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Nadat F, Clark B. Forming a new perspective: Post-structural approaches to determination of donor compatibility and post-transplant assessment of allograft health. Int J Immunogenet 2024; 51:195-205. [PMID: 38711186 DOI: 10.1111/iji.12675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/25/2024] [Indexed: 05/08/2024]
Abstract
The purpose of this review is to encourage a new perspective on the question of donor-recipient compatibility and post-transplant assessment of graft health based on functional measures. The premise is that we should be better sighted on what (and how) the immune system responds toward rather than what is merely there. Continuance of the pursuit of further and better definition of antigens and antibodies is not however discouraged but seen as necessary to improved understanding of the structural correlates of functional immunity. There currently exists, in the opinion of the authors, an opportunity for histocompatibility and immunogenetics laboratories to develop and widen their scope of involvement into these new areas of laboratory activity in support and to the benefit of the transplant programmes they serve.
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Affiliation(s)
- Fatima Nadat
- Functional Assessment of Transplant Immunology Group, St James's University Hospital, Leeds, UK
| | - Brendan Clark
- Functional Assessment of Transplant Immunology Group, St James's University Hospital, Leeds, UK
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2
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Gniewkiewicz M, Czerwinska K, Zielniok K, Durlik M. Association of Circulating Anti-HLA Donor-Specific Antibodies and Their Characteristics, including C1q-Binding Capacity, in Kidney Transplant Recipients with Long-Term Renal Graft Outcomes. J Clin Med 2023; 12:jcm12041312. [PMID: 36835848 PMCID: PMC9962721 DOI: 10.3390/jcm12041312] [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: 01/03/2023] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
Post-transplant antihuman leukocyte antigen donor-specific antibodies (anti-HLA DSAs) monitoring in kidney transplant recipients remains unclear and is currently under investigation. The pathogenicity of anti-HLA DSAs is determined by antibody classes, specificity, mean fluorescent intensity (MFI), C1q-binding capacity, and IgG subclasses. The aim of this study was to investigate the association of circulating DSAs and their characteristics with renal allograft long-term outcomes. The study included 108 consecutive patients from our transplant center who underwent kidney allograft biopsy between November 2018 and November 2020, 3 to 24 months after kidney transplantation. At the time of biopsy, patients' sera were collected for analysis of anti-HLA DSAs. Patients were followed for a median time of 39.0 months (Q1-Q3, 29.8-45.0). Detection of anti-HLA DSAs at the time of biopsy (HR = 5.133, 95% CI 2.150-12.253, p = 0.0002) and their C1q-binding capacity (HR = 14.639, 95% CI 5.320-40.283, p ≤ 0.0001) were independent predictors of the composite of sustained 30% reduction from estimated glomerular filtration rate or death-censored graft failure. Identification of anti-HLA DSAs and their C1q-binding capacity could be useful in identifying kidney transplant recipients at risk for inferior renal allograft function and graft failure. Analysis of C1q is noninvasive, accessible, and should be considered in clinical practice in post-transplant monitoring.
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Affiliation(s)
- Michal Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
- Correspondence:
| | - Katarzyna Czerwinska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Katarzyna Zielniok
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Kang ZY, Liu C, Liu W, Li DH. Effect of C1q-binding donor-specific anti-HLA antibodies on the clinical outcomes of patients after renal transplantation: A systematic review and meta-analysis. Transpl Immunol 2022; 72:101566. [DOI: 10.1016/j.trim.2022.101566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 12/01/2022]
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Tanrısev M, Ayna Kılıçaslan T, Çolak H, Ersan S, Yılmaz B, Alp A, Tuğmen C, Sevgili BE. Immunological Results of Long-Term Use of Mammalian Target of Rapamycin (mTOR) Inhibitors and Its Effects on Renal Graft Functions. Ann Transplant 2021; 26:e932434. [PMID: 34531361 PMCID: PMC8454254 DOI: 10.12659/aot.932434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Calcineurin inhibitor drugs (CNI), which are the basis of immunosuppression in kidney transplantation, contribute to renal graft loss, with increased morbidity and mortality due to their potentially harmful effects on the renal graft, cardiovascular system, and tumor pathology. For this reason, the mammalian target of rapamycin inhibitors (mTORi) such as sirolimus (SRL) and everolimus (EVE) has been preferred more frequently, as they are associated with fewer complications and longer graft function. Material/Methods We enrolled 89 adult renal transplant patients (37 patients on mTORi and 52 on CNI) who had similar age, sex, primary renal disease, dialysis type, post-transplant follow-up period, and donor type. We analyzed and compared the data between patients using mTORi for longer than 5 years and those using CNI regarding pre- and post-transplant panel reactive antibody (PRA), and donor-specific antibody (DSA), as well as post-transplantation and current graft functions. Results Although those using mTORi for more than 5 years had significantly higher mismatch rates (P=0.024) than those using CNI, there was no significant change in PRA and DSA levels. Transplant time was longer in mTORi users (P=0.025). The switch time to mTORi in patients ranged from 0 to 19 years, but the average was 4 years. As expected, actual spot urine protein/creatinine was significantly higher in those using mTORi (P=0.009). Diabetes mellitus (DM) and BK virus nephropathy (BKVN) rates were significantly higher due to switching the regimen from CNI to mTORi. Conclusions Long-term use of mTORi does not appear to be an immunological problem.
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Affiliation(s)
- Mehmet Tanrısev
- Department of Nephrology, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Tülay Ayna Kılıçaslan
- Department of Medical Biology and Tissue Typing Laboratory, SBU İzmir Tepecik Training and Research Hospital, Medical Faculty, İzmir Katip Çelebi University, İzmir, Turkey
| | - Hülya Çolak
- Department of Nephrology, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Sibel Ersan
- Department of Nephrology, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Banu Yılmaz
- Department of Nephrology, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Alper Alp
- Department of Nephrology, Medical Faculty, Muğla Sıtkı Koçman University, Muğla, Turkey
| | - Cem Tuğmen
- Department of General Surgery, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Bahar Engin Sevgili
- Department of Internal Medicine, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey
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Tambur AR, Campbell P, Chong AS, Feng S, Ford ML, Gebel H, Gill RG, Kelsoe G, Kosmoliaptsis V, Mannon RB, Mengel M, Reed EF, Valenzuela NM, Wiebe C, Dijke IE, Sullivan HC, Nickerson P. Sensitization in transplantation: Assessment of risk (STAR) 2019 Working Group Meeting Report. Am J Transplant 2020; 20:2652-2668. [PMID: 32342639 PMCID: PMC7586936 DOI: 10.1111/ajt.15937] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/01/2020] [Accepted: 04/20/2020] [Indexed: 01/25/2023]
Abstract
The purpose of the STAR 2019 Working Group was to build on findings from the initial STAR report to further clarify the expectations, limitations, perceptions, and utility of alloimmune assays that are currently in use or in development for risk assessment in the setting of organ transplantation. The goal was to determine the precision and clinical feasibility/utility of such assays in evaluating both memory and primary alloimmune risks. The process included a critical review of biologically driven, state-of-the-art, clinical diagnostics literature by experts in the field and an open public forum in a face-to-face meeting to promote broader engagement of the American Society of Transplantation and American Society of Histocompatibility and Immunogenetics membership. This report summarizes the literature review and the workshop discussions. Specifically, it highlights (1) available assays to evaluate the attributes of HLA antibodies and their utility both as clinical diagnostics and as research tools to evaluate the effector mechanisms driving rejection; (2) potential assays to assess the presence of alloimmune T and B cell memory; and (3) progress in the development of HLA molecular mismatch computational scores as a potential prognostic biomarker for primary alloimmunity and its application in research trial design.
