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Edginton O, George M, Bandara C, Johnston M, Rao A, Howse M, Ridgway D, Goldsmith P. Renal transplantation in older adults: retrospective cohort study to examine the impact of the new 2019 kidney offering scheme on older adult transplant recipients. Ann R Coll Surg Engl 2024. [PMID: 39377692 DOI: 10.1308/rcsann.2024.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
INTRODUCTION In 2019, a new kidney offering scheme was launched in the United Kingdom, aiming to better match estimated patient survival and graft life expectancy. The scheme's impact on older patients undergoing kidney transplantation (KT) is unknown. This study aims to compare the outcomes of older adult KT recipients before and after introduction of the 2019 scheme. METHODS A retrospective observational cohort study of older adults who underwent KT was undertaken. Group 1 were transplanted between 1 September 2017 and 31 August 2019 (2006 allocation scheme) and group 2 between 1 September 2019 and 31 August 2021 (2019 offering scheme). An older adult was any person ≥60 years old at the time of KT. Univariable binary logistic regression analysis was performed to determine odds ratios (OR) and 95% confidence intervals (CI). RESULTS There were 107 older adult deceased donor KT recipients, 62 from group 1 and 45 from group 2. Median age at transplantation was 68 (interquartile range [IQR] 62-71) and 67 (IQR 64-73) years, respectively. Univariable analysis showed that re-intervention (OR 6.486, 95% CI 1.306-32.216, p = 0.022) and critical care admission (OR 5.619, 95% CI 1.448-21.812, p = 0.013) were significantly more likely in group 2. Group 2 recipients were significantly more likely to have a level 4 human leucocyte antigen (HLA) mismatch (OR 4.667, 95% CI 1.640-13.275, p = 0.004) and to have undergone previous KT (OR 4.691, 95% CI 1.385-15.893, p = 0.013). CONCLUSIONS The introduction of the 2019 offering scheme was associated with re-intervention and critical care admission for older KT recipients. We also observed less-favourable HLA matches but more KT in difficult-to-match groups.
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Affiliation(s)
| | | | - C Bandara
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - M Johnston
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - A Rao
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - M Howse
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - D Ridgway
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - P Goldsmith
- University of Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, UK
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2
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Zwirner U, Kleine-Döpke D, Wagner A, Störzer S, Gronau F, Beetz O, Richter N, Gwinner W, Kulik U, Schmelzle M, Schrem H. Prediction of Renal Graft Function 1 Year After Adult Deceased-Donor Kidney Transplantation Using Variables Available Prior to Transplantation. Ann Transplant 2024; 29:e944603. [PMID: 39350474 PMCID: PMC11453122 DOI: 10.12659/aot.944603] [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: 03/24/2024] [Accepted: 06/13/2024] [Indexed: 10/07/2024] Open
Abstract
BACKGROUND Kidney transplantation is still the best therapy for patients with end-stage renal disease, but the demand for donor organs persistently surpasses the supply. A prognostic model using pre-transplant data for the prediction of renal graft function would be helpful to optimize organ allocation and avoid futile transplantations. MATERIAL AND METHODS Retrospective data of 2431 patients who underwent kidney transplantation between January 01, 2000, and December 31, 2012 with subsequent ten-year clinical follow-up in our transplant center were analyzed. Of these, 1172 patients met the inclusion criteria. Multivariable regression modelling was used to develop a prognostic model for the prediction of graft function after 1 year utilizing only pre-transplant data. The final model was assessed with the area under the receiver operating characteristic (AUROC) curve. RESULTS Donor age, donor serum creatinine, recipient body mass index, re-transplantations beyond the second kidney transplantation, and cold ischemia time had an independent, significant influence on graded renal graft function 1 year after kidney transplantation. AUROC analysis of the prognostic model was >0.700 for all GFR categories except KDIGO G5, indicating high sensitivity and specificity of prediction. CONCLUSIONS For improvement of renal graft function, organs from older donors or donors with high serum creatinine should not be used in obese recipients and for re-transplantations beyond the second one. Cold ischemia time should be as short as possible.
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Affiliation(s)
- Ulrich Zwirner
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Dennis Kleine-Döpke
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Wagner
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Simon Störzer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Gronau
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Oliver Beetz
- Department of General, Visceral, Pediatric and Transplant Surgery, Aachen University Hospital, Aachen, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Wilfried Gwinner
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Department of General and Visceral Surgery, Klinikum Chemnitz, Chemnitz, Germany
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3
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Alowidi N, Ali R, Sadaqah M, Naemi FMA. Advancing Kidney Transplantation: A Machine Learning Approach to Enhance Donor-Recipient Matching. Diagnostics (Basel) 2024; 14:2119. [PMID: 39410523 PMCID: PMC11475881 DOI: 10.3390/diagnostics14192119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/07/2024] [Accepted: 07/19/2024] [Indexed: 10/20/2024] Open
Abstract
(1) Background: Globally, the kidney donor shortage has made the allocation process critical for patients awaiting a kidney transplant. Adopting Machine Learning (ML) models for donor-recipient matching can potentially improve kidney allocation processes when compared with traditional points-based systems. (2) Methods: This study developed an ML-based approach for donor-recipient matching. A comprehensive evaluation was conducted using ten widely used classifiers (logistic regression, decision tree, random forest, support vector machine, gradient boosting, boost, CatBoost, LightGBM, naive Bayes, and neural networks) across three experimental scenarios to ensure a robust approach. The first scenario used the original dataset, the second used a merged version of the dataset, and the last scenario used a hierarchical architecture model. Additionally, a custom ranking algorithm was designed to identify the most suitable recipients. Finally, the ML-based donor-recipient matching model was integrated into a web-based platform called Nephron. (3) Results: The gradient boost model was the top performer, achieving a remarkable and consistent accuracy rate of 98% across the three experimental scenarios. Furthermore, the custom ranking algorithm outperformed the conventional cosine and Jaccard similarity methods in identifying the most suitable recipients. Importantly, the platform not only facilitated efficient patient selection and prioritisation for kidney allocation but can be flexibly adapted for other solid organ allocation systems built on similar criteria. (4) Conclusions: This study proposes an ML-based approach to optimize donor-recipient matching within the kidney allocation process. Successful implementation of this methodology demonstrates significant potential to enhance both efficiency and fairness in kidney transplantation.
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Affiliation(s)
- Nahed Alowidi
- Department of Computer Science, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Razan Ali
- Department of Computer Science, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Munera Sadaqah
- Department of Computer Science, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatmah M. A. Naemi
- Histocompatibility and Immunogenetics Laboratory, King Fahad General Hospital, Jeddah 21589, Saudi Arabia;
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4
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Escribá R, Beksac M, Bennaceur-Griscelli A, Glover JC, Koskela S, Latsoudis H, Querol S, Alvarez-Palomo B. Current Landscape of iPSC Haplobanks. Stem Cell Rev Rep 2024:10.1007/s12015-024-10783-7. [PMID: 39276260 DOI: 10.1007/s12015-024-10783-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2024] [Indexed: 09/16/2024]
Abstract
The use of allogeneic induced pluripotent stem cell (iPSC)-derived cell therapies for regenerative medicine offers an affordable and realistic alternative to producing individual iPSC lines for each patient in need. Human Leukocyte Antigens (HLA)-homozygous iPSCs matched in hemi-similarity could provide cell therapies with reduced immune rejection covering a wide range of the population with a few iPSC lines. Several banks of HLA-homozygous iPSCs (haplobanks) have been established worldwide or are underway, to provide clinical grade starting material for cell therapies covering the most frequent HLA haplotypes for certain populations. Harmonizing quality standards among haplobanks and creating a global registry could minimize the collective effort and provide a much wider access to HLA-compatible cell therapies for patients with less frequent haplotypes. In this review we present all the current haplobank initiatives and their potential benefits for the global population.
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Affiliation(s)
- Rubén Escribá
- Cell Therapy Service, Banc de Sang I Teixits, 106 Passeig de Taulat, 08005, Barcelona, Spain
| | - Meral Beksac
- Ankara Liv Hospital Istinye University and Cord Blood Bank, Ankara University, Ankara, Turkey
| | - Annelise Bennaceur-Griscelli
- CiTHERA, Center of iPS Cell Therapy, Infrastructure INGESTEM University Paris Saclay Inserm U1310, 28 Rue Henri Desbruères, 91100, Corbeil-Essonnes, France
| | - Joel C Glover
- Norwegian Center for Stem Cell Research and Norwegian Core Facility for Human Pluripotent Stem Cells, Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Satu Koskela
- Finnish Red Cross Blood Service Biobank, Härkälenkki 13, 01730, Vantaa, Finland
| | - Helen Latsoudis
- Information Systems Laboratory, Institute of Computer Sciences, Foundation for Research and Technology Hellas, 70013, Heraklion, Crete, Greece
- Haemopoiesis Research Laboratory, School of Medicine, University of Crete, 71003, Heraklion, Crete, Greece
| | - Sergi Querol
- Cell Therapy Service, Banc de Sang I Teixits, 106 Passeig de Taulat, 08005, Barcelona, Spain
| | - Belén Alvarez-Palomo
- Cell Therapy Service, Banc de Sang I Teixits, 106 Passeig de Taulat, 08005, Barcelona, Spain.
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Ferreira ES, Requião-Moura L, Nakamura MR, Foresto RD, Medina Pestana J, Tedesco-Silva H. Impact of Dialysis Time on Long-term Outcomes in HLA-identical Living Donor Kidney Transplant Recipients. Transplant Direct 2024; 10:e1703. [PMID: 39188532 PMCID: PMC11346849 DOI: 10.1097/txd.0000000000001703] [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: 06/28/2024] [Accepted: 07/12/2024] [Indexed: 08/28/2024] Open
Abstract
Background Dialysis vintage is associated with worse outcomes after kidney transplantation. The reasons behind this observation include immunological and nonimmunological risk factors. To mitigate the influence of immunological factors, we examined the association between time on dialysis and clinical outcomes in a cohort of HLA-identical kidney transplant recipients. Methods This retrospective study included 13 321 kidney transplant recipients between 1999 and 2016, of whom 589 were HLA identical followed for at least 5 y. Patient and graft survivals were compared according to dialysis time (<12 or >12 mo) using the log-rank test and Cox regression analysis. We compared surgical complications, cytomegalovirus infection, acute rejection, disease recurrence, and the trajectories of estimated glomerular filtration rate (eGFR). Results Median time on dialysis was 15 mo; 9.2% of patients received preemptive transplants, and 55.3% of patients were on dialysis for >12 mo. After a median follow-up time of 154 mo, there were no differences in unadjusted and adjusted patient and graft survivals (1, 5, 10, and 15 y) between the 2 groups. There were no differences in the incidence of surgical complications (6.2% versus 3.1%), acute rejection (6.1% versus 7.7%), cytomegalovirus infection (7.6% versus 4.0%), and disease recurrence (4.2% versus 4.0%), respectively. There were no differences in mean eGFR during 5 y or in the proportion of patients with an eGFR <30 mL/min at 5 y (9.9% versus 9.2%). Conclusions In this low immunological risk cohort of HLA-identical kidney transplant recipients, we did not observe any association between dialysis vintage on patient survival and graft survival.
