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Pan X, Peng J, Zhu R, An N, Pei J. Non-invasive biomarkers of acute rejection in pediatric kidney transplantation: New targets and strategies. Life Sci 2024; 348:122698. [PMID: 38710278 DOI: 10.1016/j.lfs.2024.122698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Kidney transplantation is the preferred treatment for pediatric end-stage renal disease. However, pediatric recipients face unique challenges due to their prolonged need for kidney function to accommodate growth and development. The continual changes in the immune microenvironment during childhood development and the heightened risk of complications from long-term use of immunosuppressive drugs. The overwhelming majority of children may require more than one kidney transplant in their lifetime. Acute rejection (AR) stands as the primary cause of kidney transplant failure in children. While pathologic biopsy remains the "gold standard" for diagnosing renal rejection, its invasive nature raises concerns regarding potential functional impairment and the psychological impact on children due to repeated procedures. In this review, we outline the current research status of novel biomarkers associated with AR in urine and blood after pediatric kidney transplantation. These biomarkers exhibit superior diagnostic and prognostic performance compared to conventional ones, with the added advantages of being less invasive and highly reproducible for long-term graft monitoring. We also integrate the limitations of these novel biomarkers and propose a refined monitoring model to optimize the management of AR in pediatric kidney transplantation.
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Affiliation(s)
- Xingyu Pan
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jinpu Peng
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Rong Zhu
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Nini An
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jun Pei
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China.
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2
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Milligan C, Williams RJ, Singh TP, Bastardi HJ, Esteso P, Almond CS, Gauvreau K, Daly KP. Impact of a positive crossmatch on pediatric heart transplant outcomes. J Heart Lung Transplant 2024; 43:963-972. [PMID: 38423415 PMCID: PMC11090719 DOI: 10.1016/j.healun.2024.02.1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Pediatric heart transplant (HT) candidates experience high waitlist mortality due to a limited donor pool that is constrained in part by anti-HLA sensitization. We evaluated the impact of CDC and Flow donor-specific crossmatch (XM) results on pediatric HT outcomes. METHODS All pediatric HTs between 1999 and 2019 in the OPTN database were included. Donor-specific XM results were sub-categorized based on CDC and Flow results. Primary outcomes were treated rejection in the first year and time to death or allograft loss. Propensity scores were utilized to adjust for differences in baseline characteristics. RESULTS A total of 4,695 pediatric HT patients with T-cell XM data were included. After propensity score adjustment, a positive T-cell CDC-XM was associated with 2 times higher odds of treated rejection (OR 2.29 (1.56, 3.37)) and shorter time to death/allograft loss (HR 1.50 (1.19, 1.88)) compared to a negative Flow-XM. HT recipients who were Flow-XM positive with negative/unknown CDC-XM did not have higher odds of rejection or shorter time to death/allograft loss. An isolated positive B-cell XM was also not associated with worse outcomes. Over the study period XM testing shifted from CDC- to Flow-based assays. CONCLUSIONS A positive donor-specific T-cell CDC-XM was associated with rejection and death/allograft loss following pediatric HT. This association was not observed with a positive T-cell Flow-XM or B-cell XM result alone. The shift away from performing the CDC-XM may result in loss of important prognostic information unless the clinical relevance of quantitative Flow-XM results on heart transplant outcomes is systematically studied.
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Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ryan J Williams
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Heather J Bastardi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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3
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Laroche C, Engen RM. Immune monitoring in pediatric kidney transplant. Pediatr Transplant 2024; 28:e14785. [PMID: 38766986 DOI: 10.1111/petr.14785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Long-term outcomes in pediatric kidney transplantation remain suboptimal, largely related to chronic rejection. Creatinine is a late marker of renal injury, and more sensitive, early markers of allograft injury are an active area of current research. METHODS This is an educational review summarizing existing strategies for monitoring for rejection in kidney transplant recipients. RESULTS We summarize supporting currently available clinical tests, including surveillance biopsy, donor specific antibodies, and donor-derived cell free DNA, as well as the potential limitations of these studies. In addition, we review the current avenues of active research, including transcriptomics, proteomics, metabolomics, and torque tenovirus levels. CONCLUSION Advancing the use of noninvasive immune monitoring will depend on well-designed multicenter trials that include patients with stable graft function, include biopsy results on all patients, and can demonstrate both association with a patient-relevant clinical endpoint such as graft survival or change in glomerular filtration rate and a potential timepoint for intervention.
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Affiliation(s)
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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4
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Panicker AJ, Prokop LJ, Hacke K, Jaramillo A, Griffiths LG. Outcome-based Risk Assessment of Non-HLA Antibodies in Heart Transplantation: A Systematic Review. J Heart Lung Transplant 2024:S1053-2498(24)01683-8. [PMID: 38796046 DOI: 10.1016/j.healun.2024.05.012] [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: 11/06/2023] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND Current monitoring after heart transplantation (HT) employs repeated invasive endomyocardial biopsies (EMB). Although positive EMB confirms rejection, EMB fails to predict impending, subclinical, or EMB-negative rejection events. While non-human leukocyte antigen (non-HLA) antibodies have emerged as important risk factors for antibody-mediated rejection after HT, their use in clinical risk stratification has been limited. A systematic review of the role of non-HLA antibodies in rejection pathologies has the potential to guide efforts to overcome deficiencies of EMB in rejection monitoring. METHODS Databases were searched to include studies on non-HLA antibodies in HT recipients. Data collected included the number of patients, type of rejection, non-HLA antigen studied, association of non-HLA antibodies with rejection, and evidence for synergistic interaction between non-HLA antibodies and donor-specific anti-human leukocyte antigen antibody (HLA-DSA) responses. RESULTS A total of 56 studies met the inclusion criteria. Strength of evidence for each non-HLA antibody was evaluated based on the number of articles and patients in support versus against their role in mediating rejection. Importantly, despite previous intense focus on the role of anti-major histocompatibility complex class I chain-related gene A (MICA) and anti-angiotensin II type I receptor antibodies (AT1R) in HT rejection, evidence for their involvement was equivocal. Conversely, the strength of evidence for other non-HLA antibodies supports that differing rejection pathologies are driven by differing non-HLA antibodies. CONCLUSIONS This systematic review underscores the importance of identifying peri-HT non-HLA antibodies. Current evidence supports the role of non-HLA antibodies in all forms of HT rejection. Further investigations are required to define the mechanisms of action of non-HLA antibodies in HT rejection.
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Affiliation(s)
- Anjali J Panicker
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Immunology, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Katrin Hacke
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona
| | - Andrés Jaramillo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona
| | - Leigh G Griffiths
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, Minnesota.
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5
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Pearl MH. Clinical conundrums in pediatric kidney transplantation: What we know about the role of angiotensin II type I receptor antibodies in pediatric kidney transplantation and the path forward. Pediatr Transplant 2024; 28:e14762. [PMID: 38650537 PMCID: PMC11060698 DOI: 10.1111/petr.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/17/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
Antibodies to angiotensin II type 1 receptor (AT1R-Abs) are among the most well-studied non-HLA antibodies in renal transplantation. These antibodies have been shown to be common in pediatric kidney transplantation and associated with antibody-mediated rejection (AMR), vascular inflammation, development of human leukocyte donor-specific antibodies (HLA DSA), and allograft loss. As AT1R-Ab testing becomes more readily accessible, evidence to guide clinical practice for testing and treating AT1R-Ab positivity in pediatric kidney transplant recipients remains limited. This review discusses the clinical complexities of evaluating AT1R-Abs given the current available evidence.
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Affiliation(s)
- Meghan H Pearl
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
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6
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Xu Q, Zeevi A, Ganoza A, Cruz RJ, Mazariegos GV. Current approaches for risk assessment of intestinal transplant patients: A view from the histocompatibility laboratory. Hum Immunol 2024; 85:110768. [PMID: 38433035 DOI: 10.1016/j.humimm.2024.110768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
Despite its recent decline in volumes, intestinal transplantation remains an important option for patients with irreversible intestinal failures. The long-term outcome of an intestinal transplant has stagnated. The major cause of graft loss is rejection, resulting from mismatches in human leukocyte antigens (HLA) and the presence of antibodies to mismatched donor-specific HLA antigens (DSA). Literature has reported that DSAs, either preformed before transplantation or developed de novo after transplantation, are harmful to intestinal grafts, especially for those without combined liver grafts. A comprehensive assessment of DSA by the histocompatibility laboratory is critical for successful intestinal transplantation and its long-term survival. This paper briefly reviews the history and current status of different methods for detecting DSA and their clinical applications in intestinal transplantation. The focus is on applying different antibody assays to manage immunologically challenging intestinal transplant patients before and after transplantation. A clinical case is presented to illustrate the complexity of HLA tests and the necessity of multiple assays. The review of risk assessment by the histocompatibility laboratory also highlights the need for close interaction between the laboratory and the intestinal transplant program.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology, University of Pittsburgh, USA.
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, USA
| | | | - Ruy J Cruz
- Department of Surgery, University of Pittsburgh, USA; Gastrointestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, USA
| | - George V Mazariegos
- Department of Surgery, University of Pittsburgh, USA; Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, USA
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7
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Khalili M, Famure O, Minkovich M, Tinckam KJ, Kim SJ. Selective Elimination and Rationalization of Cell-based Assays in Deceased Donor Kidney Transplant Crossmatching. Transplant Direct 2024; 10:e1603. [PMID: 38464424 PMCID: PMC10923350 DOI: 10.1097/txd.0000000000001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/30/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
Background While there is increasing reliance on a negative virtual crossmatch to proceed with deceased donor kidney transplantation, a flow cytometry crossmatch (FCXM) is still usually performed after the transplant has already occurred. Our center has eliminated pretransplant physical crossmatches for most patients, and since 2018, we have eliminated the systematic performance of posttransplant FCXMs. Methods We studied all deceased donor kidney transplants in our program between June 1, 2018, and March 31, 2021, to evaluate the impact of eliminating retrospective FCXMs on resource utilization and graft outcomes (ie, the occurrence of antibody-mediated rejection [AMR] in the first 3-mo posttransplant). Results A total of 358 kidney transplants occurred during the study period, and approximately 70% of these transplants proceeded without the performance of any FCXM. Incidence rates of AMR were low (9.63 per 1000 person-months), which compared favorably with the incidence rate of AMR during the 3-y period preceding the policy (4.82 per 1000 person-months, P = 0.21). Conclusions Our results suggest that moving away from retrospective FCXM and relying exclusively on the virtual crossmatch is safe and efficient for kidney allocation.
