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El Hag MI, Kaneku H, Jorgensen D, Zeevi A, Stevenson HL, Yadak N, Hassan M, Du X, Demetris AJ. Morphologic and immunophenotypic evaluation of liver allograft biopsies with contemporaneous serum DSA measurements. Clin Transplant 2023; 37:e14997. [PMID: 37096730 DOI: 10.1111/ctr.14997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/27/2023] [Accepted: 04/09/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Acute antibody mediated rejection is increasingly identified in liver allografts as a unique form of alloimmune injury associated with donor specific antibodies (DSA). This manifests pathologically as microvascular injury and C4d uptake. Despite the liver allograft's relative resistance to alloimmune injury, liver allografts are not impervious to cellular and antibody-mediated rejection. METHODS In this blinded control study, we evaluated CD163 immunohistochemistry and applied the Banff 2016 criteria for diagnosis of acute AMR on a group of indication allograft liver biopsies from DSA positive patients and compared them to indication biopsies from DSA negative controls. RESULTS Most DSA positive patients were females (75%, p = .027), and underwent transplantation for HCV infection. Significant histopathological predictors of serum DSA positivity were Banff H-score (p = .01), moderate to severe cholestasis (p = .03), and CD163 score > 2 (p = .029). Other morphologic features that showed a trend with DSA positivity include Banff portal C4d-score (p = .06), bile ductular reaction (p = .07), and central perivenulitis (p = .07). The odds of DSA sMFI ≥5000 was 12.5 times higher in those with a C4d score >1 than those with a C4d score ≤ 1 (p = .04). Incidence of definite for aAMR in the DSA positive cohort was 25% (n = 5), and 0% in the DSA negative cohort. A group of 5 DSA positive cases were not classifiable by the current scheme. CONCLUSION Sinusoidal CD163, Banff H-score, and diffuse C4d are predictors of serum DSA, and facilitate recognition of histopathological features associated with serum DSA and tissue-antibody interaction.
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Affiliation(s)
- Mohamed I El Hag
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hugo Kaneku
- Department of Surgery - Immunology and Histocompatibility Laboratory, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dana Jorgensen
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adriana Zeevi
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Hepatic and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nour Yadak
- Department of Pathology, Methodist University Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Mohamed Hassan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaotang Du
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Anthony J Demetris
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Hepatic and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yerly P, Rotman S, Regamey J, Aubert V, Aur S, Kirsch M, Hullin R, Pascual M. Complement blockade with eculizumab to treat acute symptomatic humoral rejection after heart transplantation. Xenotransplantation 2022; 29:e12726. [PMID: 35001433 PMCID: PMC9285545 DOI: 10.1111/xen.12726] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/23/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022]
Abstract
Antibody‐mediated rejection (AMR) is a major barrier preventing successful discordant organ xenotransplantation, but it also occurs in allotransplantation due to anti‐HLA antibodies. Symptomatic acute AMR is rare after heart allograft but carries a high risk of mortality, especially >1 year after transplant. As complement activation may play a major role in mediating tissue injury in acute AMR, drugs blocking the terminal complement cascade like eculizumab may be useful, particularly since “standards of care” like plasmapheresis are not based on strong evidence. Eculizumab was successfully used to treat early acute kidney AMR, a typical condition of “active AMR,” but showed mitigated results in late AMR, where “chronic active” lesions are more prevalent. Here, we report the case of a heart recipient who presented with acute heart failure due to late acute AMR with eight de novo donor‐specific anti‐HLA antibodies (DSA), and who fully recovered allograft function and completely cleared DSA following plasmapheresis‐free upfront eculizumab administration in addition to thymoglobulin, intravenous immunoglobulins (IVIG), and rituximab. Several clinical (acute onset, abrupt and severe loss of graft function), biological (sudden high‐level production of DSA), and pathological features (microvascular injury, C4d deposits) of this cardiac recipient are shared with early kidney AMR and may indicate a strong role of complement in the pathogenesis of acute graft injury that may respond to drugs like eculizumab. Terminal complement blockade should be further explored to treat acute AMR in recipients of heart allografts and possibly also in recipients of discordant xenografts in the future.
