hospital, Paris, France
| | - Vincent Audard
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Tomek Kofman
- AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Caroline Suberbielle
- AP-HP (Assistance Publique-Hôpitaux de Paris), Immunology and Histocompatibility Department, Saint Louis Hospital, Paris, France
| | - Philippe Lang
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Eric Rondeau
- INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Intensive Care Nephrology and Renal Transplantation, Tenon Hospital, Paris, France
| | - Philippe Grimbert
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,AP-HP, CIC-BT 504, Créteil, France
| | - Marie Matignon
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,AP-HP, CIC-BT 504, Créteil, France
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Acute and Chronic Micro- and Macrovascular Lesions in Pancreas Transplants: Implications for the Diagnosis of T Cell-Mediated and Antibody-Mediated Allograft Rejection. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0143-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chow KV, Flint SM, Shen A, Landgren A, Finlay M, Murugasu A, Masterson R, Hughes P, Cohney SJ. Histological and Extended Clinical Outcomes After ABO-Incompatible Renal Transplantation Without Splenectomy or Rituximab. Transplantation 2017; 101:1433-1440. [DOI: 10.1097/tp.0000000000001415] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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38
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Jung HY, Kim YJ, Choi JY, Cho JH, Park SH, Kim YL, Kim HK, Huh S, Won DI, Kim CD. Increased Circulating T Lymphocytes Expressing HLA-DR in Kidney Transplant Recipients with Microcirculation Inflammation. J Korean Med Sci 2017; 32:908-918. [PMID: 28480647 PMCID: PMC5426246 DOI: 10.3346/jkms.2017.32.6.908] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/19/2017] [Indexed: 01/27/2023] Open
Abstract
We consecutively enrolled 82 kidney transplant recipients (KTRs) with stable renal function and 24 KTRs who underwent indication biopsy to compare the histological grading of renal allografts with the activity of circulating T lymphocyte subsets and monocytes determined by flow cytometry, which were obtained at 2 weeks after kidney transplantation (KT) and at the time of indication biopsy, respectively. The sum of the scores of glomerulitis (g) + peritubular capillaritis (ptc), inflammation (i) + tubulitis (t), interstitial fibrosis (ci) + tubular atrophy (ct), and fibrointimal thickening (cv) + arteriolar hyaline thickening (ah) was used to assign a histological grade to the renal allograft samples. The frequencies of CD4⁺HLA-DR⁺/CD4⁺ T cells and CD8⁺HLA-DR⁺/CD8⁺ T cells were significantly increased in KTRs with a microcirculation inflammation (MI) sum score ≥ 1 when compared with KTRs with an MI sum score = 0 as well as stable KTRs. In these 2 subsets, only CD4⁺HLA-DR⁺/CD4⁺ T cells were positively correlated with MI sum scores. Analysis using the receiver operating characteristic (ROC) curve showed that antibody-mediated rejection (AMR) could be predicted with a sensitivity of 80.0% and a specificity of 94.7%, using a cutoff value of 29.6% frequency of CD4⁺HLA-DR⁺/CD4⁺ T cells. MI was significantly associated with an increased frequency of activated T lymphocytes expressing human leukocyte antigen-antigen D related (HLA-DR). Further studies should focus on validating the utility of circulating CD4⁺HLA-DR⁺/CD4⁺ T cells as a noninvasive, immunologic monitoring tool for the prediction of AMR.
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Affiliation(s)
- Hee Yeon Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Jin Kim
- Department of Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji Young Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jang Hee Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun Hee Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Dong Il Won
- Department of Clinical Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chan Duck Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
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Abstract
Complement is a major contributor to inflammation and graft injury. This system is especially important in ischemia-reperfusion injury/delayed graft function as well as in acute and chronic antibody-mediated rejection (AMR). The latter is increasingly recognized as a major cause of late graft loss, for which we have few effective therapies. C1 inhibitor (C1-INH) regulates several pathways which contribute to both acute and chronic graft injuries. However, C1-INH spares the alternative pathway and the membrane attack complex (C5–9) so innate antibacterial defenses remain intact. Plasma-derived C1-INH has been used to treat hereditary angioedema for more than 30 years with excellent safety. Studies with C1-INH in transplant recipients are limited, but have not revealed any unique toxicity or serious adverse events attributed to the protein. Extensive data from animal and ex vivo models suggest that C1-INH ameliorates ischemia-reperfusion injury. Initial clinical studies suggest this effect may allow transplantation of donor organs which are now discarded because the risk of primary graft dysfunction is considered too great. Although the incidence of severe early AMR is declining, accumulating evidence strongly suggests that complement is an important mediator of chronic AMR, a major cause of late graft loss. Thus, C1-INH may also be helpful in preserving function of established grafts. Early clinical studies in transplantation suggest significant beneficial effects of C1-INH with minimal toxicity. Recent results encourage continued investigation of this already-available therapeutic agent.