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Affiliation(s)
- Myriam Khalili
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olusegun Famure
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Michelle Minkovich
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Kathryn J Tinckam
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sang Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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8
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Flynn PA, Fernando S, Worthington JE, Poulton KV. Predicting flow cytometry crossmatch results from single-antigen bead testing. Int J Immunogenet 2024; 51:93-99. [PMID: 38374539 DOI: 10.1111/iji.12658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 02/06/2024] [Indexed: 02/21/2024]
Abstract
The aim of this study was to devise an algorithm that would predict flow cytometry crossmatch (FCXM) results using single-antigen bead (SAB) mean fluorescent intensity (MFI) levels using samples received through the National External Quality Assurance Scheme (NEQAS) 2B external proficiency testing scheme between 2019 and 2023. A total of 159 serum samples were retrospectively screened using LABScreen Single Antigen Class I and II (SAB), and 40 peripheral blood samples were human leucocyte antigen (HLA) typed with LABType SSO. Donor-specific antibodies were identified for each cell-serum combination tested, and cumulative MFI values were calculated for each test before correlating the screening result with the consensus crossmatch results for this scheme. HLA Class I MFIs were combined to predict the T cell crossmatch. For the B cell crossmatch prediction, two options were considered: (i) HLA Class II MFI values alone and (ii) HLA Class I + Class II MFIs. Receiver operating characteristic analysis was carried out to identify the combined MFI threshold that predicted NEQAS consensus results with the greatest sensitivity and specificity. HLA Class I combined MFI >5000 predicted T cell crossmatch results with 96% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 92% negative predictive value (NPV). For B cell results, HLA Class I + Class II combined MFIs >11,000 gave the best model, showing 97% sensitivity, 82% specificity, 96% PPV and 85% NPV. However, for samples with only HLA Class II sensitization, combined MFIs >13,000 improved the B cell crossmatch predictions: 92% sensitivity, 95% specificity, 96% PPV and 91% NPV. Using this model, combined MFI can be used to predict the immunological risk posed by donor-specific antibodies when it is not possible to carry out an FCXM.
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Affiliation(s)
- Patrick A Flynn
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester, UK
| | - Sebastian Fernando
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester, UK
- School of Health Education and Public Health Sciences
| | | | - Kay V Poulton
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester, UK
- School of Health Education and Public Health Sciences
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9
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Harmacek D, Weidmann L, Castrezana Lopez K, Schmid N, Korach R, Bortel N, von Moos S, Rho E, Helmchen B, Gaspert A, Schachtner T. Molecular diagnosis of antibody-mediated rejection: Evaluating biopsy-based transcript diagnostics in the presence of donor-specific antibodies but without microvascular inflammation, a single-center descriptive analysis. Am J Transplant 2024:S1600-6135(24)00244-2. [PMID: 38548057 DOI: 10.1016/j.ajt.2024.03.034] [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: 10/10/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
Biopsy-based transcript diagnostics may identify molecular antibody-mediated rejection (AMR) when microvascular inflammation (MVI) is absent. In this single-center cohort, biopsy-based transcript diagnostics were validated in 326 kidney allograft biopsies. A total of 71 histological AMR and 35 T cell-mediated rejection (TCMR) cases were identified as molecular AMR and TCMR in 55% and 63%, respectively. Among 121 cases without MVI (glomerulitis + peritubular capillaritis = 0), 45 (37%) donor-specific antibody (DSA)-positive and 76 (63%) DSA-negative cases were analyzed. Twenty-one out of the 121 (17%) cases showed borderline changes, or TCMR, while BK nephropathy was excluded. None of the 45 DSA-positive patients showed molecular AMR. Among 76 DSA-negative patients, 2 had mixed molecular AMR/TCMR. All-AMR phenotype scores (sum of R4-R6) exhibited median values of 0.13 and 0.12 for DSA-positive and DSA-negative patients, respectively (P = .84). A total of 13% (6/45) DSA-positive and 11% (8/76) DSA-negative patients showed an all-AMR phenotype score > 0.30 (P = .77). Patients with a higher all-AMR phenotype score showed 33% more histologic TCMR (P = .005). The median all-AMR phenotype scores of glomerular basement membrane double contours = 0 and glomerular basement membrane double contours > 0 biopsies were 0.12 and 0.10, respectively (P = .35). Biopsy-based transcript diagnostics did not identify molecular AMR in cases without MVI. Follow-up biopsies and outcome data should evaluate the clinical relevance of subthreshold molecular alterations.
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Affiliation(s)
- Dusan Harmacek
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Lukas Weidmann
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | | | - Nicolas Schmid
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Raphael Korach
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Nicola Bortel
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Elena Rho
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Birgit Helmchen
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ariana Gaspert
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland.
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10
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Abraha J, Rao P, Morris GP. Modes of assay interference and the effectiveness of serum pretreatment approaches in detection of anti-HLA antibodies. J Clin Pathol 2024; 77:284-290. [PMID: 36600574 DOI: 10.1136/jcp-2022-208371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
AIMS Several modes of assay interference common to immunoassays affect solid-phase single-antigen bead-based immunoassays (SAB) used to detect antibodies against human leucocyte antigens (HLA). Best practice recommendations include methods to address assay interference, though the clinical impact and optimal approaches are undefined. We sought to evaluate assay interference in HLA SAB to identify an efficient approach for avoiding erroneous results. METHODS Retrospective analysis of 14 059 patient samples tested for anti-HLA antibodies was performed. This included 4685 samples tested prior to implementation of serum pretreatment with EDTA and 4982 samples tested with routine EDTA treatment using the same testing algorithm. An algorithm for efficiently identifying and processing samples with suspected interference was evaluated in a separate cohort of 4392 EDTA-treated samples. RESULTS EDTA serum pretreatment reduced assay interference, but did not eliminate all modes of interference. A protocol for identification and testing of samples with suspected interference facilitated efficient detection of interference while reducing the amount of additional testing required. CONCLUSIONS Our data indicate that a single-method approach is insufficient to address all sources of interference in HLA SAB. A multimodal approach with a proactive screening is a more effective way to minimise risk of erroneous results.
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Affiliation(s)
- Joseph Abraha
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Ping Rao
- Aurora Health Care, Milwaukee, Wisconsin, USA
| | - Gerald P Morris
- Department of Pathology, University of California San Diego, La Jolla, California, USA
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11
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Ramalhete L, Araújo R, Teixeira C, Teixeira A, Almeida P, Silva I, Lima A. Evaluation of rapid optimized flow cytometry crossmatch (Halifaster) in living donor kidney transplantation. HLA 2024; 103:e15391. [PMID: 38372638 DOI: 10.1111/tan.15391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024]
Abstract
Kidney transplantation is often the preferred treatment for end-stage renal disease. However, the presence of preformed donor-specific antibodies (DSA), including those against HLA, can lead to antibody-mediated rejection and significantly impact transplant outcomes. The Flow Cytometry Crossmatch (FCXM) is a crucial tool in kidney transplantation, as it also enables the measurement of low levels of anti-HLA DSA antibodies. However, current methodologies for detecting these antibodies, however, are time-consuming and require extensive reagents. In this study, we analyzed the performance of the Halifaster FCXM protocol in 133 consecutive living kidney donor pairs, correlating these results with single antigen-based anti-HLA DSA results. Anti-HLA DSA was identified in 31 patients (23.3%). Both T and B lymphocyte FCXM assays demonstrated high sensitivity and specificity in detecting anti-HLA DSA. Furthermore, a Tree model to determine the levels of anti-HLA DSA to produce a flow crossmatch positivity, was developed offering an accuracy of 93% and 90% for T and B lymphocytes, respectively. Both approaches point to a thresh old of 1000-2000 MFI for T lymphocytes and 3000 MFI for B lymphocytes. Our findings indicate that the Halifaster protocol facilitates fast and efficient FCXM testing without compromising accuracy, marking a significant advancement in the field of kidney transplantation. The inclusion of HLA-specific antibody analysis underscores the protocol's comprehensive approach to improving transplant outcomes.
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Affiliation(s)
- Luis Ramalhete
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- iNOVA4Health - Advancing Precision Medicine, RG11: Reno-Vascular Diseases Group, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rúben Araújo
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Cristiana Teixeira
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
| | - Ana Teixeira
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
| | - Paula Almeida
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
| | - Isabel Silva
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
| | - Alice Lima
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisboa, Portugal
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12
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Shih NR, Nong T, Murphey C, Lopez-Cepero M, Nickerson PW, Taupin JL, Devriese M, Nilsson J, Matignon MB, Bray RA, Lee JH. HLA class I peptide polymorphisms contribute to class II DQβ0603:DQα0103 antibody specificity. Nat Commun 2024; 15:609. [PMID: 38242876 PMCID: PMC10798988 DOI: 10.1038/s41467-024-44912-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
Antibodies reactive to human leukocyte antigens (HLA) represent a barrier for patients awaiting transplantation. Based on reactivity patterns in single-antigen bead (SAB) assays, various epitope matching algorithms have been proposed to improve transplant outcomes. However, some antibody reactivities cannot be explained by amino acid motifs, leading to uncertainty about their clinical relevance. Antibodies against the HLA class II molecule, DQβ0603:DQα0103, present in some candidates, represent one such example. Here, we show that peptides derived from amino acids 119-148 of the HLA class I heavy chain are bound to DQβ0603:DQα0103 proteins and contribute to antibody reactivity through an HLA-DM-dependent process. Moreover, antibody reactivity is impacted by the specific amino acid sequence presented. In summary, we demonstrate that polymorphic HLA class I peptides, bound to HLA class II proteins, can directly or indirectly be part of the antibody binding epitope. Our findings have potential important implications for the field of transplant immunology and for our understanding of adaptive immunity.
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Affiliation(s)
- N Remi Shih
- Terasaki Innovation Center, Los Angeles, CA, USA
| | - Thoa Nong
- Terasaki Innovation Center, Los Angeles, CA, USA
| | - Cathi Murphey
- Southwest Immunodiagnostics, Inc., San Antonio, TX, USA
| | | | - Peter W Nickerson
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité and INSERM U976 IRSL, Hôpital Saint-Louis APHP, Paris, France
| | - Magali Devriese
- Laboratoire d'Immunologie et Histocompatibilité and INSERM U976 IRSL, Hôpital Saint-Louis APHP, Paris, France
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | | | - Robert A Bray
- Department of Pathology, Emory University, Atlanta, GA, USA
| | - Jar-How Lee
- Terasaki Innovation Center, Los Angeles, CA, USA.
