1
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Lee H, Lee H, Eum SH, Ko EJ, Min JW, Oh EJ, Yang CW, Chung BH. Impact of Low-Level Donor-Specific Anti-HLA Antibody on Posttransplant Clinical Outcomes in Kidney Transplant Recipients. Ann Lab Med 2023; 43:364-374. [PMID: 36843405 PMCID: PMC9989540 DOI: 10.3343/alm.2023.43.4.364] [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: 09/02/2022] [Revised: 12/07/2022] [Accepted: 01/27/2023] [Indexed: 02/28/2023] Open
Abstract
Background The clinical significance of low-level donor-specific anti-HLA antibody (low-DSA) remains controversial. We investigated the impact of low-DSA on posttransplant clinical outcomes in kidney transplant (KT) recipients. Methods We retrospectively reviewed 1,027 KT recipients, namely, 629 living donor KT (LDKT) recipients and 398 deceased donor KT (DDKT) recipients, in Seoul St. Mary's Hospital (Seoul, Korea) between 2010 and 2018. Low-DSA was defined as a positive anti-HLA-DSA result in the Luminex single antigen assay (LABScreen single antigen HLA class I - combi and class II - group 1 kits; One Lambda, Canoga Park, CA, USA) but a negative result in a crossmatch test. We compared the incidence of biopsy-proven allograft rejection (BPAR), changes in allograft function, allograft survival, patient survival, and posttransplant infections between subgroups according to pretransplant low-DSA. Results The incidence of overall BPAR and T cell-mediated rejection did not differ between the subgroups. However, antibody-mediated rejection (ABMR) developed more frequently in patients with low-DSA than in those without low-DSA in the total cohort and the LDKT and DDKT subgroups. In multivariate analysis, low-DSA was identified as a risk factor for ABMR development. Its impact was more pronounced in DDKT (odds ratio [OR]: 9.60, 95% confidence interval [CI]: 1.79-51.56) than in LDKT (OR: 3.76, 95% CI: 0.99-14.26) recipients. There were no significant differences in other outcomes according to pretransplant low-DSA. Conclusions Pretransplant low-DSA has a significant impact on the development of ABMR, and more so in DDKT recipients than in LDKT recipients, but not on long-term outcomes.
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Affiliation(s)
- Haeun Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hanbi Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hun Eum
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Eun Jeong Ko
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Transplant Research Center, Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
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2
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Unagami K, Ishida H, Furusawa M, Kitajima K, Hirai T, Kakuta Y, Toki D, Shimizu T, Omoto K, Okumi M, Nitta K, Tanabe K. Influence of a low-dose tacrolimus protocol on the appearance of de novo donor-specific antibodies during 7 years of follow-up after renal transplantation. Nephrol Dial Transplant 2021; 36:1120-1129. [PMID: 33280052 PMCID: PMC8160958 DOI: 10.1093/ndt/gfaa258] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Tacrolimus (TAC) is a key immunosuppressant drug for kidney transplantation (KTx). However, the optimal serum trough level of TAC for good long-term outcomes remains unclear. This study aimed to investigate the relationship between the maintenance TAC trough level and the appearance of de novo donor-specific anti-human leukocyte antigen (HLA) antibodies (dnDSAs). METHODS A total of 584 KTx recipients were enrolled in this study, of whom 164 developed dnDSAs during the follow-up period and 420 did not. RESULTS We found no significant relationship between TAC trough level during the follow-up period and dnDSA incidence. Patients who developed dnDSAs had a significantly greater number of HLA-A/B/DR mismatches (3.4 ± 1.3 versus 2.8 ± 1.5; P < 0.001), were more likely to have preformed DSAs (48.2% versus 27.1%; P < 0.001) and showed poor allograft outcome. CONCLUSIONS There was no clear relationship between TAC trough level and dnDSA incidence for KTx recipients whose TAC trough levels were kept within the narrow range of 4-6 ng/mL during the immunosuppression maintenance period.
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Affiliation(s)
- Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan.,Nephrology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Miyuki Furusawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kumiko Kitajima
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Toki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomokazu Shimizu
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Nephrology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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3
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Park Y, Lee H, Ko EJ, Lee S, Ban TH, Min JW, Yoon HE, Oh EJ, Yang CW, Chung BH. Impact of high body mass index on allograft outcomes in kidney transplant recipients with presensitization to human leukocyte antigen. Kidney Res Clin Pract 2021; 40:304-316. [PMID: 34024089 PMCID: PMC8237112 DOI: 10.23876/j.krcp.20.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to investigate whether high body mass index (BMI) and presensitization to human leukocyte antigen (HLA) in kidney transplant recipients (KTRs) affected allograft outcomes. Methods From January 2010 to December 2018, 1,290 kidney transplantations (KTs) were performed at the Seoul St Mary’s Hospital. Of these, 682 cases of ABO-compatible living donor KT patients were enrolled. They were divided into four groups (low BMI-non-sensitized, high BMI-non-sensitized, low BMI-sensitized, and high BMI-sensitized) according to the median BMI value (22.7 kg/m2) and HLA presensitization status (anti-HLA antibody mean fluorescence intensity > 3,000). Short-term and long-term allograft outcomes were compared between groups. Results In the high BMI-sensitized group, the decline in allograft function was higher than that in the other three groups. Death-censored graft loss (DCGL) rates were highest in the high BMI-sensitized group (4 of 21 [19.0%], p = 0.04). In the multivariable Cox regression hazard regression model analysis, the hazard ratio (HR) for DCGL was intensified when high BMI and presensitization statuses were combined (HR, 3.75; p = 0.03); these statuses significantly interacted with each other (p-value for interaction = 0.008). Conclusion Our results suggest that presensitization to HLA and high BMI might have an interactive adverse impact on allograft outcomes in KTRs.
