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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Impact of Glomerulitis on Long-term Outcomes After Kidney Transplantation. Transplant Direct 2022; 8:e1381. [PMID: 36204188 PMCID: PMC9529059 DOI: 10.1097/txd.0000000000001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/26/2022] Open
Abstract
The Banff classification scheme provides a framework for interpreting transplant kidney biopsies and has undergone various updates in the past 2 decades especially related to antibody-mediated rejection. The clinical significance of early glomerulitis seen within 4 mo on protocol biopsies has received limited attention. We hypothesized that early glomerulitis seen on protocol biopsies will lead to significant adverse outcomes as assessed by histopathology and allograft outcome.
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Jahn L, Rüster C, Schlosser M, Winkler Y, Foller S, Grimm MO, Wolf G, Busch M. Rate, Factors, and Outcome of Delayed Graft Function After Kidney Transplantation of Deceased Donors. Transplant Proc 2021; 53:1454-1461. [PMID: 33612277 DOI: 10.1016/j.transproceed.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/08/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Delayed graft function (DGF) is a frequent complication after kidney transplantation affecting long-term outcome. PATIENTS AND METHODS A total of 525 consecutive recipients (age 54.2 ± 13.4 years, 33% female) of kidneys from deceased donors transplanted between 2005 and 2012 were retrospectively examined. DGF was defined as the need of dialysis within the first week after transplantation. RESULTS DGF developed in 21.1% (n = 111). Factors associated with DGF (P ≤ .035, respectively) were recipient body mass index, C-reactive protein of the recipient, residual diuresis, cold ischemia time, donor age, and diuresis in the first hour after transplantation. Median duration of DGF was 16 (2-66) days. Patients after DGF had a significantly lower GFR compared with recipients without DGF either after 3 (32.9 ± 16.5 vs 46.3 ± 18.4 mL/min/1.73 m2) or after 12 months (38.9 ± 19.3 vs 48.6 ± 20.4 mL/min/1.73 m2, P < .001, resp.). During DGF, 12.4% developed BANFF II and 18.0% BANFF I rejection, 20.2% had signs of transplant glomerulitis (first biopsy), and 16.2% (n = 18) remained on dialysis. CONCLUSION DGF affects 1 out of 5 kidney transplants from deceased donors. Minimizing modifiable risk factors, in particular immunologic risk, may ameliorate the incidence and outcome of DGF. The outcome of DGF depends mainly on the diagnosis of any rejection and worsens upon detection of transplant glomerulitis and pronounced interstitial fibrosis and tubular atrophy (IFTA).
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Affiliation(s)
- Laura Jahn
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Christiane Rüster
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Mandy Schlosser
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Yvonne Winkler
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Susan Foller
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Marc-Oliver Grimm
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Gunter Wolf
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Martin Busch
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany.
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Hernandez‐Fuentes MP, Franklin C, Rebollo‐Mesa I, Mollon J, Delaney F, Perucha E, Stapleton C, Borrows R, Byrne C, Cavalleri G, Clarke B, Clatworthy M, Feehally J, Fuggle S, Gagliano SA, Griffin S, Hammad A, Higgins R, Jardine A, Keogan M, Leach T, MacPhee I, Mark PB, Marsh J, Maxwell P, McKane W, McLean A, Newstead C, Augustine T, Phelan P, Powis S, Rowe P, Sheerin N, Solomon E, Stephens H, Thuraisingham R, Trembath R, Topham P, Vaughan R, Sacks SH, Conlon P, Opelz G, Soranzo N, Weale ME, Lord GM. Long- and short-term outcomes in renal allografts with deceased donors: A large recipient and donor genome-wide association study. Am J Transplant 2018; 18:1370-1379. [PMID: 29392897 PMCID: PMC6001640 DOI: 10.1111/ajt.14594] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/28/2017] [Accepted: 11/13/2017] [Indexed: 01/25/2023]
Abstract
Improvements in immunosuppression have modified short-term survival of deceased-donor allografts, but not their rate of long-term failure. Mismatches between donor and recipient HLA play an important role in the acute and chronic allogeneic immune response against the graft. Perfect matching at clinically relevant HLA loci does not obviate the need for immunosuppression, suggesting that additional genetic variation plays a critical role in both short- and long-term graft outcomes. By combining patient data and samples from supranational cohorts across the United Kingdom and European Union, we performed the first large-scale genome-wide association study analyzing both donor and recipient DNA in 2094 complete renal transplant-pairs with replication in 5866 complete pairs. We studied deceased-donor grafts allocated on the basis of preferential HLA matching, which provided some control for HLA genetic effects. No strong donor or recipient genetic effects contributing to long- or short-term allograft survival were found outside the HLA region. We discuss the implications for future research and clinical application.