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13
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Pedini P, Hubert L, Baudey JB, Etienne JM, Basire A, Vey N, Chiaroni J, Chabrières C, Ladaique P, Picard C. Comparison of HLA antibody identification methods for the selection of platelet products for HLA-mediated platelet refractory patients. HLA 2024; 103:e15276. [PMID: 37947374 DOI: 10.1111/tan.15276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/20/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
In an ineffective transfusion context, solid-phase immunoassays using the Luminex platform for the detection and characterization of HLA antibodies are currently used to select HLA-compatible platelet products. A new HLA antibody identification method, the HISTO SPOT® HLA AB test (BAG Health care GmbH, Lich, Germany), based on the detection of antibodies directed against a recombinant single antigen (SA) by colored spots detected by HISTO MATCH HLA AB module software, runs fully automated on the MR.SPOT®. The aim of this study was to compare the ability of the HISTO SPOT HLA AB and C1qScreen™ (C1q SAB) assays with that of the Labscreen single antigen class I (OL SAB) assay to detect anti-HLA class I antibodies in 56 serum samples from 54 platelet refractory acute myeloid leukemia patients who received HLA mismatch platelet concentrates at a single oncohematology center. In total, 1414 class I specificities, 433 HLA-A and 981 HLA-B, were detected by the OL SAB test. The mean fluorescence intensity (MFI) was >5000 for 874 antigens and <5000 for 655 antigens. The HISTO SPOT® HLA AB and C1q SAB tests identified 85% and 79% of OL SA-detected antigens with an MFI >5000, respectively, but did not identify 34% and 44% of OL SAB-detected antigens, highlighting the lower sensitivity of these techniques. Interestingly, the donor-specific antibodies (DSAs) identified by the HISTO SPOT® HLA AB and C1q SAB assays reacted against HLA mismatch platelet concentrates with the same specificity (86%) and positive predictive (77%) value as in the OL SAB test when the MFI threshold was >2000 for DSA detection. Although the HISTO SPOT® HLA AB test is less sensitive than the OL SAB test, this test could be used for the selection of HLA-compatible platelet products.
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Affiliation(s)
- Pascal Pedini
- Immunogenetic and Histocompatibility Laboratory, EFS PACC, Marseille, France
- ADES UMR, Aix Marseille Univ, Marseille, France
| | - Lucas Hubert
- Immunogenetic and Histocompatibility Laboratory, EFS PACC, Marseille, France
| | | | - Jean-Michel Etienne
- Immunohematology Laboratory, Institut Paoli-calmettes, EFS PACC, Marseille, France
| | - Agnes Basire
- Immunogenetic and Histocompatibility Laboratory, EFS PACC, Marseille, France
| | - Norbert Vey
- Onco-Hématology Department, Institut Paoli-calmettes, Marseille, France
| | | | - Corinne Chabrières
- Immunohematology Laboratory, Institut Paoli-calmettes, EFS PACC, Marseille, France
| | - Patrick Ladaique
- Onco-Hématology Department, Institut Paoli-calmettes, Marseille, France
| | - Christophe Picard
- Immunogenetic and Histocompatibility Laboratory, EFS PACC, Marseille, France
- ADES UMR, Aix Marseille Univ, Marseille, France
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14
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Sullivan HC, Gandhi MJ, Gaitonde S, Narasimhan R, Gendzekhadze K, Pandey S, Roby RK, Maha GC, Kaur H, Schiller JJ, McDowell J, Smith M, Liu C, Morris GP. Seventy-five years of service: an overview of the College of American Pathologists' proficiency testing program in histocompatibility and identity testing. Front Genet 2023; 14:1331169. [PMID: 38169613 PMCID: PMC10758433 DOI: 10.3389/fgene.2023.1331169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
The Histocompatibility and Identity Testing Committee offers an overview of the College of American Pathologists' (CAP) Proficiency Testing (PT) program, commemorating its significant 75th anniversary in 2024. The CAP PT program has undergone significant growth and evolution over the years, ultimately achieving Centers for Medicare and Medicaid Services approval. In 1979, CAP's partnership with the American Association for Clinical Histocompatibility Testing marked a pivotal moment, leading to the creation of the first proficiency testing survey in 1980. This laid the foundation for various PT programs managed by the CAP Histocompatibility and Identity Testing Committee, including HLA antibody testing, HLA molecular typing, engraftment monitoring, parentage/relationship testing, HLA disease associations and drug risk, and HLA-B27 typing. Each program's distinctive considerations, grading methodologies, and future prospects are detailed here, highlighting the continual evolution of histocompatibility and identity testing PT to support emerging technologies and evolving laboratory practices in the field.
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Affiliation(s)
- H. Cliff Sullivan
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - Manish J. Gandhi
- Mayo Clinic, Department of Laboratory Medicine and Pathology, Rochester, MN, United States
| | - Sujata Gaitonde
- Department of Pathology, University of Illinois Chicago, Chicago, IL, United States
| | - Ramya Narasimhan
- Boston University Medical Center, Department of Pathology and Laboratory Medicine, Boston, MA, United States
| | | | - Soumya Pandey
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Rhonda K. Roby
- Alameda County Sheriff’s Office Crime Laboratory, Oakland, CA, United States
| | | | - Harmeet Kaur
- Cuyahoga County Regional Forensic Science Lab, Cleveland, OH, United States
| | | | - Julie McDowell
- College of American Pathologist (CAP), Chicago, IL, United States
| | - Maria Smith
- College of American Pathologist (CAP), Chicago, IL, United States
| | - Chang Liu
- Washington University in St. Louis, Department of Pathology and Immunology, Saint Louis, MO, United States
| | - Gerald P. Morris
- Department of Pathology, Univeristy of California San Diego, San Diego, CA, United States
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15
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Marco I, López-Azor García JC, González Martín J, Severo Sánchez A, García-Cosío Carmena MD, Mancebo Sierra E, de Juan Bagudá J, Castrodeza Calvo J, Hernández Pérez FJ, Delgado JF. De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians. J Clin Med 2023; 12:7474. [PMID: 38068526 PMCID: PMC10707043 DOI: 10.3390/jcm12237474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 04/12/2024] Open
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.
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Affiliation(s)
- Irene Marco
- Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Juan Carlos López-Azor García
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain; (J.C.L.-A.G.); (F.J.H.P.)
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Javier González Martín
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - María Dolores García-Cosío Carmena
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Esther Mancebo Sierra
- Immunology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier de Juan Bagudá
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier Castrodeza Calvo
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | | | - Juan Francisco Delgado
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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16
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Kim HJ, Chung Y, Kim H, Ko DH. Clinical significance of IgM and IgG isoagglutinins in ABO-incompatible solid organ transplantation: Insights from materno-fetal immunoglobulin status. Transfus Apher Sci 2023; 62:103786. [PMID: 37657949 DOI: 10.1016/j.transci.2023.103786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Han Joo Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, the Republic of Korea
| | - Yousun Chung
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Seoul, the Republic of Korea
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, the Republic of Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, the Republic of Korea.
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17
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Wiebe C, Balshaw R, Gibson IW, Ho J, Shaw J, Karpinski M, Trachtenberg A, Pochinco D, Goldberg A, Birk P, Pinsk M, Rush DN, Nickerson PW. A rational approach to guide cost-effective de novo donor-specific antibody surveillance with tacrolimus immunosuppression. Am J Transplant 2023; 23:1882-1892. [PMID: 37543094 DOI: 10.1016/j.ajt.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
De novo donor-specific antibody (dnDSA) after renal transplantation has been shown to correlate with antibody-mediated rejection and allograft loss. However, the lack of proven interventions and the time and cost associated with annual screening for dnDSA are difficult to justify for all recipients. We studied a well-characterized consecutive cohort (n = 949) with over 15 years of prospective dnDSA surveillance to identify risk factors that would help institute a resource-responsible surveillance strategy. Younger recipient age and HLA-DR/DQ molecular mismatch were independent predictors of dnDSA development. Combining both risk factors into recipient age molecular mismatch categories, we found that 52% of recipients could be categorized as low-risk for dnDSA development (median subclinical dnDSA-free survival at 5 and 10 years, 98% and 97%, respectively). After adjustment, multivariate correlates of dnDSA development included tacrolimus versus cyclosporin maintenance immunosuppression (hazard ratio [HR], 0.37; 95% CI, 0.2-0.6; P < .0001) and recipient age molecular mismatch category: intermediate versus low (HR, 2.48; 95% CI, 1.5-4.2; P = .0007), high versus intermediate (HR, 2.56; 95% CI, 1.6-4.2; P = .0002), and high versus low (HR, 6.36; 95% CI, 3.7-10.8; P < .00001). When combined, recipient age and HLA-DR/DQ molecular mismatch provide a novel data-driven approach to reduce testing by >50% while selecting those most likely to benefit from dnDSA surveillance.
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Affiliation(s)
- Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada.
| | - Rob Balshaw
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ian W Gibson
- Shared Health Services Manitoba, Winnipeg, Manitoba, Canada; Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Jamie Shaw
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Karpinski
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aaron Trachtenberg
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Aviva Goldberg
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia Birk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maury Pinsk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David N Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Peter W Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
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18
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Gnanaraj J, Doss SA, Stephen S, Pratheeba M, Daniel D. Fallacies of a purely virtual platform: Virtual plus reality versus virtual reality - A case study. Transpl Immunol 2023; 81:101956. [PMID: 37952899 DOI: 10.1016/j.trim.2023.101956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Abstract
Pretransplant immunological assessment of a transplant donor has evolved significantly over the last few decades with the advent of testing platforms with enhanced sensitivity and varying formats. The single antigen bead assay (SAB) assay, a virtual crossmatch (vXM) is used extensively and considered the gold standard for defining donor-specific antibodies (DSA) in many parts of the World. A country like India, is however challenged by the lack of adequate representation of locally frequent HLA alleles and hence in our institution, we continue to perform a physical crossmatch (pXM) on the Complement Dependent Cytotoxicity and flow cytometry platforms alongside the SAB. We report here a case report where the discrepancy between platforms of testing have raised certain pertinent questions in our interpretation of the vXM.
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Affiliation(s)
- John Gnanaraj
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sam Arul Doss
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Stephen
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - M Pratheeba
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Department of Transfusion medicine & Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India.
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19
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Han HS, Lubetzky ML. Immune monitoring of allograft status in kidney transplant recipients. FRONTIERS IN NEPHROLOGY 2023; 3:1293907. [PMID: 38022723 PMCID: PMC10663942 DOI: 10.3389/fneph.2023.1293907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
Kidney transplant patients require careful management of immunosuppression to avoid rejection while minimizing the risk of infection and malignancy for the best long-term outcome. The gold standard for monitoring allograft status and immunosuppression adequacy is a kidney biopsy, but this is invasive and costly. Conventional methods of allograft monitoring, such as serum creatinine level, are non-specific. Although they alert physicians to the need to evaluate graft dysfunction, by the time there is a clinical abnormality, allograft damage may have already occurred. The development of novel and non-invasive methods of evaluating allograft status are important to improving graft outcomes. This review summarizes the available conventional and novel methods for monitoring allograft status after kidney transplant. Novel and less invasive methods include gene expression, cell-free DNA, urinary biomarkers, and the use of artificial intelligence. The optimal method to manage patients after kidney transplant is still being investigated. The development of less invasive methods to assess allograft function has the potential to improve patient outcomes and allow for a more personalized approach to immunosuppression management.
