1
|
Harmacek D, Weidmann L, Castrezana Lopez K, Schmid N, Korach R, Bortel N, von Moos S, Rho E, Helmchen B, Gaspert A, Schachtner T. Molecular diagnosis of antibody-mediated rejection: Evaluating biopsy-based transcript diagnostics in the presence of donor-specific antibodies but without microvascular inflammation, a single-center descriptive analysis. Am J Transplant 2024; 24:1652-1663. [PMID: 38548057 DOI: 10.1016/j.ajt.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
Biopsy-based transcript diagnostics may identify molecular antibody-mediated rejection (AMR) when microvascular inflammation (MVI) is absent. In this single-center cohort, biopsy-based transcript diagnostics were validated in 326 kidney allograft biopsies. A total of 71 histological AMR and 35 T cell-mediated rejection (TCMR) cases were identified as molecular AMR and TCMR in 55% and 63%, respectively. Among 121 cases without MVI (glomerulitis + peritubular capillaritis = 0), 45 (37%) donor-specific antibody (DSA)-positive and 76 (63%) DSA-negative cases were analyzed. Twenty-one out of the 121 (17%) cases showed borderline changes, or TCMR, while BK nephropathy was excluded. None of the 45 DSA-positive patients showed molecular AMR. Among 76 DSA-negative patients, 2 had mixed molecular AMR/TCMR. All-AMR phenotype scores (sum of R4-R6) exhibited median values of 0.13 and 0.12 for DSA-positive and DSA-negative patients, respectively (P = .84). A total of 13% (6/45) DSA-positive and 11% (8/76) DSA-negative patients showed an all-AMR phenotype score > 0.30 (P = .77). Patients with a higher all-AMR phenotype score showed 33% more histologic TCMR (P = .005). The median all-AMR phenotype scores of glomerular basement membrane double contours = 0 and glomerular basement membrane double contours > 0 biopsies were 0.12 and 0.10, respectively (P = .35). Biopsy-based transcript diagnostics did not identify molecular AMR in cases without MVI. Follow-up biopsies and outcome data should evaluate the clinical relevance of subthreshold molecular alterations.
Collapse
Affiliation(s)
- Dusan Harmacek
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Lukas Weidmann
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | | | - Nicolas Schmid
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Raphael Korach
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Nicola Bortel
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Elena Rho
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Birgit Helmchen
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ariana Gaspert
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Schachtner
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
2
|
Diebold M, Mayer KA, Hidalgo L, Kozakowski N, Budde K, Böhmig GA. Chronic Rejection After Kidney Transplantation. Transplantation 2024:00007890-990000000-00858. [PMID: 39192468 DOI: 10.1097/tp.0000000000005187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
In kidney transplantation, ongoing alloimmune processes-commonly triggered by HLA incompatibilities-can trigger chronic transplant rejection, affecting the microcirculation and the tubulointerstitium. Continuous inflammation may lead to progressive, irreversible graft injury, culminating in graft dysfunction and accelerated transplant failure. Numerous experimental and translational studies have delineated a complex interplay of different immune mechanisms driving rejection, with antibody-mediated rejection (AMR) being an extensively studied rejection variant. In microvascular inflammation, a hallmark lesion of AMR, natural killer (NK) cells have emerged as pivotal effector cells. Their essential role is supported by immunohistologic evidence, bulk and spatial transcriptomics, and functional genetics. Despite significant research efforts, a substantial unmet need for approved rejection therapies persists, with many trials yielding negative outcomes. However, several promising therapies are currently under investigation, including felzartamab, a monoclonal antibody targeting the surface molecule CD38, which is highly expressed in NK cells and antibody-producing plasma cells. In an exploratory phase 2 trial in late AMR, this compound has demonstrated potential in resolving molecular and morphologic rejection activity and injury, predominantly by targeting NK cell effector function. These findings inspire hope for effective treatments and emphasize the necessity of further pivotal trials focusing on chronic transplant rejection.
Collapse
Affiliation(s)
- Matthias Diebold
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Luis Hidalgo
- HLA Laboratory, Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
3
|
Wellekens K, Coemans M, Callemeyn J, Cleenders E, Debyser T, De Pelsmaeker S, Emonds MP, Koshy P, Kuypers D, Pagliazzi A, Roufosse C, Senev A, Van Loon E, Vaulet T, Naesens M. Probable antibody-mediated rejection in kidney transplantation is a rare and challenging phenotype to define: Findings from a single-center study. Am J Transplant 2024:S1600-6135(24)00437-4. [PMID: 39029874 DOI: 10.1016/j.ajt.2024.07.014] [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: 01/10/2024] [Revised: 07/09/2024] [Accepted: 07/12/2024] [Indexed: 07/21/2024]
Abstract
The Banff 2022 consensus introduced probable antibody-mediated rejection (AMR), characterized by mild AMR histologic features and human leukocyte antigen (HLA) donor-specific antibody (DSA) positivity. In a single-center observational cohort study of 1891 kidney transplant recipients transplanted between 2004 and 2021, 566 kidney biopsies were performed in 178 individual HLA-DSA-positive transplants. Evaluated at time of the first HLA-DSA-positive biopsy of each transplant (N = 178), 84 of the 178 (47.2%) of first biopsies were scored as no AMR, 22 of the 178 (12.4%) as probable AMR, and 72 of the 178 (40.4%) as AMR. The majority (77.3%) of probable AMR cases were first diagnosed in indication biopsies. Probable AMR was associated with lower estimated glomerular filtration rate (mL/min/1.73m2) than no AMR (20.2 [8.3-32.3] vs 40.1 [25.4-53.3]; P = .001). The one-year risk of (repeat) AMR was similar for probable AMR and AMR (subdistribution hazard ratio (sHR), 0.99; 0.42-2.31; P = .97) and higher than after no AMR (sHR, 3.05; 1.07-8.73; P = .04). Probable AMR had a higher five-year risk of transplant glomerulopathy vs no AMR (sHR, 4.29; 0.92-19.98; P = 06), similar to AMR (sHR, 1.74; 0.43-7.04; P = .44). No significant differences in five-year risk of graft failure emerged between probable AMR and AMR (sHR, 1.14; 0.36-3.58; P = .82) or no AMR (sHR, 2.46; 0.78-7.74; P = .12). Probable AMR is a rare phenotype, however, sharing significant similarities with AMR in this single-center study. Future studies are needed to validate reproducible diagnostic criteria and associated clinical outcomes to allow for defining best management of this potentially relevant phenotype.
Collapse
Affiliation(s)
- Karolien Wellekens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Evert Cleenders
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Tim Debyser
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Steffi De Pelsmaeker
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Priyanka Koshy
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Angelica Pagliazzi
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Candice Roufosse
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Aleksandar Senev
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Elisabet Van Loon
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Thibaut Vaulet
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
4
|
Cortes Garcia E, Giarraputo A, Racapé M, Goutaudier V, Ursule-Dufait C, de la Grange P, Adoux L, Raynaud M, Couderau C, Mezine F, Dagobert J, Bestard O, Moreso F, Villard J, Halleck F, Giral M, Brouard S, Danger R, Gourraud PA, Rabant M, Couzi L, Le Quintrec M, Kamar N, Morelon E, Vrtovsnik F, Taupin JL, Snanoudj R, Legendre C, Anglicheau D, Budde K, Lefaucheur C, Loupy A, Aubert O. Antibody Mediated Rejection and T-cell Mediated Rejection Molecular Signatures Using Next-Generation Sequencing in Kidney Transplant Biopsies. Transpl Int 2024; 37:13043. [PMID: 39050190 PMCID: PMC11267505 DOI: 10.3389/ti.2024.13043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/06/2024] [Indexed: 07/27/2024]
Abstract
Recently, interest in transcriptomic assessment of kidney biopsies has been growing. This study investigates the use of NGS to identify gene expression changes and analyse the pathways involved in rejection. An Illumina bulk RNA sequencing on the polyadenylated RNA of 770 kidney biopsies was conducted. Differentially-expressed genes (DEGs) were determined for AMR and TCMR using DESeq2. Genes were segregated according to their previous descriptions in known panels (microarray or the Banff Human Organ Transplant (B-HOT) panel) to obtain NGS-specific genes. Pathway enrichment analysis was performed using the Reactome and Kyoto Encyclopaedia of Genes and Genomes (KEGG) public repositories. The differential gene expression using NGS analysis identified 6,141 and 8,478 transcripts associated with AMR and TCMR. While most of the genes identified were included in the microarray and the B-HOT panels, NGS analysis identified 603 (9.8%) and 1,186 (14%) new specific genes. Pathways analysis showed that the B-HOT panel was associated with the main immunological processes involved during AMR and TCMR. The microarrays specifically integrated metabolic functions and cell cycle progression processes. Novel NGS-specific based transcripts associated with AMR and TCMR were discovered, which might represent a novel source of targets for drug designing and repurposing.