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40
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Evidence for CD16a-Mediated NK Cell Stimulation in Antibody-Mediated Kidney Transplant Rejection. Transplantation 2017; 101:e102-e111. [PMID: 27906829 DOI: 10.1097/tp.0000000000001586] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Natural killer (NK) cells localize in the microcirculation in antibody-mediated rejection (AMR) and have been postulated to be activated by donor-specific anti-HLA antibodies triggering their CD16a Fc receptors. However, direct evidence for NK cell CD16a triggering in AMR is lacking. We hypothesized that CD16a-inducible NK cell-selective transcripts would be expressed in human AMR biopsies and would offer evidence for CD16a triggering. METHODS We stimulated human NK cells through CD16a in vitro, characterized CD16a-inducible transcripts, and studied their expression in human kidney transplant biopsies with AMR and in an extended human cell panel to determine their selectivity. RESULTS In NK cells, CD16a stimulation induced increased expression of 276 transcripts (FC > 2x, false discovery rate < 0.05), including IFNG, TNF, CSF2, chemokines, such as CCL3, CCL4, and XCL1, and modulators of NK cell effector functions (TNFRSF9, CRTAM, CD160). Examination in an extended human cell panel revealed that CD160 and XCL1 were likely to be selective for NK cells in AMR. In biopsies, 8 of the top 30 CD16a-inducible transcripts were highly associated with AMR (P < 5 × 10): CCL4, CD160, CCL3, XCL1, CRTAM, FCRL3, STARD4, TNFRSF9. Other NK cell transcripts (eg, GNLY) were increased in AMR but not CD16a-inducible, their presence in AMR probably reflecting NK cell localization. CONCLUSIONS The association of CD16a-inducible NK cell-selective transcripts CD160 and XCL1 with biopsies with AMR provides evidence for NK cell CD16a activation in AMR. This raises the possibility of other CD16a-triggered effects that are not necessarily transcriptional, including NK localization and cytotoxicity.
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41
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Antibody-mediated rejection in the cardiac allograft: diagnosis, treatment and future considerations. Curr Opin Cardiol 2017; 32:326-335. [PMID: 28212151 DOI: 10.1097/hco.0000000000000390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the latest publications dealing with antibody-mediated rejection (AMR) and defines areas of controversy and future steps that may improve the outcome for patients with this virulent form of rejection. RECENT FINDINGS Recent progress includes publication of standardized pathologic criteria for acute AMR by the International Society for Heart and Lung Transplantation (ISHLT) and guidelines for treatment of acute AMR by the American Heart Association, endorsed by ISHLT as well. Recently published review articles emphasize the important role of innate immune mechanisms, clarify the role of viral infection and provide insights into vascular biology and the role of innate effector populations, macrophages and dendritic cells. SUMMARY Strategies for future studies are discussed in the context of these new findings and similar efforts undertaken by renal and liver allograft investigators.
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Garces JC, Giusti S, Staffeld-Coit C, Bohorquez H, Cohen AJ, Loss GE. Antibody-Mediated Rejection: A Review. Ochsner J 2017; 17:46-55. [PMID: 28331448 PMCID: PMC5349636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection. METHODS We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies. RESULTS Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody). CONCLUSION AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.