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Affiliation(s)
- Hwarang S. Han
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, United States
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20
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Karahan GE, Haasnoot GW, Voogt-Bakker K, Claas FHJ, Roelen D, Heidt S. A modeling approach for mean fluorescence intensity value harmonization and cutoff prediction for luminex single antigen bead assays of two different vendors. HLA 2023; 102:557-569. [PMID: 37130801 DOI: 10.1111/tan.15082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
Luminex single antigen bead (SAB) kits from One Lambda (OL) and Lifecodes (LC) are widely used for HLA antibody detection but have substantial differences in design and assay protocol resulting in different mean fluorescence intensity (MFI) values. Here, we present a non-linear modeling approach to accurately convert MFI values between two vendors and to establish user-independent MFI cutoffs when analyzing big datasets. HLA antibody data from a total of 47 EDTA-treated sera tested using both OL and LC SAB kits were analyzed. MFI comparisons were made for the common 84 HLA class I and 63 class II beads. In the exploration set (n = 24), a non-linear hyperbola model on raw MFI corrected by locus-specific highest self MFI subtraction yielded the highest correlation (class I r2 : 0.946, class II r2 : 0.898). Performance of the model was verified in an independent validation set (n = 12) (class I r2 : 0.952, class II r2 : 0.911). Furthermore, in an independent cohort of post-transplant serum samples (n = 11) using the vendor-specific MFI cutoffs dictated by the current model, we found 94% accuracy in bead-specific reactivity assignments by the two vendors. We recommend using the non-linear hyperbola modeling approach with self HLA correction and locus-specific analyzes to harmonize MFI values between two vendors in particular research datasets. As there are considerable variations between the two assays, using MFI conversion for individual patient samples is not recommended.
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Affiliation(s)
- Gonca E Karahan
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Geert W Haasnoot
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim Voogt-Bakker
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans H J Claas
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dave Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
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21
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Battle R, Pritchard D, Peacock S, Hastie C, Worthington J, Jordan S, McCaughlan JA, Barnardo M, Cope R, Collins C, Diaz-Burlinson N, Rosser C, Foster L, Kallon D, Shaw O, Briggs D, Turner D, Anand A, Akbarzad-Yousefi A, Sage D. BSHI and BTS UK guideline on the detection of alloantibodies in solid organ (and islet) transplantation. Int J Immunogenet 2023; 50 Suppl 2:3-63. [PMID: 37919251 DOI: 10.1111/iji.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
Solid organ transplantation represents the best (and in many cases only) treatment option for patients with end-stage organ failure. The effectiveness and functioning life of these transplants has improved each decade due to surgical and clinical advances, and accurate histocompatibility assessment. Patient exposure to alloantigen from another individual is a common occurrence and takes place through pregnancies, blood transfusions or previous transplantation. Such exposure to alloantigen's can lead to the formation of circulating alloreactive antibodies which can be deleterious to solid organ transplant outcome. The purpose of these guidelines is to update to the previous BSHI/BTS guidelines 2016 on the relevance, assessment, and management of alloantibodies within solid organ transplantation.
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Affiliation(s)
- Richard Battle
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | | | - Sarah Peacock
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Sue Jordan
- National Blood Service Tooting, London, UK
| | | | - Martin Barnardo
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebecca Cope
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Luke Foster
- Birmingham Blood Donor Centre, Birmingham, UK
| | | | - Olivia Shaw
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David Turner
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Arthi Anand
- Imperial College Healthcare NHS Trust, London, UK
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22
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van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
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Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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23
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Betjes MGH, De Weerd A. Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and clinical dots. Front Med (Lausanne) 2023; 10:1215167. [PMID: 37502354 PMCID: PMC10368955 DOI: 10.3389/fmed.2023.1215167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
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Marinaki S, Vittoraki A, Tsiakas S, Kofotolios I, Darema M, Ioannou S, Vallianou K, Boletis J. Clinical Outcome of Kidney Transplant Recipients with C1q-Binding De Novo Donor Specific Antibodies: A Single-Center Experience. J Clin Med 2023; 12:4475. [PMID: 37445510 DOI: 10.3390/jcm12134475] [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: 02/19/2023] [Revised: 07/01/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
Complement activation by HLA antibodies is a key component of immune-mediated graft injury. We examined the clinical outcomes of kidney transplant recipients with complement-fixing de novo donor-specific antibodies (dnDSA) who were followed in our center. The C1q-binding ability was retrospectively assessed in 69 patients with dnDSA and mean fluorescence intensity (MFI) values > 2000 out of the 1325 kidney transplant recipients who were screened for DSA between 2015 and 2019. Luminex IgG single antigen beads (SAB)and C1q-SAB assays (One Lambda) were used. C1q-binding dnDSA was identified in 32/69 (46.4%) of the patients. Significantly higher MFI values were observed in C1q-positive DSA (18,978 versus 5840, p < 0.001). Renal graft biopsies were performed in 43 of the kidney transplant recipients (62.3%) with allograft dysfunction. Antibody-mediated rejection (ABMR) was detected in 29/43 (67.4%) of the patients. The incidence of ABMR was similar among patients with C1q-binding and non-C1q-binding DSA (51.7% vs. 48.3%, p = 0.523). Graft loss occurred in 30/69 (43.5%) of the patients at a median time of 82.5 months (IQR 45-135) from DSA detection. C1q-binding DSA was present in more patients who experienced graft loss (53.1% vs. 35.1%, p = 0.152). Higher MFI values and inferior clinical outcomes occurred in most of the kidney transplant recipients with C1q-binding dnDSA.
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Affiliation(s)
- Smaragdi Marinaki
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Angeliki Vittoraki
- Immunology Department, National Tissue Typing Center, General Hospital of Athens "G. Gennimatas", 11527 Athens, Greece
| | - Stathis Tsiakas
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Ioannis Kofotolios
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Maria Darema
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - Sofia Ioannou
- Immunology Department, National Tissue Typing Center, General Hospital of Athens "G. Gennimatas", 11527 Athens, Greece
| | - Kalliopi Vallianou
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
| | - John Boletis
- Clinic of Nephrology and Renal Transplantation, National and Kapodistrian University of Athens Medical School, Laiko Hospital, 11527 Athens, Greece
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Lee H, Lee H, Eum SH, Ko EJ, Min JW, Oh EJ, Yang CW, Chung BH. Impact of Low-Level Donor-Specific Anti-HLA Antibody on Posttransplant Clinical Outcomes in Kidney Transplant Recipients. Ann Lab Med 2023; 43:364-374. [PMID: 36843405 PMCID: PMC9989540 DOI: 10.3343/alm.2023.43.4.364] [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: 09/02/2022] [Revised: 12/07/2022] [Accepted: 01/27/2023] [Indexed: 02/28/2023] Open
Abstract
Background The clinical significance of low-level donor-specific anti-HLA antibody (low-DSA) remains controversial. We investigated the impact of low-DSA on posttransplant clinical outcomes in kidney transplant (KT) recipients. Methods We retrospectively reviewed 1,027 KT recipients, namely, 629 living donor KT (LDKT) recipients and 398 deceased donor KT (DDKT) recipients, in Seoul St. Mary's Hospital (Seoul, Korea) between 2010 and 2018. Low-DSA was defined as a positive anti-HLA-DSA result in the Luminex single antigen assay (LABScreen single antigen HLA class I - combi and class II - group 1 kits; One Lambda, Canoga Park, CA, USA) but a negative result in a crossmatch test. We compared the incidence of biopsy-proven allograft rejection (BPAR), changes in allograft function, allograft survival, patient survival, and posttransplant infections between subgroups according to pretransplant low-DSA. Results The incidence of overall BPAR and T cell-mediated rejection did not differ between the subgroups. However, antibody-mediated rejection (ABMR) developed more frequently in patients with low-DSA than in those without low-DSA in the total cohort and the LDKT and DDKT subgroups. In multivariate analysis, low-DSA was identified as a risk factor for ABMR development. Its impact was more pronounced in DDKT (odds ratio [OR]: 9.60, 95% confidence interval [CI]: 1.79-51.56) than in LDKT (OR: 3.76, 95% CI: 0.99-14.26) recipients. There were no significant differences in other outcomes according to pretransplant low-DSA. Conclusions Pretransplant low-DSA has a significant impact on the development of ABMR, and more so in DDKT recipients than in LDKT recipients, but not on long-term outcomes.
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Affiliation(s)
- Haeun Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hanbi Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hun Eum
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Eun Jeong Ko
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Nam M, Song EY. Impact of Low-level Donor-specific Antibody Determined With a Positive Luminex and Negative Flow Cytometric Crossmatch on Kidney Transplantation Outcomes. Ann Lab Med 2023; 43:325-327. [PMID: 36843400 PMCID: PMC9989535 DOI: 10.3343/alm.2023.43.4.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Affiliation(s)
- Minjeong Nam
- Laboratory Medicine, Korea University College of Medicine, Seoul, Korea
| | - Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
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Kueht ML, Dongur LP, Mujtaba MA, Cusick MF. Antibody Therapeutics as Interfering Agents in Flow Cytometry Crossmatch for Organ Transplantation. J Pers Med 2023; 13:1005. [PMID: 37373995 DOI: 10.3390/jpm13061005] [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: 04/17/2023] [Revised: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Donor-recipient matching is a highly individualized and complex component of solid organ transplantation. Flowcytometry crossmatching (FC-XM) is an integral step in the matching process that is used to detect pre-formed deleterious anti-donor immunoglobulin. Despite high sensitivity in detecting cell-bound immunoglobulin, FC-XM is not able to determine the source or function of immunoglobulins detected. Monoclonal antibody therapeutic agents used in a clinic can interfere with the interpretation of FC-XM. We combined data from the prospectively maintained Antibody Society database and Human Protein Atlas with a comprehensive literature review of PubMed to summarize known FC-XM-interfering antibody therapeutics and identify potential interferers. We identified eight unique FC-XM-interfering antibody therapeutics. Rituximab (anti-CD20) was the most-cited agent. Daratumuab (anti-CD38) was the newest reported agent. We identified 43 unreported antibody therapeutics that may interfere with FC-XM. As antibody therapeutic agents become more common, identifying and mitigating FC-XM interference will likely become an increased focus for transplant centers.