Collapse
Affiliation(s)
- Esteban Cortes Garcia
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Alessia Giarraputo
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Maud Racapé
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Valentin Goutaudier
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Cindy Ursule-Dufait
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | | | - Lucie Adoux
- Université Paris Cité, Centre National de la Recherche Scientifique (CNRS), INSERM, Institut Cochin, Paris, France
| | - Marc Raynaud
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Clément Couderau
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Fariza Mezine
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Jessie Dagobert
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Moreso
- Department of Nephrology and Kidney Transplantation, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jean Villard
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Department of Diagnostic, Geneva University Hospitals, Geneva, Switzerland
| | - Fabian Halleck
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Magali Giral
- Nantes Université, INSERM, CRT2I-Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Sophie Brouard
- Nantes Université, INSERM, CRT2I-Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Richard Danger
- Nantes Université, INSERM, CRT2I-Center for Research in Transplantation and Translational Immunology, Nantes, France
| | - Pierre-Antoine Gourraud
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique des données, INSERM, Centre d’Investigation Clinique 1413, Nantes, France
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Lionel Couzi
- Centre Hospitalier Universitaire de Bordeaux, Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Bordeaux, France
| | - Moglie Le Quintrec
- Department of Nephrology Dialysis and Kidney Transplantation, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Lyon, France
| | - François Vrtovsnik
- Department of Kidney Transplantation, Bichat Hospital, Assistance Publique—Hôpitaux de Paris (APHP), Paris, France
| | - Jean-Luc Taupin
- Laboratory of Immunology and Histocompatibility, Hôpital Saint-Louis Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Renaud Snanoudj
- Assistance Publique des Hôpitaux de Paris (AP-HP), Université Paris-Saclay, Hôpital de Bicêtre, Service de Néphrologie et Transplantation, Le Kremlin-Bicêtre, France
| | - Christophe Legendre
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Dany Anglicheau
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Olivier Aubert
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
- Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| |
Collapse
|
5
|
Kozakowski N. [Update kidney allograft pathology : A better depiction of microvascular inflammation]. PATHOLOGIE (HEIDELBERG, GERMANY) 2024; 45:269-276. [PMID: 38649466 PMCID: PMC11199282 DOI: 10.1007/s00292-024-01328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The Banff Foundation produces recommendations for classifying various lesions in renal allografts. Experts gather to update the classification every other year based on new scientific and clinical evidence. OBJECTIVES This article presents the most important changes incorporated into the new recommendations after the last Banff conference. MATERIALS AND METHODS The author of this article personally took part in the Banff conference and the subsequent survey, reported on the activities of a Banff working group (peritubular capillaritis) on-site, and contributed to drafting the recently published meeting report. RESULTS Lesions of antibody-mediated kidney allograft rejection (AMR), especially microvascular inflammation, have been part of the diagnostic algorithm for over 20 years. Experts advocated for a simplified AMR algorithm and mindful inclusion of molecular pathological data in the clinicopathological reflection regarding therapeutic decision. A new, more descriptive diagnostic entity-microvascular inflammation, C4d negative and DSA negative-has been introduced into the AMR category to acknowledge this histological constellation and motivate research into this pathophysiologically and immunologically probably different phenotype. CONCLUSIONS The Banff classification provides a structure for diagnosing kidney transplant pathology. Regular updates serve to adapt to ever-growing knowledge about alloimmunity. Particular challenges are capturing the complexity of various immunological scenarios and ensuring an understandable representation of these in a pathology report.
Collapse
Affiliation(s)
- Nicolas Kozakowski
- Klinisches Institut für Pathologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| |
Collapse
|
6
|
Rabant M, Adam BA, Aubert O, Böhmig GA, Clahsen Van-Groningen M, Cornell LD, de Vries APJ, Huang E, Kozakowski N, Perkowska-Ptasinska A, Riella LV, Rosales IA, Schinstock C, Simmonds N, Thaunat O, Willicombe M. Banff 2022 Kidney Commentary: Reflections and Future Directions. Transplantation 2024:00007890-990000000-00793. [PMID: 38886879 DOI: 10.1097/tp.0000000000005112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
In September 2022, in Banff, Alberta, Canada, the XVIth Banff meeting, corresponding to the 30th anniversary of the Banff classification, was held, leading to 2 recent publications. Discussions at the Banff meeting focused on proposing improvements to the Banff process as a whole. In line with this, a unique opportunity was offered to a selected group of 16 representatives from the pathology and transplant nephrology community, experts in the field of kidney transplantation, to review these 2 Banff manuscripts. The aim was to provide an insightful commentary, to gauge any prospective influence the proposed changes may have, and to identify any potential areas for future enhancement within the Banff classification. The group expressed its satisfaction with the incorporation of 2 new entities, namely "microvascular inflammation/injury donor-specific antibodies-negative and C4d negative" and "probable antibody-mediated rejection," into category 2. These changes expand the classification, facilitating the capture of more biopsies and providing an opportunity to explore the clinical implications of these lesions further. However, we found that the Banff classification remains complex, potentially hindering its widespread utilization, even if a degree of complexity may be unavoidable given the intricate pathophysiology of kidney allograft pathology. Addressing the histomorphologic diagnosis of chronic active T cell-mediated rejection (CA TCMR), potentially reconsidering a diagnostic-agnostic approach, as for category 2, to inflammation in interstitial fibrosis and tubular atrophy and chronic active T cell-mediated rejection was also an important objective. Furthermore, we felt a need for more evidence before molecular diagnostics could be routinely integrated and emphasized the need for clinical and histologic context determination and the substantiation of its clinical impact through rigorous clinical trials. Finally, our discussions stressed the ongoing necessity for multidisciplinary decision-making regarding patient care.
Collapse
Affiliation(s)
- Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Olivier Aubert
- Kidney Transplant Department, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georg A Böhmig
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marian Clahsen Van-Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Aiko P J de Vries
- Division of Nephrology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Leonardo V Riella
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Carrie Schinstock
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naomi Simmonds
- Department of Pathology, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| |
Collapse
|
7
|
Balakrishnan S, Alexander MP, Schinstock C. Challenges and opportunities for designing clinical trials for antibody mediated rejection. FRONTIERS IN TRANSPLANTATION 2024; 3:1389005. [PMID: 38993760 PMCID: PMC11235363 DOI: 10.3389/frtra.2024.1389005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 07/13/2024]
Abstract
Significant progress has been made in kidney transplantation, with 1-year graft survival nearing 95%. However, long-term allograft survival remains suboptimal, with a 10-year overall graft survival rate of only 53.6% for deceased donor transplant recipients. Chronic active antibody-mediated rejection (ABMR) is a leading cause of death-censored graft loss, yet no therapy has demonstrated efficacy in large, randomized trials, despite substantial investment from pharmaceutical companies. Several clinical trials aimed to treat chronic ABMR in the past decade have yielded disappointing results or were prematurely terminated, attributed to factors including incomplete understanding of disease mechanisms, heterogeneous patient populations with comorbidities, slow disease progression, and limited patient numbers. This review aims to discuss opportunities for improving retrospective and prospective studies of ABMR, focusing on addressing heterogeneity, outcome measurement, and strategies to enhance patient enrollment to inform study design, data collection, and reporting.
Collapse
Affiliation(s)
- Suryanarayanan Balakrishnan
- Division of Hypertension and Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Carrie Schinstock
- Division of Hypertension and Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
8
|
Berger M, Baliker M, Van Gelder T, Böhmig GA, Mannon RB, Kumar D, Chadban S, Nickerson P, Lee LA, Djamali A. Chronic Active Antibody-mediated Rejection: Opportunity to Determine the Role of Interleukin-6 Blockade. Transplantation 2024; 108:1109-1114. [PMID: 37941113 PMCID: PMC11042519 DOI: 10.1097/tp.0000000000004822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 11/10/2023]
Abstract
Chronic active antibody-mediated rejection (caAMR) is arguably the most important cause of late kidney allograft failure. However, there are no US Food and Drug Administration (FDA)-approved treatments for acute or chronic AMR and there is no consensus on effective treatment. Many trials in transplantation have failed because of slow and/or inadequate enrollment, and no new agent has been approved by the FDA for transplantation in over a decade. Several lines of evidence suggest that interleukin-6 is an important driver of AMR, and clazakizumab, a humanized monoclonal antibody that neutralizes interleukin-6, has shown promising results in phase 2 studies. The IMAGINE trial (Interleukin-6 Blockade Modifying Antibody-mediated Graft Injury and Estimated Glomerular Filtration Rate Decline) (NCT03744910) is the first to be considered by the FDA using a reasonably likely surrogate endpoint (slope of estimated glomerular filtration rate decline >1 y) for accelerated approval and is the only ongoing clinical trial for the treatment of chronic rejection. This trial offers us the opportunity to advance the care for our patients in need, and this article is a call to action for all transplant providers caring for patients with caAMR.
Collapse
Affiliation(s)
- Mel Berger
- Departments of Pediatrics and Pathology, Case Western Reserve University, Cleveland, OH
| | | | - Teun Van Gelder
- Department Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Deepali Kumar
- Department of Medicine, Division of Transplant Infectious Disease, Ajmera Transplant Centre, Toronto, ON, Canada
| | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Nickerson
- Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Laurie A. Lee
- Research and Development, Transplant Therapeutic Area, CSL Behring, King of Prussia, Pennsylvania, PA
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, ME
| |
Collapse
|
9
|
Van Loon E, Tinel C, de Loor H, Bossuyt X, Callemeyn J, Coemans M, De Vusser K, Sauvaget V, Olivre J, Koshy P, Kuypers D, Sprangers B, Van Craenenbroeck AH, Vaulet T, Anglicheau D, Naesens M. Automated Urinary Chemokine Assays for Noninvasive Detection of Kidney Transplant Rejection: A Prospective Cohort Study. Am J Kidney Dis 2024; 83:467-476. [PMID: 37777058 DOI: 10.1053/j.ajkd.2023.07.022] [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: 10/26/2022] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Prior studies have demonstrated the diagnostic potential of urinary chemokines C-X-C motif ligand 9 (CXCL9) and CXCL10 for kidney transplant rejection. However, their benefit in addition to clinical information has not been demonstrated. We evaluated the diagnostic performance for detecting acute rejection of urinary CXCL9 and CXCL10 when integrated with clinical information. STUDY DESIGN Single-center prospective cohort study. SETTING & PARTICIPANTS We analyzed 1,559 biopsy-paired urinary samples from 622 kidney transplants performed between April 2013 and July 2019 at a single transplant center in Belgium. External validation was performed in 986 biopsy-paired urinary samples. TESTS COMPARED We quantified urinary CXCL9 (uCXCL9) and CXCL10 (uCXCL10) using an automated immunoassay platform and normalized the values to urinary creatinine. Urinary chemokines were incorporated into a multivariable model with routine clinical markers (estimated glomerular filtration rate, donor-specific antibodies, and polyoma viremia) (integrated model). This model was then compared with the tissue diagnosis according to the Banff classification for acute rejection. OUTCOME Acute rejection detected on kidney biopsy using the Banff classification. RESULTS Chemokines integrated with routine clinical markers had high diagnostic value for detection of acute rejection (n=150) (receiver operating characteristic area under the curve 81.3% [95% CI, 77.6-85.0]). The integrated model would help avoid 59 protocol biopsies per 100 patients when the risk for rejection is predicted to be below 10%. The performance of the integrated model was similar in the external validation cohort. LIMITATIONS The cross-sectional nature obviates investigating the evolution over time and prediction of future rejection. CONCLUSIONS The use of an integrated model of urinary chemokines and clinical markers for noninvasive monitoring of rejection could enable a reduction in the number of biopsies. Urinary chemokines may be useful noninvasive biomarkers whose use should be further studied in prospective randomized trials to clarify their role in guiding clinical care and the use of biopsies to detect rejection after kidney transplantation. PLAIN-LANGUAGE SUMMARY Urinary chemokines CXCL9 and CXCL10 have been suggested to be good noninvasive biomarkers of kidney transplant rejection. However, defining a context of use and integration with clinical information is necessary before clinical implementation can begin. In this study, we demonstrated that urinary chemokines CXCL9 and CXCL10, together with clinical information, have substantial diagnostic accuracy for the detection of acute kidney transplant rejection. Application of urinary chemokines together with clinical information may guide biopsy practices following kidney transplantation and potentially reduce the need for kidney transplant biopsies.
