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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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2
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Dumortier J, Conti F, Hiriart JB, Dharancy S, Duvoux C, Besch C, Houssel-Debry P, Latournerie M, Chermak F, Meszaros M, Pageaux GP, Radenne S, Boillot O, Hardwigsen J, Kounis I, Kamar N, Saliba F, Erard D, Del Bello A. Treatment of donor-specific anti-HLA antibodies-mediated rejection after liver transplantation: A French nationwide retrospective study. Liver Transpl 2023; 29:1313-1322. [PMID: 37367954 DOI: 10.1097/lvt.0000000000000200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
The deleterious effect of donor-specific anti-HLA antibodies (DSA) after liver transplantation (LT) has been increasingly recognized during the past decade. Antibody-mediated rejection (AMR) represents a rare but severe complication in the presence of DSA. However, little is known concerning the treatment of AMR after LT. The nationwide French study aimed to describe LT recipients who received specific treatment of AMR. We performed a multicenter retrospective study on 44 patients who were treated with B-cell targeting agents from January 2008 to December 2020. Median patient age at the time of AMR treatment was 51.6 years (range: 17.9-68.0). AMR was classified as acute (n = 19) or chronic (n = 25). The diagnosis of AMR was made after a median time of 16.8 months (range: 0.4-274.2) after LT. The main therapeutic combination was plasma exchange/rituximab/IVIG (n = 25, 56.8%). The median follow-up after the treatment of AMR was 32 months (range: 1-115). After the treatment, 1-, 5- and 10-year patient and graft survivals were 77%, 55.9%, and 55.9%, and 69.5%, 47.0%, and 47.0%, respectively. Initial total bilirubin (Q1-Q3 vs. Q4) was significantly associated with patient survival (log-rank test, p = 0.005) and graft survival (log-rank test, p = 0.002). After a median follow-up of 21 months (range: 12-107), DSA became undetectable in 15/38 patients (39.5%) with available DSA monitoring. In conclusion, specific treatment of AMR in LT recipients has slowly emerged in France during the past decade and has probably been considered in the most severe patients; this explains the global poor outcome, even if the outcome was favorable in some cases.
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Affiliation(s)
- Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Fédération des Spécialités digestives, et Université Claude Bernard Lyon 1, Lyon, France
| | - Filomena Conti
- APHP, Hôpital de la Pitié Salpêtrière, Service d'hépatologie et transplantation hépatique, Paris, France
| | - Jean-Baptiste Hiriart
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service de Chirurgie hépatobiliaire et de transplantation hépatique, Bordeaux, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Claude Huriez, Service des maladies de l'appareil digestif, Lille, France
| | | | - Camille Besch
- CHRU Hautepierre, Service de chirurgie hépato-bilio-pancréatique et transplantation hépatique, Strasbourg, France
| | - Pauline Houssel-Debry
- Hôpital Universitaire de Pontchaillou, Service d'Hépatologie et Transplantation hépatique, Rennes, France
| | - Marianne Latournerie
- CHU Dijon, Service d'Hépato-gastroentérologie et oncologie digestive, Inserm EPICAD LNC-UMR1231, Université de Bourgogne-Franche Comté, Dijon, France
| | - Faiza Chermak
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service de Chirurgie hépatobiliaire et de transplantation hépatique, Bordeaux, France
| | - Magdalena Meszaros
- CHU Saint Eloi, Département d'hépato-gatroentérologie et transplantation hépatique, et Université de Montpellier, Montpellier, France
| | - Georges-Philippe Pageaux
- CHU Saint Eloi, Département d'hépato-gatroentérologie et transplantation hépatique, et Université de Montpellier, Montpellier, France
| | - Sylvie Radenne
- Hospices civils de Lyon, Hôpital de la Croix Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | - Olivier Boillot
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Fédération des Spécialités digestives, et Université Claude Bernard Lyon 1, Lyon, France
| | - Jean Hardwigsen
- APHM, Hôpital La Timone, Service chirurgie générale et transplantation hépatique Marseille, France
| | - Ilias Kounis
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM, Unité 1193, Hepatinov, et Université Paris Saclay, Villejuif, France
| | - Nassim Kamar
- CHU Rangueil, Département de Néphrologie et Transplantation d'Organes, Toulouse, France
| | - Faouzi Saliba
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM, Unité 1193, Hepatinov, et Université Paris Saclay, Villejuif, France
| | - Domitille Erard
- Hospices civils de Lyon, Hôpital de la Croix Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | - Arnaud Del Bello
- CHU Rangueil, Département de Néphrologie et Transplantation d'Organes, Toulouse, France
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3
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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: 3] [Impact Index Per Article: 3.0] [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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4
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Goto R, Fukasaku Y, Ganchiku Y, Kawamura N, Watanabe M, Ota T, Hatanaka KC, Suzuki T, Shimamura T, Taketomi A. Post-transplant donor-specific anti-HLA antibodies with a higher mean fluorescence intensity are associated with graft fibrosis in pediatric living donor liver transplantation. Front Pediatr 2023; 11:1172516. [PMID: 37181419 PMCID: PMC10168538 DOI: 10.3389/fped.2023.1172516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
The roles of post-transplant anti-HLA donor specific antibody (DSA) in pediatric liver transplantation (LT), including therapeutic strategies, remain controversial. This study aimed to identify the risks of post-transplant DSA for graft fibrosis progression in pediatric living donor LT (LDLT). We retrospectively evaluated 88 LDLT pediatric cases between December 1995 and November 2019. DSAs were assessed with single antigen bead test. Graft fibrosis was histopathologically scored with METAVIR and the centrilobular sinusoidal fibrosis system. Post-transplant DSAs were detected in 37 (52.9%) cases at 10.8 (1.3-26.9) years post-LDLT. The histopathological examination of 32 pediatric cases with post-transplant DSA revealed that 7 (21.9%) with a high DSA-MFI (≥9,378) showed graft fibrosis progression (≥F2). No graft fibrosis was observed in the subjects with a low DSA-MFI. The risk factors for developing graft fibrosis in pediatric cases with post-transplant DSA were an older graft age (>46.5 years old), lower platelet count (<10.7 × 104/ml) and higher Fib4 index (>0.7807, recipient age; >1.8952, donor age). Limited efficacy of additional immunosuppressants was observed in DSA positive pediatric cases. In conclusion, pediatric cases with a high DSA-MFI and risk factors should undergo a histological examination. The appropriate treatment for post-transplant DSA in pediatric LT needs to be determined.
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Affiliation(s)
- Ryoichi Goto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yasutomo Fukasaku
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshikazu Ganchiku
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Norio Kawamura
- Department of Transplant Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaaki Watanabe
- Department of Transplant Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takuji Ota
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kanako C. Hatanaka
- Center for Development of Advanced Diagnostics, Hokkaido University Hospital, Sapporo, Japan
| | - Tomomi Suzuki
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuyoshi Shimamura
- Division of Organ Transplantation, Hokkaido University Hospital, Sapporo, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Transplant Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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5
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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: 22] [Impact Index Per Article: 22.0] [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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Demir EA, Tutuk O, Dogan-Gocmen H, Ozyilmaz DS, Karagul MI, Kara M, Temiz M, Tumer C. CREB1 and PPAR-α/γ Pathways in Hepatic Ischemia/Reperfusion: Route for Curcumin to Hepatoprotection. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2022; 21:e133779. [PMID: 36942070 PMCID: PMC10024335 DOI: 10.5812/ijpr-133779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/31/2022] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
Background Hepatic ischemia/reperfusion injury is a major problem that can exacerbate complications, particularly in liver transplantations. Objectives This study aimed to investigate the cellular mechanisms of ischemia/reperfusion injury and hepatoprotection by curcumin. Methods Wistar albino rats were divided into four groups as Control, Sham, I/R, and Cur+I/R. Hepatic ischemia/reperfusion was induced in I/R and Cur+I/R animals, the latter of which was also given 50 mg/kg/day of curcumin for 14 days. Liver aminotransferases and the transcription regulators of inflammation (RelA, IκB, PPAR-α, PPAR-γ, CREB1) were examined along with the histological examination. Results Hepatic ischemia/reperfusion was found to disrupt hepatic microstructure and downregulate PPAR-α, PPAR-γ, and CREB1 transcripts. Curcumin supplementation in hepatic ischemia/reperfusion recovered the structural organization and promoted the hepatocyte regeneration while increasing expressions of PPARs and CREB1. RelA and IκB were found unaltered, possibly due to the crosstalk between targeted transcripts by ischemia/reperfusion and curcumin. Conclusions In sum, PPAR-α/γ and CREB1 were involved in hepatic ischemia/reperfusion and, moreover, were detected to be stimulated by curcumin. PPAR and CREB pathways were found to provide a route to hepatoprotection for curcumin supplementation as evidenced by the microstructural improvement.