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Affiliation(s)
- Jorge Carlos Garces
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Sixto Giusti
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Catherine Staffeld-Coit
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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43
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Acute antibody-mediated rejection in kidney transplant recipients. Transplant Rev (Orlando) 2017; 31:47-54. [DOI: 10.1016/j.trre.2016.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 10/05/2016] [Indexed: 01/10/2023]
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44
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Mehra NK, Baranwal AK. Clinical and immunological relevance of antibodies in solid organ transplantation. Int J Immunogenet 2016; 43:351-368. [DOI: 10.1111/iji.12294] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/10/2016] [Accepted: 10/16/2016] [Indexed: 12/22/2022]
Affiliation(s)
- N. K. Mehra
- National Chair and Former Dean (Research); All India Institute of Medical Sciences; New Delhi India
| | - A. K. Baranwal
- Department of Transplant Immunology and Immunogenetics; All India Institute of Medical Sciences; New Delhi India
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Verghese PS, Reed RC, Lihong B, Matas AJ, Kim Y. The clinical implications of the unique glomerular complement deposition pattern in transplant glomerulopathy. J Nephrol 2016; 31:157-164. [PMID: 27848227 DOI: 10.1007/s40620-016-0365-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/05/2016] [Indexed: 11/25/2022]
Abstract
The etiology and treatment of transplant glomerulopathy (TG) is not clear. TG is associated with donor-specific antibodies but the lack of C4d deposition in the peritubular capillaries (ptc-C4d) in some cases has caused the role of complement in the pathogenesis of TG to be debated. There is however, little information on C4d deposition in the glomerulus itself. We retrieved random frozen sections from 25 cases with well-established TG by light microscopy (LM) and 25 cases without TG as controls and reviewed the LM and immunofluorescence (nine biopsies were excluded due to inadequate samples). Glomerular complement deposition was assessed in all included biopsies. Glomerular C3d and C4d deposition occurred in a distinct pattern in all TG biopsies: segmental or global double linear staining of the glomerular capillary wall in 23 (100%). This pattern was not present in any NON-TG biopsies. The distinct glomerular complement deposition patterns in all TG cases are suggestive that TG is a proximal complement-mediated process and therapies should focus on proximal complement inhibition.
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Affiliation(s)
- Priya S Verghese
- Division of Pediatric Nephrology, University of Minnesota, Minneapolis, USA.
| | - Robin C Reed
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Bu Lihong
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Youngki Kim
- Division of Pediatric Nephrology, University of Minnesota, Minneapolis, USA
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Abstract
In the current era, one of the major factors limiting graft survival is chronic antibody-mediated rejection (ABMR), whilst patient survival is impacted by the effects of immunosuppression on susceptibility to infection, malignancy and atherosclerosis. IgG antibodies play a role in all of these processes, and many of their cellular effects are mediated by Fc gamma receptors (FcγRs). These surface receptors are expressed by most immune cells, including B cells, natural killer cells, dendritic cells and macrophages. Genetic variation in FCGR genes is likely to affect susceptibility to ABMR and to modulate the physiological functions of IgG. In this review, we discuss the potential role played by FcγRs in determining outcomes in solid organ transplantation, and how genetic polymorphisms in these receptors may contribute to variations in transplant outcome.
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Affiliation(s)
- Tomas Castro-Dopico
- Molecular Immunity Unit, Department of Medicine, MRC Laboratory of Molecular Biology, University of Cambridge, Francis Crick Avenue, Cambridge Biomedical Campus, Cambridge, CB2 0QH UK
| | - Menna R. Clatworthy
- Molecular Immunity Unit, Department of Medicine, MRC Laboratory of Molecular Biology, University of Cambridge, Francis Crick Avenue, Cambridge Biomedical Campus, Cambridge, CB2 0QH UK
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47
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Kaminski H, Fishman JA. The Cell Biology of Cytomegalovirus: Implications for Transplantation. Am J Transplant 2016; 16:2254-69. [PMID: 26991039 DOI: 10.1111/ajt.13791] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/17/2016] [Accepted: 03/07/2016] [Indexed: 01/25/2023]
Abstract
Interpretation of clinical data regarding the impact of cytomegalovirus (CMV) infection on allograft function is complicated by the diversity of viral strains and substantial variability of cellular receptors and viral gene expression in different tissues. Variation also exists in nonspecific (monocytes and dendritic cells) and specific (NK cells, antibodies) responses that augment T cell antiviral activities. Innate immune signaling pathways and expanded pools of memory NK cells and γδ T cells also serve to amplify host responses to infection. The clinical impact of specific memory T cell anti-CMV responses that cross-react with graft antigens and alloantigens is uncertain but appears to contribute to graft injury and to the abrogation of allograft tolerance. These responses are modified by diverse immunosuppressive regimens and by underlying host immune deficits. The impact of CMV infection on the transplant recipient reflects cellular changes and corresponding host responses, the convergence of which has been termed the "indirect effects" of CMV infection. Future studies will clarify interactions between CMV infection and allograft injury and will guide interventions that may enhance clinical outcomes in transplantation.
