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The Molecular Microscope Diagnostic System: Assessment of Rejection and Injury in Heart Transplant Biopsies. Transplantation 2023; 107:27-44. [PMID: 36508644 DOI: 10.1097/tp.0000000000004323] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review describes the development of the Molecular Microscope Diagnostic System (MMDx) for heart transplant endomyocardial biopsies (EMBs). MMDx-Heart uses microarrays to measure biopsy-based gene expression and ensembles of machine learning algorithms to interpret the results and compare each new biopsy to a large reference set of earlier biopsies. MMDx assesses T cell-mediated rejection (TCMR), antibody-mediated rejection (AMR), recent parenchymal injury, and atrophy-fibrosis, continually "learning" from new biopsies. Rejection-associated transcripts mapped in kidney transplants and experimental systems were used to identify TCMR, AMR, and recent injury-induced inflammation. Rejection and injury emerged as gradients of intensity, rather than binary classes. AMR was one-third donor-specific antibody (DSA)-negative, and many EMBs first considered to have no rejection displayed minor AMR-like changes, with increased probability of DSA positivity and subtle inflammation. Rejection-associated transcript-based algorithms now classify EMBs as "Normal," "Minor AMR changes," "AMR," "possible AMR," "TCMR," "possible TCMR," and "recent injury." Additionally, MMDx uses injury-associated transcript sets to assess the degree of parenchymal injury and atrophy-fibrosis in every biopsy and study the effect of rejection on the parenchyma. TCMR directly injures the parenchyma whereas AMR usually induces microcirculation stress but relatively little initial parenchymal damage, although slowly inducing parenchymal atrophy-fibrosis. Function (left ventricular ejection fraction) and short-term risk of failure are strongly determined by parenchymal injury. These discoveries can guide molecular diagnostic applications, either as a central MMDx system or adapted to other platforms. MMDx can also help calibrate noninvasive blood-based biomarkers to avoid unnecessary biopsies and monitor response to therapy.
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Harrington C, Krishnan S, Mack CL, Cravedi P, Assis DN, Levitsky J. Noninvasive biomarkers for the diagnosis and management of autoimmune hepatitis. Hepatology 2022; 76:1862-1879. [PMID: 35611859 PMCID: PMC9796683 DOI: 10.1002/hep.32591] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 01/07/2023]
Abstract
Autoimmune hepatitis (AIH) is a rare disease of unclear etiology characterized by loss of self-tolerance that can lead to liver injury, cirrhosis, and acute liver failure. First-line treatment consists of systemic corticosteroids, or budesonide, and azathioprine, to which most patients are initially responsive, although predictors of response are lacking. Relapses are very common, correlate with histological activity despite normal serum transaminases, and increase hepatic fibrosis. Furthermore, current regimens lead to adverse effects and reduced quality of life, whereas medication titration is imprecise. Biomarkers that can predict the clinical course of disease, identify patients at elevated risk for relapse, and improve monitoring and medication dosing beyond current practice would have high clinical value. Herein, we review novel candidate biomarkers in adult and pediatric AIH based on prespecified criteria, including gene expression profiles, proteins, metabolites, and immune cell phenotypes in different stages of AIH. We also discuss biomarkers relevant to AIH from other immune diseases. We conclude with proposed future directions in which biomarker implementation into clinical practice could lead to advances in personalized therapeutic management of AIH.
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Affiliation(s)
- Claire Harrington
- Division of Gastroenterology & HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Swathi Krishnan
- Medicine DepartmentYale School of MedicineNew HavenConnecticutUSA
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital ColoradoUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Paolo Cravedi
- Division of NephrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - David N. Assis
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA
| | - Josh Levitsky
- Division of Gastroenterology & HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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3
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Taner T, Bruner J, Emaumaullee J, Bonaccorsi-Riani E, Zarrinpar A. New Approaches to the Diagnosis of Rejection and Prediction of Tolerance in Liver Transplantation. Transplantation 2022; 106:1952-1962. [PMID: 35594482 PMCID: PMC9529763 DOI: 10.1097/tp.0000000000004160] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Immunosuppression after liver transplantation is essential for preventing allograft rejection. However, long-term drug toxicity and associated complications necessitate investigation of immunosuppression minimization and withdrawal protocols. Development of such protocols is hindered by reliance on current paradigms for monitoring allograft function and rejection status. The current standard of care for diagnosis of rejection is histopathologic assessment and grading of liver biopsies in accordance with the Banff Rejection Activity Index. However, this method is limited by cost, sampling variability, and interobserver variation. Moreover, the invasive nature of biopsy increases the risk of patient complications. Incorporating noninvasive techniques may supplement existing methods through improved understanding of rejection causes, hepatic spatial architecture, and the role of idiopathic fibroinflammatory regions. These techniques may also aid in quantification and help integrate emerging -omics analyses with current assessments. Alternatively, emerging noninvasive methods show potential to detect and distinguish between different types of rejection while minimizing risk of adverse advents. Although biomarkers have yet to replace biopsy, preliminary studies suggest that several classes of analytes may be used to detect rejection with greater sensitivity and in earlier stages than traditional methods, possibly when coupled with artificial intelligence. Here, we provide an overview of the latest efforts in optimizing the diagnosis of rejection in liver transplantation.
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Affiliation(s)
- Timucin Taner
- Departments of Surgery & Immunology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Julia Bruner
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Juliet Emaumaullee
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eliano Bonaccorsi-Riani
- Abdominal Transplant Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ali Zarrinpar
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
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4
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Assessing the Relationship Between Molecular Rejection and Parenchymal Injury in Heart Transplant Biopsies. Transplantation 2022; 106:2205-2216. [PMID: 35968995 DOI: 10.1097/tp.0000000000004231] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The INTERHEART study (ClinicalTrials.gov #NCT02670408) used genome-wide microarrays to detect rejection in endomyocardial biopsies; however, many heart transplants with no rejection have late dysfunction and impaired survival. We used the microarray measurements to develop a molecular classification of parenchymal injury. METHODS In 1320 endomyocardial biopsies from 645 patients previously studied for rejection-associated transcripts, we measured the expression of 10 injury-induced transcript sets: 5 induced by recent injury; 2 reflecting macrophage infiltration; 2 normal heart transcript sets; and immunoglobulin transcripts, which correlate with time. We used archetypal clustering to assign injury groups. RESULTS Injury transcript sets correlated with impaired function. Archetypal clustering based on the expression of injury transcript sets assigned each biopsy to 1 of 5 injury groups: 87 Severe-injury, 221 Late-injury, and 3 with lesser degrees of injury, 376 No-injury, 526 Mild-injury, and 110 Moderate-injury. Severe-injury had extensive loss of normal transcripts (dedifferentiation) and increase in macrophage and injury-induced transcripts. Late-injury was characterized by high immunoglobulin transcript expression. In Severe- and Late-injury, function was depressed, and short-term graft failure was increased, even in hearts with no rejection. T cell-mediated rejection almost always had parenchymal injury, and 85% had Severe- or Late-injury. In contrast, early antibody-mediated rejection (ABMR) had little injury, but late ABMR often had the Late-injury state. CONCLUSION Characterizing heart transplants for their injury state provides new understanding of dysfunction and outcomes and demonstrates the differential impact of T cell-mediated rejection versus ABMR on the parenchyma. Slow deterioration from ABMR emerges as a major contributor to late dysfunction.
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5
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Deshpande SR, Zangwill SD, Kindel SJ, Schroder JN, Bichell DP, Wigger MA, Richmond ME, Knecht KR, Pahl E, Gaglianello NA, Mahle WT, Stamm KD, Simpson PM, Dasgupta M, Zhang L, North PE, Tomita-Mitchell A, Mitchell ME. Relationship between donor fraction cell-free DNA and clinical rejection in heart transplantation. Pediatr Transplant 2022; 26:e14264. [PMID: 35258162 DOI: 10.1111/petr.14264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/19/2022] [Accepted: 02/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical rejection (CR) defined as decision to treat clinically suspected rejection with change in immunotherapy based on clinical presentation with or without diagnostic biopsy findings is an important part of care in heart transplantation. We sought to assess the utility of donor fraction cell-free DNA (DF cfDNA) in CR and the utility of serial DF cfDNA in CR patients in predicting outcomes of clinical interest. METHODS Patients with heart transplantation were enrolled in two sequential, multi-center, prospective observational studies. Blood samples were collected for surveillance or clinical events. Clinicians were blinded to the results of DF cfDNA. RESULTS A total of 835 samples from 269 subjects (57% pediatric) were included for this analysis, including 28 samples associated with CR were analyzed. Median DF cfDNA was 0.43 (IQR 0.15, 1.36)% for CR and 0.10 (IQR 0.07, 0.16)% for healthy controls (p < .0001). At cutoff value of 0.13%, the area under curve (AUC) was 0.82, sensitivity of 0.86, specificity of 0.67, and negative predictive value of 0.99. There was serial decline in DF cfDNA post-therapy, however, those with cardiovascular events (cardiac arrest, need for mechanical support or death) showed significantly higher levels of DF cfDNA on Day 0 (2.11 vs 0.31%) and Day 14 (0.51 vs 0.22%) compared to those who did not have such an event (p < .0001). CONCLUSION DF cfDNA has excellent agreement with clinical rejection and, importantly, serial measurement of DF cfDNA predict clinically significant outcomes post treatment for rejection in these patients.
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Affiliation(s)
- Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Elfriede Pahl
- Emeritus of Pediatrics, Cardiology, Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Karl D Stamm
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa M Simpson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mahua Dasgupta
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
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6
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Levitsky J, Kandpal M, Guo K, Zhao L, Kurian S, Whisenant T, Abecassis M. Prediction of Liver Transplant Rejection With a Biologically Relevant Gene Expression Signature. Transplantation 2022; 106:1004-1011. [PMID: 34342962 PMCID: PMC9301991 DOI: 10.1097/tp.0000000000003895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/21/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Noninvasive biomarkers distinguishing early immune activation before acute rejection (AR) could more objectively inform immunosuppression management in liver transplant recipients (LTRs). We previously reported a genomic profile distinguishing LTR with AR versus stable graft function. This current study includes key phenotypes with other causes of graft dysfunction and uses a novel random forest approach to augment the specificity of predicting and diagnosing AR. METHODS Gene expression results in LTRs with AR versus non-AR (combination of other causes of graft dysfunction and normal function) were analyzed from single and multicenter cohorts. A 70:30 approach (61 ARs; 162 non-ARs) was used for training and testing sets. Microarray data were normalized using a LT-specific vector. RESULTS Random forest modeling on the training set generated a 59-probe classifier distinguishing AR versus non-AR (area under the curve 0.83; accuracy 0.78, sensitivity 0.70, specificity 0.81, positive predictive value 0.54, negative predictive value [NPV] 0.89; F-score 0.61). Using a locked threshold, the classifier performed well on the testing set (accuracy 0.72, sensitivity 0.67, specificity 0.73, positive predictive value 0.48, NPV 0.86; F-score 0.56). Probability scores increased in samples preceding AR versus non-AR, when liver function tests were normal, and decreased following AR treatment (P < 0.001). Ingenuity pathway analysis of the genes revealed a high percentage related to immune responses and liver injury. CONCLUSIONS We have developed a blood-based biologically relevant biomarker that can be detected before AR-associated graft injury distinct from LTR never developing AR. Given its high NPV ("rule out AR"), the biomarker has the potential to inform precision-guided immunosuppression minimization in LTRs.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Manoj Kandpal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kexin Guo
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lihui Zhao
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sunil Kurian
- Scripps Clinic Bio-Repository and Bio-Informatics Core, Scripps Green Hospital, La Jolla, CA
| | - Thomas Whisenant
- Center for Computational Biology and Bioinformatics, School of Medicine, University of California San Diego, San Diego, CA
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Ravindranath MH, El Hilali F, Filippone EJ. The Impact of Inflammation on the Immune Responses to Transplantation: Tolerance or Rejection? Front Immunol 2021; 12:667834. [PMID: 34880853 PMCID: PMC8647190 DOI: 10.3389/fimmu.2021.667834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 10/11/2021] [Indexed: 12/21/2022] Open
Abstract
Transplantation (Tx) remains the optimal therapy for end-stage disease (ESD) of various solid organs. Although alloimmune events remain the leading cause of long-term allograft loss, many patients develop innate and adaptive immune responses leading to graft tolerance. The focus of this review is to provide an overview of selected aspects of the effects of inflammation on this delicate balance following solid organ transplantation. Initially, we discuss the inflammatory mediators detectable in an ESD patient. Then, the specific inflammatory mediators found post-Tx are elucidated. We examine the reciprocal relationship between donor-derived passenger leukocytes (PLs) and those of the recipient, with additional emphasis on extracellular vesicles, specifically exosomes, and we examine their role in determining the balance between tolerance and rejection. The concept of recipient antigen-presenting cell "cross-dressing" by donor exosomes is detailed. Immunological consequences of the changes undergone by cell surface antigens, including HLA molecules in donor and host immune cells activated by proinflammatory cytokines, are examined. Inflammation-mediated donor endothelial cell (EC) activation is discussed along with the effect of donor-recipient EC chimerism. Finally, as an example of a specific inflammatory mediator, a detailed analysis is provided on the dynamic role of Interleukin-6 (IL-6) and its receptor post-Tx, especially given the potential for therapeutic interdiction of this axis with monoclonal antibodies. We aim to provide a holistic as well as a reductionist perspective of the inflammation-impacted immune events that precede and follow Tx. The objective is to differentiate tolerogenic inflammation from that enhancing rejection, for potential therapeutic modifications. (Words 247).
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Affiliation(s)
- Mepur H. Ravindranath
- Department of Hematology and Oncology, Children’s Hospital, Los Angeles, CA, United States
- Terasaki Foundation Laboratory, Santa Monica, CA, United States
| | | | - Edward J. Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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8
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Halloran PF, Madill-Thomsen K, Aliabadi-Zuckermann AZ, Cadeiras M, Crespo-Leiro MG, Depasquale EC, Deng M, Gökler J, Kim DH, Kobashigawa J, Macdonald P, Potena L, Shah K, Stehlik J, Zuckermann A. Many heart transplant biopsies currently diagnosed as no rejection have mild molecular antibody-mediated rejection-related changes. J Heart Lung Transplant 2021; 41:334-344. [PMID: 34548198 DOI: 10.1016/j.healun.2021.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/12/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The Molecular Microscope (MMDx) system classifies heart transplant endomyocardial biopsies as No-rejection (NR), Early-injury, T cell-mediated (TCMR), antibody-mediated (ABMR), mixed, and possible rejection (possible TCMR, possible ABMR). Rejection-like gene expression patterns in NR biopsies have not been described. We extended the MMDx methodology, using a larger data set, to define a new "Minor" category characterized by low-level inflammation in non-rejecting biopsies. METHODS Using MMDx criteria from a previous study, molecular rejection was assessed in 1,320 biopsies (645 patients) using microarray expression of rejection-associated transcripts (RATs). Of these biopsies, 819 were NR. A new archetypal analysis model in the 1,320 data set split the NRs into NR-Normal (N = 462) and NR-Minor (N = 359). RESULTS Compared to NR-Normal, NR-Minor were more often histologic TCMR1R, with a higher prevalence of donor-specific antibody (DSA). DSA positivity increased in a gradient: NR-Normal 24%; NR-Minor 34%; possible ABMR 42%; ABMR 66%. The top 20 transcripts distinguishing NR-Minor from NR-Normal were all ABMR-related and/or IFNG-inducible, and also exhibited a gradient of increasing expression from NR-Normal through ABMR. In random forest analysis, TCMR and Early-injury were associated with reduced LVEF and increased graft loss, but NR-Minor and ABMR scores were not. Surprisingly, hearts with MMDx ABMR showed comparatively little graft loss. CONCLUSIONS Many heart transplants currently diagnosed as NR by histologic or molecular assessment have minor increases in ABMR-related and IFNG-inducible transcripts, associated with DSA positivity and mild histologic inflammation. These results suggest that low-level ABMR-related molecular stress may be operating in many more hearts than previously estimated. (ClinicalTrials.gov #NCT02670408).
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Affiliation(s)
| | | | | | | | | | | | - Mario Deng
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Daniel H Kim
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Peter Macdonald
- The Victor Chang Cardiac Research Institute, Sydney, Australia
| | | | - Keyur Shah
- Virginia Commonwealth University, Richmond, Virginia
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Kiamanesh O, Toma M. The State of the Heart Biopsy: A Clinical Review. CJC Open 2021; 3:524-531. [PMID: 34027357 PMCID: PMC8129478 DOI: 10.1016/j.cjco.2020.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/23/2020] [Indexed: 12/16/2022] Open
Abstract
Endomyocardial biopsy (EMB) is an invaluable and underused diagnostic tool for myocardial disease. The primary indications are surveillance of cardiac allograft rejection and the diagnosis of inflammatory and infiltrative cardiomyopathies. EMB is typically performed by sampling the right ventricular septum via the right internal jugular vein using fluoroscopic guidance. The diagnostic yield of EMB is improved by sampling both ventricles and with the use of guidance from imaging or electroanatomic mapping. The risk of major cardiac complications is operator dependent and < 1% in experienced centres. EMB is the gold standard and most common form of cardiac allograft rejection surveillance, whereas advanced cardiac imaging and donor-specific antibody quantification provide complementary information. Gene expression profiling is an alternative surveillance strategy to EMB for low-risk patients. EMB is recommended for myocarditis and can guide therapy for giant-cell myocarditis, necrotizing eosinophilic myocarditis, sarcoidosis, and immune checkpoint inhibitor myocarditis. There is growing interest in using EMB to guide therapy for viral myocarditis, although the uptake of this approach is limited to specialized centres. EMB has been replaced as a first-line test for infiltrative cardiomyopathy by nonbiopsy diagnostic techniques, but is still useful to clarify the diagnosis or disease subtype. The miniaturization of bioptomes and advances in laboratory techniques such as microarrays promises to improve the safety and yield of EMB. We review the contemporary use of EMB for cardiac allograft rejection, inflammatory cardiomyopathy, and infiltrative cardiomyopathy.
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Affiliation(s)
- Omid Kiamanesh
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Deng MC. The evolution of patient-specific precision biomarkers to guide personalized heart-transplant care. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021; 6:51-63. [PMID: 33768160 DOI: 10.1080/23808993.2021.1840273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Introduction In parallel to the clinical maturation of heart transplantation over the last 50 years, rejection testing has been revolutionized within the systems biology paradigm triggered by the Human Genome Project. Areas Covered We have co-developed the first FDA-cleared diagnostic and prognostic leukocyte gene expression profiling biomarker test in transplantation medicine that gained international evidence-based medicine guideline acceptance to rule out moderate/severe acute cellular cardiac allograft rejection without invasive endomyocardial biopsies. This work prompted molecular re-classification of intragraft biology, culminating in the identification of a pattern of intragraft myocyte injury, in addition to acute cellular rejection and antibody-mediated rejection. This insight stimulated research into non-invasive detection of myocardial allograft injury. The addition of a donor-organ specific myocardial injury marker based on donor-derived cell-free DNA further strengthens the non-invasive monitoring concept, combining the clinical use of two complementary non-invasive blood-based measures, host immune activity-related risk of acute rejection as well as cardiac allograft injury. Expert Opinion This novel complementary non-invasive heart transplant monitoring strategy based on leukocyte gene expression profiling and donor-derived cell-free DNA that incorporates longitudinal variability measures provides an exciting novel algorithm of heart transplant allograft monitoring. This algorithm's clinical utility will need to be tested in an appropriately designed randomized clinical trial which is in preparation.
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Affiliation(s)
- