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Roufosse C, Becker JU, Rabant M, Seron D, Bellini MI, Böhmig GA, Budde K, Diekmann F, Glotz D, Hilbrands L, Loupy A, Oberbauer R, Pengel L, Schneeberger S, Naesens M. Proposed Definitions of Antibody-Mediated Rejection for Use as a Clinical Trial Endpoint in Kidney Transplantation. Transpl Int 2022; 35:10140. [PMID: 35669973 PMCID: PMC9163810 DOI: 10.3389/ti.2022.10140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/03/2022] [Indexed: 12/15/2022]
Abstract
Antibody-mediated rejection (AMR) is caused by antibodies that recognize donor human leukocyte antigen (HLA) or other targets. As knowledge of AMR pathophysiology has increased, a combination of factors is necessary to confirm the diagnosis and phenotype. However, frequent modifications to the AMR definition have made it difficult to compare data and evaluate associations between AMR and graft outcome. The present paper was developed following a Broad Scientific Advice request from the European Society for Organ Transplantation (ESOT) to the European Medicines Agency (EMA), which explored whether updating guidelines on clinical trial endpoints would encourage innovations in kidney transplantation research. ESOT considers that an AMR diagnosis must be based on a combination of histopathological factors and presence of donor-specific HLA antibodies in the recipient. Evidence for associations between individual features of AMR and impaired graft outcome is noted for microvascular inflammation scores ≥2 and glomerular basement membrane splitting of >10% of the entire tuft in the most severely affected glomerulus. Together, these should form the basis for AMR-related endpoints in clinical trials of kidney transplantation, although modifications and restrictions to the Banff diagnostic definition of AMR are proposed for this purpose. The EMA provided recommendations based on this Broad Scientific Advice request in December 2020; further discussion, and consensus on the restricted definition of the AMR endpoint, is required.
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Affiliation(s)
- Candice Roufosse
- Department of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Jan Ulrich Becker
- Institute of Pathology, University Hospital Cologne, Cologne, Germany
| | - Marion Rabant
- Department of Pathology, Hôpital Necker-Enfants Malades, Paris, France
| | - Daniel Seron
- Department of Nephrology and Kidney Transplantation, Vall d'Hebrón University Hospital, Barcelona, Spain
| | | | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, University of Oxford, Oxford, United Kingdom
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Novotny M, Hruba P, Kment M, Voska L, Kabrtova K, Slavcev A, Viklicky O. Intimal Arteritis and Microvascular Inflammation Are Associated With Inferior Kidney Graft Outcome, Regardless of Donor-Specific Antibodies. Front Med (Lausanne) 2021; 8:781206. [PMID: 34957155 PMCID: PMC8692297 DOI: 10.3389/fmed.2021.781206] [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: 09/22/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022] Open
Abstract
Background: The prognostic role of intimal arteritis of kidney allografts in donor-specific antibody negative (DSA–) antibody-mediated rejection (ABMR) remains unclear. Methods: Seventy-two out of 881 patients who had undergone kidney transplantation from 2014 to 2017 exhibited intimal arteritis in biopsies performed during the first 12 months. In 26 DSA negative cases, the intimal arteritis was accompanied by tubulointerstitial inflammation as part of T cell-mediated vascular rejection (TCMRV, N = 26); intimal arteritis along with microvascular inflammation occurred in 29 DSA negative (ABMRV/DSA–) and 19 DSA positive cases (ABMRV, DSA+, N = 17). In 60 (83%) patients with intimal arteritis, the surveillance biopsies after antirejection therapy were performed. Hundred and two patients with non-vascular ABMR with DSA (ABMR/DSA+, N = 55) and without DSA (ABMR/DSA–, N = 47) served as controls. Time to transplant glomerulopathy (TG) and graft failure were the study endpoints. Results: Transplant glomerulopathy -free survival at 36 months was 100% in TCMRV, 85% in ABMR/DSA–, 65% in ABMRV/DSA-, 54% in ABMR/DSA+ and 31% in ABMRV/DSA+ (log rank p < 0.001). Death-censored graft survival at 36 months was 98% in ABMR/DSA-, 96% in TCMRV, 86% in ABMRV/DSA–, 79% in ABMR/DSA+, and 64% in ABMRV/DSA+ group (log rank p = 0.001). In surveillance biopsies, the resolution of rejection was found in 19 (90%) TCMRV, 14 (58%) ABMRV/DSA–, and only 4 (27%) ABMRV/DSA+ patients (p = 0.006). In the multivariable model, intimal arteritis as part of ABMR represented a significant risk for TG development (HR 2.1, 95% CI 1.2–3.8; p = 0.012) regardless of DSA status but not for graft failure at 36 months. Conclusions: Intimal arteritis as part of ABMR represented a risk for early development of TG regardless of the presence or absence of DSA. Intimal arteritis in DSA positive ABMR represented the high-risk phenotype.
