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Napoli C, Benincasa G, Fiorelli A, Strozziero MG, Costa D, Russo F, Grimaldi V, Hoetzenecker K. Lung transplantation: Current insights and outcomes. Transpl Immunol 2024; 85:102073. [PMID: 38889844 DOI: 10.1016/j.trim.2024.102073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
Until now, the ability to predict or retard immune-mediated rejection events after lung transplantation is still limited due to the lack of specific biomarkers. The pressing need remains to early diagnose or predict the onset of chronic lung allograft dysfunction (CLAD) and its differential phenotypes that is the leading cause of death. Omics technologies (mainly genomics, epigenomics, and transcriptomics) combined with advanced bioinformatic platforms are clarifying the key immune-related molecular routes that trigger early and late events of lung allograft rejection supporting the biomarker discovery. The most promising biomarkers came from genomics. Both unregistered and NIH-registered clinical trials demonstrated that the increased percentage of donor-derived cell-free DNA in both plasma and bronchoalveolar lavage fluid showed a good diagnostic performance for clinically silent acute rejection events and CLAD differential phenotypes. A further success arose from transcriptomics that led to development of Molecular Microscope® Diagnostic System (MMDx) to interpret the relationship between molecular signatures of lung biopsies and rejection events. Other immune-related biomarkers of rejection events may be exosomes, telomer length, DNA methylation, and histone-mediated neutrophil extracellular traps (NETs) but none of them entered in registered clinical trials. Here, we discuss novel and existing technologies for revealing new immune-mediated mechanisms underlying acute and chronic rejection events, with a particular focus on emerging biomarkers for improving precision medicine of lung transplantation field.
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Affiliation(s)
- Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | - Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, Department of Translation Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | | | - Dario Costa
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | | | - Vincenzo Grimaldi
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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2
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Mohanty RP, Moghbeli K, Singer JP, Calabrese DR, Hays SR, Iasella C, Lieber S, Leard LE, Shah RJ, Venado A, Kleinhenz ME, Golden JA, Martinu T, Love C, Ward R, Langelier CR, McDyer J, Greenland JR. Small airway brush gene expression predicts chronic lung allograft dysfunction and mortality. J Heart Lung Transplant 2024:S1053-2498(24)01743-1. [PMID: 39115489 DOI: 10.1016/j.healun.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/24/2024] [Accepted: 07/13/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) limits survival following lung transplant, but substantial lung damage occurs before diagnosis by traditional methods. We hypothesized that small airway gene expression patterns could identify CLAD risk before spirometric diagnosis and predict subsequent graft failure. METHODS Candidate genes from 4 rejection-associated transcript sets were assessed for associations with CLAD or graft failure in a derivation cohort of 156 small airway brushes from 45 CLAD cases and 37 time-matched controls with >1-year stable lung function. Candidate genes not associated with CLAD and time to graft failure were excluded, yielding the Airway Inflammation 2 (AI2) gene set. Area under the receiver operating curve (AUC) for CLAD and competing risks of death or graft failure were assessed in an independent validation cohort of 37 CLAD cases and 37 controls. RESULTS Thirty-two candidate genes were associated with CLAD and graft failure, comprising the AI2 score, which clustered into 3 subcomponents. The AI2 score identified CLAD before its onset, in early and late post-CLAD brushes, as well as in the validation cohort (AUC 0.69-0.88). The AI2 score association with CLAD was independent of positive microbiology, CLAD stage, or CLAD subtype. However, transcripts most associated with CLAD evolved over time from CLAD onset. The AI2 score predicted time to graft failure and retransplant-free survival in both cohorts (p ≤ 0.03). CONCLUSIONS This airway inflammation gene score is associated with CLAD development, graft failure, and death. Future studies defining the molecular heterogeneity of airway inflammation could lead to endotype-targeted therapies.