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Affiliation(s)
- Enver Ahmet Demir
- Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
- Corresponding Author: Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, 31040, Hatay, Turkey.
| | - Okan Tutuk
- Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Hatice Dogan-Gocmen
- Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Duygu Seren Ozyilmaz
- Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Meryem Ilkay Karagul
- Department of Histology and Embryology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Mikail Kara
- Department of Histology and Embryology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Muhyittin Temiz
- Department of General Surgery, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Cemil Tumer
- Department of Physiology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
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7
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Barbetta A, Meeberg G, Rocque B, Barhouma S, Weaver C, Gilmour S, Faytrouni F, Guttman O, Zielsdorf S, Etesami K, Kwon Y, Yanni G, Campbell P, Shapiro J, Emamaullee J. Immunologic benefits of maternal living donor allografts in pediatric liver transplantation: fewer rejection episodes and no evidence of de novo allosensitization. Pediatr Transplant 2022; 26:e14197. [PMID: 34806273 PMCID: PMC9053650 DOI: 10.1111/petr.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/23/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric liver transplant (LT) recipients of maternal living liver donor (LLD) grafts have been reported to experience fewer rejection episodes. However, it is unclear whether this benefit translates to reduction in developing donor-specific antibody (DSA) among maternal-LLD recipients. The aim of this study was to compare immunologic outcomes among maternal-LLD, non-maternal-LLD, and deceased donor liver transplant (DDLT) recipients. METHODS Children (≤18 years) who underwent LT between 1/1998 and 12/2019 at two high-volume LT centers in North America were evaluated. Patients were divided into three groups by type of graft received (maternal-LLD, non-maternal LLD, and DDLT). Clinical variables and outcomes were compared according to each graft type. RESULTS A total of 450 pediatric primary LT were analyzed: 275 (61.1%) DDLT, 73 (16.2%) maternal-LLD, and 102 (22.6%) non-maternal-LLD. Children receiving LLD grafts were less likely to develop rejection when compared to the DDLT group (DDLT 46.9% vs. maternal-LLD 31.5% vs. non-maternal-LLD 28.4%, p = 0.001). There was no difference in rejection rates between maternal and non-maternal-LLD recipients. A higher percentage of maternal-LLD recipients were on immunosuppression monotherapy compared to non-maternal-LLD and DDLT recipients (6.7% vs. 1.2 vs. 2.4%, respectively). A subgroup of 68 patients were tested for DSA post-LT. Maternal-LLD recipients were less likely to develop de novo DSA (maternal-LLD 11.8% vs. non-maternal-LLD 19.3% vs. DDLT 43%, p = 0.018). None of the maternal-LLD recipients developed antibody-mediated rejection. CONCLUSIONS These data support the concept of immunologic benefit of maternal-LLD in pediatric LT, with lower rates of rejection and allosensitization post-LT when compared to DDLT recipients.
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Affiliation(s)
- Arianna Barbetta
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA
| | | | - Brittany Rocque
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA
| | | | - Carly Weaver
- Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital-Los Angeles, Los Angeles, CA USA
| | | | - Farah Faytrouni
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Orlee Guttman
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Shannon Zielsdorf
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA,University of Southern California, Los Angeles, CA, USA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital-Los Angeles, Los Angeles, CA USA
| | - Kambiz Etesami
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA,University of Southern California, Los Angeles, CA, USA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital-Los Angeles, Los Angeles, CA USA
| | - Yong Kwon
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA,University of Southern California, Los Angeles, CA, USA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital-Los Angeles, Los Angeles, CA USA
| | - George Yanni
- University of Southern California, Los Angeles, CA, USA,Department of Pediatrics, Children’s Hospital-Los Angeles, Los Angeles, CA USA
| | - Patricia Campbell
- Alberta Transplant Institute, Edmonton, AB, Canada,Departemtent of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | | | - Juliet Emamaullee
- Department of Surgery, Division of Abdominal Organ Transplant, University of Southern California, Los Angeles, CA, USA,University of Southern California, Los Angeles, CA, USA,Division of Hepatobiliary and Abdominal Organ Transplantation Surgery, Children’s Hospital-Los Angeles, Los Angeles, CA USA
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8
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Levitsky J, Kandpal M, Guo K, Zhao L, Kurian S, Whisenant T, Abecassis M. Prediction of Liver Transplant Rejection With a Biologically Relevant Gene Expression Signature. Transplantation 2022; 106:1004-1011. [PMID: 34342962 PMCID: PMC9301991 DOI: 10.1097/tp.0000000000003895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/21/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Noninvasive biomarkers distinguishing early immune activation before acute rejection (AR) could more objectively inform immunosuppression management in liver transplant recipients (LTRs). We previously reported a genomic profile distinguishing LTR with AR versus stable graft function. This current study includes key phenotypes with other causes of graft dysfunction and uses a novel random forest approach to augment the specificity of predicting and diagnosing AR. METHODS Gene expression results in LTRs with AR versus non-AR (combination of other causes of graft dysfunction and normal function) were analyzed from single and multicenter cohorts. A 70:30 approach (61 ARs; 162 non-ARs) was used for training and testing sets. Microarray data were normalized using a LT-specific vector. RESULTS Random forest modeling on the training set generated a 59-probe classifier distinguishing AR versus non-AR (area under the curve 0.83; accuracy 0.78, sensitivity 0.70, specificity 0.81, positive predictive value 0.54, negative predictive value [NPV] 0.89; F-score 0.61). Using a locked threshold, the classifier performed well on the testing set (accuracy 0.72, sensitivity 0.67, specificity 0.73, positive predictive value 0.48, NPV 0.86; F-score 0.56). Probability scores increased in samples preceding AR versus non-AR, when liver function tests were normal, and decreased following AR treatment (P < 0.001). Ingenuity pathway analysis of the genes revealed a high percentage related to immune responses and liver injury. CONCLUSIONS We have developed a blood-based biologically relevant biomarker that can be detected before AR-associated graft injury distinct from LTR never developing AR. Given its high NPV ("rule out AR"), the biomarker has the potential to inform precision-guided immunosuppression minimization in LTRs.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Manoj Kandpal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kexin Guo
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lihui Zhao
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sunil Kurian
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Green Hospital, La Jolla, CA
| | - Thomas Whisenant
- Center for Computational Biology and Bioinformatics, School of Medicine, University of California San Diego, San Diego, CA
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9
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Goto R, Ito M, Kawamura N, Watanabe M, Ganchiku Y, Kamiyama T, Shimamura T, Taketomi A. The impact of preformed donor‐specific antibodies in living donor liver transplantation according to graft volume. Immun Inflamm Dis 2022; 10:e586. [PMID: 35064772 PMCID: PMC8926496 DOI: 10.1002/iid3.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ryoichi Goto
- Department of Gastroenterological Surgery I Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Makoto Ito
- Division of Laboratory and Transfusion Medicine Hokkaido University Hospital Sapporo Japan
| | - Norio Kawamura
- Department of Transplant Surgery Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Masaaki Watanabe
- Department of Transplant Surgery Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Yoshikazu Ganchiku
- Department of Gastroenterological Surgery I Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Tsuyoshi Shimamura
- Division of Organ Transplantation Hokkaido University Hospital Sapporo Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I Hokkaido University Graduate School of Medicine Sapporo Japan
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10
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Levitsky J, Kandpal M, Guo K, Kleiboeker S, Sinha R, Abecassis M. Donor-derived cell-free DNA levels predict graft injury in liver transplant recipients. Am J Transplant 2022; 22:532-540. [PMID: 34510731 DOI: 10.1111/ajt.16835] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/15/2021] [Accepted: 09/02/2021] [Indexed: 01/25/2023]
Abstract
Donor-derived cell-free DNA (dd-cfDNA) has been evaluated as a rejection marker in organ transplantation. This study sought to assess the utility of dd-cfDNA to diagnose graft injury in liver transplant recipients (LTR) and as a predictive biomarker prior to different causes of graft dysfunction. Plasma from single and multicenter LTR cohorts was analyzed for dd-cfDNA. Phenotypes of treated biopsy-proven acute rejection (AR, N = 57), normal function (TX, N = 94), and acute dysfunction no rejection (ADNR; N = 68) were divided into training and test sets. In the training set, dd-cfDNA was significantly different between AR versus TX (AUC 0.95, 5.3% cutoff) and AR versus ADNR (AUC 0.71, 20.4% cutoff). Using these cutoffs in the test set, the accuracy and NPV were 87% and 100% (AR vs. TX) and 66.7% and 87.8% (AR vs. ADNR). Blood samples collected serially from LTR demonstrated incremental elevations in dd-cfDNA prior to the onset of graft dysfunction (AR > ADNR), but not in TX. Dd-cfDNA also decreased following treatment of rejection. In conclusion, the serial elevation of dd-cfDNA identifies pre-clinical graft injury in the context of normal liver function tests and is greatest in rejection. This biomarker may help detect early signs of graft injury and rejection to inform LTR management strategies.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Manoj Kandpal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Biostatistics Collaboration Center, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kexin Guo
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Biostatistics Collaboration Center, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rohita Sinha
- Eurofins Viracor Clinical Diagnostics, Lee's Summit, Missouri
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11
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Ono K, Ide K, Tanaka Y, Ohira M, Tahara H, Tanimine N, Yamane H, Ohdan H. Molecular Mismatch Predicts T Cell-Mediated Rejection and De Novo Donor-Specific Antibody Formation After Living Donor Liver Transplantation. Liver Transpl 2021; 27:1592-1602. [PMID: 34310028 DOI: 10.1002/lt.26238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/24/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023]
Abstract
Human leukocyte antigen (HLA) molecular mismatch (MM) analysis improves the prediction of clinical outcomes in kidney transplantation compared with prediction via traditional antigen MM. However, it remains unclear whether the level of MM can be used for risk stratification among liver transplantation (LT) recipients. A retrospective observational study of 45 living donor LTs was performed to evaluate eplet MM as a risk factor for both T cell-mediated rejection (TCMR) in the first month and de novo donor-specific antibody (dnDSA) formation. A total of 9 (20%) patients displayed TCMR. HLA-A, HLA-B, HLA-C, and HLA-DRB1 eplet MM numbers were not associated with TCMR. By contrast, HLA-DQB1 eplet MM (DQB1-EpMM) number was significantly high in patients with TCMR. The predicted indirectly recognizable HLA epitopes (PIRCHE-II) score for the HLA-DQB1 locus (DQB1-PIRCHE-II) was also significantly higher in the TCMR group than in the no-TCMR group. There was a high probability for TCMR to occur with either a DQB1-EpMM ≥7 or a DQB1-PIRCHE-II ≥13. Pretransplant mixed lymphocyte response analyses indicated that there were no significant differences between the antidonor T cell proliferation activities of patients with low-number (<7) and high-number (≥7) DQB1-EpMMs. However, the proportion of CD25 expression on proliferating antidonor CD8+ T cells, used as a cytotoxic activity marker, was high in DQB1-EpMMs ≥7. Moreover, both DQB1-EpMMs ≥9 and DQB1-PIRCHE-II ≥3 were predictors of dnDSA formation. Thus, MM analysis may be applied toward tailored immunosuppression based on individual risks.
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Affiliation(s)
- Kosuke Ono
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoki Tanimine
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroaki Yamane
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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12
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Immunosuppression in liver and intestinal transplantation. Best Pract Res Clin Gastroenterol 2021; 54-55:101767. [PMID: 34874848 DOI: 10.1016/j.bpg.2021.101767] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 02/07/2023]
Abstract
Immunosuppression handling plays a key role in the early and long-term results of transplantation. The development of multiple immunosuppressive drugs led to numerous clincial trials searching to reach the ideal regimen. Due to heterogeneity of the studied patient cohorts and flaws in many, even randomized controlled, study designs, the answer still stands out. Nowadays triple-drug immunosuppression containing a calcineurin inhibitor (preferentially tacrolimus), an antimetabolite (using mycophenolate moffettil or Azathioprine) and short-term steroids with or without induction therapy (using anti-IL2 receptor blocker or anti-lymphocytic serum) is the preferred option in both liver and intestinal transplantation. This chapter aims, based on a critical review of the definitions of rejection, corticoresistant rejection and standard immunosuppression to give some reflections on how to reach an optimal immunosuppressive status and to conduct trials allowing to draw solid conclusions. Endpoints of future trials should not anymore focus on biopsy proven, acute and chronic, rejection but also on graft and patient survival. Correlation between early- and long-term biologic, immunologic and histopathologic findings will be fundamental to reach in much more patients the status of operational tolerance.
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13
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Sakamoto S, Akamatsu N, Hasegawa K, Ohdan H, Nakagawa K, Egawa H. The efficacy of rituximab treatment for antibody-mediated rejection in liver transplantation: A retrospective Japanese nationwide study. Hepatol Res 2021; 51:990-999. [PMID: 33818877 DOI: 10.1111/hepr.13643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/17/2021] [Accepted: 03/27/2021] [Indexed: 12/17/2022]
Abstract
AIM Antibody-mediated rejection (AMR) has been consistently elucidated in liver transplantation (LT); however, the treatment for AMR, including rituximab, has not been indicated as a strongly recommended therapeutic protocol. METHODS This study was conducted as the Japanese multicenter retrospective study to accumulate data on the use of rituximab for AMR among patients undergoing LT between August 2001 and December 2016. Thirteen patients (five children and eight adults) were enrolled. RESULTS The types of AMR in the pediatric cases were chronic AMR in four cases and indeterminate AMR in one case. Among the pediatric cases, rituximab treatment only showed therapeutic efficacy in two patients with chronic AMR. Among the adult patients, five patients had chronic AMR, and three had acute AMR. Although two patients with chronic AMR died due to graft failure, liver function tests revealed improvement after rituximab treatment in the other patients. Two of the three patients with acute AMR died due to graft failure; rituximab treatment showed no therapeutic efficacy in these cases. Although bacterial infections occurred within 3 months after rituximab administration in three patients, rituximab treatment could be safely administered without any direct adverse effects. CONCLUSIONS The indication of rituximab therapy as an additional treatment for mild acute AMR and chronic AMR may be feasible; however, a prospective randomized control study is needed to evaluate the therapeutic efficacy of rituximab treatment for AMR.
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Affiliation(s)
- Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Tokyo University Graduate School of Medicine, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Tokyo University Graduate School of Medicine, Tokyo, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Nakagawa
- Department of Urology, Ichikawa General Hospital Tokyo Dental College, Chiba, Japan
| | - Hiroto Egawa
- Department of Gastroenterological Surgery, Institute of Gastroenterology, Tokyo Women's Medical University of Medicine, Tokyo, Japan
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14
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Rituximab Desensitization in Liver Transplant Recipients With Preformed Donor-specific HLA Antibodies: A Japanese Nationwide Survey. Transplant Direct 2021; 7:e729. [PMID: 34291151 PMCID: PMC8288898 DOI: 10.1097/txd.0000000000001180] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/03/2021] [Accepted: 04/20/2021] [Indexed: 12/14/2022] Open
Abstract
Background. The significance of preformed donor-specific anti-HLA antibodies (DSAs) in liver transplant recipients is controversial. Moreover, there has been no established desensitization protocol for DSA-positive recipients. Methods. A Japanese nationwide survey was performed to investigate the clinical practice among preformed DSA-positive patients with special reference to rituximab desensitization. Results. There was a total of 47 cases, including 2 pediatric cases, in which rituximab (287 ± 159 mg [319 (50–916)/m2]) was administered to desensitize preformed DSA. The decision for the indication of rituximab desensitization was based on a single-antigen assay in the majority of cases (83%, 39/47), and the most frequent protocol was rituximab monotherapy (n = 12) followed by quadruple treatment with rituximab tacrolimus, mycophenolate mofetil, and plasmapheresis (n = 11). The overall 1-, 3-, and 5-y graft and patient survival rates among adult patients were 85%, 83%, 83%, and 81%, 77%, 74%, respectively, while neither graft loss nor death was observed in the 2 pediatric cases. The 1-, 3-, and 12-mo cumulative incidence of antibody-mediated rejection (AMR) was 11%, 13%, and 13%, respectively. The incidence of AMR was significantly higher in the lower rituximab dose group than in the higher rituximab dose group (cutoff 300 mg/m2, 4% versus 24%, P = 0.041). The rate of infusion-related adverse drug reactions (ADRs) was 4.4%, and all ADRs were mild and self-limiting. A total of 99 ADRs among 27 patients were reported, none of which were severe adverse events associated with rituximab. Conclusions. The rituximab induction was well tolerated among DSA-positive liver transplant recipients with a satisfactory outcome. A rituximab dose >300 mg/m2 was observed to achieve less incidence of the development of AMR.
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15
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Gül-Klein S, Hegermann H, Röhle R, Schmelzle M, Tacke F, Schöning W, Öllinger R, Dziodzio T, Maier P, Plewe JM, Horst D, Sauer IM, Pratschke J, Lachmann N, Eurich D. Donor-Specific Antibodies Against Donor Human Leukocyte Antigen are Associated with Graft Inflammation but Not with Fibrosis Long-Term After Liver Transplantation: An Analysis of Protocol Biopsies. J Inflamm Res 2021; 14:2697-2712. [PMID: 34188517 PMCID: PMC8236257 DOI: 10.2147/jir.s307778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background Donor-specific antibodies (DSA) against donor human leukocyte antigen after liver transplantation, which are associated with histological changes, have been widely studied with respect to their sustained impact on transplant function. However, their long-term impact after liver transplantation remains unclear. Methods We performed a cross-sectional analysis from June 2016 to July 2017 that included all patients who presented themselves for scheduled follow-up after receiving a liver transplantation between September 1989 and December 2016. In addition to a liver protocol biopsy, patients were screened for human leukocyte antigen antibodies (HLAab) and donor-specific antibodies. Subsequently, the association between human leukocyte antigen antibodies, donor-specific antibodies, histologic and clinical features, and immunosuppression was analyzed. Results Analysis for human leukocyte antigen antibodies and donor-specific antibodies against donor human leukocyte antigen was performed for 291 and 271 patients. A significant association between higher inflammation grades and the presence of human leukocyte antigen antibodies and donor-specific antibodies was detected, while fibrosis stages remained unaffected. These results were confirmed by multivariate logistic regression for inflammation showing a significant increase for presence of human leukocyte antigen antibodies and donor-specific antibodies (OR: 4.43; 95% CI: 1.67–12.6; p=0.0035). Furthermore, the use of everolimus in combination with tacrolimus was significantly associated with the status of negative human leukocyte antigen antibodies and donor-specific antibodies. Viral etiology for liver disease, hepatocellular carcinoma (HCC) and higher steatosis grades of the graft were significantly associated with a lower rate of human leukocyte antigen antibodies. The impact of human leukocyte antigen antibodies and donor-specific antibodies against donor human leukocyte antigen was associated with higher levels of laboratory parameters, such as transaminases and bilirubin. Conclusion Donor-specific antibodies against donor human leukocyte antigen are associated with histological and biochemical graft inflammation after liver transplantation, while fibrosis seems to be unaffected. Future studies should validate these findings for longer observation periods and specific subgroups.
