1
|
Allen UD, L'Huillier AG, Bollard CM, Gross TG, Hayashi RJ, Höcker B, Maecker-Kolhoff B, Marks SD, Mazariegos GV, Smets F, Trappe RU, Visner G, Chinnock RE, Comoli P, Danziger-Isakov L, Dulek DE, Dipchand AI, Ferry JA, Martinez OM, Metes DM, Michaels MG, Preiksaitis J, Squires JE, Swerdlow SH, Wilkinson JD, Dharnidharka VR, Green M, Webber SA, Esquivel CO. The IPTA Nashville consensus conference on post-transplant lymphoproliferative disorders after solid organ transplantation in children: IV-consensus guidelines for the management of post-transplant lymphoproliferative disorders in children and adolescents. Pediatr Transplant 2024; 28:e14781. [PMID: 38808744 DOI: 10.1111/petr.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
The International Pediatric Transplant Association convened an expert consensus conference to assess current evidence and develop recommendations for various aspects of care relating to post-transplant lymphoproliferative disorders (PTLD) after pediatric solid organ transplantation. This report addresses the outcomes of deliberations by the PTLD Management Working Group. A strong recommendation was made for reduction in immunosuppression as the first step in management. Similarly, strong recommendations were made for the use of the anti-CD20 monoclonal antibody (rituximab) as was the case for chemotherapy in selected scenarios. In some scenarios, there is uncoupling of the strength of the recommendations from the available evidence in situations where such evidence is lacking but collective clinical experiences drive decision-making. Of note, there are no large, randomized phase III trials of any treatment for PTLD in the pediatric age group. Current gaps and future research priorities are highlighted.
Collapse
Affiliation(s)
- Upton D Allen
- Division of Infectious Diseases, Department of Paediatrics, Transplant and Regenerative Medicine Center, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Arnaud G L'Huillier
- Pediatric Infectious Diseases Unit and Laboratory of Virology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital, The George Washington University, Washington, District of Columbia, USA
| | - Thomas G Gross
- Center for Cancer and Blood Diseases, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Britta Höcker
- Department of Pediatrics I, Medical Faculty, University Children's Hospital, Heidelberg University, Heidelberg, Germany
| | | | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - George Vincent Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany
- Department of Internal Medicine II: Hematology and Oncology, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | | | - Patrizia Comoli
- Cell Factory & Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Junior Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judith A Ferry
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Olivia M Martinez
- Department of Surgery and Program in Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Diana M Metes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jutta Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven H Swerdlow
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension & Apheresis, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Michael Green
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | | |
Collapse
|
2
|
Antala S, DiNorcia J, Bucuvalas J. Balancing immunosuppression in pediatric liver transplantation: Playing the long game. Pediatr Transplant 2023; 27:e14575. [PMID: 37439035 DOI: 10.1111/petr.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/03/2023] [Indexed: 07/14/2023]
Abstract
The overarching goal in the care of pediatric liver transplant recipients is to optimize allograft and patient health. Balancing immunosuppression to maintain allograft health while avoiding medication side effects is essential for long-term survival and optimal quality of life in pediatric liver transplant recipients. Utilizing precision medicine to personalize immunosuppression, which includes minimization and withdrawal, is core to this effort. The unique anatomy and physiology of the liver make it more tolerant to immune-mediated injury and a more favorable organ for immunosuppression minimization and withdrawal. However, several challenges exist. Standard biochemical values and histologic features may not reliably predict allograft health after a reduction in immunosuppression. Additionally, biochemical values alone do not reliably identify which patients can successfully develop operational tolerance, as there may be occult allograft injury despite normal liver enzymes. Finally, the durability of tolerance after successful reduction in immunosuppression remains uncertain over time. Innovative tools show promise in circumventing these challenges, but more research is needed to determine actual clinical utility. While immunosuppression-free transplant may not be a current reality for most pediatric liver transplant recipients, strategies to safely minimize immunosuppression without compromising allograft health are within reach. Each liver allograft and recipient pair requires a different degree of immune modulation, and through a structured process of minimization and withdrawal, immunosuppression can indeed be tailored in a precise, personalized way to optimize outcomes. This review focuses on the progress that has been made to individualize immunosuppression in pediatric liver transplantation to ensure optimal allograft and recipient health.
Collapse
Affiliation(s)
- Swati Antala
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
| | - Joseph DiNorcia
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York City, New York, USA
| | - John Bucuvalas
- Department of Pediatrics, Icahn School of Medicine, Kravis Children's Hospital at Mount Sinai, New York City, New York, USA
| |
Collapse
|
3
|
Sood V, Lal BB, Ashwini N, Khanna R, Pamecha V, Trehanpati N, Alam S. Operational Tolerance after Liver Transplantation: First Report from India. J Clin Exp Hepatol 2023; 13:178-181. [PMID: 36647413 PMCID: PMC9840074 DOI: 10.1016/j.jceh.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/08/2022] [Indexed: 01/19/2023] Open
Abstract
Operational tolerance after liver transplantation is an ideal goal to avoid long-term morbidities associated with chronic immunosuppressive medication use. It is achievable in a highly selected group of post-transplant recipients but requires long-term follow-up and strict monitoring. We hereby report a post-transplant case who achieved spontaneous operational tolerance after inadvertent immunosuppression withdrawal.
