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Kim PJ, Cusi V, Cardenas A, Tada Y, Vaida F, Wettersten N, Chak J, Bijlani P, Pretorius V, Urey MA, Morris GP, Lin G. Antibody Mediated Rejection is not Associated with Worse Survival in Adherent Heart Transplant Patients in the Contemporary Era. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.01.23299311. [PMID: 38106112 PMCID: PMC10723500 DOI: 10.1101/2023.12.01.23299311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background C4d immunostaining of surveillance endomyocardial biopsies (EMB) and testing for donor specific antibodies (DSA) are routinely performed in the first year of heart transplantation (HTx) in adult patients. C4d and DSA positivity have not been evaluated together with respect to clinical outcomes in the contemporary era (2010-current). Methods This was a single center, retrospective study of consecutive EMBs performed between November 2010 and April 2023. The primary objective was to determine whether history of C4d and/or DSA positivity could predict death, cardiac death, or retransplant. Secondary analyses included cardiac allograft dysfunction and cardiac allograft vasculopathy. Cox proportional hazards models were used for single predictor and multipredictor analyses. Results A total of 6,033 EMBs from 519 HTx patients were reviewed for the study. There was no significant difference (p = 0.110) in all-cause mortality or cardiac retransplant between four groups: C4d+/DSA+, C4d+/DSA-, C4d-/DSA+, and C4d-/DSA-. The risk for cardiac mortality or retransplant was significantly higher in C4d+/DSA+ versus C4d-/DSA- patients (HR = 4.73; pc = 0.042) but not significantly different in C4d+/DSA- versus C4d-/DSA- patients (pc = 1.000). Similarly, the risk for cardiac allograft dysfunction was significantly higher in C4d+/DSA+ versus C4d-/DSA- patients (HR 3.26; pc = 0.001) but not significantly different in C4d+/DSA- versus C4d-/DSA- patients (pc = 1.000). Accounting for nonadherence, C4d/DSA status continued to predict cardiac allograft dysfunction but no longer predicted cardiac death or retransplant. Conclusions Medically adherent C4d+/DSA+ HTx patients show significantly greater risk for cardiac allograft dysfunction but not cardiac mortality or retransplant. In contrast, C4d+/DSA- patients represent a new immunopathologic group with a clinical course similar to that of HTx patients without antibody mediated rejection.
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Affiliation(s)
| | | | - Ashley Cardenas
- Department of Pathology, University of California, San Diego, California, USA
| | | | - Florin Vaida
- Department of Family Medicine and Public Health, UC San Diego, La Jolla, CA
| | - Nicholas Wettersten
- Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | | | | | - Victor Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California, USA
| | | | - Gerald P Morris
- Department of Pathology, University of California, San Diego, California, USA
| | - Grace Lin
- Department of Pathology, University of California, San Diego, California, USA
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2
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Saldan A, Mengoli C, Sgarabotto D, Fedrigo M, Angelini A, Feltrin G, Gambino A, Gerosa G, Barzon L, Abate D. Human cytomegalovirus and Epstein-Barr virus infections occurring early after transplantation are risk factors for antibody-mediated rejection in heart transplant recipients. Front Immunol 2023; 14:1171197. [PMID: 37256129 PMCID: PMC10225529 DOI: 10.3389/fimmu.2023.1171197] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/25/2023] [Indexed: 06/01/2023] Open
Abstract
Background Antibody-mediated rejection (AMR) is a serious complication affecting the survival of patients receiving transplantation. Human cytomegalovirus (CMV) and Epstein-Barr virus (EBV) are common viral infections that occur after transplantation, frequently emerging as viral reactivation in donor grafts or transplant recipients. The present study aimed to investigate the association between CMV and EBV infections and early-onset AMR. Materials and methods This study was conducted at the Heart Transplantation Center of Padova General Hospital and included a cohort of 47 heart transplant recipients (HTxs), including 24 HTxs diagnosed with AMR and 23 control HTxs with no episodes of AMR. Only early cases of CMV and/or EBV infections (1-90 days after transplantation) were considered. Fisher's exact test and logistic regression analysis were used to statistically analyze the correlation and association between AMR and CMV or EBV infection. Results We observed a positive statistical association between CMV and EBV infections (two-sided Fisher's exact test, p = 0.0136) and between EBV infection and AMR (two-sided Fisher's exact test, p = 0.0034). Logistic regression analysis revealed a direct statistical association between CMV and EBV infections and AMR risk (p = 0.037 and 0.006 and odds ratio = 1.72 and 2.19, respectively). AMR occurrence was associated with increased viral loads of both CMV and EBV early after transplantation. Discussion These findings suggest the role of CMV and EBV infections as relevant risk factors for AMR in HTxs for the first time.
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Affiliation(s)
- Alda Saldan
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Carlo Mengoli
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Dino Sgarabotto
- Transplant Infectious Disease Unit, Padova General Hospital, Padova, Italy
| | - Marny Fedrigo
- Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Annalisa Angelini
- Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Antonio Gambino
- Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Gino Gerosa
- Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Luisa Barzon
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Davide Abate
- Department of Molecular Medicine, University of Padova, Padova, Italy
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3
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Ghaleb S, Wittekind SG, Martinez H, Kasten J, Gao Z, Hengehold T, Chin C. Antithymocyte globulin induction therapy and myocardial complement deposition in pediatric heart transplantation. Pediatr Transplant 2021; 25:e13998. [PMID: 33704881 DOI: 10.1111/petr.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/11/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antithymocyte globulin (ATG) consists of polyclonal antibodies directed primarily against human T lymphocytes but may contain antibodies with affinity for other tissues in the transplanted organ, resulting in complement (C4d) deposition. This phenomenon has been demonstrated in endomyocardial biopsies (EMBs) of adult cardiac transplants. We examined the relationship of induction immunosuppression with ATG and C4d deposition in EMB of pediatric cardiac transplants. METHODS Results of C4d immunohistochemistry were available from all EMB of patients transplanted at our center between June 2012 and April 2018 (n = 48) who received induction immunosuppression with either ATG (n = 20) or basiliximab (n = 28) as the standard of care. RESULTS C4d deposition in the first year post-heart transplant was more commonly seen among patients who received ATG induction (20% of EMBs in ATG group vs 1% of EMBs in basiliximab group; p < .0001). C4d deposition related to ATG was observed early post-transplant (50% ATG vs 0% basiliximab on first EMB; p < .0001 and 35% ATG vs 0% basiliximab on the second EMB; p = .0012). While this difference waned by the third EMB (5% ATG vs 0% basiliximab; p = .41), positive C4d staining persisted to the sixth EMB in the ATG group only (6%). CONCLUSION C4d deposition is common on EMB up to 1 year post-pediatric cardiac transplant following ATG induction. This high rate of positive C4d staining in the absence of histologic AMR after ATG induction therapy must be accounted for in making clinical decisions regarding cardiac allograft rejection diagnosis and treatment.
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Affiliation(s)
- Stephanie Ghaleb
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Samuel G Wittekind
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Hugo Martinez
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Jennifer Kasten
- Department of Pathology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Tricia Hengehold
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
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4
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Fujino T, Kumai Y, Yang B, Kalantari S, Rodgers D, Henriksen K, Chang A, Husain A, Kim G, Sayer G, Uriel N. Discordance between immunofluorescence and immunohistochemistry C4d staining and outcomes following heart transplantation. Clin Transplant 2021; 35:e14242. [PMID: 33539043 DOI: 10.1111/ctr.14242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/17/2021] [Accepted: 01/25/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Capillary deposition of C4d is an important marker of antibody-mediated rejection (AMR) following heart transplantation (HT). There are two immunopathologic assay methods for detecting C4d: frozen-tissue immunofluorescence (IF) and paraffin immunohistochemistry (IHC). The clinical significance of discrepancy between the results of IF and IHC has not been understood. METHODS AND RESULTS We reviewed 2187 biopsies from 142 HT recipients who had biopsies with assessment of both IF and IHC staining. Among them, 103 (73%) patients had negative IF and IHC C4d staining (Negative Group) and 32 (23%) patients had positive IF but negative IHC staining (Discordant Group). At the time of positive biopsy, 6 (19%) Discordant patients had graft dysfunction, compared to 5 (5%) Negative patients (p = .022). Cumulative incidence of cellular rejection at 1 year was comparable (31% vs. 29%, p = .46); however, cumulative incidence of AMR was significantly higher in the Discordant group (21% vs. 4%, p = .004). Overall 1-year survival was comparable (90% vs. 96%, p = .24); however, freedom from heart failure (HF) was significantly lower in the Discordant group (70% vs. 96%, p < .001). CONCLUSION The Discordant group showed higher rates of graft dysfunction, AMR and HF admission than the Negative group.
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Affiliation(s)
- Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Yuto Kumai
- Cardiology Division, Columbia University, New York, NY, USA
| | - Benjamin Yang
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Anthony Chang
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Aliya Husain
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Gabriel Sayer
- Cardiology Division, Columbia University, New York, NY, USA
| | - Nir Uriel
- Cardiology Division, Columbia University, New York, NY, USA
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5
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[Pathology of heart transplantation: Where are we now?]. Ann Pathol 2021; 41:38-49. [PMID: 33413972 DOI: 10.1016/j.annpat.2020.12.001] [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: 11/07/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 11/23/2022]
Abstract
Pathology is still the gold standard for the diagnosis of rejection in heart transplantation. During the last decade, molecular pathology has emerged as a powerful tool for the understanding of the processes implicated in allograft rejection. Transcriptomic analysis of the allograft may also help the pathologist for diagnosis and accurate classification of rejection. This review will describe the recent advances and perspectives of molecular pathology in the field of heart transplantation.
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6
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Label-free Identification of Antibody-mediated Rejection in Cardiac Allograft Biopsies Using Infrared Spectroscopic Imaging. Transplantation 2018; 103:698-704. [PMID: 30278018 DOI: 10.1097/tp.0000000000002465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) in cardiac allograft recipients remains less well-understood than acute cellular rejection, is associated with worse outcomes, and portends a greater risk of developing chronic allograft vasculopathy. Diffuse immunohistochemical C4d staining of capillary endothelia in formalin-fixed, paraffin-embedded right ventricular endomyocardial biopsies is diagnostic of immunopathologic AMR but serves more as a late-stage marker. Infrared (IR) spectroscopy may be a useful tool in earlier detection of rejection. We performed mid-IR spectroscopy to identify a unique biochemical signature for AMR. METHODS A total of 30 posttransplant formalin-fixed paraffin-embedded right ventricular tissue biopsies (14 positive for C4d and 16 negative for C4d) and 14 native heart biopsies were sectioned for IR analysis. Infrared images of entire sections were acquired and regions of interest from cardiomyocytes were identified. Extracted spectra were averaged across many pixels within each region of interest. Principal component analysis coupled with linear discriminant analysis and predictive classifiers were applied to the data. RESULTS Comparison of averaged mid-IR spectra revealed unique features among C4d-positive, C4d-negative, and native heart biopsies. Principal component analysis coupled with linear discriminant analysis and classification models demonstrated that spectral features from the mid-IR fingerprint region of these 3 groups permitted accurate automated classification into each group. CONCLUSIONS In cardiac allograft biopsies with immunopathologic AMR, IR spectroscopy reveals a biochemical signature unique to AMR compared with that of nonrejecting cardiac allografts and native hearts. Future study will focus on the predictive capabilities of this IR signature.