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Affiliation(s)
- Safak Gül-Klein
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Henriette Hegermann
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Robert Röhle
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Coordinating Center for Clinical Studies, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Moritz Schmelzle
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Hepatology & Gastroenterology, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Wenzel Schöning
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Robert Öllinger
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Tomasz Dziodzio
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Patrick Maier
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Julius M Plewe
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - David Horst
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Igor Maximilian Sauer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Nils Lachmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, HLA Laboratory, Institute of Transfusion Medicine, Histocompatibility and Immunogenetics, Charité - Universitätsmedizin, Berlin, Germany
| | - Dennis Eurich
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
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16
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Xu Q, McAlister VC, House AA, Molinari M, Leckie S, Zeevi A. Autoantibodies to LG3 are associated with poor long-term survival after liver retransplantation. Clin Transplant 2021; 35:e14318. [PMID: 33871888 DOI: 10.1111/ctr.14318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/12/2021] [Accepted: 04/02/2021] [Indexed: 12/21/2022]
Abstract
Autoantibodies are detrimental to the survival of organ transplantation. We demonstrated that Angiotensin II Type I Receptor agonistic autoantibodies (AT1R-AA) were associated with poor outcomes after liver retransplantation. To examine the effect of other autoantibodies, we studied a retrospective cohort of 93 patients who received a second liver transplant. Pre-retransplant sera were tested with Luminex-based solid-phase assays. Among 33 tested autoantibodies, 15 were significantly higher in 48 patients who lost their regrafts than 45 patients whose regrafts were still functioning. Specifically, patients with autoantibodies to the C-terminal laminin-like globular domain of Perlecan (LG3) experienced significantly worse regraft survival (p = .002) than those with negative LG3 autoantibodies (LG3-A). In multivariate analysis, LG3-A (HR = 2.35 [1.11-4.98], p = .027) and AT1R-AA (HR = 2.09 [1.07-4.10], p = .032) remained significant predictors of regraft loss after adjusting for recipient age and sex. There were synergistic deleterious effects on regraft survival in patients who were double-positive for LG3-A and donor-specific antibody (DSA) (HR = 5.26 [2.15-12.88], p = .001), or LG3-A and AT1R-AA (HR = 3.23 [1.37-7.66], p = .008). All six double-positive patients lost their liver regrafts. In conclusion, LG3-A is associated with inferior long-term outcomes of a second liver transplant. Screening anti-HLA antibodies and autoantibodies such as LG3-A/AT1R-AA identifies patients with a higher risk for liver transplantation.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vivian C McAlister
- Department of Surgery, University of Western Ontario, London, ON, Canada
| | - Andrew A House
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steve Leckie
- Department of Pathology and Lab Medicine, London Health Science Center, London, ON, Canada
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Abstract
PURPOSE OF REVIEW Achieving operational tolerance remains a priority in liver transplantation. Although several biomarkers of tolerance and rejection have been identified, few have been reproducible and validated across centers, and therefore have yet to reach clinical practice. Here we summarize findings from prior seminal studies and review current developments in profiling the liver allograft. RECENT FINDINGS Substantial efforts and progress have been made in the recent years towards the discovery of reliable biomarkers that can predict and guide successful immunosuppression withdrawal. Recent studies have also investigated the transcriptomic signatures underlying not only acute rejection but also subclinical inflammation and chronic allograft injury. SUMMARY As new genomic and sequencing technologies continue to develop, clinical trials are underway to validate biomarkers of tolerance, as well as better understand the mechanisms of both acute and subclinical rejection, with the goal of maximizing allograft survival. Altogether, this will hopefully enable the implementation of immunosuppression withdrawal protocols into clinical practice and make operational tolerance reliably attainable in the near future.
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Affiliation(s)
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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18
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Beyzaei Z, Geramizadeh B, Bagheri Z, Karimzadeh S, Shojazadeh A. De Novo Donor Specific Antibody and Long-Term Outcome After Liver Transplantation: A Systematic Review and Meta-Analysis. Front Immunol 2020; 11:613128. [PMID: 33424868 PMCID: PMC7786049 DOI: 10.3389/fimmu.2020.613128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022] Open
Abstract
Background The impact of de novo anti-HLA donor-specific alloantibodies (DSA) which develop after long-term liver transplantation (LT) remains controversial and unclear. The aim of this study was to investigate the role of de novo DSAs on the outcome in LT. Methods We did a systematic review and meta-analysis of observational studies published until Dec 31, 2019, that reported de novo DSA outcome data (≥1 year of follow-up) after liver transplant. A literature search in the MEDLINE/PubMed, EMBASE, Cochrane Library, Scopus and Web of Science Core Collection databases was performed. Results Of 5,325 studies identified, 15 fulfilled our inclusion criteria. The studies which reported 2016 liver transplant recipients with de novo DSAs showed an increased complication risk, i.e. graft loss and chronic rejection (OR 3.61; 95% CI 1.94-6.71, P < 0.001; I2 58.19%), and allograft rejection alone (OR 6.43; 95% CI: 3.17-13.04; P < 0.001; I2 49.77%); they were compared to patients without de novo DSAs. The association between de novo DSAs and overall outcome failure was consistent across all subgroups and sensitivity analysis. Conclusions Our study suggested that de novo DSAs had a significant deleterious impact on the liver transplant risk of rejection. The routine detection of de novo DSAs may be beneficial as noninvasive biomarker-guided risk stratification.
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Affiliation(s)
- Zahra Beyzaei
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Bagheri
- Department of Biostatistics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Karimzadeh
- Shiraz Medical School Library, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shojazadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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19
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Kohut TJ, Barandiaran JF, Keating BJ. Genomics and Liver Transplantation: Genomic Biomarkers for the Diagnosis of Acute Cellular Rejection. Liver Transpl 2020; 26:1337-1350. [PMID: 32506790 DOI: 10.1002/lt.25812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/26/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
Acute cellular rejection (ACR) is a common complication in liver transplantation recipients (LTRs), especially within the first 12 months, and it is associated with increased morbidity and mortality. Although abnormalities in standard liver biochemistries may raise the clinical suspicion for ACR, it lacks specificity, and invasive liver biopsies, which are associated with numerous risks, are required for definitive diagnoses. Biomarker discovery for minimally invasive tools for diagnosis and prognostication of ACR after liver transplantation (LT) has become a rapidly evolving field of research with a recent shift in focus to omics-based biomarker discovery. Although none are yet ready to replace the standard of care, there are several promising minimally invasive, blood-derived biomarkers that are under intensive research for the diagnosis of ACR in LTRs. These omics-based biomarkers, encompassing DNA, RNA, proteins, and metabolites, hold tremendous potential. Some are likely to become integrated into ACR diagnostic algorithms to assist clinical decision making with a high degree of accuracy that is cost-effective and reduces or even obviates the need for an invasive liver biopsy.
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Affiliation(s)
- Taisa J Kohut
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA.,The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jose F Barandiaran
- Department of General Surgery, Main Line Health System, Lankenau Medical Center, Wynnewood, PA
| | - Brendan J Keating
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
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20
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DSA Are Associated With More Graft Injury, More Fibrosis, and Upregulation of Rejection-associated Transcripts in Subclinical Rejection. Transplantation 2020; 104:551-561. [PMID: 31651790 DOI: 10.1097/tp.0000000000003034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Subclinical T cell-mediated rejection (subTCMR) is commonly found after liver transplantation and has a good short-term prognosis, even when it is left untreated. Donor-specific antibodies (DSA) are putatively associated with a worse prognosis for recipient and graft after liver transplantation. METHODS To assess the immune regulation in subTCMR grafts, gene expression of 93 transcripts for graft injury, tolerance, and immune regulation was analyzed in 77 biopsies with "no histologic rejection" (NHR; n = 25), "clinical TCMR" (cTMCR; n = 16), and subTCMR (n = 36). In addition, all available subTCMR biopsies (n = 71) were tested for DSA with bead assays. RESULTS SubTCMR showed heterogeneous and intermediate expression profiles of transcripts that were upregulated in cTCMR. Graft gene expression suggested a lower activation of effector lymphocytes and a higher activation of regulatory T cells in grafts with subTCMR compared to cTCMR. DSA positivity in subTCMR was associated with histological evidence of more severe graft inflammation and fibrosis. This more severe DSA+ associated graft injury in subTCMR was converged with an upregulation of cTCMR-associated transcripts. In nonsupervised analysis, DSA positive subTCMR mostly clustered together with cTCMR, while DSA negative subTCMR clustered together with NHR. CONCLUSIONS T cell-mediated rejection seems to form a continuum of alloimmune activation. Although subTCMR exhibited less expression of TCMR-associated transcript, DSA positivity in subTCMR was associated with an upregulation of rejection-associated transcripts. The identification of DSA positive subclinical rejection might help to define patients with more inflammation in the graft and development of fibrosis.