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Affiliation(s)
- Marek Novotny
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Institute of Physiology, First Medical Faculty, Charles University, Prague, Czechia
| | - Petra Hruba
- Transplant Laboratory, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Martin Kment
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Ludek Voska
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Katerina Kabrtova
- Department of Immunogenetics, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Antonij Slavcev
- Department of Immunogenetics, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Institute of Physiology, First Medical Faculty, Charles University, Prague, Czechia
- Transplant Laboratory, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- *Correspondence: Ondrej Viklicky
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Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection. BMC Nephrol 2019; 20:373. [PMID: 31623566 PMCID: PMC6796330 DOI: 10.1186/s12882-019-1563-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background Medication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown. Methods We conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome. Results A total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012]. Conclusions After adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.
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Clinical and Pathological Features of Plasma Cell-Rich Acute Rejection After Kidney Transplantation. Transplantation 2019; 102:853-859. [PMID: 29319615 DOI: 10.1097/tp.0000000000002041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Plasma cell-rich acute rejection (PCAR) is a rare type of allograft rejection characterized by the presence of mature plasma cells. In general, the prognosis of PCAR is poor, and its clinical and pathological features remain unclear. METHODS We performed a retrospective observational study and compared allograft survival between kidney transplant recipients who developed PCAR and those who did not develop PCAR. We further analyzed clinical and pathological risk factors for allograft failure in PCAR patients. RESULTS Of 1956 recipients, 40 developed PCAR. There was a higher prevalence of deceased donor transplants (27.5% vs 11.7%, P = 0.0059), longer median total ischemia time (99 minutes; interquartile range, 71-144 vs 77 minutes; interquartile range, 59-111; P = 0.0309), and lower prevalence of ABO-incompatible transplantation (7.5% vs 22.5%; P = 0.0206) in patients with PCAR than in those without PCAR.Multivariate Cox regression analysis showed that development of PCAR was associated with allograft loss (hazard ratio, 8.03; 95% confidence interval, 3.89-14.80; P < 0.0001).We classified PCAR according to the Banff 2015 criteria into a borderline change group, a T cell-mediated rejection (TCMR) group, an antibody-mediated rejection (AMR) or suspected of having AMR (AMR/sAMR) group, and a mixed rejection (TCMR/AMR) group. The AMR/sAMR group was associated with a lower rate of allograft survival without significant difference (log-rank test, P = 0.1692). CONCLUSIONS The results indicated that PCAR was an independent risk factor for allograft loss. PCAR presented with all types of rejection in the Banff 2015 criteria, and AMR/sAMR was associated with poor allograft survival.