Collapse
Affiliation(s)
- Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Claire Tinel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven
| | - Henriette de Loor
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven
| | - Xavier Bossuyt
- Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven; Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven
| | - Katrien De Vusser
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Laboratory of Molecular Immunology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, Leuven
| | - Amaryllis H Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Thibaut Vaulet
- ESAT STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven
| | - Dany Anglicheau
- INSERM U1151, Université de Paris, Paris, France; Department of Nephrology and Kidney Transplantation, RTRS Centaure, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Kidney Transplantation Research Group, KU Leuven, Leuven; Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
10
|
Mengel M, Adam BA. Emerging phenotypes in kidney transplant rejection. Curr Opin Organ Transplant 2024; 29:97-103. [PMID: 38032262 DOI: 10.1097/mot.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE OF REVIEW This review focuses on more recently emerging rejection phenotypes in the context of time post transplantation and the resulting differential diagnostic challenges. It also discusses how novel ancillary diagnostic tools can potentially increase the accuracy of biopsy-based rejection diagnosis. RECENT FINDINGS With advances in reducing immunological risk at transplantation and improved immunosuppression treatment renal allograft survival improved. However, allograft rejection remains a major challenge and represent a frequent course for allograft failure. With prolonged allograft survival, novel phenotypes of rejection are emerging, which can show complex overlap and transition between cellular and antibody-mediated rejection mechanisms as well as mixtures of acute/active and chronic diseases. With the emerging complexity in rejection phenotypes, it is crucial to achieve diagnostic accuracy in the individual patient. SUMMARY The prospective validation and adoption of novel molecular and computational diagnostic tools into well defined and appropriate clinical context of uses will improve our ability to accurately diagnose, stage, and grade allograft rejection.
Collapse
Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
11
|
Naesens M, Roufosse C, Haas M, Lefaucheur C, Mannon RB, Adam BA, Aubert O, Böhmig GA, Callemeyn J, Clahsen-van Groningen M, Cornell LD, Demetris AJ, Drachenberg CB, Einecke G, Fogo AB, Gibson IW, Halloran P, Hidalgo LG, Horsfield C, Huang E, Kikić Ž, Kozakowski N, Nankivell B, Rabant M, Randhawa P, Riella LV, Sapir-Pichhadze R, Schinstock C, Solez K, Tambur AR, Thaunat O, Wiebe C, Zielinski D, Colvin R, Loupy A, Mengel M. The Banff 2022 Kidney Meeting Report: Reappraisal of microvascular inflammation and the role of biopsy-based transcript diagnostics. Am J Transplant 2024; 24:338-349. [PMID: 38032300 DOI: 10.1016/j.ajt.2023.10.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/04/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
The XVI-th Banff Meeting for Allograft Pathology was held at Banff, Alberta, Canada, from 19th to 23rd September 2022, as a joint meeting with the Canadian Society of Transplantation. To mark the 30th anniversary of the first Banff Classification, premeeting discussions were held on the past, present, and future of the Banff Classification. This report is a summary of the meeting highlights that were most important in terms of their effect on the Classification, including discussions around microvascular inflammation and biopsy-based transcript analysis for diagnosis. In a postmeeting survey, agreement was reached on the delineation of the following phenotypes: (1) "Probable antibody-mediated rejection (AMR)," which represents donor-specific antibodies (DSA)-positive cases with some histologic features of AMR but below current thresholds for a definitive AMR diagnosis; and (2) "Microvascular inflammation, DSA-negative and C4d-negative," a phenotype of unclear cause requiring further study, which represents cases with microvascular inflammation not explained by DSA. Although biopsy-based transcript diagnostics are considered promising and remain an integral part of the Banff Classification (limited to diagnosis of AMR), further work needs to be done to agree on the exact classifiers, thresholds, and clinical context of use.
Collapse
Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
| | - Candice Roufosse
- Department of Immunology and Inflammation, Faculty Medicine, Imperial College London, London, UK.
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Nephrology and Transplantation, Saint-Louis Hospital, Paris, France
| | | | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Olivier Aubert
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Marian Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus University Center Rotterdam, Rotterdam, The Netherlands, Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony J Demetris
- UPMC Hepatic and Transplantation Pathology, Pittsburgh, Pennsylvania, USA
| | | | - Gunilla Einecke
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
| | - Philip Halloran
- Department of Medicine, Alberta Transplant Applied Genomics Centre, Heritage Medical Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Luis G Hidalgo
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Edmund Huang
- Department of Medicine, Division of Nephrology, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | | | - Brian Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Marion Rabant
- Pathology department, Necker-Enfants Malades Hospital, Paris, France
| | - Parmjeet Randhawa
- Department of Pathology, Thomas E. Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leonardo V Riella
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruth Sapir-Pichhadze
- Division of Nephrology & Multi-Organ Transplant Program, McGill University, Montreal, Quebec, Canada
| | - Carrie Schinstock
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Kim Solez
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Anat R Tambur
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - Olivier Thaunat
- Department of Transplantation Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Chris Wiebe
- Department of Medicine and Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Dina Zielinski
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Robert Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandre Loupy
- Université Paris Cité, INSERM, PARCC, Paris Institute for Transplantation and Organ Regeneration, France & Department of Transplantation, Necker Hospital, Paris, France
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| |
Collapse
|
12
|
Qin S, Wang X, Wang J, Wu H. Complement C4d as a biomarker for systemic lupus erythematosus and lupus nephritis. Lupus 2024; 33:111-120. [PMID: 38227433 DOI: 10.1177/09612033231226351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Background: Increasing studies in the last decade have led to the widespread understanding that C4d, a split product of complement component 4 (C4), is a potential biomarker for systemic lupus erythematosus (SLE) and lupus nephritis (LN).Purpose: The aim of this review is to summarize the highlights of studies investigating the use of C4d as a biomarker for diagnosing and monitoring SLE and LN patients.Data collection: we searched PubMed/Medline and Wanfang databases using the terms "C4d and systemic lupus erythematosus", "C4d and lupus nephritis", and "Complement C4d".Results: The deposition of C4d on circulating blood cells has been shown in several clinical studies to be a potential diagnostic marker that can be used to monitor patients with SLE. In addition, C4d deposits on circulating blood cells may be a helpful diagnostic marker for LN, one of the most severe complications of SLE. Meanwhile, studies utilizing renal biopsy specimens have indicated that C4d deposition in the renal peritubular capillaries of LN patients may predict more severe LN or a worse patient prognosis. Generally, a high plasma C4d level and a high plasma C4d/C4 ratio may also be promising indicators that can be used to monitor patients with SLE and LN.Conclusions: C4d detection may be a novel strategy for further clinical prediction and therapy.
Collapse
Affiliation(s)
- Sihao Qin
- Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, Genetic Diagnosis Center, The First Hospital of Jilin University, Changchun, China
| | - Xueyao Wang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Jiahui Wang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Hao Wu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
13
|
Beadle J, Papadaki A, Toulza F, Santos E, Willicombe M, McLean A, Peters J, Roufosse C. Application of the Banff Human Organ Transplant Panel to kidney transplant biopsies with features suspicious for antibody-mediated rejection. Kidney Int 2023; 104:526-541. [PMID: 37172690 DOI: 10.1016/j.kint.2023.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/07/2023] [Accepted: 04/14/2023] [Indexed: 05/15/2023]
Abstract
The Banff Classification for Allograft Pathology includes the use of gene expression in the diagnosis of antibody-mediated rejection (AMR) of kidney transplants, but a predictive set of genes for classifying biopsies with 'incomplete' phenotypes has not yet been studied. Here, we developed and assessed a gene score that, when applied to biopsies with features of AMR, would identify cases with a higher risk of allograft loss. To do this, RNA was extracted from a continuous retrospective cohort of 349 biopsies randomized 2:1 to include 220 biopsies in a discovery cohort and 129 biopsies in a validation cohort. The biopsies were divided into three groups: 31 that fulfilled the 2019 Banff Criteria for active AMR, 50 with histological features of AMR but not meeting the full criteria (Suspicious-AMR), and 269 with no features of active AMR (No-AMR). Gene expression analysis using the 770 gene Banff Human Organ Transplant NanoString panel was carried out with LASSO Regression performed to identify a parsimonious set of genes predictive of AMR. We identified a nine gene score that was highly predictive of active AMR (accuracy 0.92 in the validation cohort) and was strongly correlated with histological features of AMR. In biopsies suspicious for AMR, our gene score was strongly associated with risk of allograft loss and independently associated with allograft loss in multivariable analysis. Thus, we show that a gene expression signature in kidney allograft biopsy samples can help classify biopsies with incomplete AMR phenotypes into groups that correlate strongly with histological features and outcomes.
Collapse
Affiliation(s)
- Jack Beadle
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK; Imperial College Renal and Transplant Centre, Imperial College NHS Trust, London, UK.
| | - Artemis Papadaki
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Frederic Toulza
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Eva Santos
- H&I Laboratory, North West London Pathology, London, UK
| | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK; Imperial College Renal and Transplant Centre, Imperial College NHS Trust, London, UK
| | - Adam McLean
- Imperial College Renal and Transplant Centre, Imperial College NHS Trust, London, UK
| | - James Peters
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK; Department of Cellular Pathology, North West London Pathology, London, UK
| |
Collapse
|
14
|
Atlas-Lazar A, Levy-Erez D. Approach to acute kidney injury following paediatric kidney transplant. Curr Opin Pediatr 2023; 35:268-274. [PMID: 36591982 DOI: 10.1097/mop.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW In a child with evidence of acute kidney injury (AKI) following renal transplantation, it is important to quickly and accurately diagnose the cause to enable timely initiation of therapeutic interventions. The following article will discuss the differential diagnosis of acute graft dysfunction in paediatric kidney transplant recipients. This review will systematically guide the clinician through the common and less common causes and provide updates on current treatments. RECENT FINDINGS In patients with signs of graft dysfunction, rejection is an important cause to consider. Diagnosis of rejection relies on biopsy findings, an invasive and costly technique. Over the past 5 years, there has been a focus on noninvasive methods of diagnosing rejection, including serum and urinary biomarkers. SUMMARY This review discusses the differential diagnosis of acute graft dysfunction following transplant, with a focus on acute rejection, urinary tract infections and common viral causes, prerenal and postrenal causes, nephrotoxic medications, specifically calcineurin inhibitor toxicity, thrombotic microangiopathy and recurrence of the underlying disease. Each condition is discussed in detail, with a focus on clinical clues to the cause, incidence in the paediatric population, workup and treatment.
Collapse
Affiliation(s)
| | - Daniella Levy-Erez
- Schneider Children's Medical Center in Israel, Petah Tikva
- Tel Aviv, University School of Medicine, Tel Aviv, Israel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
15
|
Buxeda A, Llinàs-Mallol L, Gimeno J, Redondo-Pachón D, Arias-Cabrales C, Burballa C, Puche A, López-Botet M, Yélamos J, Vilches C, Naesens M, Pérez-Sáez MJ, Pascual J, Crespo M. Microvascular inflammation in the absence of human leukocyte antigen-donor-specific antibody and C4d: An orphan category in Banff classification with cytotoxic T and natural killer cell infiltration. Am J Transplant 2023; 23:464-474. [PMID: 36710135 DOI: 10.1016/j.ajt.2022.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
Isolated microvascular inflammation (iMVI) without HLA donor-specific antibodies or C4d deposition in peritubular capillaries remains an enigmatic phenotype that cannot be categorized as antibody-mediated rejection (ABMR) in recent Banff classifications. We included 221 kidney transplant recipients with biopsies with ABMR (n = 73), iMVI (n = 32), and normal (n = 116) diagnoses. We compared peripheral blood leukocyte distribution by flow cytometry and inflammatory infiltrates in kidney transplant biopsies among groups. Flow cytometry showed fewer lymphocytes and total, CD4+, and CD8+ peripheral T cells in iMVI compared with ABMR and normal cases. ABMR and iMVI had fewer total natural Killer (NK) cells but more NKG2A+ NK cells. Immunohistochemistry indicated that ABMR and iMVI had greater CD3+ and CD68+ glomerular infiltration than normal biopsies, whereas CD8+ and TIA1+ cells showed only increased iMVI, suggesting they are cytotoxic T cells. Peritubular capillaries displayed more CD3+, CD56+, TIA1+, and CD68+ cells in both ABMR and iMVI. In contrast, iMVI had less plasma cell infiltration in peritubular capillaries and interstitial aggregates than ABMR. iMVI displayed decreased circulating T and NK cells mirrored by T cell and NK cell infiltration in the renal allograft, similar to ABMR. However, the lesser plasma cell infiltration in iMVI may suggest an antibody-independent underlying stimulus.
Collapse
Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Javier Gimeno
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Dolores Redondo-Pachón
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carlos Arias-Cabrales
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carla Burballa
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Adrián Puche
- Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Miguel López-Botet
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain
| | - José Yélamos
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Immunology, Hospital del Mar, Barcelona, Spain
| | - Carlos Vilches
- Immunogenetics-HLA, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Madrid, Spain
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Julio Pascual
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| |
Collapse
|
16
|
Estimation of Sensitization Status in Renal Transplant Recipients by Assessing Indirect Pathway CD4+ T cell Response to Donor Cell-pulsed Dendritic Cell. Transplantation 2023; 107:1079-1088. [PMID: 36814087 DOI: 10.1097/tp.0000000000004491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND . Generation of donor-specific human leukocyte antigen antibody (DSA) via indirect allorecognition is detrimental to long-term survival of transplant organs. The detection of such immune responses would make it possible to define patients with high risk of sensitization. In this study, we established a novel method for evaluating indirect allorecognition to assess sensitization in kidney transplant recipients. METHODS . Recipient CD14+ monocytes were mixed with donor peripheral blood mononuclear cells; cultured in the presence of IL-4, GM-CSF, IL-1β, and TNFα; and used as pulsed dendritic cells (DCs). Cell proliferation and cytokine production were evaluated by carboxyfluorescein diacetate succinimidyl ester-based T cell proliferation assay and Enzyme-Linked ImmunoSpot assay, respectively. RESULTS . CD4+ T cell proliferation was strongly observed in following coculture with allogeneic antigen-pulsed DC leading to interferon-γ and IL-21 production. About 1% of CD4+ T cells exhibited Tfh-like phenotype (PD-1highCXCR5+ICOS+CD40L+). Recipient DC pulsed with donor peripheral blood mononuclear cells was cocultured with recipient CD45RA+CD4+ and CD45RA-CD4+ (generally defined as naive and memory in humans, respectively) T cells. Irrespective of preformed or de novo DSA status, CD45RA+CD4+ T cells constantly produced IL-21. In contrast, IL-21-produced CD45RA-CD4+ T cells were significantly higher in preformed DSA-positive patients than those in negative patients (80.8 ± 51.2 versus 14.8 ± 20.4, P < 0.001). In de novo DSA-positive patients, IL-21-produced CD45RA-CD4+ T cells were significantly increased after transplantation compared with before transplantation (9.23 ± 9.08 versus 43.9 ± 29.1, P < 0.001). CONCLUSIONS . Assessment of indirect pathway CD4+ T cell response could provide new insights into the underlying mechanism of de novo DSA production, leading to the development of effective strategies against antibody-mediated rejection.
Collapse
|
17
|
Haas M, Mirocha J, Huang E, Najjar R, Peng A, Sethi S, Vo A, Anglicheau D, Jordan SC, Rabant M. A Banff-based histologic chronicity index is associated with graft loss in patients with a kidney transplant and antibody-mediated rejection. Kidney Int 2023; 103:187-195. [PMID: 36332728 DOI: 10.1016/j.kint.2022.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/19/2022] [Accepted: 09/16/2022] [Indexed: 11/15/2022]
Abstract
Antibody-mediated rejection (AMR) is the major cause of graft loss in kidney transplant recipients. The Banff classification defines two classes of AMR, active and chronic active but over time this classification has become increasingly complex. To simplify the approach to AMR, we developed activity and chronicity indices based on kidney transplant biopsy findings and examined their association with graft survival in 147 patients with active or chronic active AMR, all of whom had donor-specific antibodies and were treated for AMR. The activity index was determined as the sum of Banff glomerulitis (g), peritubular capillaritis (ptc), arteritis (v) and C4d scores, with a maximum score of 12. The chronicity index was the sum of interstitial fibrosis (ci), tubular atrophy (ct), chronic vasculopathy (cv), and chronic glomerulopathy (cg) scores, the latter doubled, with a maximum score of 15. While the activity index was generally not associated with graft loss, the chronicity index was significantly associated with graft loss with an optimal threshold value of 4 or greater for predicting graft loss. The association of the chronicity index of 4 or greater with graft loss was independent of other parameters associated with graft loss, including the estimated glomerular filtration rate at the time of biopsy, chronic active (versus active) AMR, AMR with de novo (versus persistent/rebound) donor-specific antibodies, Banff (g+ptc) scores, concurrent T cell-mediated rejection and donor-specific antibody reduction post-biopsy. The association of the chronicity index of 4 or greater with graft loss was confirmed in an independent cohort of 61 patients from Necker Hospital, Paris. Thus, our findings suggest that the chronicity index may be valuable as a simplified approach to decision-making in patients with AMR.
Collapse
Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - James Mirocha
- General Clinical Research Center, Clinical & Translational Science Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Reiad Najjar
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Supreet Sethi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dany Anglicheau
- Deparment of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, AP-HP, INSERM U1151, Université Paris Cite, Paris, France
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, AP-HP, Université Paris Cite, Paris, France
| |
Collapse
|
18
|
Llinàs-Mallol L, Raïch-Regué D, Pascual J, Crespo M. Alloimmune risk assessment for antibody-mediated rejection in kidney transplantation: A practical proposal. Transplant Rev (Orlando) 2023; 37:100745. [PMID: 36572001 DOI: 10.1016/j.trre.2022.100745] [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: 08/04/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
Kidney transplantation is the treatment of choice for patients with end-stage renal disease. Although an improvement in graft survival has been observed in the last decades with the use of different immunosuppressive drugs, this is still limited in time with antibody-mediated rejection being a main cause of graft-loss. Immune monitoring and risk assessment of antibody-mediated rejection before and after kidney transplantation with useful biomarkers is key to tailoring treatments to achieve the best outcomes. Here, we provide a review of the rationale and several accessible tools for immune monitoring, from the most classic to the modern ones. Finally, we end up discussing a practical proposal for alloimmune risk assessment in kidney transplantation, including histocompatibility leukocyte antigen (HLA) and non-HLA antibodies, HLA molecular mismatch analysis and characterization of peripheral blood immune cells.
Collapse
Affiliation(s)
- Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Dàlia Raïch-Regué
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Julio Pascual
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| |
Collapse
|
19
|
Tambur AR, Bestard O, Campbell P, Chong AS, Barrio MC, Ford ML, Gebel HM, Heidt S, Hickey M, Jackson A, Kosmoliaptsis V, Lefaucheur C, Louis K, Mannon RB, Mengel M, Morris A, Pinelli DF, Reed EF, Schinstock C, Taupin JL, Valenzuela N, Wiebe C, Nickerson P. Sensitization in transplantation: Assessment of Risk 2022 Working Group Meeting Report. Am J Transplant 2023; 23:133-149. [PMID: 36695615 DOI: 10.1016/j.ajt.2022.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/20/2022] [Accepted: 11/02/2022] [Indexed: 01/13/2023]
Abstract
The Sensitization in Transplantation: Assessment of Risk workgroup is a collaborative effort of the American Society of Transplantation and the American Society of Histocompatibility and Immunogenetics that aims at providing recommendations for clinical testing, highlights gaps in current knowledge, and proposes areas for further research to enhance histocompatibility testing in support of solid organ transplantation. This report provides updates on topics discussed by the previous Sensitization in Transplantation: Assessment of Risk working groups and introduces 2 areas of exploration: non-human leukocyte antigen antibodies and utilization of human leukocyte antigen antibody testing measurement to evaluate the efficacy of antibody-removal therapies.
Collapse
Affiliation(s)
- Anat R Tambur
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA.
| | - Oriol Bestard
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Patricia Campbell
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Anita S Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - Martha Crespo Barrio
- Department of Nephrology, Hospital del Mar & Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Mandy L Ford
- Department of Surgery and Emory Transplant Center, Emory University, Atlanta, Georgia, USA
| | - Howard M Gebel
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Netherlands
| | - Michelle Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Annette Jackson
- Department of Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale UMR-S970, Université de Paris, Paris, France
| | - Kevin Louis
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale UMR-S970, Université de Paris, Paris, France
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Mengel
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Anna Morris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David F Pinelli
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Jean-Luc Taupin
- Department of Immunology, Saint Louis Hospital and University Paris-Cité, Paris, France
| | - Nicole Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
20
|
Nickerson PW. Rationale for the IMAGINE study for chronic active antibody-mediated rejection (caAMR) in kidney transplantation. Am J Transplant 2022; 22 Suppl 4:38-44. [PMID: 36453707 DOI: 10.1111/ajt.17210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
Chronic active antibody-mediated rejection (caAMR) in kidney transplantation is a major cause of late graft loss and despite all efforts to date, there is no proven effective therapy. Indeed, the Transplant Society (TTS) consensus opinion called for a conservative approach optimizing baseline immunosuppression and supportive care focused on blood pressure, blood glucose, and lipid control. This review provides the rationale and early evidence in kidney transplant recipients with caAMR that supported the design of the IMAGINE study whose goal is to evaluate the potential impact of targeting the IL6/IL6R pathway.
Collapse
Affiliation(s)
- Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| |
Collapse
|
21
|
Gong N, Zhao Y, Zhu H, Wang C. Editorial: Novel mechanisms and approaches in kidney/pancreas-kidney transplant-related injury. Front Immunol 2022; 13:1082590. [PMID: 36483561 PMCID: PMC9724645 DOI: 10.3389/fimmu.2022.1082590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Nianqiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Key Laboratory of Organ Transplantation of Ministry of Education, National Health Commission and Chinese Academy of Medical Sciences, Wuhan, China,*Correspondence: Nianqiao Gong, ; Yuanyuan Zhao, ; Hua Zhu, ; Chenhui Wang,
| | - Yuanyuan Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Key Laboratory of Organ Transplantation of Ministry of Education, National Health Commission and Chinese Academy of Medical Sciences, Wuhan, China,*Correspondence: Nianqiao Gong, ; Yuanyuan Zhao, ; Hua Zhu, ; Chenhui Wang,
| | - Hua Zhu
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Nianqiao Gong, ; Yuanyuan Zhao, ; Hua Zhu, ; Chenhui Wang,
| | - Chenhui Wang
- The Key Laboratory for Human Disease Gene Study of Sichuan Province and the Department of Laboratory Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Nianqiao Gong, ; Yuanyuan Zhao, ; Hua Zhu, ; Chenhui Wang,
| |
Collapse
|
22
|
López del Moral C, Wu K, Naik M, Osmanodja B, Akifova A, Lachmann N, Stauch D, Hergovits S, Choi M, Bachmann F, Halleck F, Schrezenmeier E, Schmidt D, Budde K. The natural history of de novo donor-specific HLA antibodies after kidney transplantation. Front Med (Lausanne) 2022; 9:943502. [PMID: 36186822 PMCID: PMC9523126 DOI: 10.3389/fmed.2022.943502] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background De novo donor-specific HLA antibodies (dnDSA) are key factors in the diagnosis of antibody-mediated rejection (ABMR) and related to graft loss. Methods This retrospective study was designed to evaluate the natural course of dnDSA in graft function and kidney allograft survival and to assess the impact of mean fluorescence intensity (MFI) evolution as detected by annual Luminex® screening. All 400 kidney transplant recipients with 731 dnDSA against the last graft (01/03/2000-31/05/2021) were included. Results During 8.3 years of follow-up, ABMR occurred in 24.8% and graft loss in 33.3% of the cases, especially in patients with class I and II dnDSA, and those with multiple dnDSA. We observed frequent changes in MFI with 5-year allograft survivals post-dnDSA of 74.0% in patients with MFI reduction ≥ 50%, 62.4% with fluctuating MFI (MFI reduction ≥ 50% and doubling), and 52.7% with doubling MFI (log-rank p < 0.001). Interestingly, dnDSA in 168 (24.3%) cases became negative at some point during follow-up, and 38/400 (9.5%) patients became stable negative, which was associated with better graft survival. Multivariable analysis revealed the importance of MFI evolution and rejection, while class and number of dnDSA were not contributors in this model. Conclusion In summary, we provide an in-depth analysis of the natural course of dnDSA after kidney transplantation, first evidence for the impact of MFI evolution on graft outcomes, and describe a relevant number of patients with a stable disappearance of dnDSA, related to better allograft survival.
Collapse
Affiliation(s)
- Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
- *Correspondence: Covadonga López del Moral,
| | - Kaiyin Wu
- Department of Pathology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Aylin Akifova
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Lachmann
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Diana Stauch
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Hergovits
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Charité – Universitätsmedizin Berlin, BIH Academy, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
23
|
Halloran PF, Madill‐Thomsen KS, Pon S, Sikosana MLN, Böhmig GA, Bromberg J, Einecke G, Eskandary F, Gupta G, Hidalgo LG, Myslak M, Viklicky O, Perkowska‐Ptasinska A. Molecular diagnosis of ABMR with or without donor-specific antibody in kidney transplant biopsies: Differences in timing and intensity but similar mechanisms and outcomes. Am J Transplant 2022; 22:1976-1991. [PMID: 35575435 PMCID: PMC9540308 DOI: 10.1111/ajt.17092] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We studied the clinical, histologic, and molecular features distinguishing DSA-negative from DSA-positive molecularly defined antibody-mediated rejection (mABMR). We analyzed mABMR biopsies with available DSA assessments from the INTERCOMEX study: 148 DSA-negative versus 248 DSA-positive, compared with 864 no rejection (excluding TCMR and Mixed). DSA-positivity varied with mABMR stage: early-stage (EABMR) 56%; fully developed (FABMR) 70%; and late-stage (LABMR) 58%. DSA-negative patients with mABMR were usually sensitized, 60% being HLA antibody-positive. Compared with DSA-positive mABMR, DSA-negative mABMR was more often C4d-negative; earlier by 1.5 years (average 2.4 vs. 3.9 years); and had lower ABMR activity and earlier stage in molecular and histology features. However, the top ABMR-associated transcripts were identical in DSA-negative versus DSA-positive mABMR, for example, NK-associated (e.g., KLRD1 and GZMB) and IFNG-inducible (e.g., PLA1A). Genome-wide class comparison between DSA-negative and DSA-positive mABMR showed no significant differences in transcript expression except those related to lower intensity and earlier time of DSA-negative ABMR. Three-year graft loss in DSA-negative mABMR was the same as DSA-positive mABMR, even after adjusting for ABMR stage. Thus, compared with DSA-positive mABMR, DSA-negative mABMR is on average earlier, less active, and more often C4d-negative but has similar graft loss, and genome-wide analysis suggests that it involves the same mechanisms. SUMMARY SENTENCE: In 398 kidney transplant biopsies with molecular antibody-mediated rejection, the 150 DSA-negative cases are earlier, less intense, and mostly C4d-negative, but use identical molecular mechanisms and have the same risk of graft loss as the 248 DSA-positive cases.
Collapse
Affiliation(s)
- Philip F. Halloran
- Alberta Transplant Applied Genomics CentreEdmontonAlbertaCanada,Department of Medicine, Division of Nephrology and Transplant ImmunologyUniversity of AlbertaEdmontonAlbertaCanada
| | | | - Shane Pon
- Alberta Transplant Applied Genomics CentreEdmontonAlbertaCanada
| | | | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine IIIMedical University of ViennaViennaAustria
| | | | - Gunilla Einecke
- Department of NephrologyHannover Medical SchoolHannoverGermany
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine IIIMedical University of ViennaViennaAustria
| | - Gaurav Gupta
- Division of NephrologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | | | - Marek Myslak
- Department of Clinical Interventions, Department of Nephrology and Kidney Transplantation SPWSZ HospitalPomeranian Medical UniversitySzczecinPoland
| | - Ondrej Viklicky
- Department of Nephrology and Transplant CenterInstitute for Clinical and Experimental MedicinePragueCzech Republic
| | | | | |
Collapse
|
24
|
Bräsen JH. [Current insights on monitoring of renal transplants-Banff and beyond]. PATHOLOGIE (HEIDELBERG, GERMANY) 2022; 43:134-136. [PMID: 36378289 DOI: 10.1007/s00292-022-01148-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Renal transplantation represents the best treatment for end-stage renal disease. Much effort has been invested in improvement of longevity of the transplanted organ including a comprehensive and regularly updated histological scoring system (Banff classification) for surveillance; however, survival of transplanted kidneys is still limited to median 15 years. Molecular analyses have increased the understanding of damaging mechanisms within the transplant, especially antibody-mediated rejection, which can be difficult to identify using histological methods. Changes in the Banff classification necessitate to reclassify biopsies included in studies according to current consensus. Digital and molecular innovations as well as new immunologic mechanisms are anticipated.
Collapse
Affiliation(s)
- Jan Hinrich Bräsen
- Bereichsleitung Nephropathologie, Institut für Pathologie, OE 5110, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| |
Collapse
|
25
|
The Ratio of CD226 and TIGIT Expression in Tfh and PD-1 +ICOS +Tfh Cells Are Potential Biomarkers for Chronic Antibody-Mediated Rejection in Kidney Transplantation. J Immunol Res 2022; 2022:5326083. [PMID: 35733922 PMCID: PMC9206998 DOI: 10.1155/2022/5326083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 05/12/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is the ideal treatment for end-stage renal disease (ESRD). Chronic antibody-mediated rejection (CAMR) is the main cause of graft failure. Tfh and B cells are key immune cells that play important roles in CAMR. In this study, the populations of different Tfh cell phenotypes and B cell subsets in CAMR were investigated in a total of 36 patients. Based on Banff-2019, 15 patients were diagnosed with CAMR (CAMR group), 11 recipients were diagnosed with recurrent or de novo IgA nephropathy (IgAN group), and 10 patients displayed stable renal function (stable group). The Tfh and B cell subsets were analyzed by flow cytometry. The percentage and absolute number of PD-1+ICOS+Tfh cells were significantly higher in CAMR (p < 0.05), as was the ratio of CD226+Tfh cells to TIGIT+Tfh cells (p < 0.05). Compared with stable recipients, CAMR patients had lower naïve B cells and higher unswitched memory B cells, which were also significantly related to renal function (p < 0.05). Using the logistic regression model, we concluded that the estimated glomerular filtration rate (eGFR), absolute number of PD-1+ICOS+Tfh cells, and ratio of CD226+Tfh cells to TIGIT+Tfh cells were independent risk factors for CAMR. The combination of eGFR, PD-1+ICOS+Tfh cells, and the ratio of CD226+Tfh cells to TIGIT+Tfh cells showed better diagnostic efficacy for CAMR than each single parameter. The collective findings show that monitoring different Tfh phenotypes and B cell subsets is beneficial to kidney transplant recipients and implicate the combination of eGFR, number of PD-1+ICOS+Tfh cells, and ratio of CD226+Tfh cells to TIGIT+Tfh cells as a biomarker for diagnosing CAMR. The findings may also inform new strategies to identify and treat CAMR.
Collapse
|
26
|
Mayer KA, Budde K, Jilma B, Doberer K, Böhmig GA. Emerging drugs for antibody-mediated rejection after kidney transplantation: a focus on phase II & III trials. Expert Opin Emerg Drugs 2022; 27:151-167. [PMID: 35715978 DOI: 10.1080/14728214.2022.2091131] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antibody-mediated rejection (ABMR) is a leading cause of kidney allograft failure. Its therapy continues to be challenge, and no treatment has been approved for the market thus far. AREAS COVERED In this article, we discuss the pathophysiology and phenotypic presentation of ABMR, the current level of evidence to support the use of available therapeutic strategies, and the emergence of tailored drugs now being evaluated in systematic clinical trials. We searched PubMed, Clinicaltrials.gov and Citeline's Pharmaprojects for pertinent information on emerging anti-rejection strategies, laying a focus on phase II and III trials. EXPERT OPINION Currently, we rely on the use of apheresis for alloantibody depletion and intravenous immunoglobulin (referred to as standard of care), preferentially in early active ABMR. Recent systematic trials have questioned the benefits of using the CD20 antibody rituximab or the proteasome inhibitor bortezomib. However, there are now several promising treatment approaches in the pipeline, which are being trialed in phase II and III studies. These include interleukin-6 antagonism, CD38-targeting antibodies, and selective inhibitors of complement. On the basis of the information that has emerged so far, it seems that innovative treatment strategies for clinical use in ABMR may be available within the next 5-10 years.
Collapse
Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
27
|
McCloskey C, Zubrycki M, Lawrence C. The Molecular Microscope Diagnostic System (MMDx) interpretation of solid organ allograft biopsies: Restoring the perspective. Clin Transplant 2022; 36:e14711. [PMID: 35668041 DOI: 10.1111/ctr.14711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Chris McCloskey
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
| | - Michelle Zubrycki
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
| | - Christopher Lawrence
- Transplant Diagnostics Division, Thermo Fisher Scientific, West Hills, California, USA
| |
Collapse
|
28
|
Wu K, Schmidt D, López del Moral C, Osmanodja B, Lachmann N, Halleck F, Choi M, Bachmann F, Ronicke S, Duettmann W, Naik M, Schrezenmeier E, Rudolph B, Budde K. Poor Outcomes in Patients With Transplant Glomerulopathy Independent of Banff Categorization or Therapeutic Interventions. Front Med (Lausanne) 2022; 9:889648. [PMID: 35646957 PMCID: PMC9133540 DOI: 10.3389/fmed.2022.889648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTransplant glomerulopathy (TG) may indicate different disease entities including chronic AMR (antibody-mediated rejection). However, AMR criteria have been frequently changed, and long-term outcomes of allografts with AMR and TG according to Banff 2017 have rarely been investigated.Methods282 kidney allograft recipients with biopsy-proven TG were retrospectively investigated and diagnosed according to Banff'17 criteria: chronic AMR (cAMR, n = 72), chronic active AMR (cAAMR, n = 76) and isolated TG (iTG, n = 134). Of which 25/72 (34.7%) patients of cAMR group and 46/76 (60.5%) of cAAMR group were treated with antihumoral therapy (AHT).ResultsUp to 5 years after indication biopsy, no statistically significant differences were detected among iTG, cAMR and cAAMR groups in annual eGFR decline (−3.0 vs. −2.0 vs. −2.8 ml/min/1.73 m2 per year), 5-year median eGFR (21.5 vs. 16.0 vs. 20.0 ml/min/1.73 m2), 5-year graft survival rates (34.1 vs. 40.6 vs. 31.8%) as well as urinary protein excretion during follow-up. In addition, cAMR and cAAMR patients treated with AHT had similar graft and patient survival rates in comparison with those free of AHT, and similar comparing with iTG group. The TG scores were not associated with 5-year postbiopsy graft failure; whereas the patients with higher scores of chronic allograft scarring (by mm-, ci- and ct-lesions) had significantly lower graft survival rates than those with mild scores. The logistic-regression analysis demonstrated that Banff mm-, ah-, t-, ci-, ct-lesions and the eGFR level at biopsy were associated with 5-year graft failure.ConclusionsThe occurrence of TG is closely associated with graft failure independent of disease categories and TG score, and the long-term clinical outcomes were not influenced by AHT. The Banff lesions indicating progressive scarring might be better suited to predict an unfavorable outcome.
Collapse
Affiliation(s)
- Kaiyin Wu
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
- *Correspondence: Kaiyin Wu
| | - Danilo Schmidt
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Covadonga López del Moral
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Lachmann
- HLA Laboratory, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, BIH, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Simon Ronicke
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wiebke Duettmann
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| | - Birgit Rudolph
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universitätzu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health (BIH), Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
29
|
Nankivell BJ, P’Ng CH, Shingde M. Glomerular C4d Immunoperoxidase in Chronic Antibody-Mediated Rejection and Transplant Glomerulopathy. Kidney Int Rep 2022; 7:1594-1607. [PMID: 35812271 PMCID: PMC9263257 DOI: 10.1016/j.ekir.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The diagnosis of late antibody-mediated rejection (AMR) is compromised by frequent absence of C4d in peritubular capillaries (C4dptc), termed “C4d-negative” AMR. We hypothesized that glomerular capillary C4d (C4dglom) reflected endothelial interaction with antibody and could improve immunologic classification of transplant glomerulopathy (TG). Methods We evaluated C4d using immunoperoxidase in 3524 consecutive, kidney transplant biopsies from a single center. Results C4dglom was detected in 16.5% and C4dptc in 9.9% of biopsies. C4dglom occurred in 60.3% of TG (n = 174) and was absent in normal glomeruli. Epidemiologic risk factors for C4dglom were younger, female, living-donor recipients with early AMR, prior treated rejection, and late presentation using multivariable analysis. Semiquantitative C4dglom score correlated with donor specific antibody (DSA) level, C4dptc, microvascular inflammation (MVI), Banff cg scores, renal dysfunction, and proteinuria. Principal component analysis colocalized C4dglom with histologic AMR. Multivariable analysis of TG found DSA, C4dptc, and post-transplant time associated with C4dglom. Addition of C4dglom into Banff chronic AMR schema improved its diagnostic sensitivity for TG (verified by electron microscopy [EM]) from 22.2% to 82.4% and accuracy from 59.6% to 93.9%, compared with Banff 2019 using only C4dptc. Tissue C4dglom and chronic AMR diagnosis incorporating C4dglom were associated with death-censored allograft failure in TG (P < 0.001), independent of the severity of glomerulopathy and chronic interstitial fibrosis. Conclusion C4dglom is a promising diagnostic biomarker of endothelial interaction with antibody which substantially improved test performance of the Banff schema to correctly classify TG by pathophysiology and prognosticate graft loss. We recommend routine C4d immunoperoxidase to minimize underdiagnosis of late AMR in TG.