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Affiliation(s)
- Evelyn S. Ferreira
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Lucio Requião-Moura
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | - Mônica R. Nakamura
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Demarchi Foresto
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | - José Medina Pestana
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | - Hélio Tedesco-Silva
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
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Dekeyser M, de Goër de Herve MG, Hendel-Chavez H, Lhotte R, Scriabine I, Bargiel K, Boutin E, Herr F, Taupin JL, Taoufik Y, Durrbach A. Allogeneic CD4 T Cells Sustain Effective BK Polyomavirus-Specific CD8 T Cell Response in Kidney Transplant Recipients. Kidney Int Rep 2024; 9:2498-2513. [PMID: 39156165 PMCID: PMC11328547 DOI: 10.1016/j.ekir.2024.04.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction BK polyomavirus-associated nephropathy (BKPyVAN) is a significant complication in kidney transplant recipients (KTRs), associated with a higher level of plasmatic BK polyomavirus (BKPyV) replication and leading to poor graft survival. Methods We prospectively followed-up with 100 KTRs with various degrees of BKPyV reactivation (no BKPyV reactivation, BKPyV-DNAuria, BKPyV-DNAemia, and biopsy-proven BKPyVAN [bp-BKPyVAN], 25 patients per group) and evaluated BKPyV-specific T cell functionality and phenotype. Results We demonstrate that bp-BKPyVAN is associated with a loss of BKPyV-specific T cell proliferation, cytokine secretion, and cytotoxic capacities. This severe functional impairment is associated with an overexpression of lymphocyte inhibitory receptors (programmed cell death 1 [PD1], cytotoxic T lymphocyte-associated protein 4, T cell immunoreceptor with Ig and ITIM domains, and T cell immunoglobulin and mucin domain-containing-3), highlighting an exhausted-like phenotype of BKPyV-specific CD4 and CD8 T cells in bp-BKPyVAN. This T cell dysfunction is associated with low class II donor-recipient human leukocyte antigen (HLA) divergence. In contrast, in the context of higher class II donor-recipient HLA (D/R-HLA) divergence, allogeneic CD4 T cells can provide help that sustains BKPyV-specific CD8 T cell responses. In vitro, allogeneic HLA-mismatched CD4 T cells rescue BKPyV-specific CD8 T cell responses. Conclusion Our findings suggest that in KTRs, allogeneic CD4 T cells can help to maintain an effective BKPyV-specific CD8 T cell response that better controls BKPyV replication in the kidney allograft and may protect against BKPyVAN.
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Affiliation(s)
- Manon Dekeyser
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
- Department of Nephrology, Center Hospitalier Régional Universitaire d'Orléans, Orléans, France
| | | | - Houria Hendel-Chavez
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Romain Lhotte
- Laboratory of Immunology and Histocompatibility, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U976 (Team 3), Paris, France
| | - Ivan Scriabine
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Karen Bargiel
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Emmanuelle Boutin
- Unit of Clinical Research, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Creteil, France
- Paris Est Creteil University, INSERM, IMRB, CEpiA Team, Creteil, France
| | - Florence Herr
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Jean-Luc Taupin
- Laboratory of Immunology and Histocompatibility, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U976 (Team 3), Paris, France
| | - Yassine Taoufik
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Antoine Durrbach
- INSERM 1186, Gustave Roussy Institute, Villejuif, France
- Paris-Saclay University, Paris, France
- Department of Nephrology and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Creteil, France
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7
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Cohen GS, Gareau AJ, Kallarakal MA, Farooq T, Bettinotti MP, Sullivan HC, Madbouly A, Krummey SM. HLA Genotype Imputation Results in Largely Accurate Epitope Mismatch Risk Categorization Across Racial Groups. Transplant Direct 2024; 10:e1639. [PMID: 38911277 PMCID: PMC11191912 DOI: 10.1097/txd.0000000000001639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/09/2024] [Indexed: 06/25/2024] Open
Abstract
Background Biomarkers that predict posttransplant alloimmunity could lead to improved long-term graft survival. Evaluation of the number of mismatched epitopes between donor and recipient HLA proteins, termed molecular mismatch analysis, has emerged as an approach to classify transplant recipients as having high, intermediate, or low risk of graft rejection. When high-resolution genotypes are unavailable, molecular mismatch analysis requires algorithmic assignment, or imputation, of a high-resolution genotyping. Although imputation introduces inaccuracies in molecular mismatch analyses, it is unclear whether these inaccuracies would impact the clinical risk assessment for graft rejection. Methods Using renal transplant patients and donors from our center, we constructed cohorts of surrogate donor-recipient pairs with high-resolution and low-resolution HLA genotyping that were racially concordant or discordant. We systemically assessed the impact of imputation on molecular mismatch analysis for cohorts of 180-200 donor-recipient pairs for each of 4 major racial groups. We also evaluated the effect of imputation for a racially diverse validation cohort of 35 real-world renal transplant pairs. Results In the surrogate donor-recipient cohorts, imputation preserved the molecular mismatch risk category for 90.5%-99.6% of racially concordant donor-recipient pairs and 92.5%-100% of racially discordant pairs. In the validation cohort, which comprised 72% racially discordant pairs, we found that imputation preserved the molecular mismatch risk category for 97.1% of pairs. Conclusions Overall, these data demonstrate that imputation preserves the molecular mismatch risk assessment in the vast majority of cases and provides evidence supporting imputation in the performance of molecular mismatch analysis for clinical assessment.
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Affiliation(s)
- Gregory S. Cohen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alison J. Gareau
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
| | | | - Tayyiaba Farooq
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Maria P. Bettinotti
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
| | - H. Cliff Sullivan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Abeer Madbouly
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Scott M. Krummey
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Immunogenetics Laboratory, Baltimore, MD
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Mankowski MA, Gragert L, Segev DL, Montgomery R, Gentry SE, Mangiola M. Balancing Equity and HLA Matching in Deceased-Donor Kidney Allocation with Eplet Mismatch. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.13.23290644. [PMID: 38947023 PMCID: PMC11213093 DOI: 10.1101/2024.06.13.23290644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background Prioritization of HLA antigen-level matching in the US kidney allocation system intends to improve post-transplant survival but causes racial disparities and thus has been substantially de-emphasized. Recently, molecular matching based on eplets has been found to improve risk stratification compared to antigen matching. Methods To assign eplets unambiguously, we utilized a cohort of 5193 individuals with high resolution allele-level HLA genotypes from the National Kidney Registry. Using repeated random sampling to simulate donor-recipient genotype pairings based on the ethnic composition of the historical US deceased donor pool, we profiled the percentage of well-matched donors for candidates by ethnicity. Results The percentage of well-matched donors with zero-DR/DQ eplet mismatch was 3-fold less racially disparate for Black and Asian candidates than percentage of donors with zero-ABDR antigen mismatches, and 2-fold less racially disparate for Latino candidates. For other HLA antigen and eplet mismatch thresholds, the percentage of well-matched donors was more similar across candidate ethnic groups. Conclusions Compared to the current zero-ABDR antigen mismatch, prioritizing a zero-DR/DQ eplet mismatch in allocation would decrease racial disparities and increase the percentage of well-matched donors. High resolution HLA deceased donor genotyping would enable unambiguous assignment of eplets to operationalize molecular mismatch metrics in allocation. Key Points Question: What is the impact of prioritizing low molecular mismatch transplants on racial and ethnic disparities in US deceased-donor kidney allocation, compared to the current prioritization of antigen-level matching?Findings: The lowest-risk eplet mismatch approach decreases racial disparities up to 3-fold compared to lowest-risk antigen mismatch and identifies a larger number of the lowest allo-immune risk donors.Meaning: Prioritizing eplet matching in kidney transplant allocation could both improve outcomes and reduce racial disparities compared to the current antigen matching.
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9
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Kitpermkiat R, Kantachuvesiri S, Thotsiri S, Thammanichanond D, Rostaing L, Wiwattanathum P. Impact of donor-specific antibody with low mean fluorescence intensity on allograft outcomes in kidney transplant. Transpl Immunol 2024; 84:102054. [PMID: 38750972 DOI: 10.1016/j.trim.2024.102054] [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: 03/12/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Immune-mediated rejection is the most common cause of allograft failure in kidney transplant (KT) patients. Exposure to alloantigen, including human leukocyte antigen (HLA), results in the production of donor-specific antibodies (DSA). There are limited data about low levels of mean fluorescence intensity (MFI) DSA, especially post-transplantation. This study evaluated allograft outcomes in KT patients with low MFI DSA. METHODS From January 2007 to December 2021, KT patients who were tested for post-transplant DSA at Ramathibodi Hospital, Bangkok, Thailand, with the DSA MFI ≤ 1000 were evaluated. These KT patients were categorized into two groups: very low DSA (VLL; MFI = 1-500) and low DSA (LL; MFI = 501-1000). All KT patients were evaluated for the primary outcomes, such as the incidence of acute rejection, serum creatinine levels at one and five years after transplantation as well as allograft and patient survivals. RESULTS Among 36 KT patients 25 were included as those with VLL and 11 as those with LL. The LL group had significantly higher T-cell mediated allograft rejection (TCMR) than the VLL group (45% vs. 12%, P = 0.04). In addition, 10 patients, 5 in the VLL group and 5 in the LL group developed antibody-mediated allograft rejection (ABMR). Both TCMR and ABMR were confirmed by biopsy results. There was a trend toward higher MFI in KT patients with ABMR than without ABMR (P = 0.22). At 5 post-transplant years, serum creatinine, allograft and patient survivals were comparable between these two groups. Furthermore, the univariate and multivariate analyzes revealed that the LL group was a high risk for rejection. CONCLUSION Low MFI DSA values after transplantation may be associated with a higher incidence of rejection, but this finding did not show differences in allograft and patient survival in this study's analysis.
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Affiliation(s)
- Rungthiwa Kitpermkiat
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Excellent Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Surasak Kantachuvesiri
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Excellent Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sansanee Thotsiri
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Excellent Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Duangtawan Thammanichanond
- Excellent Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Histocompatibility and Immunogenetics Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Transplantation, CHU Grenoble-Alps, La Tronche, France
| | - Punlop Wiwattanathum
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Excellent Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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10
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Rompianesi G, Montalti R, Vrakas G, Zarrinpar A, Warren C, Loiaco G, Rubba F, Troisi RI. Benchmark Outcomes in Deceased Donor Kidney Transplantation: A Multicenter Analysis of 80 996 Transplants From 126 Centers. Transplant Direct 2024; 10:e1618. [PMID: 38606349 PMCID: PMC11005896 DOI: 10.1097/txd.0000000000001618] [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: 11/24/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 04/13/2024] Open
Abstract
Background We defined clinically relevant benchmark values in deceased donor kidney transplantation (KT), to assess the best achievable results in low-risk patient cohorts from experienced centers. Methods We identified the "ideal" cases from the United Network for Organ Sharing Standard Transplant Analysis and Research files from centers performing ≥50 KT per year between 2010 and 2018. Cases have been selected based on the kidney donor profile index values (<35%), a cold ischemia time (CIT) ≤18 h, a HLA mismatch ≤4, and excluding blood group (ABO) incompatible, dual and combined transplants. The outcomes of the benchmark cohort have been compared with a group of patients excluded from the benchmark cohort because but not meeting 1 or more of the abovementioned criteria. Results The 171 424 KT patients in the United Network for Organ Sharing Standard Transplant Analysis and Research files were screened and 8694 benchmark cases of a total of 80 996 KT (10.7%) from 126 centers meeting the selection criteria were identified. The benchmarks for 1-, 3-, and 5-y patient survival are ≥97%, ≥92.5%, and ≥86.7%, and ≥95.4%, ≥87.8%, and ≥79.6% for graft survival. Benchmark cutoff for hospital length of stay is ≤5 d, ≤23.6% for delayed graft function, and ≤7.5% and ≤9.1% for 6-mo and 1-y incidence of acute rejection. Overall 1-, 3-, and 5-y actuarial graft survivals were 96.6%, 91.1%, and 84.2% versus 93.5%, 85.4%, and 75.5% in the benchmark and comparison groups, respectively (P < 0.001). Overall 1-, 3-, and 5-y actuarial patient survivals were 98.1%, 94.8%, and 90.0% versus 96.6%, 91.1%, and 83.0% in the benchmark and comparison groups, respectively (P < 0.001). Conclusions For the first time, we quantified the best achievable postoperative results in an ideal scenario in deceased donor KT, aimed at improving the clinical practice guided by the comparison of center performances with the ideal outcomes defined.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Roberto Montalti
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Georgios Vrakas
- Department of Surgery, University of Florida, Gainesville, FL
| | - Ali Zarrinpar
- Department of Surgery, University of Florida, Gainesville, FL
| | - Curtis Warren
- Department of Surgery, University of Florida, Gainesville, FL
| | - Giuseppe Loiaco
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Fabiana Rubba
- Public Health Department, Federico II University Hospital, Naples, Italy
| | - Roberto I. Troisi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
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11
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Crane C, Niemann M, Dale B, Gragert L, Shah M, Ingulli E, Morris GP. High-resolution HLA genotyping improves PIRCHE-II assessment of molecular mismatching in kidney transplantation. Hum Immunol 2024; 85:110813. [PMID: 38749805 DOI: 10.1016/j.humimm.2024.110813] [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: 02/27/2024] [Revised: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 06/04/2024]
Abstract
HLA matching in solid organ transplant is performed with the aim of assessing immunologic compatibility in order to avoid hyperacute rejection and assess the risk of future rejection events. Molecular mismatch algorithms are intended to improve granularity in histocompatibility assessment and risk stratification. PIRCHE-II uses HLA genotyping to predict indirectly presented mismatched donor HLA peptides, though most clinical validation studies rely on imputing high resolution (HR) genotypes from low resolution (LR) typing data. We hypothesized that use of bona fide HR typing could overcome limitations in imputation, improving accuracy and predictive ability for donor-specific antibody development and acute rejection. We performed a retrospective analysis of adult and pediatric kidney transplant donor/recipient pairs (N = 419) with HR typing and compared the use of imputed LR genotyping verses HR genotyping for PIRCHE-II analysis and outcomes. Imputation success was highly dependent on the reference population used, as using historic Caucasian reference populations resulted in 10 % of pairs with unsuccessful imputation while multiethnic reference populations improved successful imputation with only 1 % unable to be imputed. Comparing PIRCHE-II analysis with HR and LR genotyping produced notably different results, with 20 % of patients discrepantly classified to immunologic risk groups. These data emphasize the importance of using multiethnic reference panels when performing imputation and indicate HR HLA genotyping has clinically meaningful benefit for PIRCHE-II analysis compared to imputed LR typing.