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Affiliation(s)
- Rashmi Prava Mohanty
- Department of Medicine, University of California, San Francisco, California; Medical Service, Veterans Affairs Health Care System, San Francisco, California
| | - Kaveh Moghbeli
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California
| | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California; Medical Service, Veterans Affairs Health Care System, San Francisco, California
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California
| | - Carlo Iasella
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sophia Lieber
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lorriana E Leard
- Department of Medicine, University of California, San Francisco, California
| | - Rupal J Shah
- Department of Medicine, University of California, San Francisco, California
| | - Aida Venado
- Department of Medicine, University of California, San Francisco, California
| | - Mary E Kleinhenz
- Department of Medicine, University of California, San Francisco, California
| | - Jeffery A Golden
- Department of Medicine, University of California, San Francisco, California
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Christina Love
- Department of Medicine, University of California, San Francisco, California
| | - Ryan Ward
- Department of Medicine, University of California, San Francisco, California
| | | | - John McDyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California; Medical Service, Veterans Affairs Health Care System, San Francisco, California.
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3
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Pavlisko EN, Adam BA, Berry GJ, Calabrese F, Cortes-Santiago N, Glass CH, Goddard M, Greenland JR, Kreisel D, Levine DJ, Martinu T, Verleden SE, Weigt SS, Roux A. The 2022 Banff Meeting Lung Report. Am J Transplant 2024; 24:542-548. [PMID: 37931751 DOI: 10.1016/j.ajt.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
The Lung Session of the 2022 16th Banff Foundation for Allograft Pathology Conference-held in Banff, Alberta-focused on non-rejection lung allograft pathology and novel technologies for the detection of allograft injury. A multidisciplinary panel reviewed the state-of-the-art of current histopathologic entities, serologic studies, and molecular practices, as well as novel applications of digital pathology with artificial intelligence, gene expression analysis, and quantitative image analysis of chest computerized tomography. Current states of need as well as prospective integration of the aforementioned tools and technologies for complete assessment of allograft injury and its impact on lung transplant outcomes were discussed. Key conclusions from the discussion were: (1) recognition of limitations in current standard of care assessment of lung allograft dysfunction; (2) agreement on the need for a consensus regarding the standardized approach to the collection and assessment of pathologic data, inclusive of all lesions associated with graft outcome (eg, non-rejection pathology); and (3) optimism regarding promising novel diagnostic modalities, especially minimally invasive, which should be integrated into large, prospective multicenter studies to further evaluate their utility in clinical practice for directing personalized therapies to improve graft outcomes.
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Affiliation(s)
- Elizabeth N Pavlisko
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA.
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Nahir Cortes-Santiago
- Department of Pathology and Immunology, Texas Children's Hospital, Houston, Texas, USA
| | - Carolyn H Glass
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Martin Goddard
- Pathology Department, Royal Papworth Hospital, NHS Trust, Papworth Everard, Cambridge, UK
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, USA; Veterans Affairs Health Care System, San Francisco, California, USA
| | - Daniel Kreisel
- Department of Surgery, Department of Pathology and Immunology, Washington University, St. Louis, Missouri, USA
| | - Deborah J Levine
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, California, USA
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Stijn E Verleden
- Lung Transplant Unit, Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium; Department of ASTARC, University of Antwerp, Wilrijk, Belgium
| | - S Sam Weigt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Antoine Roux
- Department of Respiratory Medicine, Foch Hospital, Suresnes, France
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4
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Greenland JR, Guo R, Lee S, Tran L, Kapse B, Kukreja J, Hays SR, Golden JA, Calabrese DR, Singer JP, Wolters PJ. Short airway telomeres are associated with primary graft dysfunction and chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:1700-1709. [PMID: 37648073 PMCID: PMC10858720 DOI: 10.1016/j.healun.2023.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/17/2023] [Accepted: 08/20/2023] [Indexed: 09/01/2023] Open
Abstract
Primary graft dysfunction (PGD) is a major risk factor for chronic lung allograft dysfunction (CLAD) following lung transplantation, but the mechanisms linking these pathologies are poorly understood. We hypothesized that the replicative stress induced by PGD would lead to erosion of telomeres, and that this telomere dysfunction could potentiate CLAD. In a longitudinal cohort of 72 lung transplant recipients with >6 years median follow-up time, we assessed tissue telomere length, PGD grade, and freedom from CLAD. Epithelial telomere length and fibrosis-associated gene expression were assessed on endobronchial biopsies taken at 2 to 4 weeks post-transplant by TeloFISH assay and nanoString digital RNA counting. Negative-binomial mixed-effects and Cox-proportional hazards models accounted for TeloFISH staining batch effects and subject characteristics including donor age. Increasing grade of PGD severity was associated with shorter airway epithelial telomere lengths (p = 0.01). Transcriptomic analysis of fibrosis-associated genes showed alteration in fibrotic pathways in airway tissue recovering from PGD, while telomere dysfunction was associated with inflammation and impaired remodeling. Shorter tissue telomere length was in turn associated with increased CLAD risk, with a hazard ratio of 1.89 (95% CI 1.16-3.06) per standard deviation decrease in airway telomere length, after adjusting for subject characteristics. PGD may accelerate telomere dysfunction, potentiating immune responses and dysregulated repair. Epithelial cell telomere dysfunction may represent one of several mechanisms linking PGD to CLAD.
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Affiliation(s)
- John R Greenland
- Department of Medicine, University of California, San Francisco, San Francisco California; Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco California.
| | - Ruyin Guo
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Seoyeon Lee
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Lily Tran
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Bhavya Kapse
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, San Francisco California
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, San Francisco California; Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco California
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, San Francisco California
| | - Paul J Wolters
- Department of Medicine, University of California, San Francisco, San Francisco California
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5
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Lunardi F, Abbrescia DI, Vedovelli L, Pezzuto F, Fortarezza F, Comacchio GM, Guzzardo V, Ferrigno P, Loy M, Giraudo C, Fraia AS, Faccioli E, Braccioni F, Cozzi E, Gregori D, Verleden GM, Calabrese F, Schena FP, Rea F. Molecular Profiling of Tissue Samples with Chronic Rejection from Patients with Chronic Lung Allograft Dysfunction: A Pilot Study in Cystic Fibrosis Patients. Biomolecules 2023; 13:biom13010097. [PMID: 36671482 PMCID: PMC9856133 DOI: 10.3390/biom13010097] [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: 11/08/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Chronic rejection (CR) is the main culprit for reduced survival and quality of life in patients undergoing lung transplantation (Ltx). High-throughput approaches have been used to unveil the molecular pathways of CR, mainly in the blood and/or in bronchoalveolar lavage. We hypothesized that a distinct molecular signature characterizes the biopsies of recipients with clinically confirmed histological signs of CR. Eighteen cystic fibrosis patients were included in the study and RNA sequencing was performed in 35 scheduled transbronchial biopsies (TBBs): 5 with acute cellular rejection, 9 with CR, and 13 without any sign of post-LTx complication at the time of biopsy; 8 donor lung samples were used as controls. Three networks with 33, 26, and 36 differentially expressed genes (DEGs) were found in TBBs with CR. Among these, seven genes were common to the identified pathways and possibly linked to CR and five of them (LCN2, CCL11, CX3CL1, CXCL12, MUC4) were confirmed by real-time PCR. Immunohistochemistry was significant for LCN2 and MUC4. This study identified a typical gene expression pattern in TBBs with histological signs of CR and the LCN2 gene appeared to play a central role. Thus, it could be crucial in CR pathophysiology.