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Affiliation(s)
- Michael L Kueht
- Department of Surgery, Multiorgan Transplant and Hepatobiliary Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Laxmi Priya Dongur
- Department of Surgery, Multiorgan Transplant and Hepatobiliary Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Muhammad A Mujtaba
- Department of Medicine, Transplant Nephrology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Matthew F Cusick
- Department of Pathology, Division of Histocompatibility and Immunogenetics, University of Michigan Medicine, 2800 Plymouth Rd., Building 36, Ann Arbor, MI 48109, USA
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28
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Martin-González ID, Barrera-Lozano LM, Villada-Ochoa OA, Ramírez-Arbeláez JA, López-Pompey NA, Palacios DA, Becerra-Romero JA, Muñoz CL, González-Arroyave D, Ardila CM. Comparison of Outcomes and Survival of Two Cohorts of Patients with Simultaneous Pancreas-Kidney Transplantation: A Retrospective Cohort Study in a Latin American Hospital. BIOMED RESEARCH INTERNATIONAL 2023; 2023:2734072. [PMID: 37359049 PMCID: PMC10287523 DOI: 10.1155/2023/2734072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
Background Simultaneous pancreas-kidney transplantation (SPKT) is a complex and demanding procedure with a considerable risk of morbidity and mortality. Advances in surgical techniques and organ preservation have introduced changes in care protocols. Two cohorts of patients receiving SPKT with two different protocols were compared to determine overall survival and pancreatic and renal graft failure-free survival. Methods This retrospective observational study was conducted in two cohorts of SPKT recipient patients that underwent surgery between 2001 and 2021. Outcomes were compared in transplant patients between 2001 and 2011 (cohort 1; initial protocol) and 2012-2021 (cohort 2; improved protocol). In addition to the temporality, the cohorts were defined by a protocolization of technical aspects and medical management in cohort 2 (improved protocol), compared to a wide variability in the procedures carried out in cohort 1 (initial protocol). Overall survival and pancreatic and renal graft failure-free survival were the primary outcomes. These outcomes were determined using Kaplan-Meier survival analysis and the log-rank test. Results Fifty-five SPKT were performed during the study period: 32 in cohort 1 and 23 in cohort 2. In the survival analysis, an average of 2546 days (95% CI: 1902-3190) was found in cohort 1, while in cohort 2, it was 2540 days (95% CI: 2100-3204) (p > 0.05). Pancreatic graft failure-free survival had an average of 1705 days (95% CI: 1037-2373) in cohort 1, lower than the average in cohort 2 (2337 days; 95% CI: 1887-2788) (p = 0.016). Similarly, renal graft failure-free survival had an average of 2167 days (95% CI: 1485-2849) in cohort 1, lower than the average in cohort 2 (2583 days; 95% CI: 2159-3006) (p = 0.017). Conclusions This analysis indicates that pancreatic and renal graft failure-free survival associated with SPKT decreased significantly in cohort 2, with results related to improvements in the treatment protocol implemented in that cohort.
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Affiliation(s)
| | - Luis Manuel Barrera-Lozano
- Digestive Diseases and Transplant Functional Unit, Hospital San Vicente Fundación, Rionegro, Colombia
- Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Oscar Alonso Villada-Ochoa
- Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
- Research Unit, Hospital San Vicente Fundación, Rionegro, Colombia
| | | | | | - Dabely América Palacios
- Digestive Diseases and Transplant Functional Unit, Hospital San Vicente Fundación, Rionegro, Colombia
| | - Jorge Andrés Becerra-Romero
- Digestive Diseases and Transplant Functional Unit, Hospital San Vicente Fundación, Rionegro, Colombia
- Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Cristian Leonardo Muñoz
- Digestive Diseases and Transplant Functional Unit, Hospital San Vicente Fundación, Rionegro, Colombia
| | - Daniel González-Arroyave
- Digestive Diseases and Transplant Functional Unit, Hospital San Vicente Fundación, Rionegro, Colombia
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29
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Schneider MM, Scheidt T, Priddey AJ, Xu CK, Hu M, Meisl G, Devenish SRA, Dobson CM, Kosmoliaptsis V, Knowles TPJ. Microfluidic antibody affinity profiling of alloantibody-HLA interactions in human serum. Biosens Bioelectron 2023; 228:115196. [PMID: 36921387 DOI: 10.1016/j.bios.2023.115196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/17/2023] [Accepted: 03/03/2023] [Indexed: 03/07/2023]
Abstract
Antibody profiling is a fundamental component of understanding the humoral response in a wide range of disease areas. Most currently used approaches operate by capturing antibodies onto functionalised surfaces. Such measurements of surface binding are governed by an overall antibody titre, while the two fundamental molecular parameters, antibody affinity and antibody concentration, are challenging to determine individually from such approaches. Here, by applying microfluidic diffusional sizing (MDS), we show how we can overcome this challenge and demonstrate reliable quantification of alloantibody binding affinity and concentration of alloantibodies binding to Human Leukocyte Antigens (HLA), an extensively used clinical biomarker in organ transplantation, both in buffer and in crude human serum. Capitalising on the ability to vary both serum and HLA concentrations during MDS, we show that both affinity and concentration of HLA-specific antibodies can be determined directly in serum when neither of these parameters is known. Finally, we provide proof of principle in clinical transplant patient sera that our assay enables differentiation of alloantibody reactivity against HLA proteins of highly similar structure, providing information not attainable through currently available techniques. These results outline a path towards detection and in-depth profiling of humoral immunity and may enable further insights into the clinical relevance of antibody reactivity in clinical transplantation and beyond.
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Affiliation(s)
- Matthias M Schneider
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Tom Scheidt
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Ashley J Priddey
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Catherine K Xu
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Mengsha Hu
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Georg Meisl
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Sean R A Devenish
- Fluidic Analytics, Unit A, The Paddocks Business Centre, Cherry Hinton Rd, Cambridge, CB1 8DH, UK
| | - Christopher M Dobson
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK; NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK; NIHR Cambridge Biomedical Research Centre, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Tuomas P J Knowles
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, CB2 1EW, UK; Cavendish Laboratory, Department of Physics, University of Cambridge, JJ Thomson Ave, Cambridge, CB3 0HE, UK.
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30
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Steinbach EJ, Barletta GM, Patel HP, Hooper DK, Garro R, Harshman LA. Donor specific antibody surveillance among pediatric kidney transplant programs: A report from the improving renal outcome collaborative. Pediatr Transplant 2023; 27:e14498. [PMID: 36898856 PMCID: PMC10305844 DOI: 10.1111/petr.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/23/2023] [Accepted: 02/22/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Kidney transplantation (KT) is the preferred treatment for children with end-stage kidney disease. Recent advances in immunosuppression and advances in donor specific antibody (DSA) testing have resulted in prolonged allograft survival; however, standardized approaches for surveillance DSA monitoring and management of de novo (dn) DSA are widely variable among pediatric KT programs. METHODS Pediatric transplant nephrologists in the multi-center Improving Renal Outcomes Collaborative (IROC) participated in a voluntary, web-based survey between 2019 and 2020. Centers provided information pertaining to frequency and timing of routine DSA surveillance and theoretical management of dnDSA development in the setting of stable graft function. RESULTS 29/30 IROC centers responded to the survey. Among the participating centers, screening for DSA occurs, on average, every 3 months for the first 12 months post-transplant. Antibody mean fluorescent intensity and trend most frequently directed changes in patient management. Increased creatinine above baseline was reported by all centers as an indication for DSA assessment outside of routine surveillance testing. 24/29 centers would continue to monitor DSA and/or intensify immunosuppression after detection of antibodies in the setting of stable graft function. In addition to enhanced monitoring, 10/29 centers reported performing an allograft biopsy upon detection of dnDSA, even in the setting of stable graft function. CONCLUSIONS This descriptive report is the largest reported survey of pediatric transplant nephrologist practice patterns on this topic and provides a reference for monitoring dnDSA in the pediatric kidney transplant population.
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Affiliation(s)
- Emily J Steinbach
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Gina M Barletta
- Department of Pediatric Nephrology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Hiren P Patel
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rouba Garro
- Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lyndsay A Harshman
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
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31
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Neeraja M, Kesireddy S, Kumar NR, Kumar MP, Pullaiah P, Chittampalli R. Donor-Specific Antibody Detection by Single-Antigen Bead Assay for Renal Transplantation: A 2-Year Experience from South India. Indian J Nephrol 2023; 33:170-176. [PMID: 37448891 PMCID: PMC10337226 DOI: 10.4103/ijn.ijn_462_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 09/12/2021] [Accepted: 05/08/2022] [Indexed: 07/15/2023] Open
Abstract
Introduction Recipient sensitization against donor human leukocyte antigens (HLA) plays a key role in transplant rejection, and this risk is best minimized by efficient pre transplant antibody detection. Determination of antibody specificity with the highest sensitivity and degree of resolution to the allelic antigen level is achieved by using single-antigen bead (SAB) assay. Methods This study evaluated the correlation of Luminex cross match (LXM) with SAB assay for detection of donor-specific antibodies (DSA). A total of 2075 renal transplant patients were screened for the presence of DSA by LXM, complement-dependent cytotoxicity (CDC) cross match, and 125 patients for SAB from January 2018 to December 2019. Results There was a male preponderance among recipients (P < 0.0001), and the most affected age group was 21-40 years. HLA typing was done in 550/2075 by DNA PCR-reverse sequence-specific oligonucleotide probes (SSOP) method. HLA DSA by LXM was detected in 16.3% of recipients (338/2075). Majority 180/338 (53.2%) of the patients were class II DSA positive, (P < 0.0001). Among the class II DSA positive patients, 20/180 (11.1%) samples gave false-positive results by LXM. SAB for class I and class II HLA IgG antibodies was done in 125/338 renal transplant recipients, which included 20 recipients with false-positive class II Luminex DSA, to check whether the DSA detected were really donor specific or not. The results showed that although 20/125 patients had some antibodies detected in their serum, they were not against the donor HLA antigens, as per the HLA typing reports of the donors. When compared to SAB assay, LXM showed more discrepant results, particularly to class II DSA. Conclusion In conclusion, LXM, if used in combination with SAB assay and HLA typing of donors if necessary for virtual cross match, will help in avoiding unnecessary exclusion of donors for renal transplant recipients and also for post transplant monitoring of recipients, especially in cadaveric donor transplants.
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Affiliation(s)
- Mamidi Neeraja
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| | - Sreedhar Kesireddy
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| | - Neerudi Raj Kumar
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| | - Madasu Praveen Kumar
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| | - Potlapally Pullaiah
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| | - Raju Chittampalli
- Department of Transplant Immunology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
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32
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Nascimento E, Filho AS, Lucas-Junior FDM, Jobim LFJ, Lasmar MF, Tavares-Filho HA, Fabreti-Oliveira RA. Remarkable 107-year-old kidney with a 49-year of long-term allograph survival through continuous azathioprine monotherapy. Transpl Immunol 2023; 78:101821. [PMID: 36921732 DOI: 10.1016/j.trim.2023.101821] [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: 09/19/2022] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The main goal of kidney allograft transplantation is to improve survival in patients with end-stage kidney failure. Herein, we report a 49-year long-term allograft survival with non-identical human leukocyte antigens (HLA). The purpose of this study was to report the successful clinical outcome of 49 years of transplant survival in a 79-year-old patient with a 107-year-old kidney undergoing continued immunosuppressive monotherapy. MATERIAL AND METHODS The patient was evaluated clinically and immunologically with HLA typing and anti-HLA antibodies before transplantation. Post-transplant, the patient's clinical and immunological survival were monitored for 49 years. The state of the chimerism was assessed using the polymerase chain reaction to amplify 24 short tandem repeats using a DNA thermocycler and DNA analyzer. RESULTS The patient and donor were haploidentical and the patient was treated with azathioprine monotherapy. Donor-specific antibodies were detected only for the HLA-DPB1* 03:01 mismatch. This patient developed multiple skin tumors 26 years after transplant, which were successfully treated with topical therapy or surgical removal. The patient developed an intestinal adenocarcinoma 43 years after kidney transplantation, which was surgically removal; six years later, adenocarcinoma was diagnosed in a finger, followed by axillar and hepatic metastases. After 49 years of graft survival of a kidney of 107 years old in a patient with 79 years of age, the patient's health worsened with severe dehydration, anemia, and bacterial infection. The patient was hospitalized with a serum creatinine level of 3.45 mg/dL, urea level of 188 mg/dL, and estimated glomerular filtration rate of 22 mL/1.72 m2; septicemia developed and was treated with antibiotics. The patient had poor clinical progress, was intubated, and later died due to septic shock. CONCLUSIONS To the best of our knowledge, this is the first case of a 107-year-old kidney, transplanted into a recipient who was treated with azathioprine monotherapy for 49 years.