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Affiliation(s)
- Patrick Yerly
- Service of Cardiology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Samuel Rotman
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Julien Regamey
- Service of Cardiology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology and Allergology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Stefania Aur
- Service of Cardiology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Roger Hullin
- Service of Cardiology, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
| | - Manuel Pascual
- Center for Organ Transplantation, Lausanne University Hospital (CHUV) and Lausanne University, Lausanne, Switzerland
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Corelattions Between CD31, CD68, MMP-2 and MMP-9 Expression in Allograft Cardiac Rejection – Immunohistochemical Study. ARS MEDICA TOMITANA 2020. [DOI: 10.2478/arsm-2019-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction. The cardiac allograft rejections from the post-transplant period are attributable to the acute cellular rejection monitored by multiple endomyocardial biopsies. Compared to this, humoral rejection remains a matter of debate, with multiple therapeutic strategies, poor prognosis, and persisting uncertainty about diagnostic criteria. Acute allograft rejection is associated with significant modifications of the extracellular matrix compartment mainly regulated by matrix metalloproteinases (MMPs). In this context, the aim of this study was to evaluate the expression of MMP-2 and -9 and CD31, CD68 (endothelial and histiocytic markers) and the correlations between them using immunohistochemistry, in patients with cardiac allografts.
Materials and methods. Tissue fragments were obtained by endomyocardial biopsy from 5 patients with allograft heart transplant, 2 in the medium post-transplant phase and 2 in late phase. After identifying and characterizing the morphological context the probes were processed by standard immunohistochemical technique using anti-MMP-2 and anti-MMP-9 antibodies (Santa Cruz Biotechnology, Inc.) and anti-CD31, anti-CD68 antibodies (Sigma). The samples were examined using the Olympus BX40 microscope with an Olympus E330 camera attached.
Results and discussions. Sample examination revealed in all 4 cases the lack of IR (-) for CD31 and weak IR (+) for CD68 compared to MMPs, where we found moderate IR (++) for MMP-9 and weak IR (+) for MMP-2. These aspects complets the histological lesional aspects of these cases, indicating the lack of acute rejection. In conclusion, CD31 and CD68 IR correlated with MMPs IR (especially MMP-9) appear to represent predictive markers for cardiac allograft rejection and require further studies.
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Rotman S, Koch N, Wiesner L, Aubert V, Rosales IA, Colvin RB, Raffoul W, Pascual M. Nonvascularized human skin chronic allograft rejection. Am J Transplant 2019; 19:3191-3196. [PMID: 31344327 DOI: 10.1111/ajt.15542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 01/25/2023]
Abstract
A 65-year-old man had extensive burns of the lower legs in 1991, at the age of 40 years. He was treated by nonvascularized and de-epithelialized, allogeneic split-thickness skin allograft and cyclosporine monotherapy for 2 months. Ulcers developed between 10 and 25 years after transplantation and a surgical debridement on the lower extremities was required. Analyses of the removed tissue allografts showed chronic antibody-mediated and cellular rejection with extensive and dense fibrosis, and diffuse capillary C4d deposits. An anti-DRB1*08:01, donor-specific antibody was present. A unique clinical condition with late immunopathological features of human skin chronic allograft rejection is reported.
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Affiliation(s)
- Samuel Rotman
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nathalie Koch
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Lucie Wiesner
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wassim Raffoul
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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Does the antibody mediated rejection grading scale have prognostic prediction? Yes, but the picture is still blurry. Curr Opin Organ Transplant 2019; 24:265-270. [PMID: 31090634 DOI: 10.1097/mot.0000000000000652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (ABMR) is a condition difficult to diagnose and treat, which may significantly impair the outcome of heart transplant recipients. In clinical practice, diagnosis is based on immunopathology grading of endomyocardial biopsies (EMB). Despite its value, the current diagnostic system has several pitfalls that have been addressed in recent literature. RECENT FINDINGS Pathology grading of ABMR (pAMR) has a relevant prognostic factor. However, it does not capture several nuances, such as chronic vs. acute ABMR, mixed rejection or microvascular inflammation. Molecular biology-based assays are shedding new light on the mechanisms of ABMR, which could improve the precision of ABMR diagnosis. SUMMARY These new findings have the potential to rearrange EMB grading system and to guide more precisely decision-making, but studies validating the therapeutic management based on molecular-pathology coupling are still missing.