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Affiliation(s)
- Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Luca Vedovelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesco Fortarezza
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Giovanni Maria Comacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Pia Ferrigno
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Monica Loy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Chiara Giraudo
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Anna Sara Fraia
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Eleonora Faccioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Fausto Braccioni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Geert M. Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8272268
| | | | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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6
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Halloran K, Mackova M, Parkes MD, Hirji A, Weinkauf J, Timofte IL, Snell GI, Westall GP, Lischke R, Zajacova A, Havlin J, Hachem R, Kreisel D, Levine D, Kubisa B, Piotrowska M, Juvet S, Keshavjee S, Jaksch P, Klepetko W, Halloran PF. The molecular features of chronic lung allograft dysfunction in lung transplant airway mucosa. J Heart Lung Transplant 2022; 41:1689-1699. [PMID: 36163162 DOI: 10.1016/j.healun.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many lung transplants fail due to chronic lung allograft dysfunction (CLAD). We recently showed that transbronchial biopsies (TBBs) from CLAD patients manifest severe parenchymal injury and dedifferentiation, distinct from time-dependent changes. The present study explored time-selective and CLAD-selective transcripts in mucosal biopsies from the third bronchial bifurcation (3BMBs), compared to those in TBBs. METHODS We used genome-wide microarray measurements in 324 3BMBs to identify CLAD-selective changes as well as time-dependent changes and develop a CLAD classifier. CLAD-selective transcripts were identified with linear models for microarray data (limma) and were used to build an ensemble of 12 classifiers to predict CLAD. Hazard models and random forests were then used to predict the risk of graft loss using the CLAD classifier, transcript sets associated with rejection, injury, and time. RESULTS T cell-mediated rejection and donor-specific antibody were increased in CLAD 3BMBs but most had no rejection. Like TBBs, 3BMBs showed a time-dependent increase in transcripts expressed in inflammatory cells that was not associated with CLAD or survival. Also like TBBs, the CLAD-selective transcripts in 3BMBs reflected severe parenchymal injury and dedifferentiation, not inflammation or rejection. While 3BMBs and TBBs did not overlap in their top 20 CLAD-selective transcripts, many CLAD-selective transcripts were significantly increased in both for example LOXL1, an enzyme controlling matrix remodeling. In Cox models for one-year survival, the 3BMB CLAD-selective transcripts and CLAD classifier predicted graft loss and correlated with CLAD stage. Many 3BMB CLAD-selective transcripts were also increased by injury in kidney transplants and correlated with decreased kidney survival, including LOXL1. CONCLUSIONS Mucosal and transbronchial biopsies from CLAD patients reveal a diffuse molecular injury and dedifferentiation state that impacts prognosis and correlates with the physiologic disturbances. CLAD state in lung transplants shares features with failing kidney transplants, indicating elements shared by the injury responses of distressed organs.
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Affiliation(s)
| | | | | | - Alim Hirji
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Greg I Snell
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | - Glen P Westall
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | | | | | - Jan Havlin
- University Hospital Motol, Prague, Czech Republic
| | - Ramsey Hachem
- Washington University in St Louis, St. Louis, Missouri
| | | | | | | | | | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
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7
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Santos J, Calabrese DR, Greenland JR. Lymphocytic Airway Inflammation in Lung Allografts. Front Immunol 2022; 13:908693. [PMID: 35911676 PMCID: PMC9335886 DOI: 10.3389/fimmu.2022.908693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplant remains a key therapeutic option for patients with end stage lung disease but short- and long-term survival lag other solid organ transplants. Early ischemia-reperfusion injury in the form of primary graft dysfunction (PGD) and acute cellular rejection are risk factors for chronic lung allograft dysfunction (CLAD), a syndrome of airway and parenchymal fibrosis that is the major barrier to long term survival. An increasing body of research suggests lymphocytic airway inflammation plays a significant role in these important clinical syndromes. Cytotoxic T cells are observed in airway rejection, and transcriptional analysis of airways reveal common cytotoxic gene patterns across solid organ transplant rejection. Natural killer (NK) cells have also been implicated in the early allograft damage response to PGD, acute rejection, cytomegalovirus, and CLAD. This review will examine the roles of lymphocytic airway inflammation across the lifespan of the allograft, including: 1) The contribution of innate lymphocytes to PGD and the impact of PGD on the adaptive immune response. 2) Acute cellular rejection pathologies and the limitations in identifying airway inflammation by transbronchial biopsy. 3) Potentiators of airway inflammation and heterologous immunity, such as respiratory infections, aspiration, and the airway microbiome. 4) Airway contributions to CLAD pathogenesis, including epithelial to mesenchymal transition (EMT), club cell loss, and the evolution from constrictive bronchiolitis to parenchymal fibrosis. 5) Protective mechanisms of fibrosis involving regulatory T cells. In summary, this review will examine our current understanding of the complex interplay between the transplanted airway epithelium, lymphocytic airway infiltration, and rejection pathologies.