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Affiliation(s)
- Evaldo Nascimento
- Clinical Hospital, Kidney Transplant Unit, Belo Horizonte, MG, Brazil; Faculty of the Hospital Santa Casa, Belo Horizonte, MG, Brazil; IMUNOLAB - Laboratory of Transplant Immunology, Belo Horizonte, MG, Brazil.
| | | | | | - Luiz F J Jobim
- Clinical Hospital of Porto Alegre, Rio Grande do Sul, Brazil.
| | | | | | - Raquel A Fabreti-Oliveira
- IMUNOLAB - Laboratory of Transplant Immunology, Belo Horizonte, MG, Brazil; Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil.
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Pascual J, Crespo M, Portoles J, Jimenez C, Ortega-Carrion A, Diez T, Portero I. The IMBG Test for Evaluating the Pharmacodynamic Response to Immunosuppressive Therapy in Kidney Transplant Patients: Current Evidence and Future Applications. Int J Mol Sci 2023; 24:ijms24065201. [PMID: 36982276 PMCID: PMC10049381 DOI: 10.3390/ijms24065201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Immunosuppressive drugs are widely used to prevent rejection after kidney transplantation. However, the pharmacological response to a given immunosuppressant can vary markedly between individuals, with some showing poor treatment responses and/or experiencing serious side effects. There is an unmet need for diagnostic tools that allow clinicians to individually tailor immunosuppressive therapy to a patient’s immunological profile. The Immunobiogram (IMBG) is a novel blood-based in vitro diagnostic test that provides a pharmacodynamic readout of the immune response of individual patients to a range of immunosuppressants commonly used in kidney transplant recipients. Here, we discuss the current approaches used to measure the pharmacodynamic responses of individual patients to specific immunosuppressive drugs in vitro, which can then be correlated with patient’s clinical outcomes. We also describe the procedure of the IMBG assay, and summarize the results obtained using the IMBG in different kidney transplant populations. Finally, we outline future directions and other novel applications of the IMBG, both in kidney transplant patients and other autoimmune diseases.
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Affiliation(s)
- Julio Pascual
- Nephrology Department, Hospital 12 de Octubre, 28041 Madrid, Spain
- Nephrology Department, Hospital del Mar, Institut Mar for Medical Research, 08003 Barcelona, Spain
- Correspondence:
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Institut Mar for Medical Research, 08003 Barcelona, Spain
| | - Jose Portoles
- Nephrology Department, Hospital Puerta de Hierro Mahadahonda, Institute IDHIPHIM for Medical Research, 28222 Madrid, Spain
| | - Carlos Jimenez
- Nephrology Department, Hospital La Paz, 28046 Madrid, Spain
| | | | - Teresa Diez
- Biohope Scientific Solutions for Human Health, 28760 Madrid, Spain
| | - Isabel Portero
- Biohope Scientific Solutions for Human Health, 28760 Madrid, Spain
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Narita S, Miuma S, Okudaira S, Koga Y, Fukushima M, Sasaki R, Haraguchi M, Soyama A, Hidaka M, Miyaaki H, Futakuchi M, Nagai K, Ichikawa T, Eguchi S, Nakao K. Regular protocol liver biopsy is useful to adjust immunosuppressant dose after adult liver transplantation. Clin Transplant 2023; 37:e14873. [PMID: 36443801 DOI: 10.1111/ctr.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adjusting immunosuppression to minimal levels post-adult liver transplantation (LT) is critical; however, graft rejection has been reported in LT recipients with normal liver function evaluated by liver biopsy (LBx). Continual protocol liver biopsy (PLB) is performed regularly in LT recipients with normal liver function in some centers; however, its usefulness remains inadequately evaluated. This study aimed to assess retrospectively the usefulness of late PLB after adult LT. METHODS LBx evaluations of LT recipients with normal liver function and hepatitis B and C virus seronegativity were defined as PLB. The cases requiring immunosuppressive therapy for rejection findings based on Banff criteria were extracted from the PLBs, and pathological data collected before and after immunosuppressive dosage adjustment (based on modified histological activity index [HAI] score) were compared. RESULTS Among 548 LBx cases, 213 LBx in 110 recipients fulfilled the inclusion criteria for PLB. Immunosuppressive therapy after PLB was intensified in 14 LBx (6.6%) recipients (12.7%); of these, nine had late-onset acute rejection, three had isolated perivenular inflammation, one had plasma cell-rich rejection, and one had early chronic rejection. Follow-up LBx after immunosuppressive dose adjustment showed improvement in the modified HAI score grading in 10 of 14 cases (71.4%). No clinical background and blood examination data, including those from the post-LT period, immunosuppressant trough level, or examination for de novo DSA, predicted rejection in PLB. Complications of PLB were found in only three cases. CONCLUSION PLB is useful in the management of seemingly stable LT recipients, to discover subclinical rejection and allow for appropriate immunosuppressant dose adjustment.
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Affiliation(s)
- Shohei Narita
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sadayuki Okudaira
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshito Koga
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Masanori Fukushima
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masafumi Haraguchi
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuru Futakuchi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuki Ichikawa
- Nagasaki Harbor Medical Center, Department of Gastroenterology, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
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Muro M, Legaz I. Importance of human leukocyte antigen antibodies and leukocyte antigen/killer-cell immunoglobulin-like receptor genes in liver transplantation. World J Gastroenterol 2023; 29:766-772. [PMID: 36816626 PMCID: PMC9932425 DOI: 10.3748/wjg.v29.i5.766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/25/2022] [Accepted: 01/18/2023] [Indexed: 02/06/2023] Open
Abstract
Many mechanisms have been proposed to explain the hypothetical state of hepatic tolerance, which is described by eventual imbalances or deregulation in the balance of cytokines, mediators, effectors, and regulatory cells in the complex milieu of the liver. In this section, we will comment on the importance of donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) as well as the compatibility and pairings of HLA and killer-cell immunoglobulin-like receptor (KIR) genotypes in the evolution of liver transplantation. Thus, HLA compatibility, viral infections, and HLA-C/KIR combinations have all been linked to liver transplant rejection and survival. There have been reports of increased risk of acute and chronic rejection with ductopenia, faster graft fibrosis, biliary problems, poorer survival, and even de novo autoimmune hepatitis when DSAs are present in the recipient. Higher mean fluorescence intensity (MFI) values of the DSAs and smaller graft size were associated with poorer patient outcomes, implying that high-risk patients with preformed DSAs should be considered for selecting the graft placed and desensitization methods, according to the investigators. Similarly, in a combined kidney-liver transplant, a pretransplant with a visible expression of several DSAs revealed that these antibodies were resistant to treatment. The renal graft was lost owing to antibody-mediated rejection (AMR). The HLA antigens expressed by the transplanted liver graft influenced antibody elimination. Pathologists are increasingly diagnosing AMR in liver transplants, and desensitization therapy has even been employed in situations of AMR, particularly in patients with DSAs in kidney-hepatic transplants and high-class II MFI due to Luminex. In conclusion, after revealing the negative impacts of DSAs with high MFI, pretransplant virtual crossmatch techniques may be appropriate to improve evolution; however, they may extend cold ischemia periods by requiring the donor to be typed.
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Affiliation(s)
- Manuel Muro
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca-Biomedical Research Institute of Murcia (IMIB), Murcia 30120, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum,” Faculty of Medicine, University of Murcia, Murcia 30120, Spain
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Tramper T, Roelen DL, Brand-Schaaf SH, Kal-van Gestel JA, Kho MML, Reinders MEJ, Roodnat JI, van de Wetering J, Betjes MGH, de Weerd AE. The detrimental effect of donor-specific antibodies is irrespective of its level in highly-immunized living donor kidney transplant recipients: A case-control series. Front Immunol 2023; 13:1093359. [PMID: 36703958 PMCID: PMC9873371 DOI: 10.3389/fimmu.2022.1093359] [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: 11/08/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background The impact of donor-specific antibodies (DSA) in (highly-) immunized living donor kidney transplant recipients is reported differentially in various patient cohorts. Methods We have performed a retrospective analysis of all consecutive HLA-incompatible living donor kidney transplant recipients in our center between 2010-2019. Recipients who underwent plasmafiltration for a positive CDC-crossmatch were excluded. For each DSA+ recipient (DSA+), one immunized recipient without DSA (pPRA+) and two non-immunized recipients (pPRA-) were included. Patient and graft survival were analyzed and a subgroup analysis of DSA+ recipients was performed. Results For 63 DSA+ recipients, 63 PRA+ and 126 PRA- recipients were included. 26 (41%) had class I, 24 (38%) class II and 13 (21%) combined HLA class I and II DSA. Death-censored graft survival was inferior in DSA+ recipients compared to pPRA+ (HR 2.38 [95% CI 1.00-5.70]) as well as to pPRA- (HR 3.91 [1.86-8.22]). In multivariate analysis, DSA remained of negative influence on death-censored graft survival. Flowcytometric crossmatch, MFI value, HLA class and origin of DSA were not of significant impact. Conclusion In our cohort of (highly-) immunized recipients, pretransplant DSA led to inferior death-censored graft survival. There were no "safe" DSA characteristics since only DSA per se impacted death-censored graft survival.