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Affiliation(s)
- Yohan Park
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hanbi Lee
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Ko
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sua Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye-Eun Yoon
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Woo Yang
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Ha Chung
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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4
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Murakami M, Ishida H, Yanagisawa K, Shinohara H, Ichikawa Y, Osawa K, Furuhata S, Ikezoe M, Iida S, Hirai T, Shirakawa H, Omoto K, Shimizu T, Tanabe K. Living-Donor Kidney Transplantation Performed in a Low-Volume Center by Visiting Surgeons From a High-Volume Center and Managed Clinically Solely by Nephrologists: 1-Year Outcomes. Transplant Proc 2021; 53:872-880. [PMID: 33743981 DOI: 10.1016/j.transproceed.2021.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/25/2020] [Accepted: 02/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Little is known about the outcome of living-donor kidney transplantation (LDKT) performed in low-volume centers lacking the services of full-time transplant surgeons. This retrospective cohort study assessed the outcome of LDKT performed in a low-volume center by visiting transplant surgeons from a high-volume center and managed perioperatively by transplant nephrologists. METHODS We compared Japanese adult patients who had no donor-specific antibodies and underwent LDKT between 2006 and 2015 either in a low-volume (n = 31) or high-volume (n = 481) center. In the low-volume center, visiting transplant surgeons from the high-volume center conducted LDKT and transplant nephrologists managed the recipients peri- and postoperatively. The primary outcome was the composite of infection, cardiovascular disease, or cancer during 1-year follow-up. The outcomes of the low- and high-volume centers were compared using 1:2 propensity score matching. RESULTS After matching, 9 of 29 patients in the low-volume center (31.0%) and 16 of 58 patients in the high-volume center (27.6%) experienced the primary composite outcome (risk ratio = 1.13; 95% confidence interval, 0.57-2.23). There were no significant differences between the 2 groups in graft function at 1 year, all-cause graft loss, biopsy-proven rejection, and urological complications. However, the median duration of post-LDKT hospitalization was significantly longer in the low-volume center than in the high-volume center (23 and 16 days, respectively). CONCLUSIONS Among Japanese patients without preformed donor-specific antibodies, LDKT conducted at a low-volume center by visiting transplant surgeons from a high-volume center and managed clinically by transplant nephrologists was not associated with significantly higher risk of postoperative complications.
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Affiliation(s)
- Minoru Murakami
- Department of Nephrology, Saku Central Hospital, Saku City, Nagano, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan; Department of Urology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan.
| | - Kazuki Yanagisawa
- Department of Clinical Engineering, Saku Central Hospital, Saku City, Nagano, Japan
| | - Hiromi Shinohara
- Department of Pharmacy, Saku Central Hospital, Saku City, Nagano, Japan
| | - Yuhei Ichikawa
- Department of Pharmacy, Saku Central Hospital, Saku City, Nagano, Japan
| | - Kosuke Osawa
- Department of Nephrology, Saku Central Hospital, Saku City, Nagano, Japan
| | - Shunichi Furuhata
- Department of Nephrology, Saku Central Hospital, Saku City, Nagano, Japan
| | - Masaya Ikezoe
- Department of Nephrology, Saku Central Hospital, Saku City, Nagano, Japan
| | - Shoichi Iida
- Department of Urology, Toda Chuo General Hospital, Toda City, Saitama, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Hiroki Shirakawa
- Department of Urology, Ohkubo Hospital, Shinjuku-ku, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tomokazu Shimizu
- Department of Urology, Toda Chuo General Hospital, Toda City, Saitama, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
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5
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Maenosono R, Unagami K, Kakuta Y, Furusawa M, Okumi M, Azuma H, Ishida H, Tanabe K. Association between response to rituximab and antibody-mediated rejection in ABO-incompatible living kidney transplantation. Int J Urol 2019; 26:1114-1120. [PMID: 31522467 DOI: 10.1111/iju.14108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/11/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To examine the association of response to rituximab and the incidence of antibody-mediated rejection in preconditioning of rituximab and plasma exchange without post-transplant plasmapheresis in patients undergoing ABO-incompatible living kidney transplantation. METHODS A total of 115 patients who underwent ABO-incompatible living kidney transplantation at Tokyo Women's Medical University Hospital, Tokyo, Japan, were divided into two groups based on the response to rituximab: good response (n = 75) or poor response (n = 40). The rituximab good response and poor response patients were defined as patients whose CD19+ cells were non-detected (0%) and detected on the day of transplantation (2-5 days, median 3 days, after rituximab administration), respectively. RESULTS Rituximab response and anti-A/B blood antibody titer after plasmapheresis were significant risk factors for antibody-mediated rejection (P = 0.036, 0.045, respectively). The occurrence of antibody-mediated rejection was higher in the poor response group than in the good response group (22.5% vs 8.0%; P = 0.028). The 14-day, 3-month and 1-year cumulative incidence of antibody-mediated rejection was 2.7%, 5.3% and 8.0% in the good response group, and 17.5%, 20.0% and 22.5% in the poor response group after ABO-incompatible living kidney transplantation. The patient survival was not significantly different between the two groups. However, graft survival 1 month after transplantation was lower in the poor response group. There is no significant difference in graft function and in the incidence of complications, including infection, after transplantation between the two groups. CONCLUSIONS Antibody-mediated rejection after ABO-incompatible living kidney transplantation was significantly associated with the response to rituximab in our preconditioning protocol.