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21
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Höfer A, Jonigk D, Hartleben B, Verboom M, Hallensleben M, Manns MP, Jaeckel E, Taubert R. Non-invasive screening for subclinical liver graft injury in adults via donor-specific anti-HLA antibodies. Sci Rep 2020; 10:14242. [PMID: 32859929 PMCID: PMC7455737 DOI: 10.1038/s41598-020-70938-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023] Open
Abstract
The majority of liver grafts exhibit abnormal histological findings late after transplantation, even when liver enzymes are normal. Such subclinical graft injuries were associated with rejection and fibrosis progression in recent studies. The identification of non-invasive biomarkers for subclinical graft injury might help to individualize immunosuppression. Therefore, graft injury was assessed in 133 liver biopsies with normal/near normal liver enzymes from a prospective liver biopsy program. Cytokeratin-18 cell death marker (M65) and donor specific anti-HLA antibodies (DSA) were measured as non-invasive markers in paired plasma samples in addition to routine parameters. M65 was associated with subclinical graft injury but this association was too weak for reasonable clinical application. DSA positivity was associated with more graft inflammation (OR = 5.4) and more fibrosis (OR = 4.2). Absence of DSA excluded fibrosis in 87–89%, while presence of DSA excluded histological criteria for immunosuppression minimization attempts in 92–97%. While CK18 cell death marker had no diagnostic value for the detection of subclinical liver graft injury, DSA testing can help to preselect patients for immunosuppression reduction in case of DSA negativity, while DSA positivity should prompt elastography or liver biopsy for the assessment of subclinical graft injury.
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Affiliation(s)
- Anne Höfer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Danny Jonigk
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Björn Hartleben
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael Hallensleben
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany. .,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany. .,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany.
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22
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Cousin VL, Rougemont AL, Rubbia-Brandt L, Wildhaber BE, Villard J, Ferrari-Lacraz S, McLin VA. Peripheral Donor-specific Antibodies Are Associated With Histology and Cellular Subtypes in Protocol Liver Biopsies of Pediatric Recipients. Transplantation 2020; 104:1633-1643. [PMID: 32732841 DOI: 10.1097/tp.0000000000003099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The cellular infiltrate in protocol liver biopsies (PB) following pediatric liver transplantation remains mostly uncharacterized, yet there is increasing concern about the role of inflammation and fibrosis in long-term liver allografts. We aimed to define cell types in PB and to analyze their relationship with donor-specific antibodies (DSA) and histological phenotype. METHODS PB were performed at least 1 year after transplantation. We identified 4 phenotypes: normal, fibrosis, inflammation, inflammation with fibrosis. Cell types were counted after immunostaining for CD3, CD4, CD8, CD68, CD20, MUM1, and FoxP3. RESULTS Forty-four patients underwent 1 PB between 2000 and 2015. Eleven percent (5/44) of PB displayed normal histology, 13.6% (6/44) fibrosis, 34.1% (15/44) inflammation, and 40.9% (18/44) inflammation and fibrosis. The main cell types in the portal tracts and lobules were CD3+ and CD68+ cells. Frequency of de novo DSA was 63% (27/44). The presence of CD8+ cells in the lobules was associated with fibrosis. Inflammation and fibrosis in PB were associated with the presence of circulating de novo DSA, number of de novo DSA, and C1q binding activity when compared to other phenotypes. CONCLUSIONS T cells (CD3+) and macrophages (CD68+) were the most prevalent cell-types in PB. In the presence of inflammation, portal tracts were enriched in CD3+, CD20+ but displayed fewer CD68+. This coincided with the presence and number of de novo DSA. How these cellular and humoral actors interact is unclear, but peripheral DSA may be a marker of immune cellular activity in the seemingly quiescent allograft.
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Affiliation(s)
- Vladimir L Cousin
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Anne-Laure Rougemont
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - Laura Rubbia-Brandt
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
| | - Barbara E Wildhaber
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
- Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Jean Villard
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Department of Pathology and Immunology, University of Geneva, Geneva, Switzerland
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospital and Medical School, Geneva, Switzerland
| | - Valérie A McLin
- Swiss Pediatric Liver Center, Geneva University Hospitals, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
- Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, Geneva, Switzerland
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23
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Levitsky J, Burrell BE, Kanaparthi S, Turka LA, Kurian S, Sanchez-Fueyo A, Lozano JJ, Demetris A, Lesniak A, Kirk AD, Stempora L, Yang GY, Mathew JM. Immunosuppression Withdrawal in Liver Transplant Recipients on Sirolimus. Hepatology 2020; 72:569-583. [PMID: 31721246 PMCID: PMC7217743 DOI: 10.1002/hep.31036] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS As conversion from calcineurin inhibitor to sirolimus (SRL), a mechanistic target of rapamycin inhibitor (mTOR-I), has been shown to enhance immunoregulatory profiles in liver transplant (LT) recipients (LTRs), mTOR-I therapy might allow for increased success of immunosuppression (IS) withdrawal. Our aim was to determine if operational tolerance could be observed in LTRs withdrawn from SRL and if blood/graft tolerance biomarkers were predictive of successful withdrawal. APPROACH AND RESULTS We performed a prospective trial of SRL monotherapy withdrawal in nonimmune, nonviremic LTRs > 3 years post-LT. SRL was weaned over ~6 months, and biopsies were performed 12 months postweaning or at concern for acute rejection. Twenty-one LTRs consented; 6 were excluded due to subclinical acute rejection on baseline biopsy or other reasons, and 15 underwent weaning (age 61.3 ± 8.8 years; LT to SRL weaning 6.7 ± 3 years). Eight (53%) achieved operational tolerance (TOL). Of the 7 who were nontolerant (non-TOL), 6 had mild acute rejection on biopsy near the end of weaning or at study end; 1 was removed from the trial due to liver cancer recurrence. At baseline preweaning, there were statistically increased blood tolerogenic dendritic cells and cell phenotypes correlating with chronic antigen presentation in the TOL versus non-TOL groups. A previously identified biopsy gene signature accurately predicted TOL versus non-TOL in 12/14 LTRs before weaning. At study end, biopsy staining revealed statistically significant increases in antigen-presenting cell:leukocyte pairings, FOXP3+ /CD4+ T cells, Tbet+ /CD8+ T cells, and lobular dendritic cells in the non-TOL group. CONCLUSIONS This study evaluated IS withdrawal directly from mTOR-I therapy in LTRs and achieved > 50% operational tolerance. Preweaning gene expression and peripheral blood mononuclear cell profiling may be useful as predictors of successful mTOR-I therapy withdrawal. NCT02062944.
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Affiliation(s)
- Josh Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Laurence A. Turka
- Immune Tolerance Network, Bethesda, MD; Massachusetts General Hospital, Boston, MA
| | - Sunil Kurian
- Scripps Clinic Bio-Repository and Transplantation Research, La Jolla, California, United States
| | | | - Juan J. Lozano
- Biomedical Research Center in Hepatic and Digestive Diseases, Carlos III Health Institute, Barcelona, Spain
| | | | | | | | | | - Guang-Yu Yang
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James M. Mathew
- Northwestern University Feinberg School of Medicine, Chicago, IL
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24
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Hann A, Osei-Bordom DC, Neil DAH, Ronca V, Warner S, Perera MTPR. The Human Immune Response to Cadaveric and Living Donor Liver Allografts. Front Immunol 2020; 11:1227. [PMID: 32655558 PMCID: PMC7323572 DOI: 10.3389/fimmu.2020.01227] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
The liver is an important contributor to the human immune system and it plays a pivotal role in the creation of both immunoreactive and tolerogenic conditions. Liver transplantation provides the best chance of survival for both children and adults with liver failure or cancer. With current demand exceeding the number of transplantable livers from donors following brain death, improved knowledge, technical advances and the desire to prevent avoidable deaths has led to the transplantation of organs from living, ABO incompatible (ABOi), cardiac death donors and machine based organ preservation with acceptable results. The liver graft is the most well-tolerated, from an immunological perspective, of all solid organ transplants. Evidence suggests successful cessation of immunosuppression is possible in ~20–40% of liver transplant recipients without immune mediated graft injury, a state known as “operational tolerance.” An immunosuppression free future following liver transplantation is an ambitious but perhaps not unachievable goal. The initial immune response following transplantation is a sterile inflammatory process mediated by the innate system and the mechanisms relate to the preservation-reperfusion process. The severity of this injury is influenced by graft factors and can have significant consequences. There are minimal experimental studies that delineate the differences in the adaptive immune response to the various forms of liver allograft. Apart from ABOi transplants, antibody mediated hyperacute rejection is rare following liver transplant. T-cell mediated rejection is common following liver transplantation and its incidence does not differ between living or deceased donor grafts. Transplantation in the first year of life results in a higher rate of operational tolerance, possibly due to a bias toward Th2 cytokines (IL4, IL10) during this period. This review further describes the current understanding of the immunological response toward liver allografts and highlight the areas of this topic yet to be fully understood.
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Affiliation(s)
- Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - Desley A H Neil
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Vincenzo Ronca
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Suz Warner
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,The Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.,The Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
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25
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Nilles KM, Levitsky J. Donor-Specific Antibodies in Liver Transplantation. Clin Liver Dis (Hoboken) 2020; 15:13-16. [PMID: 32104571 PMCID: PMC7041955 DOI: 10.1002/cld.871] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/05/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-1-reading-nilles a video presentation of this article Answer questions and earn https://www.wileyhealthlearning.com/Activity/7025330/disclaimerspopup.aspx.