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Affiliation(s)
- T. Tramper
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - D. L. Roelen
- HLA Laboratory, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - S. H. Brand-Schaaf
- HLA Laboratory, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - J. A. Kal-van Gestel
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. M. L. Kho
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. E. J. Reinders
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - J. I. Roodnat
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - J. van de Wetering
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. G. H. Betjes
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A. E. de Weerd
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands,*Correspondence: A. E. de Weerd,
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37
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Lund KP, Eriksson F, Pedersen BK, Sørensen SS, Bruunsgaard H. Pretransplant serum levels of endothelial cell activation markers are associated with graft loss and mortality after kidney transplantation. Scand J Immunol 2023; 97:e13225. [PMID: 36598149 PMCID: PMC10078193 DOI: 10.1111/sji.13225] [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: 05/27/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 01/06/2023]
Abstract
Long-term allograft survival remains a challenge in kidney transplantation. In this study, we aimed to identify biomarkers for potentially modifiable pathways involved in the outcome of kidney transplantation. We tested the hypothesis that a pre-existing systemic environment with endothelial cell activation in the recipient is associated with the outcome after kidney transplantation. In a retrospective study cohort of 611 kidney transplanted patients, we investigated associations between serum levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) before transplantation and delayed graft function, acute rejection, graft loss and mortality after transplantation. We adjusted associations for age, sex, preformed donor-specific antibodies (DSA), pretransplant diabetes, cardiovascular disease and dialysis. Additionally, we investigated if associations between endothelial cell activation markers and outcomes differed in recipients with and without preformed DSA. Serum levels of endothelial cell activation markers were associated with delayed graft function and mortality but not with rejection. Additionally, high levels of sICAM-1 were associated with graft loss. Associations were most pronounced in recipients without DSA, adjusted for potential confounders. Data suggest that endothelial cell activation at the time of transplantation is associated with graft loss and mortality after kidney transplantation, especially in transplant candidates without preformed DSA.
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Affiliation(s)
- Kit Peiter Lund
- Department of Clinical Immunology 7631, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark
| | - Frank Eriksson
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bente Klarlund Pedersen
- Center of Inflammation and Metabolism and Centre for Physical Activity Research, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Schwartz Sørensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology P, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark
| | - Helle Bruunsgaard
- Department of Clinical Immunology 7631, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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39
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Accommodation in allogeneic and xenogeneic organ transplantation: Prevalence, impact, and implications for monitoring and for therapeutics. Hum Immunol 2023; 84:5-17. [PMID: 36244871 DOI: 10.1016/j.humimm.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
Accommodation refers to acquired resistance of organs or tissues to immune or inflammatory reactions that might otherwise cause severe injury or rejection. As first observed in ABO-incompatible kidney transplants and heterotopic cardiac xenografts, accommodation was identified when organ transplants continued to function despite the presence of anti-graft antibodies and/or other reactants in the blood of recipients. Recent evidence suggests many and perhaps most organ transplants have accommodation, as most recipients mount B cell responses specific for the graft. Wide interest in the impact of graft-specific antibodies on the outcomes of transplants prompts questions about which mechanisms confer protection against such antibodies, how accommodation might be detected and whether and how rejection could be superimposed on accommodation. Xenotransplantation offers a unique opportunity to address these questions because immune responses to xenografts are easily detected and the pathogenic impact of immune responses is so severe. Xenotransplantation also provides a compelling need to apply these and other insights to decrease the intensity and toxicity of immunosuppression that otherwise could limit clinical application.
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40
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Calabrese DR, Chong T, Singer JP, Rajalingam R, Hays SR, Kukreja J, Leard L, Golden JA, Lanier LL, Greenland JR. CD16 + natural killer cells in bronchoalveolar lavage are associated with antibody-mediated rejection and chronic lung allograft dysfunction. Am J Transplant 2023; 23:37-44. [PMID: 36695619 PMCID: PMC10018437 DOI: 10.1016/j.ajt.2022.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/12/2022] [Accepted: 10/10/2022] [Indexed: 01/13/2023]
Abstract
Acute and chronic rejections limit the long-term survival after lung transplant. Pulmonary antibody-mediated rejection (AMR) is an incompletely understood driver of long-term outcomes characterized by donor-specific antibodies (DSAs), innate immune infiltration, and evidence of complement activation. Natural killer (NK) cells may recognize DSAs via the CD16 receptor, but this complement-independent mechanism of injury has not been explored in pulmonary AMR. CD16+ NK cells were quantified in 508 prospectively collected bronchoalveolar lavage fluid samples from 195 lung transplant recipients. Associations between CD16+ NK cells and human leukocyte antigen mismatches, DSAs, and AMR grade were assessed by linear models adjusted for participant characteristics and repeat measures. Cox proportional hazards models were used to assess CD16+ NK cell association with chronic lung allograft dysfunction and survival. Bronchoalveolar lavage fluid CD16+ NK cell frequency was associated with increasing human leukocyte antigens mismatches and increased AMR grade. Although NK frequencies were similar between DSA+ and DSA- recipients, CD16+ NK cell frequencies were greater in recipients with AMR and those with concomitant allograft dysfunction. CD16+ NK cells were associated with long-term graft dysfunction after AMR and decreased chronic lung allograft dysfunction-free survival. These data support the role of CD16+ NK cells in pulmonary AMR.
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Affiliation(s)
- Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA.
| | - Tiffany Chong
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California, USA
| | - Raja Rajalingam
- Department of Surgery, University of California, San Francisco, California, USA
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - Lorriana Leard
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, California, USA
| | - Lewis L Lanier
- Department of Microbiology and Immunology and the Parker Institute for Cancer Immunotherapy, University of California, San Francisco, California, USA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA
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41
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Krendl FJ, Fodor M, Messner F, Balog A, Vales A, Cardini B, Resch T, Maglione M, Margreiter C, Riedmann M, Ulmer H, Öfner D, Oberhuber R, Schneeberger S, Weissenbacher A. Liver Transplantation in Recipients With a Positive Crossmatch: A Retrospective Single-Center Match-Pair Analysis. Transpl Int 2023; 36:11062. [PMID: 36936441 PMCID: PMC10017503 DOI: 10.3389/ti.2023.11062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023]
Abstract
A positive crossmatch (XM+) is considered a contraindication to solid abdominal organ transplantation except liver transplantation (LT). Conflicting reports exist regarding the effects of XM+ on post-transplant outcomes. The goal of this retrospective single-center analysis is to evaluate the influence of XM+ on relevant outcome parameters such as survival, graft rejection, biliary and arterial complications. Forty-nine adult patients undergoing LT with a XM+ between 2002 and 2017 were included. XM+ LT recipients were matched 1:2 with crossmatch negative (XM-) LT recipients based on the balance of risk (BAR) score. Patient and graft survival were compared using Kaplan-Meier survival analysis and the log-rank test. Comparative analysis of clinical outcomes in XM+ and XM- groups were conducted. Patient and graft survival were similar in XM+ and XM- patients. Rejection episodes did not differ either. Recipients with a strong XM+ were more likely to develop a PCR+ CMV infection. A XM+ was not associated with a higher incidence of biliary or arterial complications. Donor age, cold ischemia time, PCR+ CMV infection and a rejection episode were associated with the occurrence of ischemic type biliary lesions. A XM+ has no effects on patient and graft survival or other relevant outcome parameters following LT.
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Affiliation(s)
- Felix J. Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Margot Fodor
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Balog
- Blood Transfusion Center, Innsbruck, Austria
| | - Anja Vales
- Blood Transfusion Center, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina Riedmann
- Department of Medical Statistics, Informatics, and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics, and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: Annemarie Weissenbacher,
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Abstract
BACKGROUND Donor-specific antibodies (DSAs) have been associated with antibody-mediated rejection, chronic lung allograft dysfunction (CLAD), and increased mortality in lung transplant recipients. Our center performs transplants in the presence of DSA, and we sought to evaluate the safety of this practice with respect to graft loss, CLAD onset, and primary graft dysfunction (PGD). METHODS We reviewed recipients transplanted from 2010 to 2017, classifying them as DSA positive (DSA+) or negative. We used Kaplan-Meier estimation to test the association between DSA status and time to death or retransplant and time to CLAD onset. We further tested associations with severe PGD and rejection in the first year using logistic regression and Fisher exact testing. RESULTS Three hundred thirteen patients met inclusion criteria, 30 (10%) of whom were DSA+. DSA+ patients were more likely to be female, bridged to transplant, and receive induction therapy. There was no association between DSA status and time to death or retransplant (log rank P = 0.581) nor death-censored time to CLAD onset (log rank P = 0.278), but DSA+ patients were at increased risk of severe PGD (odds ratio 2.88; 95% confidence interval, 1.10-7.29; P = 0.031) and more frequent antibody-mediated rejection in the first posttransplant year. CONCLUSIONS Crossing DSA at time of lung transplant was not associated with an increased risk of death or CLAD in our cohort, but patients developed severe PGD and antibody-mediated rejection more frequently. However, these risks are likely manageable when balanced against the benefits of expanded access for sensitized candidates.
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43
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Nickerson PW. Rationale for the IMAGINE study for chronic active antibody-mediated rejection (caAMR) in kidney transplantation. Am J Transplant 2022; 22 Suppl 4:38-44. [PMID: 36453707 DOI: 10.1111/ajt.17210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
Chronic active antibody-mediated rejection (caAMR) in kidney transplantation is a major cause of late graft loss and despite all efforts to date, there is no proven effective therapy. Indeed, the Transplant Society (TTS) consensus opinion called for a conservative approach optimizing baseline immunosuppression and supportive care focused on blood pressure, blood glucose, and lipid control. This review provides the rationale and early evidence in kidney transplant recipients with caAMR that supported the design of the IMAGINE study whose goal is to evaluate the potential impact of targeting the IL6/IL6R pathway.
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Affiliation(s)
- Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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44
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Liwski RS, Tafulo S, Carroll R, Lan JH, Greenshields AL. Cutting through the weeds: Evaluation of a novel adsorption with crossmatch cells and elution protocol to sharpen HLA antibody identification by the single antigen bead assay. Front Genet 2022; 13:1059650. [PMID: 36531234 PMCID: PMC9748275 DOI: 10.3389/fgene.2022.1059650] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/18/2022] [Indexed: 10/01/2023] Open
Abstract
The single antigen bead (SAB) assay is the most used test for the identification of HLA specific antibodies pre- and post-transplant. Nevertheless, detection of spurious reactivities remains a recognized assay limitation. In addition, the presence of weak reactivity patterns can complicate unacceptable antigen assignment. This work presents the evaluation of the adsorption with crossmatch cells and elution (AXE) technique, which was designed to help differentiate weak HLA specific antibodies targeting native antigens from spurious and background SAB assay reactivity. The AXE protocol uses selected donor cells to adsorb HLA specific antibodies from sera of interest. Bound antibodies are then eluted off washed cells and identified using the SAB assay. Only antibodies targeting native HLA are adsorbed. Assay evaluation was performed using five cell donors and pooled positive control serum. AXE efficiency was determined by comparing SAB reactivity of adsorbed/eluted antibody to that of the antibodies in unadsorbed sera. A robust efficiency was seen across a wide range of original MFI for donor specific antibodies (DSA). A higher absorption/elution recovery was observed for HLA class I antigens vs. class II. Locus-specific variation was also observed, with high-expression HLA loci (HLA-A/B/DR) providing the best recovery. Importantly, negligible reactivity was detected in the last wash control, confirming that AXE eluates were not contaminated with HLA antibody carry-over. Donor cells incubated with autologous and DSA-containing allogeneic sera showed that AXE selectively adsorbed HLA antibodies in a donor antigen-specific manner. Importantly, antibodies targeting denatured epitopes or other non-HLA antigens were not detected by AXE. AXE was particularly effective at distinguishing weak HLA antibodies from background reactivity. When combined with epitope analysis, AXE enhanced precise identification of antibody-targeted eplets and even facilitated the characterization of a potential novel eplet. Comparison of AXE to flow cytometric crossmatching further revealed that AXE was a more sensitive technique in the detection of weak DSA. Spurious reactivities on the current SAB assay have a deleterious impact on the assignment of clinically relevant HLA specificities. The AXE protocol is a novel test that enables users to interrogate reactive patterns of interest and discriminate HLA specific antibodies from spurious reactivity.