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Affiliation(s)
- Ryoichi Maenosono
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Osaka Medical College, Osaka, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Miyuki Furusawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, Osaka, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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6
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Sinangil A, Ucar ZA, Koc Y, Barlas S, Abouzahir S, Ecder ST, Akin EB. Outcome of Desensitization Therapy in Immunologically High-Risk Kidney Transplantation: Single-Center Experience. Transplant Proc 2019; 51:2268-2273. [PMID: 31358450 DOI: 10.1016/j.transproceed.2019.04.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/29/2019] [Accepted: 04/11/2019] [Indexed: 10/26/2022]
Abstract
AIM Sensitization to HLA antigens creates an immunologic barrier, linked to an increased risk of antibody-mediated rejection and poorer graft survival, that remains a persistent and often impenetrable deterrent to transplantation. Desensitization can improve transplantation rates in broadly sensitized kidney transplant recipients. We aimed to compare the clinical outcomes of immunologic high-risk kidney recipients who had desensitization treatment with the outcomes of those who did not. MATERIALS AND METHODS We retrospectively evaluated patients who underwent desensitization protocol due to immunologic risk between 2010 and 2018. Living-donor transplantation patients with panel reactive antibody positivity, retransplantation, donor specific antibody, and/or single antigen bead positivity were included in the study. We excluded deceased-donor transplantation recipients. Demographic data (age, sex, etiology of end-stage renal disease, blood transfusions, pregnancy, etc), immunologic status (HLA-mismatch [HLA-MM], panel reactive antibody, donor specific antibody, etc), induction and maintenance of immunosuppressive medications, and complications (all-cause hospitalizations, episodes of acute rejections, etc) were noted. We compared data and clinical outcomes of patients who had desensitization (Group 1) with data and clinical outcomes of patients who had not had desensitization (Group 2). FINDINGS There were 124 living-kidney donors (49 female, mean age 43.7 ± 12.2 years, mean body mass index [BMI] 25.8 ± 5.8 kg/m2, mean follow-up time 20.9 ± 14.6 months). Thirty-four of these patients (25 female, mean age 43.7 ± 12.5 years, mean follow-up time 26.1 ± 17.7 months, mean BMI 27 ± 6.5 kg/m2) had desensitization treatment (rituximab+plasmapheresis for 19 patients, rituximab for 11 patients, rituximab+plasmapheresis+intravenous immunoglobulin for 4 patients). Ninety patients (24 female, mean age 43.7 ± 12.2 years, mean follow-up time 18.9 ± 12.9 months, mean BMI 25.3 ± 5.4 kg/m2) had not had desensitization. There was no statistical difference between groups for age, sex, hepatitis serology, history of blood transfusion, history of pregnancy, or history of dialysis (P < .05 for all parameters). While scores for HLA-MM and HLA-relative intensity scale (RIS) were 2.7 ± 1.6 and 7.86 ± 6.2, respectively, in Group 1, in Group 2 the same scores were 2.1 ± 1.1 and 3.6 ± 2.5, respectively (P: .053 and .03). Delayed graft function, acute rejection episodes, and hospitalizations were similar between groups (P: .47, .29, and .34, respectively). Follow-up time and length of hospitalization were longer in Group 1 (P: .013 and .001, respectively). Total doses of ATG were higher in Group 1 patients (P: .007). CONCLUSION Despite the higher HLA-MM and RIS scores, clinical outcomes in desensitized patients were found to be similar to those in nondesensitized patients for acute rejection episodes and hospitalizations. Desensitization with rituximab in patients with high HLA-RIS scores can prevent acute rejection and hospitalization.