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Di Francesco A, Fedrigo M, Santovito D, Natarelli L, Castellani C, De Pascale F, Toscano G, Fraiese A, Feltrin G, Benazzi E, Nocco A, Thiene G, Valente M, Valle G, Schober A, Gerosa G, Angelini A. MicroRNA signatures in cardiac biopsies and detection of allograft rejection. J Heart Lung Transplant 2018; 37:1329-1340. [PMID: 30174164 DOI: 10.1016/j.healun.2018.06.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/28/2018] [Accepted: 06/20/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Identification of heart transplant (HTx) rejection currently relies on immunohistology and immunohistochemistry. We aimed to identify specific sets of microRNAs (miRNAs) to characterize acute cellular rejection (ACR), antibody-mediated rejection (pAMR), and mixed rejection (MR) in monitoring formalin-fixed paraffin-embedded (FFPE) endomyocardial biopsies (EMBs) in HTx patients. METHODS In this study we selected 33 adult HTx patients. For each, we chose the first positive EMB for study of each type of rejection. The next-generation sequencing (NGS) IonProton technique and reverse transcript quantitative polymerase chain reaction (RT-qPCR) analysis were performed on FFPE EMBs. Using logistic regression analysis we created unique miRNA signatures as predictive models of each rejection. In situ PCR was carried out on the same EMBs. RESULTS We obtained >2,257 mature miRNAs from all the EMBs. The 3 types of rejection showed a different miRNA profile for each group. The logistic regression model formed by miRNAs 208a, 126-5p, and 135a-5p identified MR; that formed by miRNAs 27b-3p, 29b-3p, and 199a-3p identified ACR; and that formed by miRNAs 208a, 29b-3p, 135a-5p, and 144-3p identified pAMR. The expression of miRNAs on tissue, through in situ PCR, showed different expressions of the same miRNA in different rejections. miRNA 126-5p was expressed in endothelial cells in ACR but in cardiomyocytes in pAMR. In ACR, miRNA 29b-3p was significantly overexpressed and detected in fibroblasts, whereas in pAMR it was underexpressed and detected only in cardiomyocytes. CONCLUSIONS miRNA profiling on FFPE EMBs differentiates the 3 types of rejection. Localization of expression of miRNAs on tissue showed different expression of the same miRNA for different cells, suggesting different roles of the same miRNA in different rejections.
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Affiliation(s)
- Andrea Di Francesco
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marny Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy.
| | - Donato Santovito
- Institute for Cardiovascular Prevention, Ludwig-Maximillians University, Munich, Germany
| | - Lucia Natarelli
- Institute for Cardiovascular Prevention, Ludwig-Maximillians University, Munich, Germany
| | - Chiara Castellani
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Giuseppe Toscano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Angela Fraiese
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giuseppe Feltrin
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Elena Benazzi
- Organ and Tissue Transplantation Immunology, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Angela Nocco
- Organ and Tissue Transplantation Immunology, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Gaetano Thiene
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marialuisa Valente
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giorgio Valle
- CRIBI Biotechnology Centre, University of Padova, Padova, Italy
| | - Andreas Schober
- Institute for Cardiovascular Prevention, Ludwig-Maximillians University, Munich, Germany
| | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Annalisa Angelini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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8
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Mehra NK, Baranwal AK. Clinical and immunological relevance of antibodies in solid organ transplantation. Int J Immunogenet 2016; 43:351-368. [DOI: 10.1111/iji.12294] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/10/2016] [Accepted: 10/16/2016] [Indexed: 12/22/2022]
Affiliation(s)
- N. K. Mehra
- National Chair and Former Dean (Research); All India Institute of Medical Sciences; New Delhi India
| | - A. K. Baranwal
- Department of Transplant Immunology and Immunogenetics; All India Institute of Medical Sciences; New Delhi India
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Frea S, Iacovino C, Botta M, De Filippi I, Mazzucco G, Pidello S, Biolè C, Bergerone S, Boffini M, Praticò Barbato L, Morello M, Rinaldi M, Gaita F. Does asymptomatic recurrent diffuse capillary C4d complement deposition impair cardiac allograft function? Clin Transplant 2016; 30:1314-1323. [DOI: 10.1111/ctr.12824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Simone Frea
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Cristina Iacovino
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Michela Botta
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Ilaria De Filippi
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Gianna Mazzucco
- Department of Biomedicine and Human Oncology; University of Torino; Torino Italy
| | - Stefano Pidello
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - CarloAlberto Biolè
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Serena Bergerone
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Massimo Boffini
- Division of Cardiac Surgery; Cardiovascular and Thoracic Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | | | - Mara Morello
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery; Cardiovascular and Thoracic Department; Città della Salute e della Scienza and University of Torino; Torino Italy
| | - Fiorenzo Gaita
- Division of Cardiology; Internal Medicine Department; Città della Salute e della Scienza and University of Torino; Torino Italy
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11
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Mohamedali B, Pyle J, Bhat G. Acute Cellular Rejection and C4d Positivity in Heart Transplantation : A Manifestation of Asymptomatic Antibody-Mediated Rejection? Am J Clin Pathol 2016; 145:238-43. [PMID: 26767383 DOI: 10.1093/ajcp/aqv026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES The role of routine C4d staining in endomyocardial biopsy specimens is uncertain. The implications of a diagnosis of acute cellular rejection (ACR) with a positive C4d with or without any evidence of antibody-mediated rejection (AMR) are unclear. This study sought to evaluate a distinct phenotype of ACR+/C4d+ in AMR- patients. METHODS Data on C4d, ACR, and AMR were collected. Donor-specific antibody (DSA), panel-reactive antibody (PRA), flow crossmatch, and data on ACR and AMR episodes were also reviewed. RESULTS Thirty-five patients were followed. Group I with C4d+ biopsy specimens was compared with group II with C4d- biopsy specimens. ACR greater than 1R was higher in group I compared with group II (50% vs 7.4%; P = .01). Clinical suspicion of AMR, positive retrospective crossmatches, and detection of de novo DSA were also higher in group I. CONCLUSIONS Our result indicate that C4d and ACR positivity in posttransplant patients may be a harbinger of a subclinical form of asymptomatic AMR.
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Affiliation(s)
- Burhan Mohamedali
- From the Division of Cardiology and Pathology, Rush University, Advocate Christ Medical Center, Chicago and Oak Lawn, IL.
| | - Joseph Pyle
- From the Division of Cardiology and Pathology, Rush University, Advocate Christ Medical Center, Chicago and Oak Lawn, IL
| | - Geetha Bhat
- From the Division of Cardiology and Pathology, Rush University, Advocate Christ Medical Center, Chicago and Oak Lawn, IL
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12
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Troxell ML, Lanciault C. Practical Applications in Immunohistochemistry: Evaluation of Rejection and Infection in Organ Transplantation. Arch Pathol Lab Med 2016; 140:910-25. [PMID: 26759930 DOI: 10.5858/arpa.2015-0275-cp] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Immunohistochemical analysis of tissue biopsy specimens is a crucial tool in diagnosis of both rejection and infection in patients with solid organ transplants. In the past 15 years, the concept of antibody-mediated rejection has been refined, and diagnostic criteria have been codified in renal, heart, pancreas, and lung allografts (with studies ongoing in liver, small intestine, and composite grafts), all of which include immunoanalysis for the complement split product C4d. OBJECTIVES -To review the general concepts of C4d biology and immunoanalysis, followed by organ-allograft-specific data, and interpretative nuances for kidney, pancreas, and heart, with discussion of early literature for lung and liver biopsies. Additionally, practical applications and limitations of immunostains for infectious organisms (Polyomavirus, Adenoviridae [adenovirus], and the herpes virus family, including Herpes simplex virus, Cytomegalovirus, Human herpes virus 8, and Epstein-Barr virus) are reviewed in the context of transplant recipients. DATA SOURCES -Our experience and published primary and review literature. CONCLUSIONS -Immunohistochemistry continues to have an important role in transplant pathology, most notably C4d staining in assessment of antibody-mediated rejection and assessment of viral pathogens in tissue. In all facets of transplant pathology, correlation of morphology with special studies and clinical data is critical, as is close communication with the transplant team.
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Affiliation(s)
| | - Christian Lanciault
- From the Department of Pathology, Oregon Health & Science University, Portland
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13
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Time-dependent specificity of immunopathologic (C4d-CD68) and histologic criteria of antibody-mediated rejection for donor-specific antibodies and allograft dysfunction in heart transplantation. Transplantation 2015; 99:586-93. [PMID: 24983305 DOI: 10.1097/tp.0000000000000246] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In heart transplantation, antibody-mediated rejection (AMR) is diagnosed and graded on the basis of immunopathologic (C4d-CD68) and histopathologic criteria found on endomyocardial biopsies (EMB). Because some pathologic AMR (pAMR) grades may be associated with clinical AMR, and because humoral responses may be affected by the intensity of immunosuppression during the first posttransplantation year, we investigated the incidence and positive predictive values (PPV) of C4d-CD68 and pAMR grades for clinical AMR as a function of time. METHODS All 564 EMB from 40 adult heart recipients were graded for pAMR during the first posttransplantation year. Clinical AMR was diagnosed by simultaneous occurrence of pAMR on EMB, donor specific antibodies and allograft dysfunction. RESULTS One patient demonstrated clinical AMR at postoperative day 7 and one at 6 months (1-year incidence 5%). C4d-CD68 was found on 4,7% EMB with a "decrescendo" pattern over time (7% during the first 4 months vs. 1.2% during the last 8 months; P < 0.05). Histopathologic criteria of AMR occurred on 10.3% EMB with no particular time pattern. Only the infrequent (1.4%) pAMR2 grade (simultaneous histopathologic and immunopathologic markers) was predictive for clinical AMR, particularly after the initial postoperative period (first 4 months and last 8 months PPV = 33%-100%; P < 0.05). CONCLUSION In the first posttransplantation year, AMR immunopathologic and histopathologic markers were relatively frequent, but only their simultaneous occurrence (pAMR2) was predictive of clinical AMR. Furthermore, posttransplantation time may modulate the occurrence of C4d-CD68 on EMB and thus the incidence of pAMR2 and its relevance to the diagnosis of clinical AMR.
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14
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Colvin MM, Cook JL, Chang P, Francis G, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller D, O'Connell J, Rodriguez ER, Rosengard B, Self S, White-Williams C, Zeevi A. Antibody-mediated rejection in cardiac transplantation: emerging knowledge in diagnosis and management: a scientific statement from the American Heart Association. Circulation 2015; 131:1608-39. [PMID: 25838326 DOI: 10.1161/cir.0000000000000093] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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15
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Luk A, Alba AC, Butany J, Tinckam K, Delgado D, Ross HJ. C4d immunostaining is an independent predictor of cardiac allograft vasculopathy and death in heart transplant recipients. Transpl Int 2015; 28:857-63. [DOI: 10.1111/tri.12560] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/07/2015] [Accepted: 02/27/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Adriana Luk
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Ana Carolina Alba
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Jagdish Butany
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Kathryn Tinckam
- Department of Laboratory Medicine; University Health Network; University of Toronto; Toronto Ontario Canada
- Division of Nephrology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Diego Delgado
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Heather J. Ross
- Division of Cardiology; University Health Network; University of Toronto; Toronto Ontario Canada
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Fedrigo M, Leone O, Burke MM, Rice A, Toquet C, Vernerey D, Frigo AC, Guillemain R, Pattier S, Smith J, Lota A, Potena L, Bontadini A, Ceccarelli C, Poli F, Feltrin G, Gerosa G, Manzan E, Thiene G, Bruneval P, Angelini A, Duong Van Huyen JP. Inflammatory cell burden and phenotype in endomyocardial biopsies with antibody-mediated rejection (AMR): a multicenter pilot study from the AECVP. Am J Transplant 2015; 15:526-34. [PMID: 25612500 DOI: 10.1111/ajt.12976] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 07/27/2014] [Accepted: 08/07/2014] [Indexed: 01/25/2023]
Abstract
This multicenter case-controlled pilot study evaluated myocardial inflammatory burden (IB) and phenotype in endomyocardial biopsies (EMBs) with and without pathologic antibody-mediated rejection (pAMR). Sixty-five EMBs from five European heart transplant centers were centrally reviewed as positive (grade 2, n = 28), suspicious (grade 1, n = 7) or negative (n = 30) for pAMR. Absolute counts of total, intravascular (IV) and extravascular (EV) immunophenotyped mononuclear cells were correlated with pAMR grade, capillary C4d deposition, donor specific antibody (DSA) status and acute cellular rejection (ACR). In pAMR+ biopsies, equivalent number of IV CD3+ T lymphocytes (23 ± 4/0.225 mm(2) ) and CD68+ macrophages (21 ± 4/0.225 mm(2) ) were seen. IB and cell phenotype correlated with pAMR grade, C4d positivity and DSA positivity (p < 0.0001). High numbers of IV T lymphocytes were associated with low grade ACR (p = 0.002). In late-occurring AMR EV plasma cells occurring in 34% of pAMR+ EMBs were associated with higher IB. The IB in AMR correlated with pAMR+, C4d positivity and DSA positivity. In pAMR+ equivalent numbers of IV T lymphocytes and macrophages were found. The presence of plasma cells was associated with a higher IB and occurrence of pAMR late after transplantation.