Collapse
Affiliation(s)
- Vikrant Sood
- Department of Pediatric Hepatology, New Delhi 110070, India
| | - Bikrant B. Lal
- Department of Pediatric Hepatology, New Delhi 110070, India
| | - N.S. Ashwini
- Department of Hepatopathology, New Delhi 110070, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, New Delhi 110070, India
| | - Viniyendra Pamecha
- Department of Hepato-pancreato-biliary Surgery and Liver Transplantation, New Delhi 110070, India
| | - Nirupama Trehanpati
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Seema Alam
- Department of Pediatric Hepatology, New Delhi 110070, India
| |
Collapse
|
4
|
Wozniak LJ, Venick RS, Naini BV, Scapa J, Hickey MJ, Rossetti M, Korin Y, Reed EF, Farmer DG, Busuttil RW, Vargas JH, McDiarmid SV. Operational tolerance is not always permanent: A 10-year prospective study in pediatric liver transplantation recipients. Liver Transpl 2022; 28:1640-1650. [PMID: 35395132 DOI: 10.1002/lt.26474] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/03/2022] [Accepted: 03/02/2022] [Indexed: 12/25/2022]
Abstract
Immunosuppression withdrawal can be safely performed in select liver transplantation recipients, but the long-term outcomes and sustainability of tolerance have not been well studied. We completed a 10-year prospective, observational study of 18 pediatric liver transplantation recipients with operational tolerance to (1) assess the sustainability of tolerance over time, (2) compare the clinical characteristics of patients who maintained versus lost tolerance, (3) characterize liver histopathology findings in surveillance liver biopsies; and (4) describe immunologic markers in patients with tolerance. Comparator patients from two clinical phenotype groups termed "stable" and "nontolerant" patients were used as controls. Of the 18 patients with operational tolerance, the majority of patients were males (n = 14, 78%) who were transplanted for cholestatic liver disease (n = 12, 67%). Median age at transplantation was 1.9 (range, 0.6-8) years. Median time after transplantation that immunosuppression had been discontinued was 13.1 (range, 2.9-22.1) years. As many as 11 (61%) maintained tolerance for a median of 10.4 (range, 1.9-22.1) years, whereas 7 (39%) lost tolerance after a median of 3.2 (range, 1.5-18.6) years. Populations of T regulatory cells (%CD4+ CD25hi CD127lo ) were significantly higher in patients with tolerance (p = 0.02). Our results emphasize that spontaneous operational tolerance is a dynamic and nonpermanent state. It is therefore essential for patients who are clinically stable off immunosuppression to undergo regular follow-up and laboratory monitoring, as well as surveillance biopsies to rule out subclinical rejection.
Collapse
Affiliation(s)
- Laura J Wozniak
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Robert S Venick
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Bita V Naini
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jason Scapa
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michelle J Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Immunogenetics Center, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Immunogenetics Center, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Yael Korin
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Immunogenetics Center, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Immunogenetics Center, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Douglas G Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jorge H Vargas
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sue V McDiarmid
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
5
|
Gan K, Li Z, Bao S, Fang Y, Wang T, Jin L, Ma M, Deng L, Peng Y, Li N, Zeng Z, Huang H. Clinical outcomes after ABO-incompatible liver transplantation: A systematic review and meta-analysis. Transpl Immunol 2021; 69:101476. [PMID: 34601097 DOI: 10.1016/j.trim.2021.101476] [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: 08/15/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND ABO-incompatible liver transplantation (ABOi-LT) is increasingly used to overcome donor shortage. Evidence about disadvantage and advantage in comparison with ABO-compatible liver transplantation (ABOc-LT) needs to be performed in the early and late periods. Herein, We compared the short-term and long-term outcomes between ABOi-LT and ABOc-LT cohorts. METHODS We performed a meta-analysis based on the observation studies which included outcomes at ≥1 year after ABOi-LT and ABOc-LT procedures, based on the MEDLINE (via Pubmed), the Cochrance Central Register of Controlled Trials (CENTRAL), and EMBASE (via Ovid) systems. Two researchers independently screened each study according to the pre-established inclusion and exclusion criteria to assess the quality of each study and extracted data from published studies. The primary outcome indicators were all-cause mortality and graft survival at 1, 3 and 5 years after transplantation. In the meta-analysis, we based on the value of heterogeneity using a fixed-effect and a random-effect. A fixed-effect model was used if the value of I2 was less than or equal 50%; and a random-effect model was used if the value of I2 was greater than 50%. FINDINGS Out of 335 identified records, 29 records with 10,783 patients with liver transplants; 2137 of them were ABOi-LTs and the remaining 8646 were ABOc-LTs. There was no significant difference at 1-year, 3-year, and 5-year in all-cause mortality, death-censored graft survival and complication incidence rate between ABO-incompatible living donor liver transplantation (ABOi-LDLT) group and ABO-compatible living donor liver transplantation (ABOc-LDLT) group. Compared with ABO-compatible deceased donor liver transplantation (ABOc-DDLT), ABO-incompatible deceased donor liver transplantation (ABOi-DDLT) had a higher 1-year all-cause mortality, and the value of totally pooled odds ratio (OR) was 1.89 (1.28,2.80). However, there was no significant difference at 3-year and 5-year all-cause mortality between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a lower 1-year and 5-year death-censored graft survival than ABOc-DDLT, as the value of totally pooled OR was 1.91 (1.41,2.60) and 1.52 (1.12,2.05), respectively. No significant difference was detected at 3-year death-censored graft survival between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a higher complication incidence rate than ABOc-DDLT, and the value of totally pooled OR was 2.26 (1.53,3.33). We found no obvious bias except for the complication of living donor liver transplantation (LDLT; P = 0.038). IN CONCLUSION The short-term and long-term outcomes were worse after ABOi-DDLT than ABOc-DDLT in the all-cause mortality, death-censored graft survival, and complication incidence rate. However, the same outcomes were essentially comparable between ABOi-LDLT vs. ABOc-LDLT cohorts. Considering the current shortage of liver donors, we believe that ABOi-LT from living donor and deceased donors can save lives under emergency situations.