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Affiliation(s)
- Ayse Sinangil
- Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey
| | - Zuhal Atan Ucar
- Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey
| | - Yener Koc
- Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey.
| | - Soykan Barlas
- Unit of Renal Transplantation, Department of General Surgery, Istanbul Bilim University Medical Faculty, Istanbul, Turkey
| | - Sana Abouzahir
- Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey; Department of Nephrology, Cheikh Anta Diop University, Dakar, Senegal
| | - Suleyman Tevfik Ecder
- Division of Nephrology, Department of Internal Medicine, Istanbul Bilim University Medical Faculty, Istanbul, Turkey
| | - Emin Baris Akin
- Unit of Renal Transplantation, Department of General Surgery, Istanbul Bilim University Medical Faculty, Istanbul, Turkey
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7
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Crossing low-level donor-specific antibodies in heart transplantation. Curr Opin Organ Transplant 2019; 24:227-232. [DOI: 10.1097/mot.0000000000000628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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8
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Abstract
De novo donor-specific antibody (DSA) formation is a major problem in transplantation, and associated with long-term graft decline and loss as well as sensitization, limiting future transplant options. Forming high-affinity, long-lived antibody responses involves a process called the germinal center (GC) reaction, and requires interaction between several cell types, including GC B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cells. T follicular regulatory cells are an essential component of the GC reaction, limiting its size and reducing nonspecific or self-reactive responses.An imbalance between helper function and regulatory function can lead to excessive antibody production. High proportions of Tfh cells have been associated with DSA formation in transplantation; therefore, Tfr cells are likely to play an important role in limiting DSA production. Understanding the signals that govern Tfr cell development and the balance between helper and regulatory function within the GC is key to understanding how these cells might be manipulated to reduce the risk of DSA development.This review discusses the development and function of Tfr cells and their relevance to transplantation. In particular how current and future immunosuppressive strategies might allow us to skew the ratio between Tfr and Tfh cells to increase or decrease the risk of de novo DSA formation.
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9
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Kang ES, Choi SI, Park YH, Park GB, Jang HR. Results of Questionnaire Survey of Current Immune Monitoring Practice of Transplant Clinicians and Clinical Pathologists in Korea: Basis for Establishment of Harmonized Immune Monitoring Guidelines. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo In Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youn Hee Park
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geum Borae Park
- Department of Laboratory Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hye Ryon Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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10
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Ikemiyagi M, Hirai T, Ishii R, Miyairi S, Okumi M, Tanabe K. Transitional B Cells Predominantly Reconstituted After a Desensitization Therapy Using Rituximab Before Kidney Transplantation. Ther Apher Dial 2017; 21:139-149. [DOI: 10.1111/1744-9987.12508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Masako Ikemiyagi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Toshihito Hirai
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Rumi Ishii
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Satoshi Miyairi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
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11
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Rabbit antithymocyte globulin and donor-specific antibodies in kidney transplantation — A review. Transplant Rev (Orlando) 2016; 30:85-91. [DOI: 10.1016/j.trre.2015.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/22/2015] [Indexed: 01/28/2023]
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12
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Okumi M, Toki D, Nozaki T, Shimizu T, Shirakawa H, Omoto K, Inui M, Ishida H, Tanabe K. ABO-Incompatible Living Kidney Transplants: Evolution of Outcomes and Immunosuppressive Management. Am J Transplant 2016; 16:886-96. [PMID: 26555133 DOI: 10.1111/ajt.13502] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 08/23/2015] [Accepted: 08/23/2015] [Indexed: 01/25/2023]
Abstract
ABO-incompatible living kidney transplantation (ABO-ILKT) has steadily become more widespread. However, the optimal immunosuppressive regimen for ABO-ILKT remains uncertain. We aimed to determine the longitudinal changes in the outcomes from ABO-ILKT compared with those from ABO-compatible living kidney transplantation (ABO-CLKT) over the last 25 years. Of 1195 patients who underwent living kidney transplantations (LKT) at our institute between 1989 and 2013, 1032-including 247 ABO-ILKT and 785 ABO-CLKT cases-were evaluated for graft survival, patient survival, infectious adverse events, and renal function. The patients were divided into four groups according to the transplantation era and ABO-compatibility. In the past decade, ABO-ILKT and ABO-CLKT recipients yielded almost equivalent outcomes with respect to the 9-year graft survival rates, which were 86.9% and 92.0%, respectively (hazard ratio [HR] 1.38, 95% confidence interval [CI] 0.59-3.22, p = 0.455). The graft survival rate for ABO-ILKT conducted between 2005 and 2013 was better than that for ABO-ILKT conducted between 1998 and 2004 (HR 0.30, 95% CI 0.13-0.72, p = 0.007). ABO-ILKT recipients showed substantial improvements in the graft survival rate over time. Graft survival was almost identical over the past decade, regardless of ABO-incompatibility. Currently, ABO-ILKT is an acceptable treatment for patients with end-stage renal disease.