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Affiliation(s)
- M Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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17
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Berry GJ, Burke MM, Andersen C, Bruneval P, Fedrigo M, Fishbein MC, Goddard M, Hammond EH, Leone O, Marboe C, Miller D, Neil D, Rassl D, Revelo MP, Rice A, Rene Rodriguez E, Stewart S, Tan CD, Winters GL, West L, Mehra MR, Angelini A. The 2013 International Society for Heart and Lung Transplantation Working Formulation for the standardization of nomenclature in the pathologic diagnosis of antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2014; 32:1147-62. [PMID: 24263017 DOI: 10.1016/j.healun.2013.08.011] [Citation(s) in RCA: 359] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/12/2013] [Indexed: 11/30/2022] Open
Abstract
During the last 25 years, antibody-mediated rejection of the cardiac allograft has evolved from a relatively obscure concept to a recognized clinical complication in the management of heart transplant patients. Herein we report the consensus findings from a series of meetings held between 2010-2012 to develop a Working Formulation for the pathologic diagnosis, grading, and reporting of cardiac antibody-mediated rejection. The diagnostic criteria for its morphologic and immunopathologic components are enumerated, illustrated, and described in detail. Numerous challenges and unresolved clinical, immunologic, and pathologic questions remain to which a Working Formulation may facilitate answers.
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Affiliation(s)
- Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California.
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18
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Xu L, Collins J, Drachenberg C, Kukuruga D, Burke A. Increased macrophage density of cardiac allograft biopsies is associated with antibody-mediated rejection and alloantibodies to HLA antigens. Clin Transplant 2014; 28:554-60. [PMID: 24580037 DOI: 10.1111/ctr.12348] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is characterized histologically by intracapillary macrophages. Macrophage density may be an alternative method of determining inflammatory changes in AMR. METHODS We identified 118 heart transplant patients with serologic testing for HLA alloantibodies. Macrophage density was graded as 1+ (<45/mm(2)), 2+ (46-90/mm(2)), and 3+ (>90/mm(2)). Maximal macrophage density and complement staining over multiple biopsies were correlated with peak panel reactive antibodies (PRA), donor-specific antibodies (DSA), and the clinical diagnosis of AMR. RESULTS The presence of PRA correlated with macrophage score (p = 0.001). Macrophage density correlated with any DSA (p < 0.0001), class I DSA (p < 0.0001), class II DSA (p < 0.0001), and class II DQ (p < 0.0001). Nine patients had clinical AMR. Among patients with AMR, 89% had a biopsy over the period of AMR with ≥3+ macrophage density (89% sensitivity); among patients without AMR, 93% of patients had no biopsy at any time with ≥3+ macrophage density (specificity). There was perfect concordance between the scores of C4d positivity and macrophage density in 61% and only partial concordance in 20%, with complete discordance in 19% in biopsies taken during clinical episodes of AMR. CONCLUSIONS Macrophage density in allograft endomyocardial biopsies is frequently elevated during clinical episodes of AMR and correlates well with alloantibodies.
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Affiliation(s)
- Lauren Xu
- Department of Pathology and Cardiology, University of Maryland Medical Center, Baltimore, MD, USA
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19
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Rowe P, Wasserfall C, Croker B, Campbell-Thompson M, Pugliese A, Atkinson M, Schatz D. Increased complement activation in human type 1 diabetes pancreata. Diabetes Care 2013; 36:3815-7. [PMID: 24041678 PMCID: PMC3816899 DOI: 10.2337/dc13-0203] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Evidence supporting an association between complement (C) and type 1 diabetes (T1D) includes the identification of C-fixing islet cell autoantibodies in T1D sera and genetic associations with the major histocompatibility complex III C4 region on chromosome 6. Therefore, we investigated whether C activation was present in pancreata from those with or at increased risk (positive for T1D associated autoantibodies) for T1D. RESEARCH DESIGN AND METHODS Immunohistochemical techniques were used to measure the C degradation product C4d in organ donor pancreata from patients with T1D and type 2 diabetes and autoantibody-positive and autoantibody-negative subjects. RESULTS Median C4d antigen density differed across the groups (P < 0.0001) and was highest in patients with T1D. C4d immunostaining localized to the blood vessel endothelium and extracellular matrix surrounding blood vessels and exocrine ducts. Receiver operating characteristic analysis resulted in 81.8% sensitivity and 94.4% specificity for C4d staining. CONCLUSIONS These data suggest that C activation is occurring within pancreata from patients with T1D and C4d may be a biomarker for T1D.
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Fedrigo M, Feltrin G, Poli F, Frigo AC, Benazzi E, Gambino A, Tona F, Caforio ALP, Castellani C, Toscano G, Gerosa G, Thiene G, Angelini A. Intravascular macrophages in cardiac allograft biopsies for diagnosis of early and late antibody-mediated rejection. J Heart Lung Transplant 2013; 32:404-9. [PMID: 23498161 DOI: 10.1016/j.healun.2012.12.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 11/13/2012] [Accepted: 12/13/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of our study was to evaluate the role of intravascular macrophages in the diagnosis of early and late antibody-mediated rejection (AMR) on endomyocardial biopsies (EMBs). METHODS We reviewed 1,420 consecutive EMBs from 131 patients and selected 75 C4d+ EMBs. The C4d+ group was compared with a control group (66 patients) matched for age, gender, date of transplantation, follow-up, immunosuppressive regimen and primary heart disease. A total of 141 EMBs were evaluated. Immunoperoxidase staining for C4d and CD68 were performed. Post-transplant IgG anti-HLA reactivity was investigated by Luminex technology. Clinical data were also collected. Fourteen EMBs were available from 11 symptomatic AMR patients. RESULTS Of the 141 EMBs evaluated, 53 were positive for intravascular macrophages (CD68); among them, 32 were also positive for C4d (32 of 53, 60.4%). Of the 88 CD68- EMBs, 43 were also C4d+ (43 of 88, 48.9%). Of the 53 CD68+ EMBs, 30 EMBs were within the first year since transplantation (30 of 53, 57.8%), and among these 21 were also positive for C4d (21 of 30, 70.0%). In the late period, among the 23 CD68+ EMBs (23 of 53, 42.2%) 11 were also positive for C4d (11 of 23, 47.8%). In the early period, intravascular macrophages were more common in symptomatic (3 of 3, 100%) than asymptomatic (3 of 11, 27.3%) patients. Sensitivity and specificity of intravascular macrophages in predicting donor-specific antibodies (DSA) within the first year were 50.0% and 100.0%, respectively. CONCLUSIONS Intravascular macrophages predict C4d, DSA and symptoms early after transplantation; however, in the late period, they are unable to identify patients with circulating DSA, C4d and/or symptoms.
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Affiliation(s)
- Marny Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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21
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Renal arteriolar C4d deposition: a novel characteristic of hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Transplantation 2013; 96:217-23. [PMID: 23698598 DOI: 10.1097/tp.0b013e31829807aa] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The mechanism of kidney injury in hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is not completely understood. Renal C4d staining is a marker of classic complement activation and endothelial injury and has been described in preliminary reports of HSCT recipients with TA-TMA. Our objective was to evaluate complement in the pathogenesis of small vessel injury in children receiving HSCT. We hypothesized that kidney tissue from children with TA-TMA would more frequently show C4d deposition compared with HSCT recipients without histologic TA-TMA. METHODS We reviewed kidney specimens (biopsy or autopsy) from children who had undergone HSCT at a single center. Using histologic criteria alone, subjects were divided into TA-TMA (n = 8) and non-TA-TMA (control) groups (n = 12). C4d staining was performed by immunohistochemistry and evaluated on arterioles, peritubular capillaries, glomeruli, and tubular basement membranes. RESULTS Diffuse or focal renal arteriolar C4d staining was more common in subjects with histologic TA-TMA (75%) compared with controls (8%). Rare peritubular capillary C4d staining was present in 50% of TA-TMA samples and was absent in controls. Glomerular C4d staining was seen at a similar frequency in cases and controls, whereas tubular basement membrane staining was less frequently observed and only in subjects with TA-TMA. CONCLUSIONS Arteriolar C4d deposition may be a pathologic marker of TA-TMA, implicating localized complement fixation in HSCT recipients with kidney disease secondary to small vessel injury. Further studies to better characterize the preferential arteriolar C4d staining may identify a renal compartment of injury, possibly explaining the dramatic hypertension seen in TA-TMA.
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22
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Naber U, Feingold B. The interplay of donor-specific antibodies, allograft C4d deposition, and antibody-mediated rejection. Pediatr Transplant 2013; 17:409-11. [PMID: 23672434 DOI: 10.1111/petr.12097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Urs Naber
- Pediatric Cardiology; Children's Hospital of Pittsburgh of UPMC; Pittsburgh; PA; USA
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23
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Thiene G, Bruneval P, Veinot J, Leone O. Diagnostic use of the endomyocardial biopsy: a consensus statement. Virchows Arch 2013; 463:1-5. [DOI: 10.1007/s00428-013-1430-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/10/2013] [Accepted: 05/17/2013] [Indexed: 11/24/2022]
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Xu Y, Galambos C, Reyes-Múgica M, Miller SA, Zeevi A, Webber SA, Feingold B. Utility of C4d immunostaining in the first year after pediatric and young adult heart transplantation. J Heart Lung Transplant 2013; 32:92-7. [PMID: 23260709 DOI: 10.1016/j.healun.2012.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 09/05/2012] [Accepted: 10/03/2012] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND C4d assessment of endomyocardial biopsies (EMBs) after heart transplantation (HTx) has been widely adopted to aid in the diagnosis of antibody-mediated rejection (AMR), yet it remains unclear whether or not to assess all patients routinely and with what frequency/duration. In this study we sought to evaluate the utility of routine C4d immunostaining in the first year after pediatric and young adult HTx. METHODS We reviewed pre-transplant alloantibody and clinical data, including serial EMB reports, on all 51 patients who received HTx at our center since we instituted routine C4d staining of all first-year EMBs. C4d was considered positive if diffuse capillary staining (≥ 2(+)) was present. Rare/focal capillary staining or absence of staining was considered negative. RESULTS Twenty-six of 406 first-year EMBs (6%) were C4d(+) in 6 (12%) patients. Sixty-five percent of all C4d(+) EMBs occurred by 30 days post-transplant. Five of 6 patients had pre-transplant donor-specific antibody (DSA) ≥ 4,000 MFI. The sixth patient had neither pre-transplant anti-HLA antibodies nor a positive donor-specific cytotoxicity crossmatch (DSXM), but there was clinical concern for AMR. Among the entire cohort, 5 of 10 patients with pre-transplant DSA ≥ 4,000 MFI and/or a positive DSXM were C4d(+) compared with only 1 of 41 without (50% vs 2%; p = 0.001). CONCLUSIONS In the first year after HTx, C4d(+) occurred early and only in children and young adults with pre-transplant DSA or with clinical suspicion of AMR. Although our data suggest that assessment limited to the first 90 days post-transplant in patients with pre-transplant DSA ≥ 4,000 MFI may be appropriate in the absence of clinical concern for AMR, further research is needed to determine the optimum strategy for post-transplant surveillance.
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Affiliation(s)
- Ying Xu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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25
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Intentional ABO-incompatible heart transplantation: A case report of 2 adult patients. J Heart Lung Transplant 2012; 31:1307-10. [DOI: 10.1016/j.healun.2012.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Revised: 08/29/2012] [Accepted: 09/14/2012] [Indexed: 11/18/2022] Open
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26
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Fayek SA. The value of C4d deposit in post liver transplant liver biopsies. Transpl Immunol 2012; 27:166-70. [PMID: 22975227 DOI: 10.1016/j.trim.2012.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 08/20/2012] [Accepted: 08/20/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Presence of C4d in renal and cardiac allografts is a sign of antibody-mediated rejection and is associated with worse outcomes. The value of C4d in liver specimens is controversial. We aimed to determine the association of C4d deposition with acute cellular rejection (ACR), hepatitis C (HCV) recurrence, and clinical outcome after ABO compatible liver transplants (OLT). METHODS Using immunohistochemical stain, 70 liver biopsies (44 study and 26 control groups) were evaluated for C4d deposition. Study group included for-cause post OLT biopsies. Staining of endothelial cells was considered positive. RESULTS In the study group C4d was positive in 22.7% versus 3.8% in controls (P=0.03), all had portal vein deposits. In 17 biopsies with ACR, 3 had positive C4d (17.6%) versus 7/27 with HCV recurrence (25.9%) (P=0.4). In HCV recurrence, 3/7 biopsies with fibrosing cholestatic hepatitis had positive C4d (42.9%) versus 4/20 without these features (20%) (P=0.24). Out of 10 recipients with positive C4d 4 had poor outcomes versus 3/22 with negative C4d (P=0.12). CONCLUSIONS C4d staining was significantly more frequent in post OLT biopsies compared with controls. C4d is not specifically associated with ACR and does not differentiate it from HCV recurrence but is associated with a trend toward poorer outcome.
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Gareau AJ, Nashan B, Hirsch GM, Lee TDG. Cyclosporine immunosuppression does not prevent the production of donor-specific antibody capable of mediating allograft vasculopathy. J Heart Lung Transplant 2012; 31:874-80. [PMID: 22554675 DOI: 10.1016/j.healun.2012.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 03/11/2012] [Accepted: 03/31/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Late cardiac graft rejection, primarily mediated by allograft vasculopathy (AV), remains a major limitation to cardiac transplantation, even in the face of significant calcineurin inhibitor (CNI) immunosuppression. The role played by alloantibody in AV is unclear. Evidence that CNI immunosuppression suppresses CD4(+) T-cell function would suggest that antibody production and effector function would be severely limited in CNI-treated patients. In this study we examine the capacity of CNI-treated animals to develop effective alloantibody that can mediate AV. METHODS Wild-type (WT) B6 mice were alloimmunized using donor splenocytes or a fully major histocompatibility complex-mismatched allogeneic abdominal aortic graft in the presence of CNI immunosuppression (30 or 50 mg/kg/day cyclosporine A). Anti-serum was harvested and tested using complement-dependent in vitro cytotoxicity assays. Anti-serum was passively transferred to immunodeficient RAG1(-/-) recipients of allogeneic grafts. C4d deposition was quantified in the allografts from WT recipients. RESULTS CNI immunosuppression did not prevent the development of alloantibody in response to either immunization method (p < 0.05). Passive transfer of anti-serum generated AV lesions in immunodeficient graft recipients and mediated complement-dependent destruction of donor cells (p < 0.05). C4d deposition was localized to the media of grafts of CNI treated animals. CONCLUSIONS CNI therapy does not prevent the production of alloantibody with the capacity to mediate AV. C4d deposition in the media suggests a role for medial smooth muscle cell loss in antibody-mediated AV lesion development in our model.
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Affiliation(s)
- Alison J Gareau
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
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28
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Biomarkers of heart transplant rejection: the good, the bad, and the ugly! Transl Res 2012; 159:238-51. [PMID: 22424428 DOI: 10.1016/j.trsl.2012.01.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/19/2012] [Accepted: 01/19/2012] [Indexed: 12/24/2022]
Abstract
Acute cellular rejection (ACR), antibody-mediated rejection (AMR), and cardiac allograft vasculopathy (CAV) are important limitations for the long-term survival of heart transplant recipients. Although much progress has been made in reducing ACR with modern immunosuppressive treatments and continuous biopsy surveillance, there is still a long way to go to better understand and treat AMR, to enable early detection of patients at risk of CAV, and to reduce the development and sustained progression of this irreversible disease that permanently compromises graft function. This review considers the advances made in ACR detection and treatment allowing a more prolonged survival and the risk factors leading to endothelial injury, dysfunction, inflammation, and subsequent CAV, as well as new treatment modalities for CAV. The review also evaluates the controversies around the definition, pathogenesis, and treatment of AMR. To date, much progress is still needed to significantly reduce post-transplant complications and increase graft and patient survival.