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Early isolated V-lesion may not truly represent rejection of the kidney allograft. Clin Sci (Lond) 2018; 132:2269-2284. [PMID: 30287520 PMCID: PMC6365629 DOI: 10.1042/cs20180745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/26/2023]
Abstract
Intimal arteritis is known to be a negative prognostic factor for kidney allograft survival. Isolated v-lesion (IV) is defined as intimal arteritis with minimal tubulointerstitial inflammation (TI). Although the Banff classification assesses IV as T cell-mediated rejection (TCMR), clinical, and prognostic significance of early IV (early IV, eIV) with negative C4d and donor-specific antibodies (DSA) remains unclear. To help resolve if such eIV truly represents acute rejection, a molecular study was performed. The transcriptome of eIV (n=6), T cell-mediated vascular rejection with rich TI (T cell-mediated vascular rejection, TCMRV, n=4) and non-rejection histologic findings (n=8) was compared using microarrays. A total of 310 genes were identified to be deregulated in TCMRV compared with eIV. Gene enrichment analysis categorized deregulated genes to be associated primarily with T-cells associated biological processes involved in an innate and adaptive immune and inflammatory response. Comparison of deregulated gene lists between the study groups and controls showed only a 1.7% gene overlap. Unsupervised hierarchical cluster analysis revealed clear distinction of eIV from TCMRV and showed similarity with a control group. Up-regulation of immune response genes in TCMRV was validated using RT-qPCR in a different set of eIV (n=12) and TCMRV (n=8) samples. The transcriptome of early IV (< 1 month) with negative C4d and DSA is associated with a weak immune signature compared with TCMRV and shows similarity with normal findings. Such eIV may feature non-rejection origin and reflect an injury distinct from an alloimmune response. The present study supports use of molecular methods when interpreting kidney allograft biopsy findings.
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6
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Stevenson HL, Prats MM, Isse K, Zeevi A, Avitzur Y, Ng VL, Demetris AJ. Isolated vascular "v" lesions in liver allografts: How to approach this unusual finding. Am J Transplant 2018; 18:1534-1543. [PMID: 29464837 DOI: 10.1111/ajt.14708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 01/25/2023]
Abstract
According to the Banff criteria for kidney allografts, isolated vascular or "v" lesions are defined as intimal inflammation, age-inappropriate fibro-intimal hyperplasia, or both, without the presence of associated interstitial T cell-mediated rejection (TCMR). In general, these lesions portend a worse outcome for kidney allografts, particularly in those where the "v" lesions are identified in patients with coexistent donor specific antibodies (DSA) or later after transplantation. Although affected arteries are rarely sampled in liver allograft biopsies, we identified nine patients at a mean of 1805 days posttransplantation and compared these to matched controls. Almost half (4 of 9) of the study patient biopsies showed inflammatory arteritis associated with focal or diffuse C4d positivity, which was not observed in matched controls. One "v" lesion patient progressed to rejection-related graft failure and two developed moderate/severe TCMR in subsequent biopsies, whereas only one rejection episode occurred in follow-up biopsies, and no rejection-related deaths or graft failures were detected in controls. In conclusion, patients with liver allograft isolated "v" lesions should undergo further evaluation and closer follow-up for impending TCMR and/or underlying co-existent chronic antibody-mediated rejection (AMR).