Collapse
Affiliation(s)
- Kai Gan
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Zhitao Li
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Sheng Bao
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Yuan Fang
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Tao Wang
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Li Jin
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Meidiao Ma
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Lin Deng
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Yingzheng Peng
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Na Li
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Zhong Zeng
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China.
| | - Hanfei Huang
- Department of Organ Transplantation, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China.
| |
Collapse
|
6
|
Appenzeller-Herzog C, Hartleif S, Vionnet J. Clinical parameters and biomarkers predicting spontaneous operational tolerance after liver transplantation: A scoping review. Am J Transplant 2021; 21:3312-3323. [PMID: 33783969 DOI: 10.1111/ajt.16585] [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: 10/19/2020] [Revised: 03/19/2021] [Accepted: 03/21/2021] [Indexed: 01/25/2023]
Abstract
Indefinite allograft acceptance after immunosuppression withdrawal (ISW), also known as operational tolerance (OT), can occur spontaneously after liver transplantation (LT), but reliable and reproducible prognosis of OT versus non-OT outcomes remains elusive. To prime this, systematic extraction of OT-predictive factors from the literature is crucial. We provide the first comprehensive identification and synthesis of clinical parameters and biomarkers predicting spontaneous OT in non-autoimmune/non-replicative viral LT recipients selected for ISW. We searched Embase, Medline, the Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform for articles, conference abstracts, and ongoing trials. We contacted principal investigators of stand-alone abstracts and ongoing trials for unpublished data and screened citations and references of eligible articles. Twenty-three articles reporting on 11 completed ISW studies, 13 abstracts, and five trial registry entries were included. Longer time between LT and ISW was the only clinical parameter that may increase the incidence of OT. Prognostic biomarkers conspicuously differed between pediatric and adult ISW candidates. These included allograft gene expression patterns and peripheral blood immune exhaustion markers for adults, and histological allograft scores for children. Our results will foster cross-validation efforts to facilitate safe and harmonized candidate selection for successful ISW.
Collapse
Affiliation(s)
| | - Steffen Hartleif
- University Hospital Tübingen, Pediatric Gastroenterology and Hepatology, Stuttgart, Germany
| | - Julien Vionnet
- Institute of Liver Studies, King's College Hospital, London, UK.,Transplantation Centre, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.,Service of Gastroenterology and Hepatology, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
7
|
Hann A, Osei-Bordom DC, Neil DAH, Ronca V, Warner S, Perera MTPR. The Human Immune Response to Cadaveric and Living Donor Liver Allografts. Front Immunol 2020; 11:1227. [PMID: 32655558 PMCID: PMC7323572 DOI: 10.3389/fimmu.2020.01227] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
The liver is an important contributor to the human immune system and it plays a pivotal role in the creation of both immunoreactive and tolerogenic conditions. Liver transplantation provides the best chance of survival for both children and adults with liver failure or cancer. With current demand exceeding the number of transplantable livers from donors following brain death, improved knowledge, technical advances and the desire to prevent avoidable deaths has led to the transplantation of organs from living, ABO incompatible (ABOi), cardiac death donors and machine based organ preservation with acceptable results. The liver graft is the most well-tolerated, from an immunological perspective, of all solid organ transplants. Evidence suggests successful cessation of immunosuppression is possible in ~20–40% of liver transplant recipients without immune mediated graft injury, a state known as “operational tolerance.” An immunosuppression free future following liver transplantation is an ambitious but perhaps not unachievable goal. The initial immune response following transplantation is a sterile inflammatory process mediated by the innate system and the mechanisms relate to the preservation-reperfusion process. The severity of this injury is influenced by graft factors and can have significant consequences. There are minimal experimental studies that delineate the differences in the adaptive immune response to the various forms of liver allograft. Apart from ABOi transplants, antibody mediated hyperacute rejection is rare following liver transplant. T-cell mediated rejection is common following liver transplantation and its incidence does not differ between living or deceased donor grafts. Transplantation in the first year of life results in a higher rate of operational tolerance, possibly due to a bias toward Th2 cytokines (IL4, IL10) during this period. This review further describes the current understanding of the immunological response toward liver allografts and highlight the areas of this topic yet to be fully understood.