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Affiliation(s)
- M Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - D Toki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Nozaki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Shimizu
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Shirakawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - M Inui
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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13
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Ishida H, Furusawa M, Shimizu T, Nozaki T, Tanabe K. Influence of preoperative anti-HLA antibodies on short- and long-term graft survival in recipients with or without rituximab treatment. Transpl Int 2015; 27:371-82. [PMID: 24438437 DOI: 10.1111/tri.12267] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/20/2013] [Accepted: 01/13/2014] [Indexed: 01/28/2023]
Abstract
We investigated the relationship between preoperative anti-HLA antibodies (donor-specific antibody, DSA) and the graft survival rate in recipients who had or had not received rituximab (Rit) treatment. The subjects were categorized into four groups as follows: DSA+Rit-, n = 39; DSA-Rit-, n = 121; DSA+Rit+, n = 74; and DSA-Rit+, n = 47. We examined the influence of preoperative DSA on the incidence of graft rejection and the survival rate of recipients who had or who had not received rituximab before transplantation. The 6-month acute rejection rates based on graft biopsies were 39%, 19%, 15%, and 0% for the DSA+Rit-, DSA-Rit-, DSA+Rit+, and DSA-Rit+ groups. The rates of chronic antibody-mediated rejection after more than 6 months were 50%, 22%, 18%, and 0%. The 5-year graft survival rate was significantly lower in the DSA+Rit- group (84%) than in the other groups (95% for DSA-Rit-, 98% for DSA+Rit+, and 91% for DSA-Rit+). The rate of the appearance of de novo anti-HLA antibodies was higher in the groups that did not receive rituximab treatment. The rate of graft loss associated with chronic antibody-mediated rejection was also higher in the DSA+Rit- group than in the other groups (P = 0.01). The presence of DSA and the administration of rituximab had strong impacts on not only short-term graft rejection, but also long-term graft rejection and its association with the graft survival time.
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Affiliation(s)
- Hideki Ishida
- Department of Urology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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14
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A systematic review of the use of rituximab for desensitization in renal transplantation. Transplantation 2014; 98:794-805. [PMID: 25321163 DOI: 10.1097/tp.0000000000000362] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rituximab is a B lymphocyte-depleting agent used to treat lymphoma and autoimmune diseases. Recently, it has been used for desensitization therapy in ABO-incompatible and highly sensitized recipients undergoing renal transplantation. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Four databases and three trial registries were searched for studies comparing rituximab with non-rituximab desensitization protocols. A lack of randomized evidence precluded meta-analysis, and thus a narrative review was conducted. RESULTS Forty-five records met the inclusion criteria, relating to 21 individual studies (two randomized controlled trials and 19 retrospective cohort studies). Ten studies investigated the use of rituximab in ABO-incompatible patients; most found no significant differences in patient and graft outcomes when compared most frequently to splenectomy-based protocols. Nine studies of limited quality focused on highly sensitized recipients (positive cross-match, donor-specific antibody, and elevated panel reactive antibody) and demonstrated some benefits in graft survival, acute and chronic rejection, and sensitization levels with rituximab. The remaining two studies combined ABO-incompatible and highly sensitized recipients and found no statistically significant increase in infectious complications with rituximab. CONCLUSION Evidence of limited quality was identified to support the use of rituximab desensitization in highly sensitized recipients. Among ABO-incompatible recipients, rituximab was found to be equivalent to splenectomy, indicating that this invasive surgical procedure is not necessary. Further randomized controlled trials are required to better define the efficacy, long-term safety, and optimal dosing regimen of rituximab in this setting.
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15
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Pankewycz O, Soliman K, Laftavi MR. The increasing clinical importance of alloantibodies in kidney transplantation. Immunol Invest 2014; 43:775-89. [DOI: 10.3109/08820139.2014.910016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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16
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Clinical outcome in patients with chronic antibody-mediated rejection treated with and without rituximab and intravenous immunoglobulin combination therapy. Transpl Immunol 2014; 31:140-4. [DOI: 10.1016/j.trim.2014.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/22/2014] [Accepted: 08/22/2014] [Indexed: 01/03/2023]
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17
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Analysis of Predictive and Preventive Factors for De Novo DSA in Kidney Transplant Recipients. Transplantation 2014; 98:443-50. [DOI: 10.1097/tp.0000000000000071] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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A closer look at rituximab induction on HLA antibody rebound following HLA-incompatible kidney transplantation. Kidney Int 2014; 87:409-16. [PMID: 25054778 PMCID: PMC4305036 DOI: 10.1038/ki.2014.261] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/22/2014] [Accepted: 06/05/2014] [Indexed: 01/15/2023]
Abstract
Rituximab has been used to increase the efficacy of desensitization protocols for HLA incompatible kidney transplantation, however, controlled comparisons have not been reported. Here we examined 256 post-transplant HLA antibody levels in 25 recipients desensitized with or 25 without rituximab induction, to determine the impact of B cell depletion. We found significantly less HLA antibody rebound in the rituximab-treated patients (7% of donor specific antibodies (DSAs) and 33% of non-DSAs) compared to a control cohort desensitized and transplanted without rituximab (32% DSAs and 55% non-DSAs). The magnitude of the increase was significantly larger among patients who did not receive rituximab. Interestingly, in rituximab treated patients, of the 39 HLA antibodies that increased post-transplant, 34 were specific for HLA mismatches present in previous allografts or pregnancies, implying limited efficacy in memory B cell depletion. Compared to controls, rituximab-treated patients had a significantly greater mean reduction in DSA (−2505 versus −292 mean fluorescence intensity), but a similar rate of DSA persistence (52% in rituximab treated and 40% in non-treated recipients). Thus, rituximab induction in HLA incompatible recipients reduced the incidence and magnitude of HLA antibody rebound, but did not impact DSA elimination, antibody mediated rejection, or 5 year allograft survival when compared to recipients desensitized and transplanted without rituximab.