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Affiliation(s)
- Jesse Santos
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R. Calabrese
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - John R. Greenland
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
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8
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Renaud-Picard B, Koutsokera A, Cabanero M, Martinu T. Acute Rejection in the Modern Lung Transplant Era. Semin Respir Crit Care Med 2021; 42:411-427. [PMID: 34030203 DOI: 10.1055/s-0041-1729542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute cellular rejection (ACR) remains a common complication after lung transplantation. Mortality directly related to ACR is low and most patients respond to first-line immunosuppressive treatment. However, a subset of patients may develop refractory or recurrent ACR leading to an accelerated lung function decline and ultimately chronic lung allograft dysfunction. Infectious complications associated with the intensification of immunosuppression can also negatively impact long-term survival. In this review, we summarize the most recent evidence on the mechanisms, risk factors, diagnosis, treatment, and prognosis of ACR. We specifically focus on novel, promising biomarkers which are under investigation for their potential to improve the diagnostic performance of transbronchial biopsies. Finally, for each topic, we highlight current gaps in knowledge and areas for future research.
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Affiliation(s)
- Benjamin Renaud-Picard
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
| | - Angela Koutsokera
- Division of Pulmonology, Lung Transplant Program, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Cabanero
- Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Tereza Martinu
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
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9
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Dugger DT, Fung M, Hays SR, Singer JP, Kleinhenz ME, Leard LE, Golden JA, Shah RJ, Lee JS, Deiter F, Greenland NY, Jones KD, Langelier CR, Greenland JR. Chronic lung allograft dysfunction small airways reveal a lymphocytic inflammation gene signature. Am J Transplant 2021; 21:362-371. [PMID: 32885581 PMCID: PMC8009189 DOI: 10.1111/ajt.16293] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/27/2020] [Accepted: 08/16/2020] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is the major barrier to long-term survival following lung transplantation, and new mechanistic biomarkers are needed. Lymphocytic bronchitis (LB) precedes CLAD and has a defined molecular signature. We hypothesized that this LB molecular signature would be associated with CLAD in small airway brushings independent of infection. We quantified RNA expression from small airway brushings and transbronchial biopsies, using RNAseq and digital RNA counting, respectively, for 22 CLAD cases and 27 matched controls. LB metagene scores were compared across CLAD strata by Wilcoxon rank sum test. We performed unbiased host transcriptome pathway and microbial metagenome analysis in airway brushes and compared machine-learning classifiers between the two tissue types. This LB metagene score was increased in CLAD airway brushes (p = .002) and improved prediction of graft failure (p = .02). Gene expression classifiers based on airway brushes outperformed those using transbronchial biopsies. While infection was associated with decreased microbial alpha-diversity (p ≤ .04), neither infection nor alpha-diversity was associated with LB gene expression. In summary, CLAD was associated with small airway gene expression changes not apparent in transbronchial biopsies in this cohort. Molecular analysis of airway brushings for diagnosing CLAD merits further examination in multicenter cohorts.
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Affiliation(s)
- Daniel T. Dugger
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
| | - Monica Fung
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Steven R. Hays
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jonathan P. Singer
- Department of Medicine, University of California, San Francisco, CA 94143
| | | | - Lorriana E. Leard
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jeffrey A. Golden
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Rupal J. Shah
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Joyce S. Lee
- Department of Medicine, University of Colorado, Denver, CO 80045
| | - Fred Deiter
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Nancy Y. Greenland
- Veterans Affairs Health Care System, San Francisco, CA 94121,Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | - Kirk D. Jones
- Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | | | - John R. Greenland
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
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10
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Greenland JR. Transcriptome-based diagnostics for chronic lung allograft dysfunction: A socratic question revisited. J Heart Lung Transplant 2020; 39:1338-1340. [PMID: 33250117 DOI: 10.1016/j.healun.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- John R Greenland
- Department of Medicine, University of California, San Francisco, San Francisco, California; Medical Service, San Francisco VA Health Care System, San Francisco, California.