Collapse
Affiliation(s)
- Brian J. Nankivell
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Correspondence: Brian J. Nankivell, Department of Renal Medicine, Westmead Hospital, Westmead, Sydney, 2145 New South Wales, Australia.
| | - Chow H. P’Ng
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| | - Meena Shingde
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| |
Collapse
|
30
|
Wu K, Schmidt D, López del Moral C, Osmanodja B, Lachmann N, Zhang Q, Halleck F, Choi M, Bachmann F, Ronicke S, Duettmann W, Naik MG, Schrezenmeier E, Rudolph B, Budde K. Poor Long-Term Renal Allograft Survival in Patients with Chronic Antibody-Mediated Rejection, Irrespective of Treatment-A Single Center Retrospective Study. J Clin Med 2021; 11:jcm11010199. [PMID: 35011939 PMCID: PMC8745558 DOI: 10.3390/jcm11010199] [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: 12/06/2021] [Revised: 12/25/2021] [Accepted: 12/27/2021] [Indexed: 01/16/2023] Open
Abstract
The Banff 2017 report permits the diagnosis of pure chronic antibody-mediated rejection (cAMR) in absence of microcirculation inflammation. We retrospectively investigated renal allograft function and long-term outcomes of 67 patients with cAMR, and compared patients who received antihumoral therapy (cAMR-AHT, n = 21) with patients without treatment (cAMRwo, n = 46). At baseline, the cAMR-AHT group had more concomitant T-cell-mediated rejection (9/46 (19.2%) vs. 10/21 (47.6%); p = 0.04), a higher g-lesion score (0.4 ± 0.5 versus 0.1 ± 0.3; p = 0.01) and a higher median eGFR decline in the six months prior to biopsy (6.6 vs. 3.0 mL/min; p = 0.04). The median eGFR decline six months after biopsy was comparable (2.6 vs. 4.9 mL/min, p = 0.61) between both groups, and three-year graft survival after biopsy was statistically lower in the cAMR-AHT group (35.0% vs. 61.0%, p = 0.03). Patients who received AHT had more infections (0.38 vs. 0.20 infections/patient; p = 0.04). Currently, antihumoral therapy is more often administered to patients with cAMR and rapidly deteriorating renal function or concomitant TCMR. However, long-term graft outcomes remain poor, despite treatment.
Collapse
Affiliation(s)
- Kaiyin Wu
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Correspondence: ; Tel.: +49-30-450-514002; Fax: +49-30-450-514902
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Nils Lachmann
- Institute of Transfusion Medicine, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Qiang Zhang
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Simon Ronicke
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| | - Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
- Berlin Institute of Health, Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Birgit Rudolph
- Institute of Pathology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany; (D.S.); (C.L.d.M.); (B.O.); (Q.Z.); (F.H.); (M.C.); (F.B.); (S.R.); (W.D.); (M.G.N.); (E.S.); (K.B.)
| |
Collapse
|
31
|
Callemeyn J, Lamarthée B, Koenig A, Koshy P, Thaunat O, Naesens M. Allorecognition and the spectrum of kidney transplant rejection. Kidney Int 2021; 101:692-710. [PMID: 34915041 DOI: 10.1016/j.kint.2021.11.029] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022]
Abstract
Detection of mismatched human leukocyte antigens by adaptive immune cells is considered as the main cause of transplant rejection, leading to either T-cell mediated rejection or antibody-mediated rejection. This canonical view guided the successful development of immunosuppressive therapies and shaped the diagnostic Banff classification for kidney transplant rejection that is used in clinics worldwide. However, several observations have recently emerged that question this dichotomization between T-cell mediated rejection and antibody-mediated rejection, related to heterogeneity in the serology, histology, and prognosis of the rejection phenotypes. In parallel, novel insights were obtained concerning the dynamics of donor-specific anti-human leukocyte antigen antibodies, the immunogenicity of donor-recipient non-human leukocyte antigen mismatches, and the autoreactivity against self-antigens. Moreover, the potential of innate allorecognition was uncovered, as exemplified by natural killer cell-mediated microvascular inflammation through missing self, and by the emerging evidence on monocyte-driven allorecognition. In this review, we highlight the gaps in the current classification of rejection, provide an overview of the expanding insights into the mechanisms of allorecognition, and critically appraise how these could improve our understanding and clinical approach to kidney transplant rejection. We argue that consideration of the complex interplay of various allorecognition mechanisms can foster a more integrated view of kidney transplant rejection and can lead to improved risk stratification, targeted therapies, and better outcome after kidney transplantation.
Collapse
Affiliation(s)
- Jasper Callemeyn
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Baptiste Lamarthée
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Necker-Enfants Malades Institute, French National Institute of Health and Medical Research (INSERM) Unit 1151, Paris, France
| | - Alice Koenig
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Priyanka Koshy
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Thaunat
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
32
|
Lamarthée B, Burger C, Leclaire C, Lebraud E, Zablocki A, Morin L, Lebreton X, Charreau B, Snanoudj R, Charbonnier S, Blein T, Hardy M, Zuber J, Satchell S, Gallazzini M, Terzi F, Legendre C, Taupin JL, Rabant M, Tinel C, Anglicheau D. CRISPR/Cas9-Engineered HLA-Deleted Glomerular Endothelial Cells as a Tool to Predict Pathogenic Non-HLA Antibodies in Kidney Transplant Recipients. J Am Soc Nephrol 2021; 32:3231-3251. [PMID: 35167486 PMCID: PMC8638404 DOI: 10.1681/asn.2021050689] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/20/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND After kidney transplantation, donor-specific antibodies against human leukocyte antigen donor-specific antibodies (HLA-DSAs) drive antibody-mediated rejection (ABMR) and are associated with poor transplant outcomes. However, ABMR histology (ABMRh) is increasingly reported in kidney transplant recipients (KTRs) without HLA-DSAs, highlighting the emerging role of non-HLA antibodies (Abs). METHODS W e designed a non-HLA Ab detection immunoassay (NHADIA) using HLA class I and II-deficient glomerular endothelial cells (CiGEnCΔHLA) that had been previously generated through CRISPR/Cas9-induced B2M and CIITA gene disruption. Flow cytometry assessed the reactivity to non-HLA antigens of pretransplantation serum samples from 389 consecutive KTRs. The intensity of the signal observed with the NHADIA was associated with post-transplant graft histology assessed in 951 adequate biopsy specimens. RESULTS W e sequentially applied CRISPR/Cas9 to delete the B2M and CIITA genes to obtain a CiGEnCΔHLA clone. CiGEnCΔHLA cells remained indistinguishable from the parental cell line, CiGEnC, in terms of morphology and phenotype. Previous transplantation was the main determinant of the pretransplantation NHADIA result (P<0.001). Stratification of 3-month allograft biopsy specimens (n=298) according to pretransplantation NHADIA tertiles demonstrated that higher levels of non-HLA Abs positively correlated with increased glomerulitis (P=0.002), microvascular inflammation (P=0.003), and ABMRh (P=0.03). A pretransplantation NHADIA threshold of 1.87 strongly discriminated the KTRs with the highest risk of ABMRh (P=0.005, log-rank test). A multivariate Cox model confirmed that NHADIA status and HLA-DSAs were independent, yet synergistic, predictors of ABMRh. CONCLUSION The NHADIA identifies non-HLA Abs and strongly predicts graft endothelial injury independent of HLA-DSAs.
Collapse
Affiliation(s)
- Baptiste Lamarthée
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Carole Burger
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Charlotte Leclaire
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Emilie Lebraud
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Aniela Zablocki
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Lise Morin
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Xavier Lebreton
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Béatrice Charreau
- Center for Research in Transplantation and Immunology, INSERM UMR1064, IHU CESTI, LabEx IGO and LabEx Transplantex, Nantes University, Nantes, France
| | - Renaud Snanoudj
- Immunology and Histocompatibility Laboratory, Saint-Louis Hospital, AP-HP, LabEx Transplantex, INSERM U1160, University Paris Diderot, Paris, France
| | - Soëli Charbonnier
- Laboratory of Human Lymphohematopoiesis, Imagine Institute, INSERM U1163, University of Paris, Paris, France
| | - Tifanie Blein
- Laboratory of Human Lymphohematopoiesis, Imagine Institute, INSERM U1163, University of Paris, Paris, France
| | - Mélanie Hardy
- Immunology and Histocompatibility Laboratory, Saint-Louis Hospital, AP-HP, INSERM U976, IRSL, University of Paris, Paris, France
| | - Julien Zuber
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France,Laboratory of Human Lymphohematopoiesis, Imagine Institute, INSERM U1163, University of Paris, Paris, France
| | - Simon Satchell
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Morgan Gallazzini
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Fabiola Terzi
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean Luc Taupin
- Immunology and Histocompatibility Laboratory, Saint-Louis Hospital, AP-HP, INSERM U976, IRSL, University of Paris, Paris, France
| | - Marion Rabant
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France,Department of Pathology, Necker Hospital, AP-HP, Paris, France
| | - Claire Tinel
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France
| | - Dany Anglicheau
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, University of Paris, Paris, France,Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| |
Collapse
|
33
|
Madill-Thomsen KS, Böhmig GA, Bromberg J, Einecke G, Eskandary F, Gupta G, Hidalgo LG, Myslak M, Viklicky O, Perkowska-Ptasinska A, Halloran PF. Donor-Specific Antibody Is Associated with Increased Expression of Rejection Transcripts in Renal Transplant Biopsies Classified as No Rejection. J Am Soc Nephrol 2021; 32:2743-2758. [PMID: 34253587 PMCID: PMC8806080 DOI: 10.1681/asn.2021040433] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/20/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Donor -specific HLA antibody (DSA) is present in many kidney transplant patients whose biopsies are classified as no rejection (NR). We explored whether in some NR kidneys DSA has subtle effects not currently being recognized. METHODS We used microarrays to examine the relationship between standard-of-care DSA and rejection-related transcript increases in 1679 kidney transplant indication biopsies in the INTERCOMEX study (ClinicalTrials.gov NCT01299168), focusing on biopsies classified as NR by automatically assigned archetypal clustering. DSA testing results were available for 835 NR biopsies and were positive in 271 (32%). RESULTS DSA positivity in NR biopsies was associated with mildly increased expression of antibody-mediated rejection (ABMR)-related transcripts, particularly IFNG-inducible and NK cell transcripts. We developed a machine learning DSA probability (DSAProb) classifier based on transcript expression in biopsies from DSA-positive versus DSA-negative patients, assigning scores using 10-fold cross-validation. This DSAProb classifier was very similar to a previously described "ABMR probability" classifier trained on histologic ABMR in transcript associations and prediction of molecular or histologic ABMR. Plotting the biopsies using Uniform Manifold Approximation and Projection revealed a gradient of increasing molecular ABMR-like transcript expression in NR biopsies, associated with increased DSA (P<2 × 10-16). In biopsies with no molecular or histologic rejection, increased DSAProb or ABMR probability scores were associated with increased risk of kidney failure over 3 years. CONCLUSIONS Many biopsies currently considered to have no molecular or histologic rejection have mild increases in expression of ABMR-related transcripts, associated with increasing frequency of DSA. Thus, mild molecular ABMR-related pathology is more common than previously realized.