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29
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Cohen D, Colvin RB, Daha MR, Drachenberg CB, Haas M, Nickeleit V, Salmon JE, Sis B, Zhao MH, Bruijn JA, Bajema IM. Pros and cons for C4d as a biomarker. Kidney Int 2012; 81:628-39. [PMID: 22297669 DOI: 10.1038/ki.2011.497] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The introduction of C4d in daily clinical practice in the late nineties aroused an ever-increasing interest in the role of antibody-mediated mechanisms in allograft rejection. As a marker of classical complement activation, C4d made it possible to visualize the direct link between anti-donor antibodies and tissue injury at sites of antibody binding in a graft. With the expanding use of C4d worldwide several limitations of C4d were identified. For instance, in ABO-incompatible transplantations C4d is present in the majority of grafts but this seems to point at 'graft accommodation' rather than antibody-mediated rejection. C4d is now increasingly recognized as a potential biomarker in other fields where antibodies can cause tissue damage, such as systemic autoimmune diseases and pregnancy. In all these fields, C4d holds promise to detect patients at risk for the consequences of antibody-mediated disease. Moreover, the emergence of new therapeutics that block complement activation makes C4d a marker with potential to identify patients who may possibly benefit from these drugs. This review provides an overview of the past, present, and future perspectives of C4d as a biomarker, focusing on its use in solid organ transplantation and discussing its possible new roles in autoimmunity and pregnancy.
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Affiliation(s)
- Danielle Cohen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.
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30
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Leone O, Veinot JP, Angelini A, Baandrup UT, Basso C, Berry G, Bruneval P, Burke M, Butany J, Calabrese F, d'Amati G, Edwards WD, Fallon JT, Fishbein MC, Gallagher PJ, Halushka MK, McManus B, Pucci A, Rodriguez ER, Saffitz JE, Sheppard MN, Steenbergen C, Stone JR, Tan C, Thiene G, van der Wal AC, Winters GL. 2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovasc Pathol 2011; 21:245-74. [PMID: 22137237 DOI: 10.1016/j.carpath.2011.10.001] [Citation(s) in RCA: 351] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/28/2011] [Accepted: 10/07/2011] [Indexed: 01/04/2023] Open
Abstract
The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.
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Affiliation(s)
- Ornella Leone
- U.O. di Anatomia ed Istologia Patologica, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy.
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Role of morphologic parameters on endomyocardial biopsy to detect sub-clinical antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2011; 30:1381-8. [DOI: 10.1016/j.healun.2011.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/22/2011] [Accepted: 07/17/2011] [Indexed: 11/24/2022] Open
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Angelini A, Andersen CB, Bartoloni G, Black F, Bishop P, Doran H, Fedrigo M, Fries JW, Goddard M, Goebel H, Neil D, Leone O, Marzullo A, Ortmann M, Paraf F, Rotman S, Turhan N, Bruneval P, Frigo AC, Grigoletto F, Gasparetto A, Mencarelli R, Thiene G, Burke M. A web-based pilot study of inter-pathologist reproducibility using the ISHLT 2004 working formulation for biopsy diagnosis of cardiac allograft rejection: The European experience. J Heart Lung Transplant 2011; 30:1214-20. [DOI: 10.1016/j.healun.2011.05.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 05/06/2011] [Accepted: 05/24/2011] [Indexed: 10/17/2022] Open
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Berry GJ, Angelini A, Burke MM, Bruneval P, Fishbein MC, Hammond E, Miller D, Neil D, Revelo MP, Rodriguez ER, Stewart S, Tan CD, Winters GL, Kobashigawa J, Mehra MR. The ISHLT working formulation for pathologic diagnosis of antibody-mediated rejection in heart transplantation: evolution and current status (2005-2011). J Heart Lung Transplant 2011; 30:601-11. [PMID: 21555100 DOI: 10.1016/j.healun.2011.02.015] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 02/15/2011] [Indexed: 10/18/2022] Open
Affiliation(s)
- Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA.
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Kobashigawa J, Crespo-Leiro MG, Ensminger SM, Reichenspurner H, Angelini A, Berry G, Burke M, Czer L, Hiemann N, Kfoury AG, Mancini D, Mohacsi P, Patel J, Pereira N, Platt JL, Reed EF, Reinsmoen N, Rodriguez ER, Rose ML, Russell SD, Starling R, Suciu-Foca N, Tallaj J, Taylor DO, Van Bakel A, West L, Zeevi A, Zuckermann A. Report from a consensus conference on antibody-mediated rejection in heart transplantation. J Heart Lung Transplant 2011; 30:252-69. [PMID: 21300295 DOI: 10.1016/j.healun.2010.11.003] [Citation(s) in RCA: 225] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 11/03/2010] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The problem of AMR remains unsolved because standardized schemes for diagnosis and treatment remains contentious. Therefore, a consensus conference was organized to discuss the current status of antibody-mediated rejection (AMR) in heart transplantation. METHODS The conference included 83 participants (transplant cardiologists, surgeons, immunologists and pathologists) representing 67 heart transplant centers from North America, Europe, and Asia who all participated in smaller break-out sessions to discuss the various topics of AMR and attempt to achieve consensus. RESULTS A tentative pathology diagnosis of AMR was established, however, the pathologist felt that further discussion was needed prior to a formal recommendation for AMR diagnosis. One of the most important outcomes of this conference was that a clinical definition for AMR (cardiac dysfunction and/or circulating donor-specific antibody) was no longer believed to be required due to recent publications demonstrating that asymptomatic (no cardiac dysfunction) biopsy-proven AMR is associated with subsequent greater mortality and greater development of cardiac allograft vasculopathy. It was also noted that donor-specific antibody is not always detected during AMR episodes as the antibody may be adhered to the donor heart. Finally, recommendations were made for the timing for specific staining of endomyocardial biopsy specimens and the frequency by which circulating antibodies should be assessed. Recommendations for management and future clinical trials were also provided. CONCLUSIONS The AMR Consensus Conference brought together clinicians, pathologists and immunologists to further the understanding of AMR. Progress was made toward a pathology AMR grading scale and consensus was accomplished regarding several clinical issues.
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Can C4d Immunostaining on Endomyocardial Biopsies Be Considered a Prognostic Biomarker in Heart Transplant Recipients?: Erratum. Transplantation 2011. [DOI: 10.1097/tp.0b013e31820a3f22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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