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Affiliation(s)
- Robert S. Liwski
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sandra Tafulo
- Blood and Transplantation Center of Porto, Portuguese Institute for Blood and Transplantation, Porto, Portugal
| | - Robert Carroll
- Health and Medical Sciences, University of South Australia, Adelaide, SA, Australia
- Transplantation and Immunogenetics Service, Australian Red Cross Blood Services, Adelaide, SA, Australia
| | - James H. Lan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anna L. Greenshields
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, NS, Canada
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Yamamoto T, Pearson DS, Ababneh EI, Harris C, Nissaisorakarn P, Mahowald GK, Heher YK, Elias N, Markmann JF, Lewis GD, Riella LV. Case report: Successful simultaneous heart-kidney transplantation across a positive complement-dependent cytotoxic crossmatch. FRONTIERS IN NEPHROLOGY 2022; 2:1047217. [PMID: 37675007 PMCID: PMC10479575 DOI: 10.3389/fneph.2022.1047217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/11/2022] [Indexed: 09/08/2023]
Abstract
Preformed donor-specific antibodies are associated with a higher risk of rejection and worse graft survival in organ transplantation. However, in heart transplantation, the risk and benefit balance between high mortality on the waiting list and graft survival may allow the acceptance of higher immunologic risk donors in broadly sensitized recipients. Transplanting donor-recipient pairs with a positive complement dependent cytotoxic (CDC) crossmatch carries the highest risk of hyperacute rejection and immediate graft loss and is usually avoided in kidney transplantation. Herein we report the first successful simultaneous heart-kidney transplant with a T- and B-cell CDC crossmatch positive donor using a combination of rituximab, intravenous immunoglobulin, plasmapheresis, bortezomib and rabbit anti-thymocyte globulin induction followed by eculizumab therapy for two months post-transplant. In the year following transplantation, both allografts maintained stable graft function (all echocardiographic left ventricular ejection fractions ≥ 65%, eGFR>60) and showed no histologic evidence of antibody-mediated rejection. In addition, the patient has not developed any severe infections including cytomegalovirus or BK virus infection. In conclusion, a multitarget immunosuppressive regimen can allow for combined heart/kidney transplantation across positive CDC crossmatches without evidence of antibody-mediated rejection or significant infection. Longer follow-up will be needed to further support this conclusion.
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Affiliation(s)
- Takayuki Yamamoto
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Daniel S. Pearson
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Emad I. Ababneh
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Cynthia Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Pitchaphon Nissaisorakarn
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Grace K. Mahowald
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Yael K. Heher
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Nahel Elias
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - James F. Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Gregory D. Lewis
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
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Peitz T, Möhlendick B, Eisenberger U, Siffert W, Heinemann FM, Kribben A, Friebus-Kardash J. CC Genotype of GNAS c.393C>T (rs7121) Polymorphism Has a Protective Effect against Development of BK Viremia and BKV-Associated Nephropathy after Renal Transplant. Pathogens 2022; 11:pathogens11101138. [PMID: 36297195 PMCID: PMC9609707 DOI: 10.3390/pathogens11101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
The GNAS gene encodes the alpha-subunit of the stimulatory G-protein (Gαs) in humans and mice. The single-nucleotide polymorphism of GNAS, c.393C>T, is associated with an elevated production of Gαs and an increased formation of cyclic adenosine monophosphate (cAMP). In the present study, we analyzed the effect of this GNAS polymorphism on a renal allograft outcome. We screened a cohort of 436 renal allograft recipients, who were retrospectively followed up for up to 5 years after transplant. GNAS genotypes were determined with polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) assays. The 393T allele was detected in 319 (73%) recipients (113 recipients with TT and 206 with CT genotype) and the CC genotype in 117 (27%). The CC genotype was associated with a significantly lower frequency of BK viremia (CC, 17 recipients (15%); T 84 (26%)); p = 0.01; TT, 27 vs. CC, 17, p = 0.07; TT, 27 vs. CT, 57, p = 0. 46; CT, 57 vs. CC, 17, p = 0.01) and BKV-associated nephropathy (CC, 3 recipients (3%); T, 27 (8%); p = 0.03; TT,10 vs. CC, 3, p = 0.04; TT, 10 vs. CT,17, p = 0.85; CT, 17 vs. CC,3, p = 0.04) after transplant. BKV-associated nephropathy-free survival was significantly better among CC genotype carriers than among T allele carriers (p = 0.043; TT vs. CC, p = 0.03; CT vs. CC, p = 0.04; TT vs. CT, p = 0.83). Multivariate analysis indicated an independent protective effect of the CC genotype against the development of both BK viremia (relative risk. 0.54; p = 0.04) and BKV-associated nephropathy after renal transplant (relative risk. 0.27; p = 0.036). The GNAS 393 CC genotype seems to protect renal allograft recipients against the development of BK viremia and BKV-associated nephropathy.
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Affiliation(s)
- Tobias Peitz
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Birte Möhlendick
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Ute Eisenberger
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Winfried Siffert
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, Transplantation Diagnostics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Justa Friebus-Kardash
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
- Correspondence: ; Tel.: +49-(0)-201-7236559; Fax: +49-(0)-201-7236907
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Role of the Immune System in Renal Transplantation, Types of Response, Technical Approaches and Current Challenges. IMMUNO 2022. [DOI: 10.3390/immuno2040035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advances over the last decades have made renal transplantation an important therapy for patients with end-stage renal disease, as the incidences of acute rejection and short-term transplant loss have been significantly reduced. However, long-term transplant survival remains a challenge in the renal transplantation community. The main causes of long-term graft loss are acute and chronic rejection, as well as the complications related to immunosuppression therapy. In spite of the breakthroughs achieved in recent years, histology is the gold standard technique to confirm the activation of the immune system against the graft with all the ensuing problems that taking biopsies brings to immunosuppressed patients. For this reason, several assays have been developed to try to monitor the immune function, but they show serious constraints owing to the fact that they require substantial laboratory work, they are not clinically available and they provide controversial results, so the combination of multiple assays is often needed to obtain a reliable diagnosis. Thus, the aim of this review is to perform a retrospective study of the immune system in renal transplantation, with special emphasis on the cutting-edge technological developments for monitoring, classification and early detection of rejection episodes in order to contribute to a better adjustment of immunosuppressive therapies and, hence, to a more personalized medicine that improves the quality of life of patients.
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Heinemann FM, Lindemann M, Keles D, Witzke O, Kribben A, Baba HA, Becker JU, Heinold A, Horn PA, Eisenberger U. Cumulative mean fluorescent intensities of
HLA
specific antibodies predict antibody mediated rejections after kidney transplantation. HLA 2022; 100:553-562. [DOI: 10.1111/tan.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Falko Markus Heinemann
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Deniz Keles
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre for Infectious Diseases University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Andreas Kribben
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Hideo Andreas Baba
- Institute of Pathology University Duisburg‐Essen, University Hospital Essen Essen Germany
| | | | - Andreas Heinold
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Peter Alexander Horn
- Institute for Transfusion Medicine University Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Ute Eisenberger
- Department of Nephrology University Duisburg‐Essen, University Hospital Essen Essen Germany
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GNB3 c.825C>T (rs5443) Polymorphism and Risk of Acute Cardiovascular Events after Renal Allograft Transplant. Int J Mol Sci 2022; 23:ijms23179783. [PMID: 36077181 PMCID: PMC9456448 DOI: 10.3390/ijms23179783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
The c.825C>T single-nucleotide polymorphism (rs5443) of the guanine nucleotide-binding protein subunit β3 (GNB3) results in increased intracellular signal transduction via G-proteins. The present study investigated the effect of the GNB3 c.825C>T polymorphism on cardiovascular events among renal allograft recipients posttransplant. Our retrospective study involved 436 renal allograft recipients who were followed up for up to 8 years after transplant. The GNB3 c.825C>T polymorphism was detected with restriction fragment length polymorphism (RFLP) polymerase chain reaction (PCR). The GNB3 TT genotype was detected in 43 (10%) of 436 recipients. Death due to an acute cardiovascular event occurred more frequently among recipients with the TT genotype (4 [9%]) than among those with the CC/CT genotypes (7 [2%]; p = 0.003). The rates of myocardial infarction (MI)−free survival (p = 0.003) and acute peripheral artery occlusive disease (PAOD)−free survival (p = 0.004) were significantly lower among T-homozygous patients. A multivariate analysis showed that homozygous GNB3 c.825C>T polymorphism exerted only a mild effect for the occurrence of myocardial infarction (relative risk, 2.2; p = 0.065) or acute PAOD (relative risk, 2.4; p = 0.05) after renal transplant. Our results suggest that the homozygous GNB3 T allele exerts noticeable effects on the risk of MI and acute PAOD only in the presence of additional nonheritable risk factors.
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50
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Vij M, Rammohan A, Rela M. Long-term liver allograft fibrosis: A review with emphasis on idiopathic post-transplant hepatitis and chronic antibody mediated rejection. World J Hepatol 2022; 14:1541-1549. [PMID: 36157865 PMCID: PMC9453462 DOI: 10.4254/wjh.v14.i8.1541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is a life-saving surgical procedure and the current standard of care for most patients with end stage liver disease. With improvements in organ preservation techniques, perioperative care, and immunosuppression, there is better patient and graft survival following LT, and assessment of the liver allograft in long-term survivors is becoming increasingly important. Recurrent or de novo viral or autoimmune injury remains the most common causes of chronic hepatitis and fibrosis following liver transplantation in adults. However, no obvious cause can be identified in many adults with controlled recurrent disease and the majority of pediatric LT recipients, as they have been transplanted for non-recurrent liver diseases. Serial surveillance liver biopsies post LT have been evaluated in several adult and pediatric centers to identify long-term pathological changes. Pathological findings are frequently present in liver biopsies obtained after a year post LT. The significance of these findings is uncertain as many of these are seen in protocol liver biopsies from patients with clinically good allograft function and normal liver chemistry parameters. This narrative review summaries the factors predisposing to long-term liver allograft fibrosis, highlighting the putative role of idiopathic post-LT hepatitis and chronic antibody mediated rejection in its pathogenesis.
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Affiliation(s)
- Mukul Vij
- Department of Pathology, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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