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Affiliation(s)
- Anat R. Tambur
- Department of SurgeryComprehensive Transplant CenterNorthwestern UniversityChicagoIllinoisUSA
| | - Patricia Campbell
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Anita S. Chong
- Section of TransplantationDepartment of SurgeryThe University of ChicagoChicagoIllinoisUSA
| | - Sandy Feng
- Department of SurgeryUCSF Medical CenterSan FranciscoCaliforniaUSA
| | - Mandy L. Ford
- Department of Surgery and Emory Transplant CenterEmory UniversityAtlantaGeorgiaUSA
| | - Howard Gebel
- Department of PathologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Ronald G. Gill
- Department of ImmunologyUniversity of ColoradoDenverColoradoUSA
| | - Garnett Kelsoe
- Department of ImmunologyDuke University School of MedicineDurhamNorth CarolinaUSA
| | | | - Roslyn B. Mannon
- Department of MedicineDivision of NephrologyUniversity of Alabama School of MedicineBirminghamAlabamaUSA
| | - Michael Mengel
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Elaine F. Reed
- Department of Pathology and Laboratory MedicineDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Nicole M. Valenzuela
- Department of Pathology and Laboratory MedicineDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - I. Esme Dijke
- Department of Laboratory Medicine & PathologyUniversity of AlbertaEdmontonCanada
| | - Harold C. Sullivan
- Department of PathologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Peter Nickerson
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
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Seeto RK, Fleming JN, Dholakia S, Dale BL. Understanding and using AlloSure donor derived cell-free DNA. Biophys Rev 2020; 12:917-924. [PMID: 32683591 PMCID: PMC7429580 DOI: 10.1007/s12551-020-00713-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022] Open
Abstract
Renal transplant is a lifesaving and cost-effective intervention for patients with End Stage Renal Failure. Yet it is often regarded as replacement therapy rather than a cure given the overall failure rate over time. With a shortage of organs, this global issue has been further compounded by increased incidences of obesity, hypertension and diabetes, such that the disease burden and need for transplantation continues to increase. Considering the lifetime of immunosupression in transplant patients, there will also be significant associated co-morbidities By leveraging the advances in innovation in Next Generation Sequencing, the field of transplant can now monitor patients with an optimized surveillance schedule, and change the care paradigm in the post-transplant landscape. Notably, low grade inflammation is an independent risk for mortality across different disease states. In transplantation, sub-clinical inflammation enhances acute and chronic rejection, as well as accelerates pathologies that leads to graft loss. Cell free DNA has been shown to be increased in inflammatory processes as we all as provide an independent predictor of all-cause mortality. This review considers the utility of AlloSure, a donor derived cell free DNA molecular surveillance tool, which has shown new clinical insights on how best to manage renal transplant patients, and how to improve patient outcomes.
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Affiliation(s)
- R K Seeto
- University of Sydney, Sydney, NSW, Australia.
| | - J N Fleming
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | | | - B L Dale
- Vanderbilt University, Nashville, TN, USA
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Fujiyama N, Satoh S, Saito M, Numakura K, Inoue T, Yamamoto R, Saito T, Kanda S, Narita S, Mitobe Y, Habuchi T. Impact of persistent preformed and de novo donor-specific antibodies detected at 1 year after kidney transplantation on long-term graft survival in Japan: a retrospective study. Clin Exp Nephrol 2019; 23:1398-1406. [PMID: 31493185 DOI: 10.1007/s10157-019-01780-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 08/09/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND We evaluated the impact of persistent preformed donor-specific antibody (DSA) and de novo DSA (dnDSA) detected at 1 year posttransplantation on long-term death-censored graft survival. METHODS One hundred and sixty adult patients who received living kidney allograft with pretransplant-negative T-cell complement-dependent cytotoxicity crossmatch (CDCXM), and without periodic screening for DSA, were eligible for this study. All enrolled patients were retrospectively tested for DSA using the Luminex assay. The presence of DSA was analyzed in stored serum samples collected at 1 year posttransplantation. If the recipients had DSA, it was analyzed in the pretransplant serum sample. The detection of DSA solely in the 1 year posttransplant sample was defined as dnDSA, and DSA detection in both pretransplant and 1 year posttransplant samples was defined as persistent preformed DSA. RESULTS DSAs were identified in 14 (8.8%) of the 160 patients. Seven patients had persistent preformed DSA, 6 had dnDSA, and 1 had both persistent preformed and dnDSA at 1 year posttransplantation. Death-censored allograft survival rates of patients with DSA versus those without DSA at 7 and 11 years were 77.9 vs. 97.8% and 60.6 vs. 89.2%, respectively. The graft survival rate was lower in patients with persistent preformed DSA and/or dnDSA. Each case of preformed DSA and dnDSA was associated with long-term graft survival. CONCLUSION The presence of persistent preformed DSA or dnDSA at 1 year posttransplantation may be a predictor of long-term graft survival. Further study is needed to evaluate whether periodic screening for DSA improves long-term graft survival.