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Affiliation(s)
- Clarkson Crane
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093, USA; Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | | | | | - Loren Gragert
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Mita Shah
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Elizabeth Ingulli
- Department of Pediatrics, University of California San Diego, La Jolla, CA 92093, USA
| | - Gerald P Morris
- Department of Pathology, University of California San Diego, La Jolla, CA 92093, USA.
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12
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Grutter G, Bianculli AG, Azeka E, Giustiniani P, Iodice FG, Amodeo A, Andreani M. Role of HLA in cardiothoracic transplantation. HLA 2024; 103:e15428. [PMID: 38450875 DOI: 10.1111/tan.15428] [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: 10/05/2023] [Revised: 02/07/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
In current clinical practice, transplant clinicians create collaborative working relationships with histocompatibility laboratory scientists to identify the risk of long-term graft failure, which may assist in establishing strategies for treatment and surveillance. Transplant immunology research also focuses on optimizing human leukocyte antibody tissue typing and defines the most effective test for detecting the presence of donor-specific antibodies. Although several studies have been conducted, data on pediatric heart transplant recipients are limited. Epitope load information may be utilized to identify donors with permissible human leukocyte antibody mismatches to increase transplant success. Although current guidelines do not consider human leukocyte antibody epitope-based matching tools, these guidelines could be useful for identifying recipients at a high risk of donor-specific antibody production, which would be appropriate for routine donor-specific antibody screening to initiate early interventions to prevent antibody-mediated rejection. Human leukocyte antibody matching at the epitope level offers an effective approach for identifying acceptable mismatches in sensitized patients and provides information about epitope loads. In the future, eplet matching may be used to define the best immunosuppressive therapy protocol for cardiothoracic organ transplantation. This report provides an overview of the role of human leukocyte antibodies in heart and lung transplantation.
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Affiliation(s)
- Giorgia Grutter
- Heart Failure, Transplantation, Cardiorespiratory Mechanical Assistance Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Estela Azeka
- Unidade de Cardiologia Pediatrica e Cardiopatia Congenitas do Adulto, Departamento de Cardiologia, Instituto do Coração (InCor) Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paola Giustiniani
- Laboratory of Transplantation Immunogenetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Giovanna Iodice
- Department of Paediatric Cardiac Anesthesia and Intensive Care, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplantation, Cardiorespiratory Mechanical Assistance Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Andreani
- Laboratory of Transplantation Immunogenetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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13
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Liu DH, Tseng HC, Lee MS, Chiou GY, Wang CT, Lin YY, Lai WY, Liu YH, Wang CY, Lee CY, Kao CL, Chen CF, Chien Y. Overcoming the challenges of scalable iPSC generation in translation medicine. J Chin Med Assoc 2024; 87:163-170. [PMID: 38132887 DOI: 10.1097/jcma.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The potential of induced pluripotent stem cells (iPSCs) in revolutionizing regenerative medicine cannot be overstated. iPSCs offer a profound opportunity for therapies involving cell replacement, disease modeling, and cell transplantation. However, the widespread application of iPSC cellular therapy faces hurdles, including the imperative to regulate iPSC differentiation rigorously and the inherent genetic disparities among individuals. To address these challenges, the concept of iPSC super donors emerges, holding exceptional genetic attributes and advantageous traits. These super donors serve as a wellspring of standardized, high-quality cell sources, mitigating inter-individual variations and augmenting the efficacy of therapy. METHODS In pursuit of this goal, our study embarked on the establishment of iPSC cell lines specifically sourced from donors possessing the HLA type (A33:03-B58:01-DRB1*03:01). The reprogramming process was meticulously executed, resulting in the successful generation of iPSC lines from these carefully selected donors. Subsequently, an extensive characterization was conducted to comprehensively understand the features and attributes of these iPSC lines. RESULTS The outcomes of our research were highly promising. The reprogramming efforts culminated in the generation of iPSC lines from donors with the specified HLA type. These iPSC lines displayed a range of distinctive characteristics that were thoroughly examined and documented. This successful generation of iPSC lines from super donors possessing advantageous genetic traits represents a significant stride towards the realization of their potential in therapeutic applications. CONCLUSION In summary, our study marks a crucial milestone in the realm of regenerative medicine. The establishment of iPSC lines from super donors with specific HLA types signifies a paradigm shift in addressing challenges related to iPSC cellular therapy. The standardized and high-quality cell sources derived from these super donors hold immense potential for various therapeutic applications. As we move forward, these findings provide a solid foundation for further research and development, ultimately propelling the field of regenerative medicine toward new horizons of efficacy and accessibility.
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Affiliation(s)
- Ding-Hao Liu
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Huan-Chin Tseng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Meng-Shiue Lee
- Institute of Molecular Medicine and Bioengineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Guang-Yuh Chiou
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Chin-Tien Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Clinical Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ying Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Yi Lai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Hao Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chien-Ying Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Exercise and Health Sciences, University of Taipei, Taipei, Taiwan, ROC
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Trauma, Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chen-Yi Lee
- Department of Electronics Engineering and Institute of Electronics, National Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Chung-Lan Kao
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu, Taiwan, ROC
| | - Cheng-Fong Chen
- Department of Exercise and Health Sciences, University of Taipei, Taipei, Taiwan, ROC
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yueh Chien
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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14
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Niemann M, Matern BM, Spierings E. PIRCHE-II Risk and Acceptable Mismatch Profile Analysis in Solid Organ Transplantation. Methods Mol Biol 2024; 2809:171-192. [PMID: 38907898 DOI: 10.1007/978-1-0716-3874-3_12] [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] [Indexed: 06/24/2024]
Abstract
To optimize outcomes in solid organ transplantation, the HLA genes are regularly compared and matched between the donor and recipient. However, in many cases a transplant cannot be fully matched, due to widespread variation across populations and the hyperpolymorphism of HLA alleles. Mismatches of the HLA molecules in transplanted tissue can be recognized by immune cells of the recipient, leading to immune response and possibly organ rejection. These adverse outcomes are reduced by analysis using epitope-focused models that consider the immune relevance of the mismatched HLA.PIRCHE, an acronym for Predicted Indirectly ReCognizable HLA Epitopes, aims to categorize and quantify HLA mismatches in a patient-donor pair by predicting HLA-derived T cell epitopes. Specifically, the algorithm predicts and counts the HLA-derived peptides that can be presented by the host HLA, known as indirectly-presented T cell epitopes. Looking at the immune-relevant epitopes within HLA allows a more biologically relevant understanding of immune response, and provides an expanded donor pool for a more refined matching strategy compared with allele-level matching. This PIRCHE algorithm is available for analysis of single transplantations, as well as bulk analysis for population studies and statistical analysis for comparison of probability of organ availability and risk profiles.
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Affiliation(s)
| | - Benedict M Matern
- PIRCHE AG, Berlin, Germany
- Center for Translational Immunology, University Medical Center, Utrecht, Netherlands
| | - Eric Spierings
- Center for Translational Immunology, University Medical Center, Utrecht, Netherlands
- Central Diagnostic Laboratory, University Medical Center, Utrecht, Netherlands
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15
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Parmar M, Perrier AL. Introduction to stem cell biology and its role in treating neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 205:3-14. [PMID: 39341661 DOI: 10.1016/b978-0-323-90120-8.00005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Regenerative medicine is an emerging and rapidly evolving field of research and therapeutics aimed to restore, maintain, and improve body functions. In the adult mammalian brain, very few neurons, if any, are generated after disease onset or an injury, and its ability to self-repair is therefore limited. Replacing neurons that are lost during neurodegenerative diseases or due to injury therefore represents one of the major challenges to modern medicine. In this introductory chapter, we describe the basic biology of stem cells and outline how stem cells and cell reprogramming can be utilized to create new neurons for therapeutic purposes that are discussed in detail in other chapters in this handbook.
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Affiliation(s)
- Malin Parmar
- Developmental and Regenerative Neurobiology, Wallenberg Neuroscience Center, Lund Stem Cell Center, Department of Experimental Medical Science, Lund University, Lund, Sweden.
| | - Anselme L Perrier
- Université Paris-Saclay, CEA, CNRS, Laboratoire des Maladies Neurodégénératives: mécanismes, thérapies, imagerie, Fontenay-aux-Roses, France; Université Paris-Saclay, CEA, Molecular Imaging Research Center, Fontenay-aux-Roses, France
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16
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Tsai ET, Peng SY, Wu YR, Lin TC, Chen CY, Liu YH, Tseng YH, Hsiao YJ, Tseng HC, Lai WY, Lin YY, Yang YP, Chiou SH, Chen SP, Chien Y. HLA-Homozygous iPSC-Derived Mesenchymal Stem Cells Rescue Rotenone-Induced Experimental Leber's Hereditary Optic Neuropathy-like Models In Vitro and In Vivo. Cells 2023; 12:2617. [PMID: 37998352 PMCID: PMC10670753 DOI: 10.3390/cells12222617] [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: 09/23/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Mesenchymal stem cells (MSCs) hold promise for cell-based therapy, yet the sourcing, quality, and invasive methods of MSCs impede their mass production and quality control. Induced pluripotent stem cell (iPSC)-derived MSCs (iMSCs) can be infinitely expanded, providing advantages over conventional MSCs in terms of meeting unmet clinical demands. METHODS The potential of MSC therapy for Leber's hereditary optic neuropathy (LHON) remains uncertain. In this study, we used HLA-homozygous induced pluripotent stem cells to generate iMSCs using a defined protocol, and we examined their therapeutic potential in rotenone-induced LHON-like models in vitro and in vivo. RESULTS The iMSCs did not cause any tumorigenic incidence or inflammation-related lesions after intravitreal transplantation, and they remained viable for at least nine days in the mouse recipient's eyes. In addition, iMSCs exhibited significant efficacy in safeguarding retinal ganglion cells (RGCs) from rotenone-induced cytotoxicity in vitro, and they ameliorated CGL+IPL layer thinning and RGC loss in vivo. Optical coherence tomography (OCT) and an electroretinogram demonstrated that iMSCs not only prevented RGC loss and impairments to the retinal architecture, but they also improved retinal electrophysiology performance. CONCLUSION The generation of iMSCs via the HLA homozygosity of iPSCs offers a compelling avenue for overcoming the current limitations of MSC-based therapies. The results underscore the potential of iMSCs when addressing retinal disorders, and they highlight their clinical significance, offering renewed hope for individuals affected by LHON and other inherited retinal conditions.
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Affiliation(s)
- En-Tung Tsai
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan; (E.-T.T.)
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Shih-Yuan Peng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - You-Ren Wu
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Tai-Chi Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Chih-Ying Chen
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Yu-Hao Liu
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Yu-Hsin Tseng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Yu-Jer Hsiao
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Huan-Chin Tseng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Wei-Yi Lai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Yi-Ying Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
| | - Shih-Hwa Chiou
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan; (E.-T.T.)
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
- Genomic Research Center, Academia Sinica, Taipei 115024, Taiwan
| | - Shih-Pin Chen
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan; (E.-T.T.)
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Yueh Chien
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (S.-Y.P.); (Y.-R.W.); (Y.-H.L.); (Y.-J.H.); (Y.-Y.L.); (Y.-P.Y.)
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17
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Martins de Oliveira ML, Tura BR, Meira Leite M, Melo Dos Santos EJ, Pôrto LC, Pereira LV, Campos de Carvalho AC. Creating an HLA-homozygous iPS cell bank for the Brazilian population: Challenges and opportunities. Stem Cell Reports 2023; 18:1905-1912. [PMID: 37774702 PMCID: PMC10656352 DOI: 10.1016/j.stemcr.2023.09.001] [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: 05/20/2022] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023] Open
Abstract
Identifying human leukocyte antigen (HLA) haplotype-homozygous donors for the generation of induced pluripotent stem (iPS) cell lines permits the construction of biobanks immunologically compatible with significant numbers of individuals for use in therapy. However, two questions must be addressed to create such a bank: how many cell lines are necessary to match most of the recipient population and how many people should be tested to find these donors? In Japan and the UK, 50 and 100 distinct HLA-A, -B, and -DRB1 triple-homozygous haplotypes would cover 90% of those populations, respectively. Using data from the Brazilian National Registry of Bone Marrow Donors (REDOME), encompassing 4,017,239 individuals, we identified 1,906 distinct triple-homozygous HLA haplotypes. In Brazil, 559 triple-homozygous cell lines cover 95% of the population, and 3.8 million people would have to be screened. Finally, we show the contribution of the 30 most frequent triple-homozygous HLA haplotypes in Brazil to populations of different countries.
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Affiliation(s)
| | - Bernardo Rangel Tura
- Department of Biostatistics and Bioinformatics of National Institute of Cardiology, Ministry of Health, Rio de Janeiro, Brazil
| | - Mauro Meira Leite
- Genetics of Complex Diseases Laboratory, Federal University of Pará, Belém, Brazil
| | | | - Luís Cristóvão Pôrto
- Histocompatibility and Cryopreservation Laboratory - Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Lygia V Pereira
- Department of Genetics and Evolutionary Biology, Institute of Biosciences of University of São Paulo (USP), São Paulo, Brazil
| | - Antonio Carlos Campos de Carvalho
- Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro (UFRJ) - Cellular and Molecular Cardiology Laboratory, Rio de Janeiro, Brazil; National Institute for Science and Technology in Regenerative Medicine, Rio de Janeiro, Brazil.
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18
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Betriu S, Rovira J, Arana C, García-Busquets A, Matilla-Martinez M, Ramirez-Bajo MJ, Bañon-Maneus E, Lazo-Rodriguez M, Bartoló-Ibars A, Claas FHJ, Mulder A, Heidt S, Juan M, Bayés-Genís B, Campistol JM, Palou E, Diekmann F. Chimeric HLA antibody receptor T cells for targeted therapy of antibody-mediated rejection in transplantation. HLA 2023; 102:449-463. [PMID: 37503860 DOI: 10.1111/tan.15156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/29/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023]
Abstract
The presence of donor-specific antibodies (DSA), mainly against HLA, increases the risk of allograft rejection. Moreover, antibody-mediated rejection (ABMR) remains an important barrier to optimal long-term outcomes after solid organ transplantation. The development of chimeric autoantibody receptor T lymphocytes has been postulated for targeted therapy of autoimmune diseases. We aimed to develop a targeted therapy for DSA desensitization and ABMR, generating T cells with a chimeric HLA antibody receptor (CHAR) that specifically eliminates DSA-producing B cells. We have genetically engineered an HLA-A2-specific CHAR (A2-CHAR) and transduced it into human T cells. Then, we have performed in vitro experiments such as cytokine measurement, effector cell activation, and cytotoxicity against anti-HLA-A2 antibody-expressing target cells. In addition, we have performed A2-CHAR-Tc cytotoxic assays in an immunodeficient mouse model. A2-CHAR expressing T cells could selectively eliminate HLA-A2 antibody-producing B cells in vitro. The cytotoxic capacity of A2-CHAR expressing T cells mainly depended on Granzyme B release. In the NSG mouse model, A2-CHAR-T cells could identify and eradicate HLA-A2 antibody-producing B cells even when those cells are localized in the bone marrow. This ability is effector:target ratio dependent. CHAR technology generates potent and functional human cytotoxic T cells to target alloreactive HLA class I antibody-producing B cells. Thus, we consider that CHAR technology may be used as a selective desensitization protocol or an ABMR therapy in transplantation.
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Affiliation(s)
- Sergi Betriu
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Carolt Arana
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Ainhoa García-Busquets
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Marina Matilla-Martinez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Maria J Ramirez-Bajo
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Lazo-Rodriguez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | | | - Frans H J Claas
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arend Mulder
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Manel Juan
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Beatriu Bayés-Genís
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Eduard Palou
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
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19
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Malhotra D, Jethwani P. Preventing Rejection of the Kidney Transplant. J Clin Med 2023; 12:5938. [PMID: 37762879 PMCID: PMC10532029 DOI: 10.3390/jcm12185938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
With increasing knowledge of immunologic factors and with the advent of potent immunosuppressive agents, the last several decades have seen significantly improved kidney allograft survival. However, despite overall improved short to medium-term allograft survival, long-term allograft outcomes remain unsatisfactory. A large body of literature implicates acute and chronic rejection as independent risk factors for graft loss. In this article, we review measures taken at various stages in the kidney transplant process to minimize the risk of rejection. In the pre-transplant phase, it is imperative to minimize the risk of sensitization, aim for better HLA matching including eplet matching and use desensitization in carefully selected high-risk patients. The peri-transplant phase involves strategies to minimize cold ischemia times, individualize induction immunosuppression and make all efforts for better HLA matching. In the post-transplant phase, the focus should move towards individualizing maintenance immunosuppression and using innovative strategies to increase compliance. Acute rejection episodes are risk factors for significant graft injury and development of chronic rejection thus one should strive for early detection and aggressive treatment. Monitoring for DSA development, especially in high-risk populations, should be made part of transplant follow-up protocols. A host of new biomarkers are now commercially available, and these should be used for early detection of rejection, immunosuppression modulation, prevention of unnecessary biopsies and monitoring response to rejection treatment. There is a strong push needed for the development of new drugs, especially for the management of chronic or resistant rejections, to prolong graft survival. Prevention of rejection is key for the longevity of kidney allografts. This requires a multipronged approach and significant effort on the part of the recipients and transplant centers.
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Affiliation(s)
- Divyanshu Malhotra
- Johns Hopkins Medicine, Johns Hopkins Comprehensive Transplant Center, Baltimore, MD 21287, USA
| | - Priyanka Jethwani
- Methodist Transplant Institute, University of Tennessee Health Science Center, Knoxville, TN 37996, USA;
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20
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Tamargo CL, Kant S. Pathophysiology of Rejection in Kidney Transplantation. J Clin Med 2023; 12:4130. [PMID: 37373823 PMCID: PMC10299312 DOI: 10.3390/jcm12124130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Kidney transplantation has been the optimal treatment for end-stage kidney disease for almost 70 years, with increasing frequency over this period. Despite the prevalence of the procedure, allograft rejection continues to impact transplant recipients, with consequences ranging from hospitalization to allograft failure. Rates of rejection have declined over time, which has been largely attributed to developments in immunosuppressive therapy, understanding of the immune system, and monitoring. Developments in these therapies, as well as an improved understanding of rejection risk and the epidemiology of rejection, are dependent on a foundational understanding of the pathophysiology of rejection. This review explains the interconnected mechanisms behind antibody-mediated and T-cell-mediated rejection and highlights how these processes contribute to outcomes and can inform future progress.
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Affiliation(s)
- Christina L. Tamargo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA;
| | - Sam Kant
- Division of Nephrology & Comprehensive Transplant Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
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21
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Dasariraju S, Gragert L, Wager GL, McCullough K, Brown NK, Kamoun M, Urbanowicz RJ. HLA amino acid Mismatch-Based risk stratification of kidney allograft failure using a novel Machine learning algorithm. J Biomed Inform 2023; 142:104374. [PMID: 37120046 PMCID: PMC10286565 DOI: 10.1016/j.jbi.2023.104374] [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: 12/12/2022] [Revised: 04/02/2023] [Accepted: 04/23/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE While associations between HLA antigen-level mismatches (Ag-MM) and kidney allograft failure are well established, HLA amino acid-level mismatches (AA-MM) have been less explored. Ag-MM fails to consider the substantial variability in the number of MMs at polymorphic amino acid (AA) sites within any given Ag-MM category, which may conceal variable impact on allorecognition. In this study we aim to develop a novel Feature Inclusion Bin Evolver for Risk Stratification (FIBERS) and apply it to automatically discover bins of HLA amino acid mismatches that stratify donor-recipient pairs into low versus high graft survival risk groups. METHODS Using data from the Scientific Registry of Transplant Recipients, we applied FIBERS on a multiethnic population of 166,574 kidney transplants between 2000 and 2017. FIBERS was applied (1) across all HLA-A, B, C, DRB1, and DQB1 locus AA-MMs with comparison to 0-ABDR Ag-MM risk stratification, (2) on AA-MMs within each HLA locus individually, and (3) using cross validation to evaluate FIBERS generalizability. The predictive power of graft failure risk stratification was evaluated while adjusting for donor/recipient characteristics and HLA-A, B, C, DRB1, and DQB1 Ag-MMs as covariates. RESULTS FIBERS's best-performing bin (on AA-MMs across all loci) added significant predictive power (hazard ratio = 1.10, Bonferroni adj. p < 0.001) in stratifying graft failure risk (where low-risk is defined as zero AA-MMs and high-risk is one or more AA-MMs) even after adjusting for Ag-MMs and donor/recipient covariates. The best bin also categorized more than twice as many patients to the low-risk category, compared to traditional 0-ABDR Ag mismatching (∼24.4% vs ∼ 9.1%). When HLA loci were binned individually, the bin for DRB1 exhibited the strongest risk stratification; relative to zero AA-MM, one or more MMs in the bin yielded HR = 1.11, p < 0.005 in a fully adjusted Cox model. AA-MMs at HLA-DRB1 peptide contact sites contributed most to incremental risk of graft failure. Additionally, FIBERS points to possible risk associated with HLA-DQB1 AA-MMs at positions that determine specificity of peptide anchor residues and HLA-DQ heterodimer stability. CONCLUSION FIBERS's performance suggests potential for discovery of HLA immunogenetics-based risk stratification of kidney graft failure that outperforms traditional assessment.
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Affiliation(s)
- Satvik Dasariraju
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Lawrenceville School, Lawrenceville, NJ, United States
| | - Loren Gragert
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Grace L Wager
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Keith McCullough
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
| | - Nicholas K Brown
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars Sinai Medical Center, Los Angeles, CA, United States.
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22
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Comparative Study of the Impact of Human Leukocyte Antigens on Renal Transplant Survival in Andalusia and the United States. Diagnostics (Basel) 2023; 13:diagnostics13040608. [PMID: 36832096 PMCID: PMC9954912 DOI: 10.3390/diagnostics13040608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023] Open
Abstract
Renal transplantation is the treatment of choice for patients suffering from chronic renal disease, one of the leading causes of death worldwide. Among the biological barriers that may increase the risk of acute renal graft rejection is the presence of human leukocyte antigen (HLA) incompatibilities between donor and recipient. This work presents a comparative study of the influence of HLA incompatibilities on renal transplantation survival in the Andalusian (South of Spain) and United States (US) population. The main objective is to analyse the extent to which results about the influence of different factors on renal graft survival can be generalised to different populations. The Kaplan-Meier estimator and the Cox model have been used to identify and quantify the impact on the survival probability of HLA incompatibilities, both in isolation and in conjunction with other factors associated with the donor and recipient. According to the results obtained, HLA incompatibilities considered in isolation have negligible impact on renal survival in the Andalusian population and a moderate impact in the US population. Grouping by HLA score presents some similarities for both populations, while the sum of all HLA scores (aHLA) only has an impact on the US population. Finally, the graft survival probability of the two populations differs when aHLA is considered in conjunction with blood type. The results suggest that the disparities in the renal graft survival probability between the two populations under study are due not only to biological and transplantation-associated factors, but also to social-health factors and ethnic heterogeneity between populations.