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Affiliation(s)
- Kathy M. Nilles
- Department of Medicine and Surgery, Division of Gastroenterology and Hepatology, Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIL
| | - Josh Levitsky
- Department of Medicine and Surgery, Division of Gastroenterology and Hepatology, Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIL
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26
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Schluckebier D, Cousin VL, Petit LM, Belli D, Wildhaber B, Rougemont AL, Villard J, Ferrari-Lacraz S, McLin VA. Preformed and de novo DSA are associated with T-cell-mediated rejection in pediatric liver transplant recipients requiring clinically indicated liver biopsy. Pediatr Transplant 2020; 24:e13611. [PMID: 31682057 DOI: 10.1111/petr.13611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 09/07/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022]
Abstract
Despite growing interest about the impact of donor-specific HLA antibodies (DSA) in LT limited data are available for pediatric recipients. Our aim was to perform a retrospective single-center chart review of children (0-16 years) having undergone LT between January 1, 2005 and December 31, 2017, to characterize DSA, to identify factors associated with the development of de novo DSA, and to analyze potential associations with the diagnosis of TCMR. Information on patient- and donor-characteristics and LB reports were analyzed retrospectively. Serum obtained before LT and at LB was analyzed for presence of recipient HLA antibody using Luminex® technology. MFI > 1000 was considered positive. In 63 pediatric LT recipients with a median follow-up of 72 months, the overall prevalence of de novo DSA was 60.3%. Most were directed against class II antigens (33/38, 86.8%). Preformed DSA were present in 30% of patients. Twenty-eight (28/63) patients (44.4%) presented at least one episode of TCMR, mostly (12/28, 43%) moderate (Banff 6-7). De novo DSA were significantly more frequent in patients with TCMR than in patients without (75% vs 48.6%, P = .03), and patients with preformed and de novo DSA had a significantly higher rate of TCMR than patients without any DSA (66.7% vs 20%, P = .02). Neither preformed DSA nor de novo DSA were associated with frequency or severity of TCMR. Recipients with lower weight at LT developed de novo DSA more frequently (P = .04). De novo DSA were highly prevalent in pediatric LT recipients. Although associated with the development of TCMR, they did not appear to impact the frequency or severity of TCMR or graft survival. Instead, de novo DSA may suggest a state of insufficient IS.
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Affiliation(s)
- Dominique Schluckebier
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Vladimir L Cousin
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Laetitia-Marie Petit
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Dominique Belli
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Barbara Wildhaber
- Division of Pediatric Surgery, Swiss Pediatric Liver Center, Geneva University Hospitals, Geneva, Switzerland
| | - Anne-Laure Rougemont
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
| | - Jean Villard
- Immunology and Transplant Unit, Geneva University Hospitals, Geneva, Switzerland
| | | | - Valérie A McLin
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
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27
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Vionnet J, Sempoux C, Pascual M, Sánchez-Fueyo A, Colmenero J. Donor-specific antibodies in liver transplantation. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:34-45. [DOI: 10.1016/j.gastrohep.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/18/2019] [Accepted: 09/30/2019] [Indexed: 12/22/2022]
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28
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Exploring pre-surgery donor-specific antibodies in the context of organ shortage in liver transplant. Langenbecks Arch Surg 2019; 404:865-874. [PMID: 31748871 DOI: 10.1007/s00423-019-01831-9] [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: 07/25/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is a growing disparity between the number of liver transplant (LT) candidates and availability of suitable liver allografts. Antibody-mediated rejection (AMR), secondary to positive donor-specific antibodies (DSA), remains a concern in liver transplantation. This study aimed to correlate expression of DSA on pre-transplant screening and outcomes of LT, specifically development of AMR in liver allografts and liver function profile in the post-operative period. METHODS Data of consecutive patients undergoing orthotopic LT (OLT) at the South Australian Liver Transplant Unit was analysed. All patients underwent DSA testing pre-transplant. RESULTS Within a cohort of 96 patients, over a post-OLT median follow-up of 849 days, only 2 patients (2%) developed AMR. While both patients had a positive DSA test preoperatively, overall DSA positivity was noted in 31% patients, with a specificity for prediction of AMR of 0.708. No significant association was noted between AMR (p = 0.092), T cell-mediated rejection/TCMR (p = 0.797) or late hepatic artery thrombosis/LHAT (p = 0.521). There was no significant interaction effect between DSA positivity and serum bilirubin or transaminases over a period of 100 days. CONCLUSION AMR following LT is uncommon. A positive DSA pre-transplant does not imply a definite risk of AMR. Also, there does not exist a significant interaction in time between DSA expression and serum bilirubin or transaminase levels. Until there emerges evidence to the contrary, it appears reasonable to consider DSA-positive donors within the broad context of marginal donors in the context of a worldwide shortage of LT donor allografts.
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29
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Tamura K, Tohyama T, Watanabe J, Nakamura T, Ueno Y, Inoue H, Honjo M, Sakamoto K, Takai A, Ogawa K, Takada Y. Preformed donor-specific antibodies are associated with 90-day mortality in living-donor liver transplantation. Hepatol Res 2019; 49:929-941. [PMID: 30991451 DOI: 10.1111/hepr.13352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 03/27/2019] [Accepted: 04/07/2019] [Indexed: 12/19/2022]
Abstract
AIM The impact of donor-specific anti-human leukocyte antigen (HLA) antibodies (DSAs) on living donor liver transplantation (LDLT) is unclear. The aim of this study was to investigate the association between DSAs and short-term outcomes in LDLT recipients, and to clarify the clinical impact of DSAs. METHOD Anti-HLA antibodies were screened in preoperative serum samples taken from 40 liver transplant recipients at Ehime University (Toon, Japan) between August 2001 and July 2015. Screening was carried out using the Flow-PRA method, and DSAs were detected in anti-HLA antibody-positive recipients using the Luminex single-antigen identification test. A mean fluorescence intensity of 1000 was used as the cut-off for positivity. We retrospectively reviewed the clinical courses of patients who were DSA-positive to elucidate early clinical manifestations in LDLT recipients. RESULTS Fifteen (12 female and 3 male) patients (38%) had anti-HLA antibodies. Eight of the 15 anti-HLA antibody-positive patients were positive for DSAs, and all were women. The 90-day survival rate of DSA-positive patients (50%) was significantly lower than that of DSA-negative patients (84.4%) (0.0112; Wilcoxon test). On univariate analysis, the DSA-positive rate was significantly higher in the 90-day mortality group. Postoperatively, the incidence of acute cellular rejection was higher in DSA-positive than DSA-negative patients. Thrombotic microangiopathy developed only in DSA-positive patients. We found no relationship between DSA status and bile duct stricture. CONCLUSION Preformed DSAs could be associated with elevated 90-day mortality in LDLT recipients. Further large-scale studies are required to verify the risk associated with DSAs in LDLT.
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Affiliation(s)
- Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taiji Tohyama
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jota Watanabe
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taro Nakamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yoshitomo Ueno
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hitoshi Inoue
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akihiro Takai
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
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30
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Levitsky J. Does the Liver Provide Immunosuppressive Advantage? Clin Liver Dis (Hoboken) 2019; 13:180-183. [PMID: 31316766 PMCID: PMC6605736 DOI: 10.1002/cld.817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/13/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Josh Levitsky
- Division of Gastroenterology & Hepatology, Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIL
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31
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Wozniak LJ, Venick RS. Donor-specific antibodies following liver and intestinal transplantation: Clinical significance, pathogenesis and recommendations. Int Rev Immunol 2019; 38:106-117. [DOI: 10.1080/08830185.2019.1630404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Laura J. Wozniak
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert S. Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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32
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Xu Q, Shrum B, Leckie S, Skaro A, McAlister VC. The impact of alloantibodies directed against the second donor on long-term outcomes of repeat liver transplantation. Hepatobiliary Surg Nutr 2019; 8:246-252. [PMID: 31245404 DOI: 10.21037/hbsn.2019.01.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Despite reports that associate donor specific antibody (DSA) with rejection after liver transplantation, grafts are still allocated according to blood group (ABO) but not human leukocyte antigen (HLA) compatibility, possibly due to the absence of an easily discernible clinical association between adverse recipient outcome and DSA. Re-transplantation provides a test environment where the presence of preformed DSA is prevalent and its effect on outcome should be apparent. Methods All patients undergoing a second liver transplantation with available pre-operative serum were included with the exception of ABO incompatible or multiple organ transplants. Banked sera were tested for anti-HLA antibodies with Luminex-based solid phase assays. Anti-HLA antibodies to the second donor (D2SA) were determined using antibodies specificity and HLA typing of 2nd liver donor. Results Preformed HLA antibodies directed to second liver transplantation (D2SA) were found in 31 (39%) of the 79 patients that were included in the study. Primary and re-transplantation characteristics were similar in both subgroups except first graft survival which was significantly shorter in recipients who are negative for D2SA. Mean survival of the second graft was similar in D2SA+ and D2SA- cohorts [8.55 (range, 0.01-24.74) vs. 7.56 (range, 0-23.53) years respectively, P=0.574]. Mean patient survival after 2nd liver transplantation was similar in D2SA+ and D2SA- cohorts [9.11 (range, 0.01-24.74) vs. 8.10 (range, 0-23.53) years respectively, P=0.504]. Subgroup univariate analysis demonstrated no detrimental effect of class, locus, or strength of D2SA on survival of the second liver transplant. In multivariate cox regression model, neither class I D2DSA (HR =1.101, P=0.92) nor class II D2SA (HR =1.74, P=0.359) were significant risks of graft failure. Conclusions Presence of D2SA was not found to be associated with inferior outcomes in this retrospective cohort study of liver re-transplantation suggesting that changes to the allocation system are not required.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology and Lab Medicine, University of Western Ontario, London, ON, Canada
| | - Brad Shrum
- Department of Surgery, University of Western Ontario, London, ON, Canada
| | - Steve Leckie
- Department of Pathology and Lab Medicine, University of Western Ontario, London, ON, Canada
| | - Anton Skaro
- Department of Surgery, University of Western Ontario, London, ON, Canada
| | - Vivian C McAlister
- Department of Surgery, University of Western Ontario, London, ON, Canada
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33
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Jucaud V, Shaked A, DesMarais M, Sayre P, Feng S, Levitsky J, Everly MJ. Prevalence and Impact of De Novo Donor-Specific Antibodies During a Multicenter Immunosuppression Withdrawal Trial in Adult Liver Transplant Recipients. Hepatology 2019; 69:1273-1286. [PMID: 30229989 DOI: 10.1002/hep.30281] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/09/2018] [Indexed: 01/07/2023]
Abstract
The development of human leukocyte antigen (HLA) donor-specific antibody/antibodies (DSA) is not well described in liver transplant (LT) patients undergoing immunosuppression (IS) withdrawal protocols despite the allograft risk associated with de novo DSA (dnDSA). We analyzed the development of dnDSA in 69 LT patients who received calcineurin inhibitor monotherapy and were enrolled in the ITN030ST study. Of these 69 patients, 40 stable patients were randomized to IS maintenance (n = 9) or IS minimization (n = 31). Nine of the 31 IS minimization patients achieved complete withdrawal and were free of IS. Among patients who achieved stable IS monotherapy 1 year after transplantation, the prevalence of dnDSA was 18.8%. Acute rejections and the biopsy-proven findings disqualifying patients from IS withdrawal attempt were factors associated with dnDSA development (P = 0.011 and P = 0.041, respectively). Among randomized patients, dnDSA prevalence was 51.7% after IS minimization and 66.7% in IS-free patients. dnDSA prevalence in patients on IS maintenance was 44.4%. dnDSA development during IS minimization was a risk factor for acute rejection (P = 0.015). The majority of dnDSA were against HLA-DQ antigens (78.7%). Conclusion. During the first year following transplantation, acute rejections increase the risk of developing dnDSA, so dnDSA positivity should be considered for IS withdrawal eligibility; during IS minimization, dnDSA development was associated with acute rejection, which prevented further IS withdrawal attempts.