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Affiliation(s)
- Nobuhiro Fujiyama
- Center for Kidney Disease and Transplantation, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Mitsuru Saito
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Kazuyuki Numakura
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Takamitsu Inoue
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Ryuhei Yamamoto
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Takuro Saito
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Sohei Kanda
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Shintaro Narita
- Department of Urology, Akita University School of Medicine, Akita, Japan
| | - Yoko Mitobe
- Center for Kidney Disease and Transplantation, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University School of Medicine, Akita, Japan
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Navas A, Molina J, Agüera ML, Guler I, Jurado A, Rodríguez-Benot A, Alonso C, Solana R. Characterization of the C1q-Binding Ability and the IgG1-4 Subclass Profile of Preformed Anti-HLA Antibodies by Solid-Phase Assays. Front Immunol 2019; 10:1712. [PMID: 31428086 PMCID: PMC6687874 DOI: 10.3389/fimmu.2019.01712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022] Open
Abstract
Humoral alloimmunity, particularly that triggered by preformed antibodies against human leukocyte antigens (HLA), is associated with an increased prevalence of rejection and reduced transplant survival. The high sensitivity of solid phase assays, based on microbeads coated with single antigens (SAB), consolidated them as the gold-standard method to characterize anti-HLA antibodies, ensuring a successful allograft allocation. Mean fluorescence intensity (MFI) provided by SAB is regularly used to stratify the immunological risk, assuming it as a reliable estimation of the antibody-level, but it is often limited by artifacts. Beyond MFI, other properties, such as the complement-binding ability or the IgG1-4 subclass profile have been examined to more accurately define the clinical relevance of antibodies and clarify their functional properties. However, there are still unresolved issues. Neat serum-samples from 20 highly-sensitized patients were analyzed by SAB-panIgG, SAB-IgG1-4 subclass and SAB-C1q assays. All 1:16 diluted serum-samples were additionally analyzed by SAB-panIgG and SAB-IgG1-4 subclass assays. A total of 1,285 anti-HLA antibodies were identified as positive, 473 (36.8%) of which were C1q-binding. As expected, serum-dilution enhanced the correlation between the C1q-binding ability and the antibody-strength, measured as the MFI (rneat = 0.248 vs. rdiluted = 0.817). SAB-subclass assay revealed at least one IgG1-4 subclass in 1,012 (78.8%) positive antibody-specificities. Among them, strong complement-binding subclasses, mainly IgG1, were particularly frequent (98.9%) and no differences were found between C1q- and non-C1q-binding antibodies regarding their presence (99.4 vs. 98.5%; p = 0.193). In contrast, weak or non-C1q-binding subclasses (IgG2/IgG4) were more commonly detected in C1q-binding antibodies (78.9 vs. 38.6%; p < 0.001). Interestingly, a strong association was found between the C1q-binding ability and the IgG1 strength (rIgG1dil = 0.796). Though lower, the correlation between the IgG2 strength and the C1q-binding ability was also strong (rIgG2dil = 0.758), being both subclasses closely related (rIgG1−IgG2 = 0.817). We did not find any correlation with the C1q-binding ability considering the remaining subclasses. In conclusion, we demonstrate that a particular profile of IgG subclasses (IgG1/IgG3) itself does not determine at all the ability to bind complement of anti-HLA antibodies assessed by SAB-C1q assay. It is the IgG subclass strength, mainly of IgG1, which usually appears in combination with IgG2, that best correlates with it.
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Affiliation(s)
- Ana Navas
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Immunology and Allergy, Reina Sofia University Hospital, Cordoba, Spain
| | - Juan Molina
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Immunology and Allergy, Reina Sofia University Hospital, Cordoba, Spain
| | - María-Luisa Agüera
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain
| | - Ipek Guler
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Aurora Jurado
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Immunology and Allergy, Reina Sofia University Hospital, Cordoba, Spain
| | - Alberto Rodríguez-Benot
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Nephrology, Reina Sofia University Hospital, Cordoba, Spain
| | - Corona Alonso
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Immunology and Allergy, Reina Sofia University Hospital, Cordoba, Spain
| | - Rafael Solana
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.,Department of Immunology and Allergy, Reina Sofia University Hospital, Cordoba, Spain
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