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23
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Hod-Dvorai R, Lee R, Muluhngwi P, Raijmakers M, Shetty A, Tambur AR, Ison MG. Development of de novo donor-specific antibodies in renal transplant recipients with BK viremia managed with immunosuppression reduction. Transpl Infect Dis 2023; 25:e13993. [PMID: 36413505 DOI: 10.1111/tid.13993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reduction of immunosuppression (IS) upon detection of Polyomavirus (BK) viremia is widely used to prevent BK virus nephropathy. This retrospective case-control study assesses the frequency of de novo donor-specific antibodies (dnDSA) in renal transplant recipients with IS modulation due to BK viremia and the associated risk of antibody mediated rejection. METHODS Our cohort included recipients of kidney transplantation between 2007 and 2017 with clinical, HLA antibody, and biopsy data. BK positivity was defined as viremia >10 000 c/ml or biopsy proven BK nephropathy. A total of 190 BK cases matched our inclusion criteria, each case was matched with two controls based on gender, donor type, and transplant within 1 year (N = 396). RESULTS Despite lower number of HLA antigen mismatches (mean = 3.5 vs. 4.4, p < .001), dnDSA rates were higher in BK cases than in control group (22.1% vs. 13.9%, p = .02), with the majority detected following IS reduction for BK infection, and arising earlier posttransplant compared with no BK infection (294d vs. 434d, p < .001). Antibody mediated rejection rates were similar between cases and controls (8.9% and 8.3%, respectively), but rejection was more likely to occur earlier posttransplant in the BK cases (354d vs. 602d, p = .03). CONCLUSION Our data suggest a link between IS reduction and the generation of dnDSA and/or rejection, supporting close monitoring for DSA in patients with reduced IS due to BK infection given their increased risk to develop dnDSA.
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Affiliation(s)
- Reut Hod-Dvorai
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Ryan Lee
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Penn Muluhngwi
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | | | - Aneesha Shetty
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Anat R Tambur
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Michael G Ison
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
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24
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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25
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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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26
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Lehmann C, Pehnke S, Weimann A, Bachmann A, Dittrich K, Petzold F, Fürst D, de Fallois J, Landgraf R, Henschler R, Lindner TH, Halbritter J, Doxiadis I, Popp B, Münch J. Extended genomic HLA typing identifies previously unrecognized mismatches in living kidney transplantation. Front Immunol 2023; 14:1094862. [PMID: 36776892 PMCID: PMC9911689 DOI: 10.3389/fimmu.2023.1094862] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/12/2023] [Indexed: 01/28/2023] Open
Abstract
Introduction Antibody mediated rejection (ABMR) is the most common cause of long-term allograft loss in kidney transplantation (KT). Therefore, a low human leukocyte antigen (HLA) mismatch (MM) load is favorable for KT outcomes. Hitherto, serological or low-resolution molecular HLA typing have been adapted in parallel. Here, we aimed to identify previously missed HLA mismatches and corresponding antibodies by high resolution HLA genotyping in a living-donor KT cohort. Methods 103 donor/recipient pairs transplanted at the University of Leipzig Medical Center between 1998 and 2018 were re-typed using next generation sequencing (NGS) of the HLA loci -A, -B, -C, -DRB1, -DRB345, -DQA1, -DQB1, -DPA1, and -DPB1. Based on these data, we compiled HLA MM counts for each pair and comparatively evaluated genomic HLA-typing with pre-transplant obtained serological/low-resolution HLA (=one-field) typing results. NGS HLA typing (=two-field) data was further used for reclassification of de novo HLA antibodies as "donor-specific". Results By two-field HLA re-typing, we were able to identify additional MM in 64.1% (n=66) of cases for HLA loci -A, -B, -C, -DRB1 and -DQB1 that were not observed by one-field HLA typing. In patients with biopsy proven ABMR, two-field calculated MM count was significantly higher than by one-field HLA typing. For additional typed HLA loci -DRB345, -DQA1, -DPA1, and -DPB1 we observed 2, 26, 3, and 23 MM, respectively. In total, 37.3% (69/185) of de novo donor specific antibodies (DSA) formation was directed against these loci (DRB345 ➔ n=33, DQA1 ➔ n=33, DPA1 ➔ n=1, DPB1 ➔ n=10). Conclusion Our results indicate that two-field HLA typing is feasible and provides significantly more sensitive HLA MM recognition in living-donor KT. Furthermore, accurate HLA typing plays an important role in graft management as it can improve discrimination between donor and non-donor HLA directed cellular and humoral alloreactivity in the long range. The inclusion of additional HLA loci against which antibodies can be readily detected, HLA-DRB345, -DQA1, -DQB1, -DPA1, and -DPB1, will allow a more precise virtual crossmatch and better prediction of potential DSA. Furthermore, in living KT, two-field HLA typing could contribute to the selection of the immunologically most suitable donors.
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Affiliation(s)
- Claudia Lehmann
- Institute for Transfusion Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Sarah Pehnke
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Antje Weimann
- Division of Visceral Surgery and Transplantation Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Anette Bachmann
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Katalin Dittrich
- Department of Pediatric Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Friederike Petzold
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Daniel Fürst
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany
| | - Jonathan de Fallois
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Ramona Landgraf
- Institute for Transfusion Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Reinhard Henschler
- Institute for Transfusion Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Tom H Lindner
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Jan Halbritter
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany.,Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ilias Doxiadis
- Institute for Transfusion Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Bernt Popp
- Institute of Human Genetics, University of Leipzig, Leipzig, Germany
| | - Johannes Münch
- Division of Nephrology, Department of Internal Medicine, University of Leipzig Medical Center, Leipzig, Germany.,Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
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27
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Tambur AR, Audry B, Glotz D, Jacquelinet C. Improving equity in kidney transplant allocation policies through a novel genetic metric: The Matched Donor Potential. Am J Transplant 2023; 23:45-54. [PMID: 36695620 DOI: 10.1016/j.ajt.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/12/2022] [Accepted: 08/21/2022] [Indexed: 01/13/2023]
Abstract
The demand for donors' kidneys continues to increase amid a shortage of available donors. Managing policies to thoughtfully allocate this scarce resource is a complex process. Although human leukocyte antigen (HLA) matching has been shown to prolong graft survival, its relative contribution to allocation schemes is empirically compromised owing to competing priorities. We explored using a new metric, Matched Donor Potential (MDP), to facilitate improved HLA matching while promoting equity. We interrogated all active kidney waitlist patients (N = 164 427), their corresponding unacceptable antigen files, and all effective donors in the Scientific Registry of Transplant Recipients (January 1, 2016-December 31, 2017). Cause-specific hazard functions were evaluated to assess the potential impact of the MDP metric on deceased donor transplant access rates for all candidates. Access was affected by ethnicity, blood group type, and calculated Panel Reactive Antibody (cPRA). Importantly, we show that access to transplantation is influenced by the patient's own HLA makeup regardless of their ethnicity and by the HLA makeup of effective donors. The MDP metric demonstrates a high association with access to transplantation. Adjusting Cox models to include this new metric resulted in improved access to kidney transplantation for waitlist candidates of minority heritage while significantly promoting HLA matching. Thus, the MDP metric accounts for balanced, equitable organ allocation algorithms.
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Affiliation(s)
- Anat R Tambur
- Comprehensive Transplant Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | | | - Denis Glotz
- Department of Nephrology and Transplantation, Hopital Saint-Louis, Paris, France
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28
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Muacevic A, Adler JR. Greater Impact of Living Donation Than HLA Mismatching in Short-Term Renal Allograft Survival. Cureus 2023; 15:e34427. [PMID: 36733571 PMCID: PMC9887496 DOI: 10.7759/cureus.34427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Living donor kidney transplantation (LDKT) is accepted as first-line treatment for patients with end-stage kidney disease with advantages over deceased donor kidney transplantation (DDKT). Still, how the known detrimental effect of HLA mismatch (MM) may hamper these advantages remains unsettled. We sought to determine the effect of the degree of HLA MM, separately in deceased and living donor renal allograft outcomes. METHODS We evaluated all adults submitted to LDKT and DDKT at our center between 2006 and 2018. Their HLA MM was classified according to the British Society of Transplantation system in low mismatch (LM) (level 1-2) and high mismatch (HM) (level 3-4). Acute rejection (AR) and global or censored graft survival were the outcomes of interest. Recipients were followed up from transplant until death, graft failure or the end of 2020. Results: One thousand sixty-eight kidney transplant recipients were analyzed, 815 (76%) received a DDKT whereas 253 (24%) received an LDKT. From those submitted to DDKT, 95 (12%) had an LM and 720 (88%) had an HM, whereas in LDKT 32 (13%) had an LM and 221 (87%) had an HM. The AR at one year was 9% in the full cohort. Significant risk factors for AR were HM DDKT (OR:2.3, P=0.047) or HM LDKT (OR:5.6, P=0.003) (LM DDKT as reference), calculated panel-reactive antibody (cPRA) ≥5% (OR:1.9, P=0.040) and delayed graft function (DGF), (OR:3.2, P<0.001). Censored graft survival (CGS) at five years was 96% in the full cohort. Independent predictors for censored graft failure (CGF) were HM LDKT (HR:0.2, P=0.046) (LM DDKT as reference), AR (HR:2.7, P=0.008) and DGF (HR:2.2, P=0.017). Global graft survival (GGS) at five years was 91% in the full cohort. Independent predictors for global graft failure (GGF) were HM LDKT (HR:0.2, P=0.042) (LM DDKT as reference), recipient age (HR:1.8, P<0.001) and DGF (HR:1.8, P=0.006). No AR, CGF or GGF episodes were observed in the LM LDKT group. CONCLUSIONS In our cohort, the level of HLA MM increased the risk of AR independently of donor type. Considering short graft survival, our results support the advantage of living donor vs deceased donor even with an increased HLA MM. However, its effect on long-term graft survival remains to be settled, emphasizing the need for further studies on this matter.
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29
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Tekguc M, Gaal RCVAN, Uzel SGM, Gupta N, Riella LV, Lewis JA, Morizane R. Kidney organoids: a pioneering model for kidney diseases. Transl Res 2022; 250:1-17. [PMID: 35750295 PMCID: PMC9691572 DOI: 10.1016/j.trsl.2022.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022]
Abstract
The kidney is a vital organ that regulates the bodily fluid and electrolyte homeostasis via tailored urinary excretion. Kidney injuries that cause severe or progressive chronic kidney disease have driven the growing population of patients with end-stage kidney disease, leading to substantial patient morbidity and mortality. This irreversible kidney damage has also created a huge socioeconomical burden on the healthcare system, highlighting the need for novel translational research models for progressive kidney diseases. Conventional research methods such as in vitro 2D cell culture or animal models do not fully recapitulate complex human kidney diseases. By contrast, directed differentiation of human induced pluripotent stem cells enables in vitro generation of patient-specific 3D kidney organoids, which can be used to model acute or chronic forms of hereditary, developmental, and metabolic kidney diseases. Furthermore, when combined with biofabrication techniques, organoids can be used as building blocks to construct vascularized kidney tissues mimicking their in vivo counterpart. By applying gene editing technology, organoid building blocks may be modified to minimize the process of immune rejection in kidney transplant recipients. In the foreseeable future, the universal kidney organoids derived from HLA-edited/deleted induced pluripotent stem cell (iPSC) lines may enable the supply of bioengineered organotypic kidney structures that are immune-compatible for the majority of the world population. Here, we summarize recent advances in kidney organoid research coupled with novel technologies such as organoids-on-chip and biofabrication of 3D kidney tissues providing convenient platforms for high-throughput drug screening, disease modelling, and therapeutic applications.
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Affiliation(s)
- Murat Tekguc
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard Stem Cell Institute (HSCI), Cambridge, Massachusetts
| | - Ronald C VAN Gaal
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts; School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Sebastien G M Uzel
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts; School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Navin Gupta
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard Stem Cell Institute (HSCI), Cambridge, Massachusetts
| | - Leonardo V Riella
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer A Lewis
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts; School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Ryuji Morizane
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard Stem Cell Institute (HSCI), Cambridge, Massachusetts; Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts.
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Reis Pereira P, Almeida M, Ribeiro B, Oliveira J, Costa L, Pedroso S, Martins LS, Dias L, Malheiro J. Biologically Unrelated Living Donor for Kidney Transplantation Associated With Higher Acute Rejection Rate but With Similar Graft Survival of a Related Living Donor. Cureus 2022; 14:e30189. [DOI: 10.7759/cureus.30189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
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Wood EL, Kogut N, Kwan L, Burrows J, Veale J, Lum EL. Clinical outcomes and complications of recipients of HLA matched living donor kidney transplants at UCLA: A retrospective chart review. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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32
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Spitznagel T, Matter LS, Kaufmann YL, Nilsson J, von Moos S, Schachtner T. PIRCHE-II scores prove useful as a predictive biomarker among kidney transplant recipients with rejection: An analysis of indication and follow-up biopsies. Front Immunol 2022; 13:949933. [PMID: 36059499 PMCID: PMC9428698 DOI: 10.3389/fimmu.2022.949933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Indication biopsies for deterioration of kidney allograft function often require follow-up biopsies to assess treatment response or lack of improvement. Immune-mediated injury, namely borderline rejection (BLR), T-cell mediated rejection (TCMR), or antibody-mediated rejection (ABMR), results from preformed or de novo alloreactivity due to donor and recipient HLA-mismatches. The impact of HLA-mismatches on alloreactivity is determined by highly immunogenic HLA-epitopes. Methods We analyzed 123 kidney transplant recipients (KTRs) from 2009 to 2019 who underwent a first indication and a follow-up biopsy. KTRs were divided into three groups according to the first biopsy: No rejection (NR)/BLR (n=68); TCMR (n=21); ABMR (n=34). The HLA-derived epitope-mismatches were calculated using the Predicted Indirectly Recognizable HLA-Epitopes (PIRCHE-II) algorithm. Results Group NR/BLR: KTRs with higher total PIRCHE-II scores were more likely to develop TCMR in the follow-up biopsy (p=0.031). Interestingly, these differences were significant for both HLA-class I- (p=0.017) and HLA-class II-derived (p=0.017) PIRCHE-II scores. Group TCMR: KTRs with ongoing TCMR in the follow-up biopsy were more likely to show higher total PIRCHE-II scores (median 101.50 vs. 74.00). Group ABMR: KTRs with higher total PIRCHE-II scores were more likely to show an increase in the microvascular inflammation score in the follow-up biopsy. This difference was more pronounced for the HLA-class II-derived PIRCHE-II scores (median 70.00 vs. 31.76; p=0.086). Conclusions PIRCHE-II scores may prove useful as a biomarker to predict the histopathological changes of immune-related injury from a first indication to a follow-up biopsy. This immunological risk stratification may contribute to individualized treatment strategies.
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Affiliation(s)
- Tahm Spitznagel
- Division of Nephrology, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Laurenz S. Matter
- Division of Nephrology, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Yves L. Kaufmann
- Division of Nephrology, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Jakob Nilsson
- Division of Immunology, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital of Zurich (USZ), Zurich, Switzerland
- *Correspondence: Thomas Schachtner,
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Bricogne C, Halliday N, Fernando R, Tsochatzis EA, Davidson BR, Harber M, Westbrook RH. Donor-recipient human leukocyte antigen A mismatching is associated with hepatic artery thrombosis, sepsis, graft loss, and reduced survival after liver transplant. Liver Transpl 2022; 28:1306-1320. [PMID: 35313059 PMCID: PMC9541857 DOI: 10.1002/lt.26458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 01/13/2023]
Abstract
Human leukocyte antigen (HLA) matching is not routinely performed for liver transplantation as there is no consistent evidence of benefit; however, the impact of HLA mismatching remains uncertain. We explored the effect of class I and II HLA mismatching on graft failure and mortality. A total of 1042 liver transplants performed at a single center between 1999 and 2016 with available HLA typing data were included. The median follow-up period was 9.38 years (interquartile range 4.9-14) and 350/1042 (33.6%) transplants resulted in graft loss and 280/1042 (26.9%) in death. Graft loss and mortality were not associated with the overall number of mismatches at HLA-A, HLA-B, HLA-C, HLA-DR, and HLA-DQ loci. However, graft failure and mortality were both increased in HLA mismatching on graft failure and mortality the presence of one (p = 0.004 and p = 0.01, respectively) and two (p = 0.01 and p = 0.04, respectively) HLA-A mismatches. Elevated hazard ratios for graft failure and death were observed with HLA-A mismatches in univariate and multivariate Cox proportional hazard models. Excess graft loss with HLA-A mismatch (138/940 [14.7%] mismatched compared with 6/102 [5.9%] matched transplants) occurred within the first year following transplantation (odds ratio 2.75; p = 0.02). Strikingly, transplants performed at a single all grafts lost due to hepatic artery thrombosis were in HLA-A-mismatched transplants (31/940 vs. 0/102), as were those lost due to sepsis (35/940 vs. 0/102). In conclusion, HLA-A mismatching was associated with increased graft loss and mortality. The poorer outcome for the HLA-mismatched group was due to hepatic artery thrombosis and sepsis, and these complications occurred exclusively with HLA-A-mismatched transplants. These data suggest that HLA-A mismatching is important for outcomes following liver transplant. Therefore, knowledge of HLA-A matching status may potentially allow for enhanced surveillance, clinical interventions in high-risk transplants or stratified HLA-A matching in high-risk recipients.
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Affiliation(s)
- Christopher Bricogne
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Neil Halliday
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Raymond Fernando
- The Anthony Nolan Research InstituteRoyal Free London NHS Foundation TrustLondonUK
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Brian R. Davidson
- UCL Division of Surgery and Interventional SciencesRoyal Free HospitalLondonUK
| | - Mark Harber
- Kidney UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Rachel H. Westbrook
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
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Tepel M, Nagarajah S, Saleh Q, Thaunat O, Bakker SJL, van den Born J, Karsdal MA, Genovese F, Rasmussen DGK. Pretransplant characteristics of kidney transplant recipients that predict posttransplant outcome. Front Immunol 2022; 13:945288. [PMID: 35958571 PMCID: PMC9357871 DOI: 10.3389/fimmu.2022.945288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Better characterization of the potential kidney transplant recipient using novel biomarkers, for example, pretransplant plasma endotrophin, will lead to improved outcome after transplantation. This mini-review will focus on current knowledge about pretransplant recipients’ characteristics, biomarkers, and immunology. Clinical characteristics of recipients including age, obesity, blood pressure, comorbidities, and estimated survival scores have been introduced for prediction of recipient and allograft survival. The pretransplant immunologic risk assessment include histocompatibility leukocyte antigens (HLAs), anti-HLA donor-specific antibodies, HLA-DQ mismatch, and non-HLA antibodies. Recently, there has been the hope that pretransplant determination of markers can further improve the prediction of posttransplant complications, both short-term and long-term outcomes including rejections, allograft loss, and mortality. Higher pretransplant plasma endotrophin levels were independently associated with posttransplant acute allograft injury in three prospective European cohorts. Elevated numbers of non-synonymous single-nucleotide polymorphism mismatch have been associated with increased allograft loss in a multivariable analysis. It is concluded that there is a need for integration of clinical characteristics and novel molecular and immunological markers to improve future transplant medicine to reach better diagnostic decisions tailored to the individual patient.
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Affiliation(s)
- Martin Tepel
- Department of Nephrology, Odense University Hospital, Odense, Denmark, and Cardiovascular and Renal Research, Institute of Molecular Medicine, Clinical Institute, University of Southern Denmark, Odense, Denmark
- *Correspondence: Martin Tepel,
| | - Subagini Nagarajah
- Department of Nephrology, Odense University Hospital, Odense, Denmark, and Cardiovascular and Renal Research, Institute of Molecular Medicine, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Qais Saleh
- Department of Nephrology, Odense University Hospital, Odense, Denmark, and Cardiovascular and Renal Research, Institute of Molecular Medicine, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Olivier Thaunat
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Transplantation, Néphrologie et Immunologie Clinique, Lyon, France
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jacob van den Born
- Division of Nephrology, Department of Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Bestard O, Thaunat O, Bellini MI, Böhmig GA, Budde K, Claas F, Couzi L, Furian L, Heemann U, Mamode N, Oberbauer R, Pengel L, Schneeberger S, Naesens M. Alloimmune Risk Stratification for Kidney Transplant Rejection. Transpl Int 2022; 35:10138. [PMID: 35669972 PMCID: PMC9163827 DOI: 10.3389/ti.2022.10138] [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: 10/21/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022]
Abstract
Different types of kidney transplantations are performed worldwide, including biologically diverse donor/recipient combinations, which entail distinct patient/graft outcomes. Thus, proper immunological and non-immunological risk stratification should be considered, especially for patients included in interventional randomized clinical trials. This paper was prepared by a working group within the European Society for Organ Transplantation, which submitted a Broad Scientific Advice request to the European Medicines Agency (EMA) relating to clinical trial endpoints in kidney transplantation. After collaborative interactions, the EMA sent its final response in December 2020, highlighting the following: 1) transplantations performed between human leukocyte antigen (HLA)-identical donors and recipients carry significantly lower immunological risk than those from HLA-mismatched donors; 2) for the same allogeneic molecular HLA mismatch load, kidney grafts from living donors carry significantly lower immunological risk because they are better preserved and therefore less immunogenic than grafts from deceased donors; 3) single-antigen bead testing is the gold standard to establish the repertoire of serological sensitization and is used to define the presence of a recipient's circulating donor-specific antibodies (HLA-DSA); 4) molecular HLA mismatch analysis should help to further improve organ allocation compatibility and stratify immunological risk for primary alloimmune activation, but without consensus regarding which algorithm and cut-off to use it is difficult to integrate information into clinical practice/study design; 5) further clinical validation of other immune assays, such as those measuring anti-donor cellular memory (T/B cell ELISpot assays) and non-HLA-DSA, is needed; 6) routine clinical tests that reliably measure innate immune alloreactivity are lacking.
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Affiliation(s)
- Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - Olivier Thaunat
- Department of Transplantation, Nephrology, and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Georg A Böhmig
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frans Claas
- Eurotransplant Reference Laboratory, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Lionel Couzi
- Department of Nephrology, Transplantation and Dialysis, Bordeaux University Hospital, Bordeaux, France
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, University of Padua, Padua, Italy
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Nizam Mamode
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, 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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Hullegie-Peelen DM, van der Zwan M, Clahsen-van Groningen MC, Mustafa DAM, Baart SJ, Reinders MEJ, Baan CC, Hesselink DA. Clinical and Molecular Profiling to Develop a Potential Prediction Model for the Response to Alemtuzumab Therapy for Acute Kidney Transplant Rejection. Clin Pharmacol Ther 2022; 111:1155-1164. [PMID: 35202481 PMCID: PMC9314084 DOI: 10.1002/cpt.2566] [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: 01/10/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023]
Abstract
Alemtuzumab, a monoclonal antibody that depletes CD52‐bearing immune cells, is an effective drug for the treatment of severe or glucocorticoid‐resistant acute kidney transplant rejection (AR). Patient‐specific predictions on treatment response are, however, urgently needed, given the severe side effects of alemtuzumab. This study developed a multidimensional prediction model with the aim of generating clinically useful prognostic scores for the response to alemtuzumab. Clinical and histological characteristics were collected retrospectively from patients who were treated with alemtuzumab for AR. In addition, targeted gene expression profiling of AR biopsy tissues was performed. Least absolute shrinkage and selection operator (LASSO) logistic regression modeling was used to construct the ALEMtuzumab for Acute Rejection (ALEMAR) prognostic score. Response to alemtuzumab was defined as patient and allograft survival and at least once an estimated glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2 during the first 6 months after treatment. One hundred fifteen patients were included, of which 84 (73%) had a response to alemtuzumab. The ALEMAR‐score accurately predicted the chance of response. Gene expression analysis identified 13 differentially expressed genes between responders and nonresponders. The combination of the ALEMAR‐score and selected genes resulted in improved predictions of treatment response. The present preliminary prediction model is potentially helpful for the development of stratified alemtuzumab treatment for acute kidney transplant rejection but requires validation.