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Affiliation(s)
- H Kaminski
- Kidney Transplant Unit, CHU Bordeaux Pellegrin, Place Raba Léon, Bordeaux, France
| | - J A Fishman
- Transplant Infectious Disease and Immunocompromised Host Program and MGH Transplant Center, Massachusetts General Hospital, Boston, MA
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Stites E, Le Quintrec M, Thurman JM. The Complement System and Antibody-Mediated Transplant Rejection. THE JOURNAL OF IMMUNOLOGY 2016; 195:5525-31. [PMID: 26637661 DOI: 10.4049/jimmunol.1501686] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Complement activation is an important cause of tissue injury in patients with Ab-mediated rejection (AMR) of transplanted organs. Complement activation triggers a strong inflammatory response, and it also generates tissue-bound and soluble fragments that are clinically useful markers of inflammation. The detection of complement proteins deposited within transplanted tissues has become an indispensible biomarker of AMR, and several assays have recently been developed to measure complement activation by Abs reactive to specific donor HLA expressed within the transplant. Complement inhibitors have entered clinical use and have shown efficacy for the treatment of AMR. New methods of detecting complement activation within transplanted organs will improve our ability to diagnose and monitor AMR, and they will also help guide the use of complement inhibitory drugs.
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Affiliation(s)
- Erik Stites
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
| | - Moglie Le Quintrec
- Department of Nephrology and Renal Transplantation, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
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González-Molina M, Ruiz-Esteban P, Caballero A, Burgos D, Cabello M, Leon M, Fuentes L, Hernandez D. Immune response and histology of humoral rejection in kidney transplantation. Nefrologia 2016; 36:354-67. [PMID: 27267916 DOI: 10.1016/j.nefro.2016.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 02/22/2016] [Accepted: 03/26/2016] [Indexed: 11/15/2022] Open
Abstract
The adaptive immune response forms the basis of allograft rejection. Its weapons are direct cellular cytotoxicity, identified from the beginning of organ transplantation, and/or antibodies, limited to hyperacute rejection by preformed antibodies and not as an allogenic response. This resulted in allogenic response being thought for decades to have just a cellular origin. But the experimental studies by Gorer demonstrating tissue damage in allografts due to antibodies secreted by B lymphocytes activated against polymorphic molecules were disregarded. The special coexistence of binding and unbinding between antibodies and antigens of the endothelial cell membranes has been the cause of the delay in demonstrating the humoral allogenic response. The endothelium, the target tissue of antibodies, has a high turnover, and antigen-antibody binding is non-covalent. If endothelial cells are attacked by the humoral response, immunoglobulins are rapidly removed from their surface by shedding and/or internalization, as well as degrading the components of the complement system by the action of MCP, DAF and CD59. Thus, the presence of complement proteins in the membrane of endothelial cells is transient. In fact, the acute form of antibody-mediated rejection was not demonstrated until C4d complement fragment deposition was identified, which is the only component that binds covalently to endothelial cells. This review examines the relationship between humoral immune response and the types of acute and chronic histological lesion shown on biopsy of the transplanted organ.
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Affiliation(s)
- Miguel González-Molina
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain.
| | - Pedro Ruiz-Esteban
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Abelardo Caballero
- Immunology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Dolores Burgos
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Mercedes Cabello
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Miriam Leon
- Pathology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Laura Fuentes
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
| | - Domingo Hernandez
- Nephrology Department, Regional University Hospital of Malaga, Malaga University, IBIMA, REDINREN RD12/0021/0015, Malaga, Spain
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Abstract
Antibody-mediated rejection (AMR) has been identified among the most important factors limiting long-term outcome in cardiac and renal transplantation. Therapeutic management remains challenging and the development of effective treatment modalities is hampered by insufficient understanding of the underlying pathophysiology. However, recent findings indicate that in addition to AMR-triggered activation of the classical complement pathway, antibody-dependent cellular cytotoxicity by innate immune cell subsets also promotes vascular graft injury. This review summarizes the accumulating evidence for the contribution of natural killer cells, the key mediators of antibody-dependent cellular cytotoxicity, to human AMR in allotransplantation and xenotransplantation and illustrates the current mechanistic conceptions drawn from animal models.
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