1
|
Nankivell BJ, P’Ng CH, Shingde M. Glomerular C4d Immunoperoxidase in Chronic Antibody-Mediated Rejection and Transplant Glomerulopathy. Kidney Int Rep 2022; 7:1594-1607. [PMID: 35812271 PMCID: PMC9263257 DOI: 10.1016/j.ekir.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The diagnosis of late antibody-mediated rejection (AMR) is compromised by frequent absence of C4d in peritubular capillaries (C4dptc), termed “C4d-negative” AMR. We hypothesized that glomerular capillary C4d (C4dglom) reflected endothelial interaction with antibody and could improve immunologic classification of transplant glomerulopathy (TG). Methods We evaluated C4d using immunoperoxidase in 3524 consecutive, kidney transplant biopsies from a single center. Results C4dglom was detected in 16.5% and C4dptc in 9.9% of biopsies. C4dglom occurred in 60.3% of TG (n = 174) and was absent in normal glomeruli. Epidemiologic risk factors for C4dglom were younger, female, living-donor recipients with early AMR, prior treated rejection, and late presentation using multivariable analysis. Semiquantitative C4dglom score correlated with donor specific antibody (DSA) level, C4dptc, microvascular inflammation (MVI), Banff cg scores, renal dysfunction, and proteinuria. Principal component analysis colocalized C4dglom with histologic AMR. Multivariable analysis of TG found DSA, C4dptc, and post-transplant time associated with C4dglom. Addition of C4dglom into Banff chronic AMR schema improved its diagnostic sensitivity for TG (verified by electron microscopy [EM]) from 22.2% to 82.4% and accuracy from 59.6% to 93.9%, compared with Banff 2019 using only C4dptc. Tissue C4dglom and chronic AMR diagnosis incorporating C4dglom were associated with death-censored allograft failure in TG (P < 0.001), independent of the severity of glomerulopathy and chronic interstitial fibrosis. Conclusion C4dglom is a promising diagnostic biomarker of endothelial interaction with antibody which substantially improved test performance of the Banff schema to correctly classify TG by pathophysiology and prognosticate graft loss. We recommend routine C4d immunoperoxidase to minimize underdiagnosis of late AMR in TG.
Collapse
Affiliation(s)
- Brian J. Nankivell
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Correspondence: Brian J. Nankivell, Department of Renal Medicine, Westmead Hospital, Westmead, Sydney, 2145 New South Wales, Australia.
| | - Chow H. P’Ng
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| | - Meena Shingde
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Hart A, Schladt DP, Matas AJ, Itzler R, Israni AK, Kasiske BL. Incidence, risk factors, and long-term outcomes associated with antibody-mediated rejection - The long-term Deterioration of Kidney Allograft Function (DeKAF) prospective cohort study. Clin Transplant 2021; 35:e14337. [PMID: 33955070 DOI: 10.1111/ctr.14337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 01/03/2023]
Abstract
Major gaps remain in our understanding of antibody-mediated rejection (AMR) after kidney transplant. We examined the incidence, risk factors, response to treatment, and effects on outcomes of AMR at seven transplant programs in the long-term Deterioration of Kidney Allograft Function prospective study cohort. Among 3131 kidney recipients, there were 194 observed AMR cases (6.2%) during (mean ± SD) 4.85 ± 1.86 years of follow-up. Time to AMR was 0.97 ± 1.17 (median, 0.48) years. Risk factors for AMR included younger recipient age, human leukocyte antigen DR mismatches, panel-reactive antibody >0%, positive T- or B-cell cross-match, and delayed graft function. Compared with no AMR, the adjusted time-dependent hazard ratio for death-censored graft failure is 10.1 (95% confidence interval, 6.5-15.7) for all AMR patients, 4.0 (2.5, 9.1) for early AMR (<90 days after transplant), and 24.0 (14.0-41.1) for late AMR (≥90 days after transplant). Patients were treated with different therapeutic combinations. Of 194 kidney transplant recipients with AMR, 50 (25.8%) did not respond to treatment, defined as second AMR within 100 days or no improvement in estimated glomerular filtration rate by 42 days. Long-term outcomes after AMR are poor, regardless of the initial response to treatment. Better prevention and new therapeutic strategies are needed to improve long-term allograft survival.