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Affiliation(s)
| | | | | | - Peter Sayre
- Immune Tolerance Network, San Francisco, CA.,University of California San Francisco, San Francisco, CA
| | - Sandy Feng
- University of California San Francisco, San Francisco, CA
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International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients. Transplantation 2019; 102:727-743. [PMID: 29485508 DOI: 10.1097/tp.0000000000002147] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.
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Honda M, Sugawara Y, Kadohisa M, Shimata K, Sakisaka M, Yoshii D, Uto K, Hayashida S, Ohya Y, Yamamoto H, Yamamoto H, Inomata Y, Hibi T. Long-term Outcomes of ABO-incompatible Pediatric Living Donor Liver Transplantation. Transplantation 2018; 102:1702-1709. [PMID: 29620615 PMCID: PMC6166697 DOI: 10.1097/tp.0000000000002197] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has been performed to compensate for donor shortage. To date, few studies have reported detailed B-cell desensitization protocols and long-term outcomes of ABOi pediatric LDLT. METHODS Twenty-nine pediatric ABOi LDLT recipients were retrospectively analyzed. We compared the clinical outcomes between ABOi (n = 29) and non-ABOi (n = 131) pediatric LDLT recipients. Furthermore, we evaluated the safety and efficacy of our rituximab-based regimen for ABOi pediatric LDLT (2 ≤ age < 18; n = 10). RESULTS There were no significant differences in the incidence of infection, vascular complications, biliary complications, and acute cellular rejection between ABOi and non-ABOi groups. The cumulative graft survival rate at 1, 3, and 5 years for non-ABOi group were 92.1%, 87.0%, and 86.1%, and those for ABOi group were 82.8%, 82.8%, and 78.2%, respectively. Rituximab-based desensitization protocol could be performed safely, and reduced CD19+ lymphocyte counts effectively. Although rituximab-treated ABOi group showed comparable clinical outcomes and graft survival rate, 2 patients developed antibody-mediated rejection. CONCLUSIONS ABOi LDLT is a feasible option for pediatric end-stage liver disease patients. However, it should be noted that current desensitization protocol does not completely prevent the onset of antibody-mediated rejection in several cases.
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Affiliation(s)
- Masaki Honda
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masashi Kadohisa
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Keita Shimata
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masataka Sakisaka
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daiki Yoshii
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Keiichi Uto
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shintaro Hayashida
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuki Ohya
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hidekazu Yamamoto
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirotoshi Yamamoto
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukihiro Inomata
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taizo Hibi
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Abu-Gazala S, Olthoff KM. Status of Adult Living Donor Liver Transplantation in the United States: Results from the Adult-To-Adult Living Donor Liver Transplantation Cohort Study. Gastroenterol Clin North Am 2018; 47:297-311. [PMID: 29735025 DOI: 10.1016/j.gtc.2018.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
This article reviews the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL). The findings show that the number of adult-to-adult living donor liver transplants is consistently increasing. Living donor liver transplantation has an important benefit for patients with acute liver failure, does not compromise donor safety, and has lower rates of acute cellular rejection in biologically related donor and recipient. The conclusions from the A2ALL consortium have been critical in transplant advancement, supporting increased use to help decrease waitlist death and improve long-term survival of transplant recipients.
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Affiliation(s)
- Samir Abu-Gazala
- Department of Surgery, Transplantation Unit, Hadassah Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel.
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Kim H, Yi NJ, Song EY, Lee K, Lee KW, Lee HW, Ahn HY, Yoon KC, Hong SK, Suh KS. Preformed donor-specific antibodies do not affect the 1-year allograft survival in living donor liver transplantation. Clin Transplant 2018; 32:e13244. [DOI: 10.1111/ctr.13244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Hyeyoung Kim
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
- Department of Surgery; Seoul Metropolitan Government - Seoul National University Boramae Medical Center; Seoul Korea
| | - Nam-Joon Yi
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Eun Young Song
- Department of Laboratory Medicine; Seoul National University College of Medicine; Seoul Korea
| | - Kyoungbun Lee
- Department of Pathology; Seoul National University College of Medicine; Seoul Korea
| | - Kwang-Woong Lee
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Hae Won Lee
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
- Department of Surgery; Seoul Metropolitan Government - Seoul National University Boramae Medical Center; Seoul Korea
| | - Hye Young Ahn
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Kyung Chul Yoon
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Suk Kyun Hong
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Kyung-Suk Suh
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
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Yamada Y, Hoshino K, Oyanagi T, Gatayama R, Maeda J, Katori N, Fuchimoto Y, Hibi T, Shinoda M, Matsubara K, Obara H, Aeba R, Kitagawa Y, Yamagishi H, Kuroda T. Successful management of living donor liver transplantation for biliary atresia with single ventricle physiology-from peri-transplant through total cavopulmonary connection: A case report. Pediatr Transplant 2018; 22:e13118. [PMID: 29457852 DOI: 10.1111/petr.13118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
Children with single ventricle physiology have complete mixing of the pulmonary and systemic circulations, requiring staged procedures to achieve a separation of these circulations, or Fontan circulation. The single ventricle physiology significantly increases the risk of mortality in children undergoing non-cardiac surgery. As liver transplantation for patients with single ventricle physiology is particularly challenging, only a few reports have been published. We herein report a case of successful LDLTx for an 8-month-old pediatric patient with biliary atresia, heterotaxy, and complex heart disease of single ventricle physiology. The cardiac anomalies included total anomalous pulmonary venous return type IIb, intermediate atrioventricular septal defect, tricuspid regurgitation grade III, coarctation of aorta, interrupted inferior vena cava, bilateral superior vena cava, and polysplenia syndrome. Following LDLTx, the patient sequentially underwent total cavopulmonary shunt + Damus-Kaye-Stansel at 3 years of age and extracardiac total cavopulmonary connection (EC-TCPC) completion at 5 years of age; 7 years have now passed since LDLTx (2 years post-EC-TCPC). We describe the details of the management of LTx in the presence of cardiac anomalies and report the long-term cardiac and liver function, from peri-LDLTx through EC-TCPC completion.
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Affiliation(s)
- Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takayuki Oyanagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Ryohei Gatayama
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Jun Maeda
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Fuchimoto
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Aeba
- Department of Cardiac Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
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Koch M, Marget M, Sterneck M, Fischer L, Thude H, Nashan B. Limited impact of pre-existing donor specific HLA-antibodies (DSA) on long term allograft survival after first adult liver transplantation. Hum Immunol 2018; 79:545-549. [PMID: 29669260 DOI: 10.1016/j.humimm.2018.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/10/2018] [Accepted: 04/13/2018] [Indexed: 12/30/2022]
Abstract
The relevance of pre-existing HLA-antibodies (HLA-Ab) in liver transplantation (LTx) is controversial. While livers are allocated without HLA match or preoperative crossmatch testing, several studies point to an impact of donor specific antibodies (DSA) for acute rejection, bile duct complications or even graft loss. To investigate the role of DSA in long term liver allograft survival we analysed 177 pre transplant sera of first LTx patients with Luminex single antigen technology defining a MFI of >1500 as positive. The analyses were done retrospectively, and the DSA results had no impact on graft acceptance or patients' therapy. Three year follow up was available for all patients. 77% of our patients had any HLA-Ab pre transplantation, 55 patients were transplanted with DSA by chance. Acute rejections or ischemic type bile duct lesions (ITBL) were not higher in the DSA group, but ITBL was associated with a higher donor age. There was no difference in long term graft function or survival in patients without HLA-Ab, with non DSA or with DSA (p = 0.712). We suggest that determination of pre-existing DSA in first LTx recipients is not appropriate and we conclude that pre-existing DSA in first LTx patients are not a contraindication for liver transplantation.