Collapse
Affiliation(s)
- Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - Desley A H Neil
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Vincenzo Ronca
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Suz Warner
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,The Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.,The Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
| |
Collapse
|
8
|
Dai H, Zheng Y, Thomson AW, Rogers NM. Transplant Tolerance Induction: Insights From the Liver. Front Immunol 2020; 11:1044. [PMID: 32582167 PMCID: PMC7289953 DOI: 10.3389/fimmu.2020.01044] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
A comparison of pre-clinical transplant models and of solid organs transplanted in routine clinical practice demonstrates that the liver is most amenable to the development of immunological tolerance. This phenomenon arises in the absence of stringent conditioning regimens that accompany published tolerizing protocols for other organs, particularly the kidney. The unique immunologic properties of the liver have assisted our understanding of the alloimmune response and how it can be manipulated to improve graft function and survival. This review will address important findings following liver transplantation in both animals and humans, and how these have driven the understanding and development of therapeutic immunosuppressive options. We will discuss the liver's unique system of immune and non-immune cells that regulate immunity, yet maintain effective responses to pathogens, as well as mechanisms of liver transplant tolerance in pre-clinical models and humans, including current immunosuppressive drug withdrawal trials and biomarkers of tolerance. In addition, we will address innovative therapeutic strategies, including mesenchymal stem cell, regulatory T cell, and regulatory dendritic cell therapy to promote liver allograft tolerance or minimization of immunosuppression in the clinic.
Collapse
Affiliation(s)
- Helong Dai
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China.,Clinical Research Center for Organ Transplantation in Hunan Province, Changsha, China.,Clinical Immunology Center, Central South University, Changsha, China
| | - Yawen Zheng
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China.,Clinical Research Center for Organ Transplantation in Hunan Province, Changsha, China.,Clinical Immunology Center, Central South University, Changsha, China.,Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Angus W Thomson
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Natasha M Rogers
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Center for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.,Renal Division, Westmead Hospital, Westmead, NSW, Australia.,Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| |
Collapse
|
9
|
Morath C, Schmitt A, Kälble F, Zeier M, Schmitt M, Sandra-Petrescu F, Opelz G, Terness P, Schaier M, Kleist C. Cell therapeutic approaches to immunosuppression after clinical kidney transplantation. Pediatr Nephrol 2018; 33:199-213. [PMID: 28229281 DOI: 10.1007/s00467-017-3599-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 12/11/2022]
Abstract
Refinement of immunosuppressive strategies has led to further improvement of kidney graft survival in recent years. Currently, the main limitations to long-term graft survival are life-threatening side effects of immunosuppression and chronic allograft injury, emphasizing the need for innovative immunosuppressive regimens that resolve this therapeutic dilemma. Several cell therapeutic approaches to immunosuppression and donor-specific unresponsiveness have been tested in early phase I and phase II clinical trials in kidney transplantation. The aim of this overview is to summarize current cell therapeutic approaches to immunosuppression in clinical kidney transplantation with a focus on myeloid suppressor cell therapy by mitomycin C-induced cells (MICs). MICs show great promise as a therapeutic agent to achieve the rapid and durable establishment of donor-unresponsiveness in living-donor kidney transplantation. Cell-based therapeutic approaches may eventually revolutionize immunosuppression in kidney transplantation in the near future.
Collapse
Affiliation(s)
- Christian Morath
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany.
| | - Anita Schmitt
- Department of Internal Medicine V, GMP Core Facility, University of Heidelberg, Heidelberg, Germany
| | - Florian Kälble
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Michael Schmitt
- Department of Internal Medicine V, GMP Core Facility, University of Heidelberg, Heidelberg, Germany
| | - Flavius Sandra-Petrescu
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.,Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gerhard Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Peter Terness
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Matthias Schaier
- Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Christian Kleist
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.,Department of Radiology, Division of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
10
|
Kullberg-Lindh C, Saalman R, Olausson M, Herlenius G, Lindh M. Epstein-Barr virus DNA monitoring in serum and whole blood in pediatric liver transplant recipients who do or do not discontinue immunosuppressive therapy. Pediatr Transplant 2017; 21. [PMID: 28039929 DOI: 10.1111/petr.12875] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
The rate of PTLD can be reduced by weaned IS guided by monitoring of EBV DNA. In this single-center retrospective case series study, we analyzed how reduction in IS influenced EBV DNA levels in whole blood and serum in 30 children during the first year after liver transplantation, and how these levels were related to symptoms putatively due to EBV. Primary and reactivated EBV infection was seen in 18 (60%) and eight patients (27%), respectively. Thirteen patients (42%) developed chronic high load the first year post-transplant. IS was successfully discontinued in six patients the first year post-transplant and in another two patients within 3 years. EBV DNA levels were reduced, but persisted long term in all the eight patients who had IS completely withdrawn. There was no case of PTLD. In summary, EBV DNAemia and chronic high load were very common after pediatric liver transplantation. Liver graft tolerance facilitates radical reduction in IS treatment, which may prevent PTLD, but EBV DNAemia may persist long term after discontinued IS.
Collapse
Affiliation(s)
- C Kullberg-Lindh
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - R Saalman
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Olausson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - G Herlenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lindh
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
11
|
Foster BJ, Dahhou M, Zhang X, Dharnidharka V, Ng V, Conway J. High Risk of Graft Failure in Emerging Adult Heart Transplant Recipients. Am J Transplant 2015; 15:3185-93. [PMID: 26189336 DOI: 10.1111/ajt.13386] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/26/2015] [Accepted: 05/19/2015] [Indexed: 01/25/2023]
Abstract
Emerging adulthood (17-24 years) is a period of high risk for graft failure in kidney transplant. Whether a similar association exists in heart transplant recipients is unknown. We sought to estimate the relative hazards of graft failure at different current ages, compared with patients between 20 and 24 years old. We evaluated 11 473 patients recorded in the Scientific Registry of Transplant Recipients who received a first transplant at <40 years old (1988-2013) and had at least 6 months of graft function. Time-dependent Cox models were used to estimate the association between current age (time-dependent) and failure risk, adjusted for time since transplant and other potential confounders. Failure was defined as death following graft failure or retransplant; observation was censored at death with graft function. There were 2567 failures. Crude age-specific graft failure rates were highest in 21-24 year olds (4.2 per 100 person-years). Compared to individuals with the same time since transplant, 21-24 year olds had significantly higher failure rates than all other age periods except 17-20 years (HR 0.92 [95%CI 0.77, 1.09]) and 25-29 years (0.86 [0.73, 1.03]). Among young first heart transplant recipients, graft failure risks are highest in the period from 17 to 29 years of age.
Collapse
Affiliation(s)
- B J Foster
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Faculty of Medicine, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - M Dahhou
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - X Zhang
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - V Dharnidharka
- Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.,St. Louis Children's Hospital, St. Louis, MO
| | - V Ng
- Division of Gastroenterology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - J Conway
- Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
12
|
Sagar N, Leithead JA, Lloyd C, Smith M, Gunson BK, Adams DH, Kelly D, Ferguson JW. Pediatric Liver Transplant Recipients Who Undergo Transfer to the Adult Healthcare Service Have Good Long-Term Outcomes. Am J Transplant 2015; 15:1864-73. [PMID: 25707583 DOI: 10.1111/ajt.13184] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 12/18/2014] [Accepted: 12/21/2014] [Indexed: 01/25/2023]
Abstract
Liver transplantation has transformed survival for children with liver disease necessitating the transfer of a growing number of patients to the adult healthcare service. The impact of transfer on outcomes remains unclear. The aim of this single-center study of 137 consecutive pediatric liver transplant recipients was to examine the effect of transfer on patient and graft survival. The median time from transplant to transfer was 10.4 years and the median age of the patients at transfer was 18.6 years. After transfer, there were 5 re-transplants and 12 deaths in 14 patients. The estimated posttransfer 10-year patient and graft survival was 89.9% and 86.2%, respectively. Overall, 4 patients demonstrated graft loss as a consequence of chronic rejection. Graft loss was associated with older age at first transplant (p = 0.008). When compared to young adult patients transplanted in the adult center, the transferred patients did not have inferior graft survival from the point of transfer (HR 0.28; 95% CI 0.10-0.77, p = 0.014). This suggests that transfer did not impact significantly on graft longevity. In conclusion, pediatric liver transplant recipients who undergo transfer to the adult service have good long-term outcomes.
Collapse
Affiliation(s)
- N Sagar
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - J A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - C Lloyd
- Liver Unit, Birmingham Children's Hospital, Birmingham, UK
| | - M Smith
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Liver Unit, Birmingham Children's Hospital, Birmingham, UK
| | - B K Gunson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - D H Adams
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - D Kelly
- Liver Unit, Birmingham Children's Hospital, Birmingham, UK
| | - J W Ferguson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
13
|
Kamran Hejazi Kenari S, Mirzakhani H, Saidi RF. Pediatric transplantation and tolerance: past, present, and future. Pediatr Transplant 2014; 18:435-45. [PMID: 24931282 DOI: 10.1111/petr.12301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 12/13/2022]
Abstract
Solid organ transplantation is the treatment of choice in children with end-stage organ failure. With improving methods of transplant surgery and post-transplant care, transplantation is more frequently performed worldwide. However, lifelong and non-specific suppression of the recipient's immune system is a cause of significant morbidity in children, including infection, diabetes, and cancer. There is a great need to develop IS minimization/withdrawal and tolerance induction approaches.