Collapse
Affiliation(s)
- Allyson Hart
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - David P Schladt
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Arthur J Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Ajay K Israni
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| |
Collapse
|
3
|
Matas AJ, Fieberg A, Mannon RB, Leduc R, Grande J, Kasiske BL, Cecka M, Gaston R, Hunsicker L, Connett J, Cosio F, Gourishankar S, Rush D. Long-term follow-up of the DeKAF cross-sectional cohort study. Am J Transplant 2019; 19:1432-1443. [PMID: 30506642 PMCID: PMC7653899 DOI: 10.1111/ajt.15204] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/24/2018] [Accepted: 11/19/2018] [Indexed: 01/25/2023]
Abstract
The DeKAF study was developed to better understand the causes of late allograft loss. Preliminary findings from the DeKAF cross-sectional cohort (with follow-up < 20 months) have been published. Herein, we present long-term outcomes in those recipients (mean follow-up ± SD, 6.6 ± 0.7 years). Eligibility included being transplanted prior to October 1, 2005; serum creatinine ≤ 2.0 mg/dL on January 1, 2006; and subsequently developing new-onset graft dysfunction leading to a biopsy. Mean time from transplant to biopsy was 7.5 ± 6.1 years. Histologic findings and DSA were studied in relation to postbiopsy outcomes. Long-term follow-up confirms and expands the preliminary results of each of 3 studies: (1) increasing inflammation in area of atrophy (irrespective of inflammation in nonscarred areas [Banff i]) was associated with increasingly worse postbiopsy death-censored graft survival; (2) hierarchical analysis based on Banff scores defined clusters (entities) that differed in long-term death-censored graft survival; and (3) C4d-/DSA- recipients had significantly better (and C4d+/DSA+ worse) death-censored graft survival than other groups. C4d+/DSA- and C4d-/DSA+ had similar intermediate death-censored graft survival. Clinical and histologic findings at the time of new-onset graft dysfunction define high- vs low-risk groups for long-term death-censored graft survival, even years posttransplant. These findings can help differentiate groups for potential intervention studies.
Collapse
Affiliation(s)
- Arthur J. Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann Fieberg
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Roslyn B. Mannon
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | - Robert Leduc
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Joe Grande
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Bertram L. Kasiske
- Chronic Disease and Research Group, Hennepin Healthcare, Minneapolis, Minnesota
| | - Michael Cecka
- Ronald Reagan UCLA Medicine Center, University of California, Los Angeles, California
| | - Robert Gaston
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | | | - John Connett
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Fernando Cosio
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Sita Gourishankar
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
4
|
Pedraza N, Girón F, Baez Y, Niño A, Rodriguez J, Orozco C. Positive C4d in kidney transplantation biopsy: clinical impact. Transplant Proc 2014; 46:2966-71. [PMID: 25420802 DOI: 10.1016/j.transproceed.2014.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deposition of C4d in peritubular capillaries of renal graft is normally associated with the presence of antibody-mediated rejection. The clinical impact of its presence in patients with renal transplant in Colombia is uncertain, as well as the association in acute rejection and the response to the management and survival of the graft. The aim of this study was to determine the risk of having positive C4d in biopsies of patients with episodes of acute cellular rejection. METHODS We retrospectively reviewed 226 biopsies of kidney transplantation, all of them with acute rejection and histopathological findings classified according to Banff criteria 2009 and performed between January 2005 and December 2012 for graft dysfunction. C4d staining was performed by immunohistochemistry. RESULTS C4d staining was positive in 25 of 226 biopsies. Rejection time in patients with positive C4d was 15 months in average vs 8 months with negative C4d. CONCLUSIONS With the use of a multivariate analysis, we found that the unique risk for C4d in our population was the positive panel reactive antibodies and elapsed time between transplant and the rejection (odds ratio: 2.12, P = .034) and that the other variables analyzed are not related to the expression of C4d.