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11
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Naikawadi RP, Green G, Jones KD, Achtar-Zadeh N, Mieleszko JE, Arnould I, Kukreja J, Greenland JR, Wolters PJ. Airway Epithelial Telomere Dysfunction Drives Remodeling Similar to Chronic Lung Allograft Dysfunction. Am J Respir Cell Mol Biol 2020; 63:490-501. [PMID: 32551854 DOI: 10.1165/rcmb.2019-0374oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Telomere dysfunction is associated with multiple fibrotic lung processes, including chronic lung allograft dysfunction (CLAD)-the major limitation to long-term survival following lung transplantation. Although shorter donor telomere lengths are associated with an increased risk of CLAD, it is unknown whether short telomeres are a cause or consequence of CLAD pathology. Our objective was to test whether telomere dysfunction contributes to the pathologic changes observed in CLAD. Histopathologic and molecular analysis of human CLAD lungs demonstrated shortened telomeres in lung epithelial cells quantified by teloFISH, increased numbers of surfactant protein C immunoreactive type II alveolar epithelial cells, and increased expression of senescence markers (β-galactosidase, p16, p53, and p21) in lung epithelial cells. TRF1F/F (telomere repeat binding factor 1 flox/flox) mice were crossed with tamoxifen-inducible SCGB1a1-cre mice to generate SCGB1a1-creTRF1F/F mice. Following 9 months of tamoxifen-induced deletion of TRF1 in club cells, mice developed mixed obstructive and restrictive lung physiology, small airway obliteration on microcomputed tomography, a fourfold decrease in telomere length in airway epithelial cells, collagen deposition around bronchioles and adjacent lung parenchyma, increased type II aveolar epithelial cell numbers, expression of senescence-associated β-galactosidase in epithelial cells, and decreased SCGB1a1 expression in airway epithelial cells. These findings demonstrate that telomere dysfunction isolated to airway epithelial cells leads to airway-centric lung remodeling and fibrosis similar to that observed in patients with CLAD and suggest that lung epithelial cell telomere dysfunction may be a molecular driver of CLAD.
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Affiliation(s)
- Ram P Naikawadi
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | - Gary Green
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | | | - Natalia Achtar-Zadeh
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | - Julia E Mieleszko
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | - Isabel Arnould
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California; and
| | - John R Greenland
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine.,Medical Service, Veterans Affairs Health Care System, San Francisco, California
| | - Paul J Wolters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
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12
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Mengel M, Loupy A, Haas M, Roufosse C, Naesens M, Akalin E, Clahsen‐van Groningen MC, Dagobert J, Demetris AJ, Duong van Huyen J, Gueguen J, Issa F, Robin B, Rosales I, Von der Thüsen JH, Sanchez‐Fueyo A, Smith RN, Wood K, Adam B, Colvin RB. Banff 2019 Meeting Report: Molecular diagnostics in solid organ transplantation-Consensus for the Banff Human Organ Transplant (B-HOT) gene panel and open source multicenter validation. Am J Transplant 2020; 20:2305-2317. [PMID: 32428337 PMCID: PMC7496585 DOI: 10.1111/ajt.16059] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/19/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
This meeting report from the XV Banff conference describes the creation of a multiorgan transplant gene panel by the Banff Molecular Diagnostics Working Group (MDWG). This Banff Human Organ Transplant (B-HOT) panel is the culmination of previous work by the MDWG to identify a broadly useful gene panel based on whole transcriptome technology. A data-driven process distilled a gene list from peer-reviewed comprehensive microarray studies that discovered and validated their use in kidney, liver, heart, and lung transplant biopsies. These were supplemented by genes that define relevant cellular pathways and cell types plus 12 reference genes used for normalization. The 770 gene B-HOT panel includes the most pertinent genes related to rejection, tolerance, viral infections, and innate and adaptive immune responses. This commercially available panel uses the NanoString platform, which can quantitate transcripts from formalin-fixed paraffin-embedded samples. The B-HOT panel will facilitate multicenter collaborative clinical research using archival samples and permit the development of an open source large database of standardized analyses, thereby expediting clinical validation studies. The MDWG believes that a pathogenesis and pathway based molecular approach will be valuable for investigators and promote therapeutic decision-making and clinical trials.