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Affiliation(s)
- Daphne M Hullegie-Peelen
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Marieke van der Zwan
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marian C Clahsen-van Groningen
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dana A M Mustafa
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,The Tumor Immuno-Pathology Laboratory, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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Karatas M, Okut G, Simsek C, Dogan SM, Tatar E, Uslu A. Outcomes of 6 Human Leukocyte Antigen-Mismatched Living Donor Kidney Transplant: A Study With Biopsy Amendment. EXP CLIN TRANSPLANT 2022; 20:149-152. [PMID: 35384827 DOI: 10.6002/ect.mesot2021.p73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In this study, we examined the graft and patient survival outcomes in patients with end-stage kidney disease who received 6 HLA-mismatched incompatible living donor kidney transplant. MATERIALS AND METHODS Patients who underwent living donor kidney transplant between January 2010 and March 2020 were evaluated retrospectively. Group A included kidney transplant recipients with 6 HLA mismatches, and group B included kidney transplant recipients with 0 to 5 HLA mismatches. Patients with <1 year of follow-up were excluded. All rejection episodes were diagnosed via Tru-Cut biopsy and histopathological evaluation. RESULTS There were 15 patients in group A and 176 patients in group B. The mean follow-up was 54.1 ± 30 months. The number of patients who underwent pretransplant immune desensitization and received tacrolimus-based triple maintenance immunosuppression therapy was significantly higher in group A. In group A, there were 13 acute rejections seen in 9 patients (81<); in group B, there were 67 acute rejections seen in 51 patients (28.9<; P = .019). No differences were observed between the groups in terms of baseline glomerular filtration rate (60 ± 16 vs 61.6 ± 20 mL/min/1.72 m2; P = .76), final control glomerular filtration rate (60.7 ± 15 vs 58 ± 19 mL/ min/1.72 m2; P = .59), graft loss (0< vs 4<; P = .94), and mortality (6.6< vs 3<; P = .39). CONCLUSIONS The presence of 6 HLA mismatches was associated with higher rates of biopsy-proven acute rejection. However, 6 HLA-mismatched incompatible living donor kidney transplant can be safely performed in centers where posttransplant followup is supported by indication and protocol biopsies and where there is a pathological infrastructure with extensive knowledge and experience.
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Affiliation(s)
- Murat Karatas
- From the Department of General Surgery and Transplantation, University of Health Sciences, Izmir Faculty of Medicine, Bozyaka Education and Research Hospital, Izmir, Turkey
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Bekbolsynov D, Mierzejewska B, Khuder S, Ekwenna O, Rees M, Green RC, Stepkowski SM. Improving Access to HLA-Matched Kidney Transplants for African American Patients. Front Immunol 2022; 13:832488. [PMID: 35401566 PMCID: PMC8989073 DOI: 10.3389/fimmu.2022.832488] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/02/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Kidney transplants fail more often in Black than in non-Black (White, non-Black Hispanic, and Asian) recipients. We used the estimated physicochemical immunogenicity for polymorphic amino acids of donor/recipient HLAs to select weakly immunogenic kidney transplants for Black vs. White or non-Black patients. Methods OPTN data for 65,040 donor/recipient pairs over a 20-year period were used to calculate the individual physicochemical immunogenicity by hydrophobic, electrostatic and amino acid mismatch scores (HMS, EMS, AMS) and graft-survival outcomes for Black vs. White or vs. non-Black recipients, using Kaplan-Meier survival and Cox regression analyses. Simulations for re-matching recipients with donors were based on race-adjusted HMS thresholds with clinically achievable allocations. Results The retrospective median kidney graft survival was 12.0 years in Black vs. 18.6 years in White (6.6-year difference; p>0.001) and 18.4 years in non-Black (6.4-year difference; p>0.01) recipients. Only 0.7% of Blacks received transplants matched at HLA-A/B/DR/DQ (HMS=0) vs. 8.1% in Whites (p<0.001). Among fully matched Blacks (HMS=0), graft survival was 16.1-years and in well-matched Blacks (HMS ≤ 3.0) it was 14.0-years. Whites had 21.6-years survival at HMS ≤ 3.0 and 18.7-years at HMS ≤ 7.0 whereas non-Blacks had 22.0-year at HMS ≤ 3.0 and 18.7-year at HMS ≤ 7.0, confirming that higher HMS thresholds produced excellent survival. Simulation of ABO-compatible donor-recipient pairs using race-adjusted HMS thresholds identified weakly immunogenic matches at HMS=0 for 6.1% Blacks and 18.0% at HMS ≤ 3.0. Despite prioritizing Black patients, non-Black patients could be matched at the same level as in current allocation (47.0% vs 56.5%, at HMS ≤ 7.0). Conclusions Race-adjusted HMS (EMS, AMS)-based allocation increased the number of weakly immunogenic donors for Black patients, while still providing excellent options for non-Black recipients.
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Affiliation(s)
- Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Beata Mierzejewska
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
| | - Sadik Khuder
- Department of Medicine and Public Health, University of Toledo, Toledo, OH, United States
| | - Obinna Ekwenna
- Department of Urology, College of Medicine, University of Toledo, Toledo, OH, United States
| | - Michael Rees
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
- Department of Urology, College of Medicine, University of Toledo, Toledo, OH, United States
- The of Alliance for Paired Donation, Maumee, OH, United States
| | - Robert C. Green
- Department of Computer Science, Bowling Green State University, Bowling Green, OH, United States
- *Correspondence: Stanislaw M. Stepkowski, ; Robert C. Green II,
| | - Stanislaw M. Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH, United States
- *Correspondence: Stanislaw M. Stepkowski, ; Robert C. Green II,
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Time to Move on: HLA Matching Should Be Reconsidered in Modern Deceased Donor Kidney Allocation. Transplant Direct 2022; 8:e1295. [PMID: 35368986 PMCID: PMC8966965 DOI: 10.1097/txd.0000000000001295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 01/12/2023] Open
Abstract
HLA matching has been the cornerstone of deceased donor kidney allocation policies worldwide but can lead to racial inequity. Although HLA matching has been shown to improve clinical outcomes, the long-term impacts of nonallogenic factors are being increasingly recognized. This has led some transplant programs to include points for nonallogenic factors, for example, age. Our study looks at long-term graft and patient outcomes based on allocation cohorts rather than individual number of HLA mismatches.
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Saleem N, Das R, Tambur AR. Molecular histocompatibility beyond Tears: The next generation version. Hum Immunol 2022; 83:233-240. [DOI: 10.1016/j.humimm.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/30/2021] [Accepted: 12/22/2021] [Indexed: 01/09/2023]
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Yeung MY. Histocompatibility Assessment in Precision Medicine for Transplantation: Towards a Better Match. Semin Nephrol 2022; 42:44-62. [DOI: 10.1016/j.semnephrol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Equity or Equality? Which Approach Brings More Satisfaction in a Kidney-Exchange Chain? J Pers Med 2021; 11:jpm11121383. [PMID: 34945855 PMCID: PMC8709455 DOI: 10.3390/jpm11121383] [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: 11/13/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
In United States (U.S.), government-funded organizations, such as NLDAC, reimburse travel and subsistence expenses incurred during living-organ donation process. However, in Iran, there is a non-governmental organization called Iranian Kidney Foundation (IKF) that funds the direct and indirect costs of donors through charitable donations and contributions from participants in the exchange program. In this article, for countries outside the U.S. that currently use an equality approach, we propose a potential new compensation-apportionment approach (equitable approach) for kidney-exchange chains and compare it with the currently available system (equality approach) in terms of the apportionment of compensation in a kidney-exchange chain to cover the expenses incurred by the initiating living donor of the chain in the act of donation. To this end, we propose a mechanism to apportion compensation among all participating pairs based on the equity approach by utilizing a prediction model to calculate the probability of graft survival in each transplant operation. These probabilities are then used to define the utility of any transplantation, considering the quality of each pair’s donated and received kidney in the chain. Afterward, the corresponding cost is apportioned by a mechanism based on the normalized differences between the utility of donated and received kidneys for each incompatible pair of the chain. In summary, we demonstrate that by utilizing the equitable approach, there is more fairness and equity in the allocation of resources in organ-procurement systems, which results in more satisfaction among incompatible pairs. Additional future prospective studies are needed to assess this proposed equitable approach for kidney-exchange chains in countries outside the U.S., such as Iran, that currently use an equality approach.
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Kernig K, Albrecht V, Dräger DL, Führer A, Mitzner S, Kundt G, Hakenberg OW. Predictors of Delayed Graft Function in Renal Transplantation. Urol Int 2021; 106:512-517. [PMID: 34915519 DOI: 10.1159/000520055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/27/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE This study aimed to analyze our data on delayed graft function (DGF) and to identify associated factors. METHODS This is a retrospective case-control study of all patients transplanted in our center over a period of 11 years (January 1, 2003, to December 31, 2014) comparing patients with immediate graft function (n = 332) to those with DGF (n = 165). DGF was defined as the need for hemodialysis within the first 7 days after transplantation. Donor and recipient characteristics as well as procedural factors were compared by univariate and multivariate logistic regression analyses. RESULTS Overall, 33% of patients had DGF. The rate of DGF declined from 2003 to 2011. In cases with DGF, donors and recipients were significantly older (p = 0.004 and p = 0.005, respectively), had longer cold ischemia times (p = 0.039), more revision surgeries (p < 0.001), and more HLA mismatches (p = 0.001), especially in the DR locus (p = 0.002). Neither donor nor recipient gender, waiting time, nor CMV status had any influence. In multivariable analysis, significant risk factors were ischemia time and mismatches at the HLA-DR loci. CONCLUSIONS DGF is a common complication in renal transplantation which occurred in 33% of our cases. Important factors identified were donor and recipient age, ischemia time, HLA mismatching, and revision surgery.
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Affiliation(s)
| | | | | | - Andreas Führer
- Section of Nephrology, Department of Internal Medicine, University Rostock, Rostock, Germany
| | - Steffen Mitzner
- Section of Nephrology, Department of Internal Medicine, University Rostock, Rostock, Germany
| | - Günther Kundt
- Institute of Biostatistics and Informatics in Medicine and Ageing Research, University Medicine, Rostock University, Rostock, Germany
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Peereboom ETM, Matern BM, Tomosugi T, Niemann M, Drylewicz J, Joosten I, Allebes WA, van der Meer A, Hilbrands LB, Baas MC, van Reekum FE, Verhaar MC, Kamburova EG, Seelen MAJ, Sanders JS, Hepkema BG, Lambeck AJ, Bungener LB, Roozendaal C, Tilanus MGJ, Voorter CE, Wieten L, van Duijnhoven EM, Gelens MACJ, Christiaans MHL, van Ittersum FJ, Nurmohamed A, Lardy NM, Swelsen W, van der Pant KA, van der Weerd NC, Ten Berge IJM, Bemelman FJ, de Vries APJ, de Fijter JW, Betjes MGH, Roelen DL, Claas FH, Otten HG, Heidt S, van Zuilen AD, Kobayashi T, Geneugelijk K, Spierings E. T-Cell Epitopes Shared Between Immunizing HLA and Donor HLA Associate With Graft Failure After Kidney Transplantation. Front Immunol 2021; 12:784040. [PMID: 34868064 PMCID: PMC8637278 DOI: 10.3389/fimmu.2021.784040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/02/2021] [Indexed: 01/04/2023] Open
Abstract
CD4+ T-helper cells play an important role in alloimmune reactions following transplantation by stimulating humoral as well as cellular responses, which might lead to failure of the allograft. CD4+ memory T-helper cells from a previous immunizing event can potentially be reactivated by exposure to HLA mismatches that share T-cell epitopes with the initial immunizing HLA. Consequently, reactivity of CD4+ memory T-helper cells toward T-cell epitopes that are shared between immunizing HLA and donor HLA could increase the risk of alloimmunity following transplantation, thus affecting transplant outcome. In this study, the amount of T-cell epitopes shared between immunizing and donor HLA was used as a surrogate marker to evaluate the effect of donor-reactive CD4+ memory T-helper cells on the 10-year risk of death-censored kidney graft failure in 190 donor/recipient combinations using the PIRCHE-II algorithm. The T-cell epitopes of the initial theoretical immunizing HLA and the donor HLA were estimated and the number of shared PIRCHE-II epitopes was calculated. We show that the natural logarithm-transformed PIRCHE-II overlap score, or Shared T-cell EPitopes (STEP) score, significantly associates with the 10-year risk of death-censored kidney graft failure, suggesting that the presence of pre-transplant donor-reactive CD4+ memory T-helper cells might be a strong indicator for the risk of graft failure following kidney transplantation.