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19
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Banasik M, Boratyńska M, Kościelska-Kasprzak K, Kamińska D, Bartoszek D, Żabińska M, Myszka M, Zmonarski S, Protasiewicz M, Nowakowska B, Hałoń A, Chudoba P, Klinger M. The influence of non-HLA antibodies directed against angiotensin II type 1 receptor (AT1R) on early renal transplant outcomes. Transpl Int 2014; 27:1029-38. [DOI: 10.1111/tri.12371] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/24/2014] [Accepted: 06/02/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Mirosław Banasik
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Maria Boratyńska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | | | - Dorota Kamińska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Dorota Bartoszek
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Marcelina Żabińska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Marta Myszka
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Sławomir Zmonarski
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | | | - Beata Nowakowska
- Institute of Immunology and Experimental Therapy; Polish Academy of Science; Wroclaw Poland
| | - Agnieszka Hałoń
- Department of Pathomorphology and Oncological Cytology; Wroclaw Medical University; Wroclaw Poland
| | - Pawel Chudoba
- Department of Vascular, General and Transplantation Surgery; Wroclaw Medical University; Wroclaw Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
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20
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Mierzejewska B, Schroder PM, Baum CE, Blair A, Smith C, Duquesnoy RJ, Marrari M, Gohara A, Malhotra D, Kaw D, Liwski R, Rees MA, Stepkowski S. Early acute antibody-mediated rejection of a negative flow crossmatch 3rd kidney transplant with exclusive disparity at HLA-DP. Hum Immunol 2014; 75:703-8. [PMID: 24755353 DOI: 10.1016/j.humimm.2014.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 02/27/2014] [Accepted: 04/05/2014] [Indexed: 02/02/2023]
Abstract
Donor-specific alloantibodies (DSA) to HLA-DP may cause antibody-mediated rejection (AMR), especially in re-transplants. We describe the immunization history of a patient who received 3 kidney transplants; the 3rd kidney was completely matched except at DPA1 and DPB1. Prior to the 3rd transplant, single antigen bead analysis (SAB) showed DSA reactivity against DPA1 shared by the 1st and 3rd donors, but B and T flow crossmatch (FXM) results were negative. Within 11 days the 3rd transplant underwent acute C4d+ AMR which coincided with the presence of complement (C1q)-binding IgG1 DSA against donor DPA1 and DPB1. Using HLAMatchmaker and SAB, we provide evidence that eplet (epitope) spreading on DPA1 and eplet sharing on differing DPB1 alleles of the 1st and 3rd transplants was associated with AMR. Since weak DSA to DPA1/DPB1 may induce acute AMR with negative FXM, donor DPA1/DPB1 high resolution typing should be considered in sensitized patients with DP-directed DSA.
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Affiliation(s)
- Beata Mierzejewska
- Department of Urology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Paul M Schroder
- Department of Microbiology and Immunology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Caitlin E Baum
- Department of Microbiology and Immunology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Annette Blair
- Department of Pathology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Connie Smith
- Department of Pathology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Rene J Duquesnoy
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Marilyn Marrari
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Amira Gohara
- Department of Pathology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Deepak Malhotra
- Department of Internal Medicine, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Dinkar Kaw
- Department of Internal Medicine, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Robert Liwski
- HLA Typing Laboratory, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael A Rees
- Department of Urology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Stanislaw Stepkowski
- Department of Microbiology and Immunology, University of Toledo College of Medicine, Toledo, OH 43614, USA.
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21
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Zachary AA, Leffell MS. Desensitization for solid organ and hematopoietic stem cell transplantation. Immunol Rev 2014; 258:183-207. [PMID: 24517434 PMCID: PMC4237559 DOI: 10.1111/imr.12150] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/24/2013] [Accepted: 11/04/2013] [Indexed: 12/25/2022]
Abstract
Desensitization protocols are being used worldwide to enable kidney transplantation across immunologic barriers, i.e. antibody to donor HLA or ABO antigens, which were once thought to be absolute contraindications to transplantation. Desensitization protocols are also being applied to permit transplantation of HLA mismatched hematopoietic stem cells to patients with antibody to donor HLA, to enhance the opportunity for transplantation of non-renal organs, and to treat antibody-mediated rejection. Although desensitization for organ transplantation carries an increased risk of antibody-mediated rejection, ultimately these transplants extend and enhance the quality of life for solid organ recipients, and desensitization that permits transplantation of hematopoietic stem cells is life saving for patients with limited donor options. Complex patient factors and variability in treatment protocols have made it difficult to identify, precisely, the mechanisms underlying the downregulation of donor-specific antibodies. The mechanisms underlying desensitization may differ among the various protocols in use, although there are likely to be some common features. However, it is likely that desensitization achieves a sort of immune detente by first reducing the immunologic barrier and then by creating an environment in which an autoregulatory process restricts the immune response to the allograft.