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Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Alexandre Loupy
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Mark Haas
- Department of Pathology and Laboratory MedicineCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Candice Roufosse
- Department of Immunology and InflammationImperial College London and North West London PathologyLondonUK
| | - Maarten Naesens
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of NephrologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Enver Akalin
- Montefiore‐Einstein Center for TransplantationMontefiore Medical CenterBronxNew YorkUSA
| | | | - Jessy Dagobert
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Anthony J. Demetris
- Department of PathologyUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPennsylvaniaUSA
| | - Jean‐Paul Duong van Huyen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Juliette Gueguen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Fadi Issa
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Blaise Robin
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Ivy Rosales
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Rex N. Smith
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Kathryn Wood
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Benjamin Adam
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Robert B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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13
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Dugger DT, Fung M, Zlock L, Caldera S, Sharp L, Hays SR, Singer JP, Leard LE, Golden JA, Shah RJ, Kukreja J, Gordon E, Finkbeiner W, Kleinhenz ME, Langelier C, Greenland JR. Cystic Fibrosis Lung Transplant Recipients Have Suppressed Airway Interferon Responses during Pseudomonas Infection. CELL REPORTS MEDICINE 2020; 1. [PMID: 32754722 PMCID: PMC7402593 DOI: 10.1016/j.xcrm.2020.100055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Lung transplantation can be lifesaving in end-stage cystic fibrosis (CF), but long-term survival is limited by chronic lung allograft dysfunction (CLAD). Persistent upper airway Pseudomonas aeruginosa (PsA) colonization can seed the allograft. While de novo PsA infection is associated with CLAD in non-CF recipients, this association is less clear for CF recipients experiencing PsA recolonization. Here, we evaluate host and pathogen contributions to this phenomenon. In the context of PsA infection, brushings from the airways of CF recipients demonstrate type 1 interferon gene suppression. Airway epithelial cell (AEC) cultures demonstrate similar findings in the absence of pathogens or immune cells, contrasting with the pre-transplant CF AEC phenotype. Type 1 interferon promoters are relatively hypermethylated in CF AECs. CF subjects in this cohort have more mucoid PsA, while non-CF PsA subjects have decreased microbiome α diversity. Peri-transplant protocols may benefit from consideration of this host and microbiome equilibrium. Lung allograft Pseudomonas infection outcomes are better for recipients with CF In CF, infected allograft airway cells demonstrate suppression of interferon genes Differential DNA methylation may contribute to this distinct epithelial phenotype Increased α diversity and mucoid forms characterize CF Pseudomonas infection
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Affiliation(s)
- Daniel T Dugger
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Monica Fung
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Lorna Zlock
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Saharai Caldera
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Louis Sharp
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Lorriana E Leard
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jefferey A Golden
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Rupal J Shah
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Erin Gordon
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Walter Finkbeiner
- Department of Pathology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Mary Ellen Kleinhenz
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Chaz Langelier
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.,Chan Zuckerberg Biohub, San Francisco, CA 94143, USA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA 94121, USA.,Lead Contact
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14
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Abstract
Introduction: Lung transplantation remains an important treatment for patients with end stage lung disease. Chronic lung allograft dysfunction (CLAD) remains the greatest limiting factor for long term survival. As the diagnosis of CLAD is based on pulmonary function tests, significant lung injury is required before a diagnosis is feasible, likely when irreversible damage has already occurred. Therefore, research is ongoing for early CLAD recognition, with biomarkers making up a substantial amount of this research.Areas covered: The purpose of this review is to describe available biomarkers, focusing on those which aid in predicting CLAD and distinguishing between different CLAD phenotypes. We describe biomarkers presenting in bronchial alveolar lavage (BAL) as well as circulating in peripheral blood, both of which offer an appealing alternative to lung biopsy.Expert opinion: Development of CLAD involves complex, multiple immune and nonimmune mechanisms. Therefore, evaluation of potential CLAD biomarkers serves a dual purpose: clinically, the goal remains early detection and identification of patients at increased risk. Simultaneously, biomarkers offer insight into the different mechanisms involved in the pathophysiology of CLAD, leading to the development of possible interventions. The ultimate goal is the development of both preventive and early intervention strategies for CLAD to improve the overall survival of our lung transplant recipients.
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Affiliation(s)
- Osnat Shtraichman
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary institute, Rabin Medical Center, Petach Tikva, Israel; Sackler School of Medicine, Tel Aviv, Israel
| | - Joshua M Diamond
- Division of Pulmonary, Allergy & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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