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Affiliation(s)
| | | | | | - Jennifer Mollon
- King's College LondonMRC Centre for TransplantationLondonUK,Department of HaematologyUniversity of Cambridge, Cambridge, UK
| | - Florence Delaney
- King's College LondonMRC Centre for TransplantationLondonUK,NIHR Biomedical Research Centre at Guy's and St Thomas’NHS Foundation Trust and King's College LondonLondonUK
| | | | | | - Richard Borrows
- Renal Institute of BirminghamDepartment of Nephrology and TransplantationBirminghamUK
| | - Catherine Byrne
- Nottingham Renal and Transplant UnitNottingham University Hospitals NHS TrustNottinghamUK
| | | | - Brendan Clarke
- Transplant and Cellular ImmunologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | | | | | - Susan Fuggle
- Transplant Immunology & ImmunogeneticsChurchill HospitalOxfordUK
| | - Sarah A. Gagliano
- Center for Statistical GeneticsDepartment of BiostatisticsUniversity of MichiganAnn ArborMIUSA
| | - Sian Griffin
- Cardiff & Vale University Health BoardCardiff UniversityCardiffUK
| | - Abdul Hammad
- The Royal Liverpool and Broadgreen University HospitalsLiverpoolUK
| | - Robert Higgins
- University Hospitals Coventry and Warwickshire NHS TrustCoventryUK
| | - Alan Jardine
- School of MedicineDentistry and NursingUniversity of GlasgowGlasgowUK
| | | | | | | | - Patrick B. Mark
- School of MedicineDentistry and NursingUniversity of GlasgowGlasgowUK
| | - James Marsh
- Epsom and St Helier University Hospitals TrustCarshaltonUK
| | - Peter Maxwell
- School of MedicineDentistry and Biomedical SciencesQueens University BelfastBelfastUK
| | - William McKane
- Sheffield Kidney InstituteSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Adam McLean
- Kidney and TransplantImperial College Healthcare NHS TrustLondonUK
| | | | - Titus Augustine
- Central Manchester University Hospitals NHS TrustManchesterUK
| | | | - Steve Powis
- Division of MedicineUniversity College LondonLondonUK
| | | | - Neil Sheerin
- The Medical SchoolNewcastle University NewcastleNewcastle upon TyneUK
| | - Ellen Solomon
- Division of Genetics& Molecular MedicineKing's College LondonLondonUK
| | | | | | - Richard Trembath
- Division of Genetics& Molecular MedicineKing's College LondonLondonUK
| | | | - Robert Vaughan
- Clinical Transplantation Laboratory at Guy's HospitalGuy's and St Thomas’ NHS TrustLondonUK
| | - Steven H. Sacks
- King's College LondonMRC Centre for TransplantationLondonUK,NIHR Biomedical Research Centre at Guy's and St Thomas’NHS Foundation Trust and King's College LondonLondonUK
| | - Peter Conlon
- Royal College of Surgeons in IrelandDublinIreland,Beaumont HospitalDublinIreland
| | - Gerhard Opelz
- University of HeidelbergTransplantation ImmunologyHeidelbergGermany
| | - Nicole Soranzo
- Welcome Trust Sanger InstituteHuman GeneticsCambridgeUK,Department of HaematologyUniversity of Cambridge, Cambridge, UK
| | - Michael E. Weale
- Division of Genetics& Molecular MedicineKing's College LondonLondonUK,Present address:
Genomics plcOxfordUK
| | - Graham M. Lord
- King's College LondonMRC Centre for TransplantationLondonUK,NIHR Biomedical Research Centre at Guy's and St Thomas’NHS Foundation Trust and King's College LondonLondonUK
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Ozluk Y, Caliskan Y, Sevinc M, Bayram A, Arikan EA, Turkmen A, Akgul S, Savran FO, Sever MS, Kilicaslan I. Re-evaluation of glomerulitis using occlusion criteria based on the Banff 2013 revision: a retrospective study. Transpl Int 2017; 30:579-588. [PMID: 28236636 DOI: 10.1111/tri.12943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/11/2017] [Accepted: 02/20/2017] [Indexed: 12/26/2022]
Abstract
The presence of occlusion/near-occlusion of glomerular capillaries was recently added to the existing definition of glomerulitis (g). We retrospectively re-evaluated 135 renal allograft biopsies regarding g to ensure no antibody-damaged grafts were missed. Previous and revised g scores (pg and rg, respectively) were compared for clinicopathologic correlations. The g score did not change in 100 (74.1%) biopsies. Thirty-five (25.9%) biopsies were changed to a lower score. Sensitivity and specificity of pg and rg for the presence of donor-specific antibodies (DSA) were 76% vs. 58% and 70% vs. 79%, respectively. Pg score indicated graft loss with 65% sensitivity and 63% specificity, whereas rg showed 46% sensitivity and 71% specificity. Area under the curve (AUC) values in ROC analysis for DSA and graft loss were as follows: pg, 0.773; rg, 0.693; and pg, 0.635; rg, 0.577, respectively. A comparison of the two AUC values revealed a significant difference between pg and rg only for DSA (P = 0.0076). Pg and post-transplant time of biopsy independently predicted graft loss, whereas rg did not. In conclusion, revised g scores showed lesser sensitivity but higher specificity for DSA and graft loss. Recent definition of g missed antibody-mediated rejection in few cases, and it was not an independent predictor for graft loss.
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Affiliation(s)
- Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasar Caliskan
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Sevinc
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aysel Bayram
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Evsen A Arikan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sebahat Akgul
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatma O Savran
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet S Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Isin Kilicaslan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Gimeno J, Redondo D, Pérez-Sáez MJ, Naranjo-Hans D, Pascual J, Crespo M. Impact of the Banff 2013 classification on the diagnosis of suspicious versus conclusive late antibody-mediated rejection in allografts without acute dysfunction. Nephrol Dial Transplant 2016; 31:1938-1946. [PMID: 27312147 DOI: 10.1093/ndt/gfw223] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 04/07/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Banff classification is used worldwide to characterize pathological findings in renal allograft biopsies. During the 11th Banff meeting, relevant changes were introduced in the diagnostic criteria for Category 2 antibody-mediated rejection (ABMR). Here, we assess the effect of these changes on the diagnosis of late chronic ABMR. METHODS Seventy-three indication renal graft biopsies (chronic dysfunction, proteinuria and/or the presence of de novo donor-specific antibodies) from 68 kidney transplant recipients initially classified following the Banff 2009 criteria were reviewed and reclassified as per the new Banff 2013 criteria. RESULTS The diagnostic category changed in 18% of the study biopsies with Banff 2013. The reclassification mainly involved Category 2 cases, from which 23.5% of the biopsies from older patients with worse graft function were overlooked by Banff 2009. ABMR was ruled out in 13% of cases under the Banff 2009 criteria. A significant number of the study samples were conclusively diagnosed as ABMR (40% as per Banff 2009 and 74% as per Banff 2013; P = 0.006), because of the inclusion of microvascular inflammation and the acceptance of some ultrastructural diagnostic criteria. However, when following the criteria of the new classification, samples with histological signs of chronic ABMR, in which human leucocyte antigen donor-specific antibodies are not detected or ultrastructural studies are not performed, may be inadequately characterized. CONCLUSIONS The Banff 2013 classification helps in making a diagnosis of late ABMR, identifying cases, decreasing the percentage of suspected ABMR and making more conclusive diagnoses.
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Affiliation(s)
- Javier Gimeno
- Department of Pathology, Hospital del Mar-IMIM, Barcelona, Spain
| | - Dolores Redondo
- Department of Nephrology, Hospital del Mar-IMIM, Barcelona, Spain
| | | | | | - Julio Pascual
- Department of Nephrology, Hospital del Mar-IMIM, Barcelona, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar-IMIM, Barcelona, Spain
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7
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Halloran PF, Merino Lopez M, Barreto Pereira A. Identifying Subphenotypes of Antibody-Mediated Rejection in Kidney Transplants. Am J Transplant 2016; 16:908-20. [PMID: 26743766 DOI: 10.1111/ajt.13551] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/11/2015] [Accepted: 09/27/2015] [Indexed: 01/25/2023]
Abstract
The key lesions in antibody-mediated kidney transplant rejection (ABMR) are microcirculation inflammation (peritubular capillaritis and/or glomerulitis lesions, abbreviated "pg") and glomerular double contours (cg lesions). We used these features to explore subphenotypes in 164 indication biopsies with ABMR-related diagnoses: 137 ABMR (109 pure and 28 mixed with T cell-mediated rejection [TCMR]) and 27 transplant glomerulopathy (TG), identified from prospective multicenter studies. The lesions indicated three ABMR subphenotypes: pgABMR, cgABMR, and pgcgABMR. Principal component analysis confirmed these subphenotypes and showed that TG can be reclassified as pgcgABMR (n = 17) or cgABMR (n = 10). ABMR-related biopsies included 45 pgABMR, 90 pgcgABMR, and 25 cgABMR, with four unclassifiable. Dominating all time intervals was the subphenotype pgcgABMR. The pgABMR subphenotype presented earliest (median <2 years), frequently mixed with TCMR, and was most associated with nonadherence. The cgABMR subphenotype presented late (median 9 years). Subphenotypes differed in their molecular changes, with pgABMR having the most histologic-molecular discrepancies (i.e. potential errors). Donor-specific antibody (DSA) was not identified in 29% of pgcgABMR and 46% of cgABMR, but failure rates and molecular findings were similar to cases where DSA was known to be positive. Thus, ABMR presents distinct subphenotypes, early pg-dominant, late cg-dominant, and combined pgcg phenotype, differing in time, molecular features, accompanying TCMR, HLA antibody, and probability of nonadherence.
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Affiliation(s)
- P F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
| | - M Merino Lopez
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada
| | - A Barreto Pereira
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Hospital Santa Julia, Manaus, Amazonas, Brazil
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WTC Clinical Papers. Transplantation 2015; 99:275-7. [PMID: 25651119 DOI: 10.1097/tp.0000000000000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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