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Affiliation(s)
- Andrea A Zachary
- Department of Medicine, Division of Immunogenetics and Transplantation Immunology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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The effect of combination therapy with rituximab and intravenous immunoglobulin on the progression of chronic antibody mediated rejection in renal transplant recipients. J Immunol Res 2014; 2014:828732. [PMID: 24741626 PMCID: PMC3987969 DOI: 10.1155/2014/828732] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 10/28/2013] [Accepted: 11/11/2013] [Indexed: 12/18/2022] Open
Abstract
The treatment for chronic active antibody-mediated rejection (CAMR) remains controversial. We investigated the efficacy of rituximab (RTX) and intravenous immunoglobulin (IVIg) for CAMR. Eighteen patients with CAMR were treated with RTX (375 mg/m2) and IVIg (0.4 g/kg) for 4 days. The efficacy of RTX/IVIg combination therapy (RIT) was assessed by decline in estimated glomerular filtration rate per month (ΔeGFR) before and after RIT. Patients were divided into responder and nonresponder groups based on decrease and no decrease in ΔeGFR, respectively, and their clinical and histological characteristics were compared. Response rate to RIT was 66.7% (12/18), and overall ΔeGFR decreased significantly to 0.4 ± 1.7 mL·min−1·1.73 m−2 per month 6 months after RIT compared to that observed 6 months before RIT (1.8 ± 1.0, P < 0.05). Clinical and histological features between the 12 responders and the 6 nonresponders were not significantly different, but nonresponders had a significantly higher proteinuria levels at the time of RIT (2.5 ± 2.5 versus 7.0 ± 3.5 protein/creatinine (g/g), P < 0.001). The effect of the RIT on ΔeGFR had dissipated in all patients by 1 year post-RIT. Thus, RIT delayed CAMR progression, and baseline proteinuria level was a prognostic factor for response to RIT.
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23
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Sicard A, Amrouche L, Suberbielle C, Carmagnat M, Candon S, Thervet E, Delahousse M, Legendre C, Chatenoud L, Snanoudj R. Outcome of kidney transplantations performed with preformed donor-specific antibodies of unknown etiology. Am J Transplant 2014; 14:193-201. [PMID: 24224759 DOI: 10.1111/ajt.12512] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/18/2013] [Accepted: 09/18/2013] [Indexed: 01/25/2023]
Abstract
The detection of preformed donor-specific alloantibodies (DSA) with multiplex-bead arrays has led to the common observation that individuals without a history of pregnancy, transfusion or transplantation can have circulating anti-HLA antibodies of unknown etiology. We retrospectively analyzed the risk of antibody-mediated rejection (AMR) and graft outcome in 41 kidney transplant recipients with DSA of unknown etiology (DSA cause-unk) at the time of transplantation. Twenty-one patients received a posttransplantation desensitization protocol, and 20 received standard immunosuppressive therapy. The mean number of DSA was 1.4 ± 0.8, ranging from 1 to 5. Complement-dependent cytotoxicity crossmatches were negative for all the patients. Flow cytometry crossmatches were positive in 47.6% of cases. The incidence of acute AMR was 14.6% at 1 year, regardless of the immunosuppressive regimen. No patients experienced graft loss following AMR. At month 12, across the entire population of patients with DSA cause-unk, the outcomes were favorable: the measured glomerular filtration rate was 63.8 ± 16.4 mL/min/1.73 m(2), the screening biopsies showed low frequencies of microvascular inflammation and no transplant glomerulopathy, and graft and patient survival were 100%. In conclusion, patients with DSA cause-unk are able to mount AMR but have favorable 1-year outcomes.
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Affiliation(s)
- A Sicard
- Service de Transplantation Rénale Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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24
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Tanabe K, Inui M. Desensitization for prevention of chronic antibody-mediated rejection after kidney transplantation. Clin Transplant 2013; 27 Suppl 26:2-8. [DOI: 10.1111/ctr.12260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 01/08/2023]
Affiliation(s)
- Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Masashi Inui
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
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25
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Schlaf G, Pollok-Kopp B, Altermann WW. Sensitive solid-phase detection of donor-specific antibodies as an aid highly relevant to improving allograft outcomes. Mol Diagn Ther 2013; 18:185-201. [PMID: 24170304 DOI: 10.1007/s40291-013-0063-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Transplant recipients who have had sensitizing events such as pregnancies, blood transfusions and previous transplants often develop antibodies directed against human leukocyte antigen (HLA)-molecules of the donor tissue. These pre-formed donor-specific antibodies (DSA) represent a high risk of organ failure as a consequence of antibody-mediated hyper-acute or acute allograft rejection. As a first assay to detect DSA, the complement-dependent lymphocytotoxicity assay (CDC) was established more than 40 years ago. However, this assay is characterized by several drawbacks such as a low sensitivity and a high susceptibility to various artificial factors generally not leading to valid and reliable outcomes under several circumstances that are reviewed in this article. Furthermore, only those antibodies that exert complement-fixing activity are detected. As a consequence, novel procedures that act independently of the complement system and that do not represent functional assays were generated in the format of solid phase assays (SPAs) (bead- or ELISA-based). In this article, we review the pros and cons of these sensitive SPA in comparison with the detection of DSA through the use of the traditional methods such as CDC and flow cytometric analyses. Potential drawbacks of the alternative methodological approaches comprising high background reactivity, susceptibility to environmental factors and the possible influence of subjective operators' errors concerning the interpretation of the results are summarized and critically discussed for each method. We provide a forecast on the future role of SPAs reliably excluding highly deleterious DSA, thus leading to an improved graft survival.