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Troxell ML, Lanciault C. Practical Applications in Immunohistochemistry: Evaluation of Rejection and Infection in Organ Transplantation. Arch Pathol Lab Med 2016; 140:910-25. [PMID: 26759930 DOI: 10.5858/arpa.2015-0275-cp] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Immunohistochemical analysis of tissue biopsy specimens is a crucial tool in diagnosis of both rejection and infection in patients with solid organ transplants. In the past 15 years, the concept of antibody-mediated rejection has been refined, and diagnostic criteria have been codified in renal, heart, pancreas, and lung allografts (with studies ongoing in liver, small intestine, and composite grafts), all of which include immunoanalysis for the complement split product C4d. OBJECTIVES -To review the general concepts of C4d biology and immunoanalysis, followed by organ-allograft-specific data, and interpretative nuances for kidney, pancreas, and heart, with discussion of early literature for lung and liver biopsies. Additionally, practical applications and limitations of immunostains for infectious organisms (Polyomavirus, Adenoviridae [adenovirus], and the herpes virus family, including Herpes simplex virus, Cytomegalovirus, Human herpes virus 8, and Epstein-Barr virus) are reviewed in the context of transplant recipients. DATA SOURCES -Our experience and published primary and review literature. CONCLUSIONS -Immunohistochemistry continues to have an important role in transplant pathology, most notably C4d staining in assessment of antibody-mediated rejection and assessment of viral pathogens in tissue. In all facets of transplant pathology, correlation of morphology with special studies and clinical data is critical, as is close communication with the transplant team.
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Affiliation(s)
| | - Christian Lanciault
- From the Department of Pathology, Oregon Health & Science University, Portland
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Thomas KA, Valenzuela NM, Gjertson D, Mulder A, Fishbein MC, Parry GC, Panicker S, Reed EF. An Anti-C1s Monoclonal, TNT003, Inhibits Complement Activation Induced by Antibodies Against HLA. Am J Transplant 2015; 15:2037-49. [PMID: 25904443 PMCID: PMC4654252 DOI: 10.1111/ajt.13273] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) of solid organ transplants (SOT) is characterized by damage triggered by donor-specific antibodies (DSA) binding donor Class I and II HLA (HLA-I and HLA-II) expressed on endothelial cells. While F(ab')2 portions of DSA cause cellular activation and proliferation, Fc regions activate the classical complement cascade, resulting in complement deposition and leukocyte recruitment, both hallmark features of AMR. We characterized the ability of an anti-C1s monoclonal antibody, TNT003, to inhibit HLA antibody (HLA-Ab)-induced complement activation. Complement deposition induced by HLA-Ab was evaluated using novel cell- and bead-based assays. Human aortic endothelial cells (HAEC) were cultured with HLA-Ab and human complement; production of activated complement proteins was measured by flow cytometry. Additionally, C3d deposition was measured on single antigen beads (SAB) mixed with HLA-Ab and human complement. TNT003 inhibited HLA-Ab mediated complement deposition on HAEC in a concentration-dependent manner; C3a, C4a and C5a anaphylatoxin production was also diminished by TNT003. Finally, TNT003 blocked C3d deposition induced by Class I (HLAI-Ab)- and Class II (HLAII-Ab)-specific antibodies on SAB. These data suggest TNT003 may be useful for modulating the effects of DSA, as TNT003 inhibits complement deposition and split product formation generated by HLA-I/II-Ab in vitro.
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Affiliation(s)
- K A Thomas
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - N M Valenzuela
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - D Gjertson
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - A Mulder
- Department of Immunohematology and Blood Transfusion, Leiden University Medical CenterLeiden, the Netherlands
| | - M C Fishbein
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - G C Parry
- True North Therapeutics, Inc.South San Francisco, CA
| | - S Panicker
- True North Therapeutics, Inc.South San Francisco, CA
| | - E F Reed
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA,*Corresponding author: Elaine F. Reed,
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