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Affiliation(s)
- Emma T M Peereboom
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Benedict M Matern
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihide Tomosugi
- Department of Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.,Department of Kidney Diseases and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | | | - Julia Drylewicz
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Irma Joosten
- Laboratory Medicine, Laboratory Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wil A Allebes
- Laboratory Medicine, Laboratory Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arnold van der Meer
- Laboratory Medicine, Laboratory Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Franka E van Reekum
- Department of Nephrology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Marianne C Verhaar
- Department of Nephrology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Elena G Kamburova
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Marc A J Seelen
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jan Stephan Sanders
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Bouke G Hepkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Annechien J Lambeck
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Laura B Bungener
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Caroline Roozendaal
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marcel G J Tilanus
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, Netherlands
| | - Christien E Voorter
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, Netherlands
| | - Lotte Wieten
- Department of Transplantation Immunology, Tissue Typing Laboratory, Maastricht University Medical Center, Maastricht, Netherlands
| | - Elly M van Duijnhoven
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Mariëlle A C J Gelens
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Frans J van Ittersum
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Azam Nurmohamed
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Neubury M Lardy
- Department of Immunogenetics/HLA Diagnostic, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Wendy Swelsen
- Department of Immunogenetics/HLA Diagnostic, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Karlijn A van der Pant
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Neelke C van der Weerd
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Ineke J M Ten Berge
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Fréderike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Aiko P J de Vries
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands.,Department of Nephrology, Erasmus MC, Rotterdam, Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Frans H Claas
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Henny G Otten
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kirsten Geneugelijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Eric Spierings
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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A Historical Cohort in Kidney Transplantation: 55-Year Follow-Up of 72 HLA-Identical, Donor-Recipient Pairs. J Clin Med 2021; 10:jcm10235505. [PMID: 34884207 PMCID: PMC8658388 DOI: 10.3390/jcm10235505] [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: 10/19/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/17/2022] Open
Abstract
The impact of HLA matching on graft survival has been well characterized in renal transplantation, with a higher degree of matching associated with superior graft survival. Additionally, living donor grafts are known to confer superior survival compared to those from deceased donors. The purpose of this study is to report our multi-decade institutional experience and outcomes for patients who received HLA-identical living donor grafts, which represent the most favorable scenario in kidney transplantation. We conducted a retrospective analysis of these graft recipients performed at a Duke University Medical Center between the years of 1965 and 2002. The recipients demonstrated excellent graft and patient survival outcomes, superior to a contemporary cohort, with median patient and graft survival of 24.2 and 30.9 years, respectively, among Duke recipients vs. 16.1 and 16.0 years in a cohort derived from national data. This study offers a broad perspective on the importance of HLA matching and graft type, and demonstrates a historical best-case-scenario in renal transplantation.
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Epitope-Level Matching—A Review of the Novel Concept of Eplets in Transplant Histocompatibility. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The development of de novo donor-specific antibodies is related to the poor matching of the human leukocyte antigen (HLA) between donor and recipient, which leads to dismal clinical outcomes and graft loss. However, new approaches that stratify the risks of long-term graft failure in solid organ transplantation have emerged, changing the paradigm of HLA compatibility. In addition, advances in software development have given rise to a new structurally based algorithm known as HLA Matchmaker, which determines compatibility at the epitope rather than the antigen level. Although this technique still has limitations, plenty of research maintains that this assessment represents a more complete and detailed definition of HLA compatibility. This review summarizes recent aspects of eplet mismatches, highlighting the most recent advances and future research directions.
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Sypek MP, Davies CE, Le Page AK, Clayton P, Hughes PD, Larkins N, Wong G, Kausman JY, Mackie F. Paediatric deceased donor kidney transplant in Australia: A 30-year review-What have paediatric bonuses achieved and where to from here? Pediatr Transplant 2021; 25:e14019. [PMID: 33942949 DOI: 10.1111/petr.14019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/21/2020] [Accepted: 12/14/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND In this 30-year national review, we describe trends in DD transplantation for paediatric recipients, assess the impact of paediatric allocation bonuses and identify outstanding areas of need for this population. METHODS A retrospective review of all DD kidney only transplants to paediatric recipients (<18 years old) in Australia between 1989 and 2018 was conducted using deidentified extracts from the ANZDATA. RESULTS Of the 1011 kidney only transplants performed in paediatric recipients during the study period, 426 (42%) were from deceased donors. Paediatric candidates on the DD waiting list had consistently higher rates of transplantation and shorter time from dialysis initiation to transplantation compared with adult candidates (median 372 vs 832 days in 2018, for example). Donor characteristics remained more favourable for paediatric recipients, despite a decline in the overall quality of the donor pool. The mean number of HLA antigen mismatches for paediatric recipients of DD transplants increased each decade (2.86 [1989-1998], 3.85 [1999-2008], 4.01 [2009-2018]). Both patient and graft survival have improved for paediatric DD transplant recipients in the most recent era (5-year graft and patient survival 85% vs 65% and 99% vs 94%, respectively, for 2009-2018 vs 1999-2008). CONCLUSIONS The current DD kidney allocation system in Australia provides rapid access to high-quality organs for paediatric recipients, and early graft loss has decreased significantly in recent years; however, additional targeted interventions to address HLA matching may improve long-term outcomes in this population.
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Affiliation(s)
- Matthew P Sypek
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Vic, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia.,Department of Nephrology, Royal Children's Hospital, Melbourne, Vic, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Amelia K Le Page
- Department of Nephrology, Monash Children's Hospital, Clayton, Vic, Australia
| | - Philip Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.,Central and Northern Adelaide Transplant Service, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter D Hughes
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Vic, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Nicholas Larkins
- Faculty of Health and Medical Sciences, Paediatrics, The University of Western Australia, Perth, WA, Australia
| | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Joshua Y Kausman
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Vic, Australia.,Department of Nephrology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Fiona Mackie
- Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Child Health, U.N.S.W., Sydney, NSW, Australia
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48
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Vinson AJ, Tennankore KK, Kiberd BA. Donor-Recipient Matching in Kidney Transplant: We're Not There Yet. Transplant Proc 2021; 53:1909-1914. [PMID: 34272053 DOI: 10.1016/j.transproceed.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Strategic organ allocation is expected to prolong patient and graft survival after transplant. This study explored differences in graft survival when kidneys are allocated based on strategic donor-recipient (D-R) pairing vs with the existing Kidney Allocation System (KAS). METHODS Using the Scientific Registry of Transplant Recipients from 2000 to 2014, we used a multivariable Cox model to assess the hazard ratios (HRs) for death or graft failure among 3 hypothetical donor kidneys transplanted into 3 hypothetical recipients, relative to an ideally matched D-R pair. Median predicted survival for each of the 9 possible D-R pairing combinations was determined, and outcomes for strategic D-R pairing were compared with those obtained using the KAS for allocation. RESULTS A total of 31,607 patients (29.7%) died or developed graft loss over the study period. Strategic allocation of kidneys resulted in HRs for graft loss of 1.74 (95% confidence interval [CI], 1.41-2.14), 1.82 (95% CI, 1.46-2.26), and 1.74 (95% CI 1.38-2.19) for recipients 1, 2 and 3 respectively, whereas by following the KAS, HRs were 1.93 (95%, CI 1.63-2.28), 2.06 (95% CI, 1.74-2.44), and 1.93 (95% CI, 1.58-2.37); corresponding to 3.84, 11.39, and 7.40 months longer predicted patient or graft survival for recipients 1, 2 and 3 with strategic D-R pairing compared with the KAS. CONCLUSIONS Allocation of kidneys by strategic D-R pairing may improve graft survival relative to allocation using the KAS.
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Affiliation(s)
- A J Vinson
- (a)Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - K K Tennankore
- (a)Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - B A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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49
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Tambur AR, Kosmoliaptsis V, Claas FHJ, Mannon RB, Nickerson P, Naesens M. Significance of HLA-DQ in kidney transplantation: time to reevaluate human leukocyte antigen matching priorities to improve transplant outcomes? An expert review and recommendations. Kidney Int 2021; 100:1012-1022. [PMID: 34246656 DOI: 10.1016/j.kint.2021.06.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
The weight of human leukocyte antigen (HLA) matching in kidney allocation algorithms, especially in the United States, has been devalued in a stepwise manner, supported by the introduction of modern immunosuppression. The intent was further to reduce the observed ethnic/racial disparity, as data emerged associating HLA matching with decreased access to transplantation for African American patients. In recent years, it has been increasingly recognized that a leading cause of graft loss is chronic antibody-mediated rejection, attributed to the development of de novo antibodies against mismatched donor HLA expressed on the graft. These antibodies are most frequently against donor HLA-DQ molecules. Beyond their impact on graft survival, generation of de novo donor-specific HLA antibodies also leads to increased sensitization, as measured by panel-reactive antibody metrics. Consequently, access to transplantation for patients returning to the waitlist in need of a second transplant is compromised. Herein, we address the implications of reduced HLA matching policies in kidney allocation. We highlight the observed diminished outcome data, the significant financial burden, the long-term health consequences, and, more important, the unintended consequences. We further provide recommendations to examine the impact of donor-recipient HLA class II and specifically HLA-DQα1β1 mismatching, focusing on collection of appropriate data, application of creative simulation approaches, and reconsideration of best practices to reduce inequalities while optimizing patient outcomes.
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Affiliation(s)
- Anat R Tambur
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA.
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge, Cambridge, UK; NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Frans H J Claas
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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50
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Impact of HLA Mismatching on Early Subclinical Inflammation in Low-Immunological-Risk Kidney Transplant Recipients. J Clin Med 2021; 10:jcm10091934. [PMID: 33947168 PMCID: PMC8125522 DOI: 10.3390/jcm10091934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 01/17/2023] Open
Abstract
The impact of human leukocyte antigen (HLA)-mismatching on the early appearance of subclinical inflammation (SCI) in low-immunological-risk kidney transplant (KT) recipients is undetermined. We aimed to assess whether HLA-mismatching (A-B-C-DR-DQ) is a risk factor for early SCI. As part of a clinical trial (Clinicaltrials.gov, number NCT02284464), a total of 105 low-immunological-risk KT patients underwent a protocol biopsy on the third month post-KT. As a result, 54 presented SCI, showing a greater number of total HLA-mismatches (p = 0.008) and worse allograft function compared with the no inflammation group (48.5 ± 13.6 vs. 60 ± 23.4 mL/min; p = 0.003). Multiple logistic regression showed that the only risk factor associated with SCI was the total HLA-mismatch score (OR 1.32, 95%CI 1.06-1.64, p = 0.013) or class II HLA mismatching (OR 1.51; 95%CI 1.04-2.19, p = 0.032) after adjusting for confounder variables (recipient age, delayed graft function, transfusion prior KT, and tacrolimus levels). The ROC curve illustrated that the HLA mismatching of six antigens was the optimal value in terms of sensitivity and specificity for predicting the SCI. Finally, a significantly higher proportion of SCI was seen in patients with >6 vs. ≤6 HLA-mismatches (62.3 vs. 37.7%; p = 0.008). HLA compatibility is an independent risk factor associated with early SCI. Thus, transplant physicians should perhaps be more aware of HLA mismatching to reduce these early harmful lesions.
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