Collapse
Affiliation(s)
- Seyed Kamran Hejazi Kenari
- Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | |
Collapse
|
14
|
Tissue biopsy monitoring of operational tolerance in liver allograft recipients. Curr Opin Organ Transplant 2013; 18:345-53. [PMID: 23619515 DOI: 10.1097/mot.0b013e3283615d48] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Highly selected, long-surviving, liver allograft recipients with normal/near normal liver injury tests can be weaned from immunosuppression. Baseline biopsies document changes before weaning and can help stratify risk of rejection or dysfunction after weaning; biopsies after weaning are used to study mechanisms of operational tolerance and to monitor for subclinical events. RECENT FINDINGS Clinicopathological features associated with successful weaning include a lack of sensitization [negative donor-specific antibodies (DSA) and lack of tissue C4d deposits]; 'inexperienced' recipient immune system with limited potential for cross-reactivity (less immunological memory; infant recipients); noninflamed allograft in those with nonviral, nonimmunological original diseases; upregulation of liver genes associated with iron metabolism; allograft colonization with 'immunosuppressive' cells (Treg and γδ-1>γδ-2); and longer time on immunosuppression, which might signal slow clonal deletion or silencing. The differential diagnosis of histopathological findings detected before and after weaning includes emerging infections, typical and atypical cellular rejection, indolent antibody-mediated rejection, 'autoimmunity', and other causes of progressive fibrosis. SUMMARY Operationally tolerant liver allograft recipients can be successfully managed with very low, and sometimes no immunosuppression, but challenges exist. Newer approaches to tissue pathology and tissue, serum, and cross-platform analytics are needed to predict successful weaning and to monitor for subclinical events.
Collapse
|
15
|
The pits and pearls in translating operational tolerance biomarkers into clinical practice. Curr Opin Organ Transplant 2013; 17:655-62. [PMID: 23080065 DOI: 10.1097/mot.0b013e32835a6f62] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review highlights the importance and the role of key biomarker studies in liver and kidney transplant tolerance, discusses the most recent findings with respect to organ-type and cell-type specificity in blood and tissue, and points out the novel research directions in the field of immunological tolerance that involve both adult and pediatric recipients. RECENT FINDINGS Recent studies indicate that biomarkers for solid organ transplant tolerance are distinct with respect to organ type and cell type, suggesting distinct tolerogenic mechanisms for different organs. In both liver and kidney transplant tolerant recipients, novel cellular mechanisms have been proposed for natural killer cells, B cells, and dendritic cells in the maintenance of stable operational tolerance. SUMMARY Major advances have been made with respect to the understanding of mechanisms and the process of discovery and early validation of peripheral blood biomarkers for operational transplant tolerance both in kidney and liver transplantation. These studies have shed light on the findings that these tolerance mechanisms may be organ specific, as the peripheral blood transcriptional profiling attempts by microarrays and PCR reveal distinct differences and suggest roles for specific cell types. Although these studies are mostly in adults and limited in children, the first tolerance gene signature for pediatric liver transplant tolerance suggests that there are common mechanisms, yet distinct peripheral biomarkers across age. Prospective trials and organ integrative studies are now needed to further develop these biomarkers for future clinical application in addition to expanding novel approaches such as the investigation of miRNAs to better understand the tolerance mechanisms.
Collapse
|
16
|
Liu XQ, Hu ZQ, Pei YF, Tao R. Clinical operational tolerance in liver transplantation: state-of-the-art perspective and future prospects. Hepatobiliary Pancreat Dis Int 2013; 12:12-33. [PMID: 23392795 DOI: 10.1016/s1499-3872(13)60002-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver transplantation is the definite treatment for end-stage liver diseases with satisfactory results. However, untoward effects of life-long immunosuppression prevent the development of alternative strategies to achieve better long-term outcome. Achieving clinical operational tolerance is the ultimate goal. DATA SOURCES A PubMed and Google Scholar search using terms: "immune tolerance", "liver transplantation", "clinical trial", "operational tolerance" and "immunosuppression withdrawal" was performed, and relevant articles published in English in the past decade were reviewed. Full-text publications relevant to the field were selected and relevant articles from reference lists were also included. Priority was given to those articles which are relevant to the review. RESULTS Because of the inherent tolerogenic property, around 20%-30% of liver transplantation recipients develop spontaneous operational tolerance after immunosuppression withdrawal, and the percentage may be even higher in pediatric living donor liver transplantation recipients. Several natural killer and gammadeltaT cell related markers have been identified to be associated with the tolerant state in liver transplantation patients. Despite the progress, clinical operational tolerance is still rare in liver transplantation. Reprogramming the recipient immune system by creating chimerism and regulatory cell therapies is among newer promising means to achieve clinical liver transplantation tolerance in the future. CONCLUSION Although clinical operational tolerance is still rare in liver transplantation recipients, ongoing basic research and collaborative clinical trials may help to decipher the mystery of transplantation tolerance and extend the potential benefits of drug withdrawal to an increasing number of patients in a more predictable fashion.
Collapse
Affiliation(s)
- Xi-Qiang Liu
- Center for Organ Transplantation and Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | | | | | | |
Collapse
|
17
|
Abstract
1. After liver transplantation (LT), the majority of children now grow into adulthood, with 10-year patient survival rates of 74% to 84% and graft survival rates of 62% to 72% according to United Network for Organ Sharing data. 2. Graft and patient survival rates decrease for patients undergoing transplantation between the ages of 12 and 17 years, and this raises the importance of dedicated adolescent care and appropriate transitioning to adult services. 3. Complications associated with long-term immunosuppression, including renal complications, infections, malignancies, and cardiovascular complications, are well described, and the risk factors are defined. 4. Biomarkers for measuring clinical immunosuppression and the concept of tolerance-inducing regimens are exciting, but further assessment is needed in large, prospective, multicenter studies. 5. As long-term medical complications are better managed, we need to focus on understanding the challenges for pediatric LT patients with respect to quality of life and health status.