Collapse
Affiliation(s)
- N Pedraza
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia.
| | - F Girón
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia
| | - Y Baez
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia
| | - A Niño
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia
| | - J Rodriguez
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia
| | - C Orozco
- Colombiana de Trasplantes, Departament: Kidney Transplant Service, Bogotá, Colombia
| |
Collapse
|
5
|
Sapir-Pichhadze R, Curran SP, John R, Tricco AC, Uleryk E, Laupacis A, Tinckam K, Sis B, Beyene J, Logan AG, Kim SJ. A systematic review of the role of C4d in the diagnosis of acute antibody-mediated rejection. Kidney Int 2014; 87:182-94. [PMID: 24827778 DOI: 10.1038/ki.2014.166] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/21/2014] [Accepted: 03/27/2014] [Indexed: 01/03/2023]
Abstract
In this study, we conducted a systematic review of the literature to re-evaluate the role of C4d in the diagnosis of acute antibody-mediated rejection of kidney allografts. Electronic databases were searched until September 2013. Eligible studies allowed derivation of diagnostic tables for the performance of C4d by immunofluorescence or immunohistochemistry with comparison to histopathological features of acute antibody-mediated rejection and/or donor-specific antibody (DSA) assays. Of 3492 unique abstracts, 29 studies encompassing 3485 indication and 868 surveillance biopsies were identified. Assessment of C4d by immunofluorescence and immunohistochemistry exhibited slight to moderate agreement with glomerulitis, peritubular capillaritis, solid-phase DSA assays, DSA with glomerulitis, and DSA with peritubular capillaritis. The sensitivity and specificity of C4d varied as a function of C4d and comparator test thresholds. Prognostically, the presence of C4d was associated with inferior allograft survival compared with DSA or histopathology alone. Thus, our findings support the presence of complement-dependent and -independent phenotypes of acute antibody-mediated rejection. Whether the presence of C4d in combination with histopathology or DSA should be considered for the diagnosis of acute antibody-mediated rejection warrants further study.
Collapse
Affiliation(s)
- Ruth Sapir-Pichhadze
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simon P Curran
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rohan John
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Andreas Laupacis
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Banu Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Beyene
- 1] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [2] Population Health Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada [3] Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alexander G Logan
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- 1] Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada [2] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada [3] Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada [4] Division of Nephrology and the Renal Transplant Program, St Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Kohei N, Tanabe T, Horita S, Omoto K, Ishida H, Yamaguchi Y, Tanabe K. Sequential analysis of donor-specific antibodies and pathological findings in acute antibody-mediated rejection in a rat renal transplantation model. Kidney Int 2013; 84:722-32. [PMID: 23615506 DOI: 10.1038/ki.2013.117] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 01/25/2013] [Accepted: 01/31/2013] [Indexed: 11/09/2022]
Abstract
Alloantibodies contribute significantly to renal transplant rejection by activation of complement and various cytokines with a variety of effector cells, and are a major cause of allograft loss. Although there is clinical evidence of antibody- and complement-mediated injury in renal transplantation, the mechanism of antibody-mediated rejection remains largely unknown. In order to understand the sequential production of antibodies and complement components, we presensitized recipient rats by skin transplantation. Anti-donor-specific IgG levels reached a maximum 2 weeks following presensitization after which the rats underwent renal transplantation from the same donor strain. We then evaluated sequential pathological findings based on the Banff classification and several factors related to graft rejection. In this presensitized model, peritubular capillaries were already dilated and stained for C4d. Neutrophil and mononuclear cell infiltration in these capillaries was detected beginning 2 h after transplantation. Donor-specific antibody IgG levels decreased rapidly and anti-IgG antibody stained glomerular and peritubular capillaries in the grafts beginning 2 h after transplantation. Additionally, several cytokines and complement components showed marked changes in the presensitized group. Thus, in the donor-specific presensitized recipient, alloantibodies and complement were activated immediately after transplant. C4d deposition in peritubular capillaries appears to be a key factor for the diagnosis of antibody-associated rejection.
Collapse
Affiliation(s)
- Naoki Kohei
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | | | | | | | | |
Collapse
|
7
|
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
|