Collapse
Affiliation(s)
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jonathan Bromberg
- Departments of Surgery and Microbiology and Immunology, University of Maryland, Baltimore, Maryland
| | - Gunilla Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia
| | - Luis G. Hidalgo
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Marek Myslak
- Pomeranian Medical University, Department of Clinical Interventions and Department of Nephrology and Kidney Transplantation, Samodzielny Publiczny Wojewodzki Szpital Zespolony, Szczecin, Poland
| | - Ondrej Viklicky
- Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Philip F. Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada,Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
34
|
Cornell LD. Histopathologic Features of Antibody Mediated Rejection: The Banff Classification and Beyond. Front Immunol 2021; 12:718122. [PMID: 34646262 PMCID: PMC8503253 DOI: 10.3389/fimmu.2021.718122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/07/2021] [Indexed: 01/27/2023] Open
Abstract
Antibody mediated rejection (ABMR) in the kidney can show a wide range of clinical presentations and histopathologic patterns. The Banff 2019 classification currently recognizes four diagnostic categories: 1. Active ABMR, 2. Chronic active ABMR, 3. Chronic (inactive) ABMR, and 4. C4d staining without evidence of rejection. This categorization is limited in that it does not adequately represent the spectrum of antibody associated injury in allograft, it is based on biopsy findings without incorporating clinical features (e.g., time post-transplant, de novo versus preformed DSA, protocol versus indication biopsy, complement inhibitor drugs), the scoring is not adequately reproducible, and the terminology is confusing. These limitations are particularly relevant in patients undergoing desensitization or positive crossmatch kidney transplantation. In this article, I discuss Banff criteria for these ABMR categories, with a focus on patients with pre-transplant DSA, and offer a framework for considering the continuum of allograft injury associated with donor specific antibody in these patients.
Collapse
Affiliation(s)
- Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
35
|
Park S, Guo K, Heilman RL, Poggio ED, Taber DJ, Marsh CL, Kurian SM, Kleiboeker S, Weems J, Holman J, Zhao L, Sinha R, Brietigam S, Rebello C, Abecassis MM, Friedewald JJ. Combining Blood Gene Expression and Cellfree DNA to Diagnose Subclinical Rejection in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2021; 16:1539-1551. [PMID: 34620649 PMCID: PMC8499014 DOI: 10.2215/cjn.05530421] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Subclinical acute rejection is associated with poor outcomes in kidney transplant recipients. As an alternative to surveillance biopsies, noninvasive screening has been established with a blood gene expression profile. Donor-derived cellfree DNA (cfDNA) has been used to detect rejection in patients with allograft dysfunction but not tested extensively in stable patients. We hypothesized that we could complement noninvasive diagnostic performance for subclinical rejection by combining a donor-derived cfDNA and a gene expression profile assay. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a post hoc analysis of simultaneous blood gene expression profile and donor-derived cfDNA assays in 428 samples paired with surveillance biopsies from 208 subjects enrolled in an observational clinical trial (Clinical Trials in Organ Transplantation-08). Assay results were analyzed as binary variables, and then, their continuous scores were combined using logistic regression. The performance of each assay alone and in combination was compared. RESULTS For diagnosing subclinical rejection, the gene expression profile demonstrated a negative predictive value of 82%, a positive predictive value of 47%, a balanced accuracy of 64%, and an area under the receiver operating curve of 0.75. The donor-derived cfDNA assay showed similar negative predictive value (84%), positive predictive value (56%), balanced accuracy (68%), and area under the receiver operating curve (0.72). When both assays were negative, negative predictive value increased to 88%. When both assays were positive, positive predictive value increased to 81%. Combining assays using multivariable logistic regression, area under the receiver operating curve was 0.81, significantly higher than the gene expression profile (P<0.001) or donor-derived cfDNA alone (P=0.006). Notably, when cases were separated on the basis of rejection type, the gene expression profile was significantly better at detecting cellular rejection (area under the receiver operating curve, 0.80 versus 0.62; P=0.001), whereas the donor-derived cfDNA was significantly better at detecting antibody-mediated rejection (area under the receiver operating curve, 0.84 versus 0.71; P=0.003). CONCLUSIONS A combination of blood-based biomarkers can improve detection and provide less invasive monitoring for subclinical rejection. In this study, the gene expression profile detected more cellular rejection, whereas donor-derived cfDNA detected more antibody-mediated rejection.
Collapse
Affiliation(s)
- Sookhyeon Park
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Kexin Guo
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond L. Heilman
- Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Phoenix, Arizona
| | - Emilio D. Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - David J. Taber
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher L. Marsh
- Department of Medicine and Surgery, Scripps Clinic and Green Hospital, La Jolla, California
| | - Sunil M. Kurian
- Bio-Repository and Bio-Informatics Core, Scripps Health, La Jolla, California
| | | | - Juston Weems
- Eurofins US Clinical Diagnostics, Lee’s Summit, Missouri
| | - John Holman
- Transplant Genomics, Inc., Mansfield, Massachusetts
| | - Lihui Zhao
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rohita Sinha
- Eurofins US Clinical Diagnostics, Lee’s Summit, Missouri
| | - Susan Brietigam
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christabel Rebello
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael M. Abecassis
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona,Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
36
|
Donor genetic variants in interleukin-6 and interleukin-6 receptor associate with biopsy-proven rejection following kidney transplantation. Sci Rep 2021; 11:16483. [PMID: 34389747 PMCID: PMC8363661 DOI: 10.1038/s41598-021-95714-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023] Open
Abstract
Rejection after kidney transplantation remains an important cause of allograft failure that markedly impacts morbidity. Cytokines are a major player in rejection, and we, therefore, explored the impact of interleukin-6 (IL6) and IL-6 receptor (IL6R) gene polymorphisms on the occurrence of rejection after renal transplantation. We performed an observational cohort study analyzing both donor and recipient DNA in 1271 renal transplant‐pairs from the University Medical Center Groningen in The Netherlands and associated single nucleotide polymorphisms (SNPs) with biopsy-proven rejection after kidney transplantation. The C-allele of the IL6R SNP (Asp358Ala; rs2228145 A > C, formerly rs8192284) in donor kidneys conferred a reduced risk of rejection following renal transplantation (HR 0.78 per C-allele; 95%-CI 0.67–0.90; P = 0.001). On the other hand, the C-allele of the IL6 SNP (at position-174 in the promoter; rs1800795 G > C) in donor kidneys was associated with an increased risk of rejection for male organ donors (HR per C-allele 1.31; 95%-CI 1.08–1.58; P = 0.0006), but not female organ donors (P = 0.33). In contrast, neither the IL6 nor IL6R SNP in the recipient showed an association with renal transplant rejection. In conclusion, donor IL6 and IL6R genotypes but not recipient genotypes represent an independent prognostic marker for biopsy-proven renal allograft rejection.
Collapse
|
37
|
Callemeyn J, Senev A, Coemans M, Lerut E, Sprangers B, Kuypers D, Koenig A, Thaunat O, Emonds MP, Naesens M. Missing Self-Induced Microvascular Rejection of Kidney Allografts: A Population-Based Study. J Am Soc Nephrol 2021; 32:2070-2082. [PMID: 34301794 PMCID: PMC8455279 DOI: 10.1681/asn.2020111558] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/29/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Circulating anti-HLA donor-specific antibodies (HLA-DSA) are often absent in kidney transplant recipients with microvascular inflammation (MVI). Missing self, the inability of donor endothelial cells to provide HLA I-mediated signals to inhibitory killer cell Ig-like receptors (KIRs) on recipient natural killer cells, can cause endothelial damage in vitro, and has been associated with HLA-DSA-negative MVI. However, missing self's clinical importance as a nonhumoral trigger of allograft rejection remains unclear. METHODS In a population-based study of 924 consecutive kidney transplantations between March 2004 and February 2013, we performed high-resolution donor and recipient HLA typing and recipient KIR genotyping. Missing self was defined as the absence of A3/A11, Bw4, C1, or C2 donor genotype, with the presence of the corresponding educated recipient inhibitory KIR gene. RESULTS We identified missing self in 399 of 924 transplantations. Co-occurrence of missing self types had an additive effect in increasing MVI risk, with a threshold at two concurrent types (hazard ratio [HR], 1.78; 95% confidence interval [95% CI], 1.26 to 2.53), independent of HLA-DSA (HR, 5.65; 95% CI, 4.01 to 7.96). Missing self and lesions of cellular rejection were not associated. No HLA-DSAs were detectable in 146 of 222 recipients with MVI; 28 of the 146 had at least two missing self types. Missing self associated with transplant glomerulopathy after MVI (HR, 2.51; 95% CI, 1.12 to 5.62), although allograft survival was better than with HLA-DSA-associated MVI. CONCLUSION Missing self specifically and cumulatively increases MVI risk after kidney transplantation, independent of HLA-DSA. Systematic evaluation of missing self improves understanding of HLA-DSA-negative MVI and might be relevant for improved diagnostic classification and patient risk stratification.
Collapse
Affiliation(s)
- Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross‐Flanders, Mechelen, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium,Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, KU Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Alice Koenig
- International Center of Infectiology research (CIRI), French Institute of Health and Medical Research (INSERM) Unit 1111, Claude Bernard University Lyon I, National Center for Scientific Research (CNRS) Mixed University Unit (UMR) 5308, Ecole Normale Supérieure de Lyon, University of Lyon, Lyon, France,Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France,Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Lyon, France
| | - Olivier Thaunat
- International Center of Infectiology research (CIRI), French Institute of Health and Medical Research (INSERM) Unit 1111, Claude Bernard University Lyon I, National Center for Scientific Research (CNRS) Mixed University Unit (UMR) 5308, Ecole Normale Supérieure de Lyon, University of Lyon, Lyon, France,Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France,Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Lyon, France
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross‐Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
38
|
Mengel M, Mannon RB. Banff and ABMR: Are we going in the right direction? Am J Transplant 2021; 21:2321-2322. [PMID: 33621422 DOI: 10.1111/ajt.16546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/07/2021] [Accepted: 02/15/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| |
Collapse
|