Collapse
Affiliation(s)
- Marianne Samyn
- King’s College Hospital, Denmark Hill, London, United Kingdom.
| |
Collapse
|
18
|
Importance of liver biopsy findings in immunosuppression management: biopsy monitoring and working criteria for patients with operational tolerance. Liver Transpl 2012; 18:1154-70. [PMID: 22645090 DOI: 10.1002/lt.23481] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Obstacles to morbidity-free long-term survival after liver transplantation (LT) include complications of immunosuppression (IS), recurrence of the original disease and malignancies, and unexplained chronic hepatitis and graft fibrosis. Many programs attempt to minimize chronic exposure to IS by reducing dosages and stopping steroids. A few programs have successfully weaned a highly select group of recipients from all IS without apparent adverse consequences, but long-term follow-up is limited. Patients subjected to adjustments in IS are usually followed by serial liver chemistry tests, which are relatively insensitive methods for detecting allograft damage. Protocol biopsy has largely been abandoned for hepatitis C virus-negative recipients, at least in part because of the inability to integrate routine histopathological findings into a rational clinical management algorithm. Recognizing a need to more precisely categorize and determine the clinical significance of findings in long-term biopsy samples, the Banff Working Group on Liver Allograft Pathology has reviewed the literature, pooled the experience of its members, and proposed working definitions for biopsy changes that (1) are conducive to lowering IS and are compatible with operational tolerance (OT) and (2) raise concern for closer follow-up and perhaps increased IS during or after IS weaning. The establishment of guidelines should help us to standardize analyses of the effects of various treatments and/or weaning protocols and more rigorously categorize patients who are assumed to show OT. Long-term follow-up using standardized criteria will help us to determine the consequences of lowering IS and to define and determine the incidence and robustness of OT in liver allografts.
Collapse
Affiliation(s)
-
- University of Pittsburgh Medical Center, 3459 5th Avenue, UPMC Montefiore E741, Pittsburgh, PA 15213, USA
| |
Collapse
|
19
|
Aini W, Miyagawa-Hayashino A, Tsuruyama T, Hashimoto S, Sumiyoshi S, Ozeki M, Tamaki K, Uemoto S, Haga H. Telomere shortening and karyotypic alterations in hepatocytes in long-term transplanted human liver allografts. Transpl Int 2012; 25:956-66. [PMID: 22775391 DOI: 10.1111/j.1432-2277.2012.01523.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The long-term fate of aged liver allografts in young recipients who received grafts from older donors is unknown. We evaluated graft aging by analyzing hepatocytic telomere length and karyotypic changes. Seventeen pediatric individuals who underwent living-donor liver transplantation for congenital biliary diseases were selected. At a median of 10.4 years post-transplant, ten had tolerated grafts with weaned off immunosuppressants, and seven had idiopathic post-transplantation hepatitis. Fluorescence in situ hybridization was used to evaluate the telomere signal intensity (TI) and karyotypic changes. First, we measured predictive age-dependent TI decline with regression analysis of donor livers. The mean TI at the earliest (within a year) and latest biopsies was significantly lower than the predicted TI of the studied allografts. With univariate analysis, a higher abnormal karyotype ratio in the donor liver was correlated with development of idiopathic post-transplantation hepatitis. With multivariate analysis that included clinical parameters, a greater TI decline at the earliest biopsy was correlated with the development of idiopathic post-transplantation hepatitis. In conclusion, graft aging as measured by TI decline and donor abnormal karyotype ratio was associated with idiopathic post-transplantation hepatitis of long-term transplanted liver allografts.
Collapse
Affiliation(s)
- Wulamujiang Aini
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Li L, Wozniak LJ, Rodder S, Heish S, Talisetti A, Wang Q, Esquivel C, Cox K, Chen R, McDiarmid SV, Sarwal MM. A common peripheral blood gene set for diagnosis of operational tolerance in pediatric and adult liver transplantation. Am J Transplant 2012; 12:1218-28. [PMID: 22300520 DOI: 10.1111/j.1600-6143.2011.03928.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To identify biomarkers of operational tolerance in pediatric and adult liver transplant recipients, transcriptional profiles were examined from 300 samples by microarrays and Q-PCR measurements of blood specimens from pediatric and adult liver transplant recipients and normal tissues. Tolerance-specific genes were validated in independent samples across two different transplant programs and validated by Q-PCR. A minimal set of 13 unique genes, highly expressed in natural killer cells (p = 0.03), were significantly expressed in both pediatric and adult liver tolerance, irrespective of different clinical and demographic confounders. The performance of this gene set by microarray in independent samples was 100% sensitivity and 83% specificity and the AUC was 0.988 for only three genes by Q-PCR. 26% of adults and 64% of children with excellent liver allograft function, on minimal or dual immunosuppression, showed high prediction scores for tolerance. Novel peripheral transcriptional profiles can be identified in operational tolerance in pediatric and adult recipients of liver allografts, suggesting a high incidence of a pro-tolerogenic phenotype in stable patients on chronic immunosuppression. Given the high incidence of viral infections and malignancies in liver transplant recipients, this gene set provides an important monitoring tool that can move the field toward personalized and predictive medicine in organ transplantation.
Collapse
Affiliation(s)
- L Li
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Liver disease in children in the developing world is a frequent occurrence, which is generally inadequately managed because of lack of resources. However, increasingly, there has been a demand for liver transplantation, where primary medical or surgical therapies have failed. The expertise and infrastructure required for a successful outcome are no different from those in more developed countries; if anything, the challenges are greater. Lack of deceased donors because of cultural and religious factors has driven the use of living donors. Short-term survival has generally been good, but long-term outcomes have rarely been reported. In this article, we review the experience of 2 centers at opposite ends of the continent and share our experience of slightly different settings and show that success can be achieved even in resource-reduced environments.
Collapse
Affiliation(s)
- Alastair J W Millar
- Department of Paediatric Surgery, School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
| | | |
Collapse
|
22
|
Abstract
Liver transplantation is the standard of care for children with life-threatening liver disease. Survival rates posttransplantation are rising with current 1-year and 5-year rates being greater than 90% and 85%, respectively. Numerous factors contribute to posttransplant outcomes of graft and patient survival, including improved surgical techniques, immunosuppressive regimens, and posttransplant management. The present review aims to discuss predictors of long-term outcomes of pediatric transplant recipients and identify potential risk factors.
Collapse
|
23
|
What is the long-term outcome of the liver allograft? J Hepatol 2011; 55:702-717. [PMID: 21426919 DOI: 10.1016/j.jhep.2011.03.005] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/11/2011] [Accepted: 03/13/2011] [Indexed: 12/11/2022]
Abstract
With improved long-term survival following liver transplantation (LT), issues relating to the assessment of the liver allograft in long-term survivors are becoming increasingly relevant. Histological abnormalities are commonly present in late post-transplant biopsies, including protocol biopsies from patients who appear to be well with good graft function. Recurrent disease is the commonest recognised cause of abnormal graft histology, but may be modified by the effects of immunosuppression or interactions with other graft complications, resulting in complex or atypical changes. Other abnormalities seen in late post-transplant biopsies include rejection (which often has different appearances to those seen in the post-transplant period), de novo disease, "idiopathic" post-transplant hepatitis (IPTH) and nodular regenerative hyperplasia. In many cases graft dysfunction has more than one cause and liver biopsy may help to identify the predominant cause of graft damage. Problems exist with the terminology used to describe less well understood patterns of graft injury, but there is emerging evidence to suggest that late rejection, de novo autoimmune hepatitis and IPTH may all be part of an overlapping spectrum of immune-mediated injury occurring in the late post-transplant liver allograft. Careful clinico-pathological correlation is very important and the wording of the biopsy report should take into account therapeutic implications, particularly whether changes in immunosuppression may be indicated. This article will provide an overview of the main histological changes occurring in long-term survivors post-LT, focusing on areas where the assessment of late post-transplant biopsies is most relevant clinically.
Collapse
|
24
|
Abstract
Every liver transplant (LT) center has had patients who either self-discontinue immunosuppressive (IS) therapy or are deliberately withdrawn due to a research protocol or clinical concern (ie, lymphoproliferative disorder [LPD], overwhelming infection). This is understandable because maintenance IS therapy, particularly calcineurin inhibitors (CNI), is associated with significant cost, side effects, and considerable long-term morbidity and mortality. Detrimental effects of IS therapy include increased risk of cardiovascular disease, metabolic syndrome, bone loss, opportunistic and community-acquired infections, and malignancy. In fact, LT recipients have among the highest rates of chronic kidney disease and associated mortality among all nonkidney solid organ recipients. This mortality is only ameliorated by undergoing a curative kidney transplant, usurping costs and valuable organ resources. The search for improved treatment algorithms includes trial and error CNI dose minimization, the use of alternative IS agents (antimetabolites, mammalian target of rapamycin [mTOR] inhibitors), or even complete CNI withdrawal. Yet those who are successful in achieving such operational tolerance (no immunosuppression and normal allograft function) are considered lucky. The vast majority of recipients will fail this approach, develop acute rejection or immune-mediated hepatitis, and require resumption of IS therapy. As such, withdrawal of IS following LT is not standard-of-care, leaving clinicians to currently maintain transplant patients on IS therapy for life. Nonetheless, the long-term complications of all IS therapies highlight the need for strategies to promote immunologic or operational tolerance. Clinically applicable biomarker assays signifying the potential for tolerance as well as tolerogenic IS conditioning are invariably needed if systematic, controlled rather than "hit or miss" approaches to withdrawal are considered. This review will provide an overview of the basic mechanisms of tolerance, particularly in relation to LT, data from previous IS withdrawal protocols and biomarker studies in tolerant recipients, and a discussion on the prospect of increasing the clinical feasibility and success of withdrawal.
Collapse
Affiliation(s)
- Josh Levitsky
- Division of Hepatology and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| |
Collapse
|