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Affiliation(s)
- H L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - M M Prats
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - K Isse
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A Zeevi
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Y Avitzur
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - V L Ng
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - A J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Viglietti D, Loupy A, Aubert O, Bestard O, Duong Van Huyen JP, Taupin JL, Glotz D, Legendre C, Jouven X, Delahousse M, Kamar N, Lefaucheur C. Dynamic Prognostic Score to Predict Kidney Allograft Survival in Patients with Antibody-Mediated Rejection. J Am Soc Nephrol 2018; 29:606-619. [PMID: 29255058 PMCID: PMC5791064 DOI: 10.1681/asn.2017070749] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/13/2017] [Indexed: 12/25/2022] Open
Abstract
No tool is available for the early assessment of response to antibody-mediated rejection (ABMR) therapies in kidney allograft recipients. This study was designed to define a dynamic composite prognostic ABMR score to predict kidney allograft survival, integrating the disease characteristics at diagnosis and the response to treatment. Among 1978 kidney recipients who underwent transplant between 2008 and 2014, we included 278 patients diagnosed with active ABMR and receiving standard treatment, including plasma exchange, intravenous Ig, and rituximab. Patients were prospectively assessed at diagnosis and after treatment for clinical data, histologic characteristics (allograft biopsy specimen), and donor-specific anti-HLA antibodies (DSA). The dynamic ABMR prediction model included GFR (P<0.001) and presence of interstitial fibrosis/tubular atrophy (P=0.003) at diagnosis and changes in GFR (P<0.001), peritubular capillaritis Banff score (P=0.002), and DSA mean fluorescence intensity (P<0.001) after treatment. Overall, this model showed good calibration and discrimination (C-statistic=0.84). The ABMR prognostic score derived from the prediction model identified three risk strata with 6-year kidney allograft survival rates of 6.0% (high-risk group, n=40), 44.9% (intermediate-risk group, n=36), and 84.4% (low-risk group, n=202), and it provided greater net clinical benefit to patients than did considering them all to have the same level of risk of allograft loss. The performance of the ABMR prognostic score was validated in an independent cohort of 202 kidney recipients with ABMR (C-statistic=0.79). The ABMR prognostic score could be used to inform therapeutic decisions in clinical practice and for the design of clinical trials.
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Affiliation(s)
- Denis Viglietti
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
- Departments of Kidney Transplant and
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France;
- Departments of Kidney Transplant and
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
| | - Oriol Bestard
- Department of Nephrology, Bellvitge University Hospital, Barcelona, Spain
| | - Jean-Paul Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
- Pathology, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean-Luc Taupin
- Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
- Departments of Kidney Transplant and
| | - Christophe Legendre
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
- Departments of Kidney Transplant and
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France
| | - Michel Delahousse
- Department of Nephrology and Kidney Transplantation, Foch Hospital, Suresnes, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universtaire Rangueil, Toulouse; and
- Institut National de la Santé et de la Recherche Médicale U1043, IFR-BMT, Centre Hospitalier Universtaire Purpan, Toulouse, Université Paul Sabatier, Toulouse, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S970, Paris, France;
- Departments of Kidney Transplant and
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Mauthner O, Claes V, Walston J, Engberg S, Binet I, Dickenmann M, Golshayan D, Hadaya K, Huynh-Do U, Calciolari S, De Geest S. ExplorinG frailty and mild cognitive impairmEnt in kidney tRansplantation to predict biomedicAl, psychosocial and health cost outcomeS (GERAS): protocol of a nationwide prospective cohort study. J Adv Nurs 2016; 73:716-734. [DOI: 10.1111/jan.13179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Oliver Mauthner
- Institute of Nursing Science; University of Basel; Switzerland
| | - Veerle Claes
- Institute of Nursing Science; University of Basel; Switzerland
| | - Jeremy Walston
- Center on Aging and Health; Johns Hopkins University; Baltimore Maryland USA
| | - Sandra Engberg
- Institute of Nursing Science; University of Basel; Switzerland
- School of Nursing; University of Pittsburgh; Pennsylvania USA
| | - Isabelle Binet
- Clinic of Nephrology and Transplantation Medicine; Cantonal Hospital St Gallen; Switzerland
| | - Michael Dickenmann
- Department for Transplantation-Immunology and Nephrology; University Hospital Basel; Switzerland
| | - Déla Golshayan
- Transplantation Centre and Transplantation Immunopathology Laboratory; University Hospital Lausanne; Switzerland
| | - Karine Hadaya
- Department of Nephrology; University Hospital Geneva; Switzerland
| | - Uyen Huynh-Do
- University Clinic for Nephrology, Hypertension and Clinical Pharmacology; University Hospital Bern; Switzerland
| | | | - Sabina De Geest
- Institute of Nursing Science; University of Basel; Switzerland
- Academic Center for Nursing and Midwifery; KU Leuven; Belgium
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