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Diebold M, Mayer KA, Hidalgo L, Kozakowski N, Budde K, Böhmig GA. Chronic Rejection After Kidney Transplantation. Transplantation 2024:00007890-990000000-00858. [PMID: 39192468 DOI: 10.1097/tp.0000000000005187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
In kidney transplantation, ongoing alloimmune processes-commonly triggered by HLA incompatibilities-can trigger chronic transplant rejection, affecting the microcirculation and the tubulointerstitium. Continuous inflammation may lead to progressive, irreversible graft injury, culminating in graft dysfunction and accelerated transplant failure. Numerous experimental and translational studies have delineated a complex interplay of different immune mechanisms driving rejection, with antibody-mediated rejection (AMR) being an extensively studied rejection variant. In microvascular inflammation, a hallmark lesion of AMR, natural killer (NK) cells have emerged as pivotal effector cells. Their essential role is supported by immunohistologic evidence, bulk and spatial transcriptomics, and functional genetics. Despite significant research efforts, a substantial unmet need for approved rejection therapies persists, with many trials yielding negative outcomes. However, several promising therapies are currently under investigation, including felzartamab, a monoclonal antibody targeting the surface molecule CD38, which is highly expressed in NK cells and antibody-producing plasma cells. In an exploratory phase 2 trial in late AMR, this compound has demonstrated potential in resolving molecular and morphologic rejection activity and injury, predominantly by targeting NK cell effector function. These findings inspire hope for effective treatments and emphasize the necessity of further pivotal trials focusing on chronic transplant rejection.
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Affiliation(s)
- Matthias Diebold
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Luis Hidalgo
- HLA Laboratory, Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Halloran PF, Madill-Thomsen KS, Böhmig G, Bromberg J, Budde K, Barner M, Mackova M, Chang J, Einecke G, Eskandary F, Gupta G, Myślak M, Viklicky O, Akalin E, Alhamad T, Anand S, Arnol M, Baliga R, Banasik M, Bingaman A, Blosser CD, Brennan D, Chamienia A, Chow K, Ciszek M, de Freitas D, Dęborska-Materkowska D, Debska-Ślizień A, Djamali A, Domański L, Durlik M, Fatica R, Francis I, Fryc J, Gill J, Gill J, Glyda M, Gourishankar S, Grenda R, Gryczman M, Hruba P, Hughes P, Jittirat A, Jurekovic Z, Kamal L, Kamel M, Kant S, Kasiske B, Kojc N, Konopa J, Lan J, Mannon R, Matas A, Mazurkiewicz J, Miglinas M, Müller T, Narins S, Naumnik B, Patel A, Perkowska-Ptasińska A, Picton M, Piecha G, Poggio E, Bloudíčkova SR, Samaniego-Picota M, Schachtner T, Shin S, Shojai S, Sikosana MLN, Slatinská J, Smykal-Jankowiak K, Solanki A, Veceric Haler Ž, Vucur K, Weir MR, Wiecek A, Włodarczyk Z, Yang H, Zaky Z. Subthreshold rejection activity in many kidney transplants currently classified as having no rejection. Am J Transplant 2024:S1600-6135(24)00461-1. [PMID: 39117038 DOI: 10.1016/j.ajt.2024.07.034] [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: 05/08/2024] [Revised: 06/19/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024]
Abstract
Most kidney transplant patients who undergo biopsies are classified as having no rejection based on consensus thresholds. However, we hypothesized that because these patients have normal adaptive immune systems, T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR) may exist as subthreshold activity in some transplants currently classified as no rejection. To examine this question, we studied genome-wide microarray results from 5086 kidney transplant biopsies (from 4170 patients). An updated molecular archetypal analysis designated 56% of biopsies as no rejection. Subthreshold molecular TCMR and/or ABMR activity molecular activity was detectable as elevated classifier scores in many biopsies classified as no rejection, with ABMR activity in many TCMR biopsies and TCMR activity in many ABMR biopsies. In biopsies classified as no rejection histologically and molecularly, molecular TCMR classifier scores correlated with increases in histologic TCMR features and molecular injury, lower estimated glomerular filtration rate, and higher risk of graft loss, and molecular ABMR activity correlated with increased glomerulitis and donor-specific antibody. No rejection biopsies with high subthreshold TCMR or ABMR activity had a higher probability of having TCMR or ABMR, respectively, diagnosed in a future biopsy. We conclude that many kidney transplant recipients have unrecognized subthreshold TCMR or ABMR activity, with significant implications for future problems.
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Affiliation(s)
- Philip F Halloran
- Department of Medicine, Division of Nephrology & Transplantation Immunology, University of Alberta, Canada
| | | | - Georg Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | | | - Klemens Budde
- Department of Nephrology, Charite-Medical University of Berlin, Germany
| | | | | | | | - Gunilla Einecke
- Department of Nephrology, Medical University of Hannover, Germany
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Gaurav Gupta
- Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, USA
| | - Marek Myślak
- Department of Clinical Interventions, Department of Nephrology and Kidney Transplantation SPWSZ Hospital, Pomeranian Medical University, Poland
| | - Ondrej Viklicky
- Department of Nephrology and Transplant Center, Institute for Experimental and Clinical Medicine, Czech Republic
| | - Enver Akalin
- Albert Einstein College of Medicine, Montefiore Medical Center, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University at St. Louis, USA
| | | | - Miha Arnol
- Department of Nephrology, University of Ljubljana, Slovenia
| | | | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine, Medical University of Wrocław, Poland
| | - Adam Bingaman
- Department of Surgery, Methodist Transplant and Specialty Hospital, USA
| | | | - Daniel Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Andrzej Chamienia
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Poland
| | - Kevin Chow
- Department of Nephrology, The Royal Melbourne Hospital, Australia
| | - Michał Ciszek
- Department of Immunology, Transplantology and Internal Diseases, Warsaw Medical University, Poland
| | - Declan de Freitas
- Department of Renal Research, Manchester Royal Infirmary, United Kingdom
| | | | - Alicja Debska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
| | | | - Leszek Domański
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Poland
| | - Magdalena Durlik
- Department of Transplantology, Immunology, Nephrology and Internal Diseases, Warsaw Medical University, Poland
| | - Richard Fatica
- Department of Kidney Medicine, Cleveland Clinic Foundation, USA
| | | | - Justyna Fryc
- 1st Department of Nephrology and Transplantation With Dialysis Unit, Medical University in Bialystok, Poland
| | | | | | | | - Sita Gourishankar
- Department of Medicine, Division of Nephrology & Transplantation Immunology, University of Alberta, Canada
| | - Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Poland
| | - Marta Gryczman
- Department of Nephrology and Kidney Transplantation, Pomeranian Medical University, Poland
| | - Petra Hruba
- Department of Nephrology, Institute for Experimental and Clinical Medicine, Czech Republic
| | - Peter Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Australia
| | | | - Zeljka Jurekovic
- Renal Replacement Therapy, Department of Nephrology, University Hospital Merkur, Croatia
| | - Layla Kamal
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, USA
| | | | - Sam Kant
- Division of Nephrology & Comprehensive Transplant Center, Department of Medicine, Johns Hopkins University School of Medicine, USA
| | | | - Nika Kojc
- Department of Pathology, University of Ljubljana, Slovenia
| | - Joanna Konopa
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Poland
| | | | - Roslyn Mannon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, USA
| | - Arthur Matas
- Department of Surgery, Division of Transplantation, University on Minnesota, USA
| | | | - Marius Miglinas
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Lithuania
| | - Thomas Müller
- Nephrology Department, University Hospital Zurich, Switzerland
| | | | - Beata Naumnik
- 1st Department of Nephrology and Transplantation With Dialysis Unit, Medical University in Bialystok, Poland
| | | | | | - Michael Picton
- Department of Renal Medicine, Manchester Royal Infirmary, United Kingdom
| | - Grzegorz Piecha
- Department of Nephrology, Transplantation and Internal Medicine, Silesian Medical University, Poland
| | - Emilio Poggio
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, USA
| | | | | | - Thomas Schachtner
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Sung Shin
- Department of Laboratory Medicine, University of Ulsan College of Medicine/Assan Medical Center, South Korea
| | - Soroush Shojai
- Division of Nephrology, Department of Medicine, University of Alberta, USA
| | - Majid L N Sikosana
- Department of Medicine, Division of Nephrology & Transplantation Immunology, University of Alberta, Canada
| | - Janka Slatinská
- Department of Nephrology, Institute for Experimental and Clinical Medicine, Czech Republic
| | | | | | | | - Ksenija Vucur
- Department of Nephrology, University Hospital Merkur, Croatia
| | - Matthew R Weir
- Department of Medicine, Division of Nephrology, University of Maryland, USA
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Silesian Medical University, Poland
| | | | - Harold Yang
- Department of Surgery, PinnacleHealth Transplant Associates, USA
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4
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Heeger PS, Haro MC, Jordan S. Translating B cell immunology to the treatment of antibody-mediated allograft rejection. Nat Rev Nephrol 2024; 20:218-232. [PMID: 38168662 DOI: 10.1038/s41581-023-00791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 01/05/2024]
Abstract
Antibody-mediated rejection (AMR), including chronic AMR (cAMR), causes ~50% of kidney allograft losses each year. Despite attempts to develop well-tolerated and effective therapeutics for the management of AMR, to date, none has obtained FDA approval, thereby highlighting an urgent unmet medical need. Discoveries over the past decade from basic, translational and clinical studies of transplant recipients have provided a foundation for developing novel therapeutic approaches to preventing and treating AMR and cAMR. These interventions are aimed at reducing donor-specific antibody levels, decreasing graft injury and fibrosis, and preserving kidney function. Innovative approaches emerging from basic science findings include targeting interactions between alloreactive T cells and B cells, and depleting alloreactive memory B cells, as well as donor-specific antibody-producing plasmablasts and plasma cells. Therapies aimed at reducing the cytotoxic antibody effector functions mediated by natural killer cells and the complement system, and their associated pro-inflammatory cytokines, are also undergoing evaluation. The complexity of the pathogenesis of AMR and cAMR suggest that multiple approaches will probably be required to treat these disease processes effectively. Definitive answers await results from large, double-blind, multicentre, randomized controlled clinical trials.
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Affiliation(s)
- Peter S Heeger
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA
| | - Maria Carrera Haro
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA.
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