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Affiliation(s)
- Martina Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Matthias Marget
- Institute of Transfusion Medicine, HLA Laboratory, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Martina Sterneck
- I. Medical Clinic, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Hansjörg Thude
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Björn Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Application and interpretation of histocompatibility data in liver transplantation. Curr Opin Organ Transplant 2018; 22:499-504. [PMID: 28708813 DOI: 10.1097/mot.0000000000000450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW There has been a resurgence of interest in histocompatibility as it applies to liver transplantation. The association of persistent and de-novo donor specific antibody (DSA) and outcomes after liver transplantation continues to be investigated. RECENT FINDINGS Consensus continues to evolve regarding the existence of acute and chronic antibody-mediated rejection (AMR) and pathogenicity of DSA and associated pathologic findings after liver transplantation. The presence of persistent high level, complement fixing DSA or emergence of de novo, Class II DSA has been associated with rejection and worse long-term graft and patient survival. Significant adverse associations of DSA extend to patients after simultaneous liver kidney (SLK) transplant as well as in pediatric recipients of liver transplantation. A higher degree of HLA incompatibility has been recently associated with worse outcomes in living donor liver transplant. SUMMARY In summary, recent consensus guidelines describe and recognize the existence of acute and chronic AMR and provide a basis upon which to build further investigation. Important adverse outcomes including decreased survival, allograft failure and liver fibrosis have been linked to the presence of DSA. Routine donor and recipient HLA typing and DSA assessment will facilitate diagnosis and provide for baseline data, which may help guide future management. Future investigations may help to clarify the role of therapeutic interventions.
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Abstract
PURPOSE OF REVIEW The review outlines the diagnosis, clinical implications, and treatment strategies for acute and chronic antibody-mediated rejection (AMR) after orthotopic liver transplantation (OLT). RECENT FINDINGS A combination of clinical work-up, histopathology, C4d staining, and donor-specific antibody (DSA) should be used to diagnose AMR. The differential diagnosis for idiopathic fibrosis now includes chronic AMR. Characterization of pathogenic DSA continues to progress. De-novo and persistent DSA, particularly of the IgG3 subtype, are associated with inferior long-term outcomes.The liver allograft may confer long-term immunologic benefits to the kidney allograft after simultaneous liver-kidney transplant.The more widespread use of rituximab has improved outcomes in ABO-incompatible OLT.Although larger long-term studies of treatment options are needed, compliance with tacrolimus-based immunosuppression and transfusion minimization are agreed upon preventive strategies. SUMMARY AMR has evolved into an established pathology in OLT recipients. Acute AMR may lead to early graft loss whereas chronic AMR results in progressive fibrosis if unrecognized. DSAs, likely in the setting of predisposing environmental factors, appear to play a role in T cell-mediated rejection and long-term graft outcomes.
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Levitsky J, Feng S. Tolerance in clinical liver transplantation. Hum Immunol 2017; 79:283-287. [PMID: 29054397 DOI: 10.1016/j.humimm.2017.10.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/11/2017] [Accepted: 10/17/2017] [Indexed: 12/22/2022]
Abstract
While advances in immunosuppressive therapy have lowered the rate of acute rejection following liver transplantation, the consequence has been an increase in morbidity and mortality related to the lifelong need for maintenance immunosuppression. These complications include an increased risk of malignancy, infection, metabolic disorders, and chronic kidney disease, as well as high health care costs associated with these therapies and the required drug monitoring. Given these issues, most clinicians attempt trial and error dose minimization with variable success rates, and there has been significant interest in full drug withdrawal in select patients through research protocols. These strategies would be more successful if immunomodulatory therapies early after transplantation could be developed and if immune activation biomarkers guiding drug tapering were available to personalize these approaches. This review will review the mechanisms of liver transplant tolerance and potential strategies to achieve immunosuppression withdrawal.
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Affiliation(s)
- Josh Levitsky
- Division of Gastroenterology & Hepatology, Northwestern University, Chicago, IL, United States.
| | - Sandy Feng
- Division of Transplant Surgery, University of California at San Francisco, San Francisco, CA, United States
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Abstract
BACKGROUND Nonmyeloablative conditioning followed by donor bone marrow infusion (BMI) to induce tolerance has not been robustly tested in liver transplantation (LT) and may be unsafe at the time of LT. We hypothesized T cell-depleted BMI is effective in inducing tolerance when delayed after LT, resulting in potentially safer future clinical applications. METHODS Nonimmunosuppressed syngeneic (Lewis to Lewis) and allogeneic (ACI to Lewis) rat LT transplants were initially performed as controls. Three experimental allogeneic LT groups were treated with tacrolimus (TAC) for 3 to 4 weeks and then underwent: (1) TAC withdrawal alone; (2) nonmyeloablative conditioning (anti-αβTCR mAb + total body irradiation [300 cGy]) followed by TAC withdrawal; (3) Nonmyeloablative conditioning + donor BMI (100 × 10 T cell-depleted bone marrow cells) followed by TAC withdrawal. RESULTS All group 1 recipients developed chronic rejection. Group 2 had long-term survival but impaired liver function and high donor-specific antibody (DSA) levels. In contrast, group 3 (conditioning + BMI) had long-term TAC-free survival with preserved liver function and histology, high mixed chimerism and blood/liver/spleen CD4 + CD25 + Foxp3+ regulatory T cells, and low DSA titers, similar to syngeneic grafts. While donor-specific tolerance was observed post-BMI, graft-versus-host disease was not. CONCLUSIONS These results support that donor-specific tolerance can be achieved with BMI even when delayed after LT and this tolerance correlates with increased mixed chimerism, regulatory T cell generation, and diminished DSA.
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Acute Rejection Increases Risk of Graft Failure and Death in Recent Liver Transplant Recipients. Clin Gastroenterol Hepatol 2017; 15:584-593.e2. [PMID: 27567694 PMCID: PMC5326609 DOI: 10.1016/j.cgh.2016.07.035] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/25/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Acute rejection is detrimental to most transplanted solid organs, but is considered to be less of a consequence for transplanted livers. We evaluated risk factors for and outcomes after biopsy-proven acute rejection (BPAR) based on an analysis of a more recent national sample of recipients of liver transplants from living and deceased donors. METHODS We analyzed data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) from 2003 through 2014 as the exploratory cohort and the Scientific Registry of Transplant Recipients (SRTR) from 2005 through 2013 as the validation cohort. We examined factors associated with time to first BPAR using multivariable Cox regression or discrete-survival analysis. Competing risks methods were used to compare causes of death and graft failure between recipients of living and deceased donors. RESULTS At least 1 BPAR episode occurred in 239 of 890 recipients in A2ALL (26.9%) and 7066 of 45,423 recipients in SRTR (15.6%). In each database, risk of rejection was significantly lower when livers came from biologically related living donors (A2ALL hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.43-0.76; and SRTR HR, 0.78; 95% CI, 0.66-0.91) and higher in liver transplant recipients with primary biliary cirrhosis, of younger age, or with hepatitis C. In each database, BPAR was associated with significantly higher risks of graft failure and death. The risks were highest in the 12 month post-BPAR period in patients whose first episode occurred more than 1 year after liver transplantation: HRs for graft failure were 6.79 in A2ALL (95% CI, 2.64-17.45) and 4.41 in SRTR (95% CI, 3.71-5.23); HRs for death were 8.81 in A2ALL (95% CI, 3.37-23.04) and 3.94 in SRTR (95% CI, 3.22-4.83). In analyses of cause-specific mortality, associations were observed for liver-related (graft failure) causes of death but not for other causes. CONCLUSIONS Contrary to previous data, acute rejection after liver transplant is associated with significantly increased risk of graft failure, all-cause mortality, and graft failure-related death, regardless of primary liver disease etiology. Living donor liver transplantation from a biologically related donor is associated with decreased risk of rejection.
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The Role of Humoral Alloreactivity in Liver Transplantation: Lessons Learned and New Perspectives. J Immunol Res 2017; 2017:3234906. [PMID: 28164136 PMCID: PMC5253491 DOI: 10.1155/2017/3234906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022] Open
Abstract
More than ten years after the initial description of the humoral theory of transplantation by Dr. Paul I. Terasaki, the significance of humoral alloimmunity in liver transplantation has yet to be clearly defined. The liver allograft has an inherent tolerogenic capacity which confers its resistance to cell-mediated as well as antibody-mediated rejection. Nevertheless, the protection against alloimmunity is not complete, and antibody-mediated tissue injury can occur in the liver graft under specific circumstances. In this article the evidence on the clinicopathologic effects of donor-specific alloantibodies in liver transplantation will be examined and interpreted in parallel with lessons learned from renal transplantation. The unique anatomic and immunologic features of the liver will be reviewed to gain new insights into the complex interactions between humoral immune system and the liver allograft.
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Mechanisms and Strategies for Tolerance in Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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