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Affiliation(s)
- Gerald Schlaf
- Tissue Typing Laboratory, University Hospital Halle/Saale, Martin-Luther University of Halle-Wittenberg, Magdeburger Strasse 16, 06112, Halle (Saale), Germany,
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26
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Lynch R, Silva I, Chen B, Punch J, Cascalho M, Platt J. Cryptic B cell response to renal transplantation. Am J Transplant 2013; 13:1713-23. [PMID: 23750851 PMCID: PMC3764435 DOI: 10.1111/ajt.12308] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 03/13/2013] [Accepted: 03/17/2013] [Indexed: 01/25/2023]
Abstract
Transplantation reliably evokes allo-specific B cell and T cell responses in mice. Yet, human recipients of kidney transplants with normal function usually exhibit little or no antibody specific for the transplant donor during the early weeks and months after transplantation. Indeed, the absence of antidonor antibodies is taken to reflect effective immunosuppressive therapy and to predict a favorable outcome. Whether the absence of donor-specific antibodies reflects absence of a B cell response to the donor, tolerance to the donor or immunity masked by binding of donor-specific antibodies to the graft is not known. To distinguish between these possibilities, we devised a novel ELISPOT, using cultured donor, recipient and third-party fibroblasts as targets. We enumerated donor-specific antibody-secreting cells in the blood of nine renal allograft recipients with normal kidney function before and after transplantation. Although none of the nine subjects had detectable donor-specific antibodies before or after transplantation, all exhibited increases in the frequency of donor-specific antibody-secreting cells eight weeks after transplantation. The responses were directed against the donor HLA-class I antigens. The increase in frequency of donor-specific antibody-secreting cells after renal transplantation indicates that B cells respond specifically to the transplant donor more often than previously thought.
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Affiliation(s)
- R.J. Lynch
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - I.A. Silva
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - B.J. Chen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - J.D. Punch
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - M. Cascalho
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA,Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - J.L. Platt
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA,Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
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27
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Piemonti L, Everly MJ, Maffi P, Scavini M, Poli F, Nano R, Cardillo M, Melzi R, Mercalli A, Sordi V, Lampasona V, Espadas de Arias A, Scalamogna M, Bosi E, Bonifacio E, Secchi A, Terasaki PI. Alloantibody and autoantibody monitoring predicts islet transplantation outcome in human type 1 diabetes. Diabetes 2013; 62:1656-64. [PMID: 23274902 PMCID: PMC3636624 DOI: 10.2337/db12-1258] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Long-term clinical outcome of islet transplantation is hampered by the rejection and recurrence of autoimmunity. Accurate monitoring may allow for early detection and treatment of these potentially compromising immune events. Islet transplant outcome was analyzed in 59 consecutive pancreatic islet recipients in whom baseline and de novo posttransplant autoantibodies (GAD antibody, insulinoma-associated protein 2 antigen, zinc transporter type 8 antigen) and donor-specific alloantibodies (DSA) were quantified. Thirty-nine recipients (66%) showed DSA or autoantibody increases (de novo expression or titer increase) after islet transplantation. Recipients who had a posttransplant antibody increase showed similar initial performance but significantly lower graft survival than patients without an increase (islet autoantibodies P < 0.001, DSA P < 0.001). Posttransplant DSA or autoantibody increases were associated with HLA-DR mismatches (P = 0.008), induction with antithymocyte globulin (P = 0.0001), and pretransplant panel reactive alloantibody >15% in either class I or class II (P = 0.024) as independent risk factors and with rapamycin as protective (P = 0.006) against antibody increases. DSA or autoantibody increases after islet transplantation are important prognostic markers, and their identification could potentially lead to improved islet cell transplant outcomes.
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Affiliation(s)
- Lorenzo Piemonti
- Diabetes Research Institute, San Raffaele Hospital Scientific Institute, Milan, Italy.
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28
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Knight R, Devos J, Patel S, Land G, Moore L, Gaber L, Gaber A. Outcomes of Living Donor Renal Transplants With a Negative Cross-Match and Pretransplant Donor-Specific Antibody. Transplant Proc 2013; 45:1399-401. [DOI: 10.1016/j.transproceed.2013.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/15/2013] [Indexed: 12/30/2022]
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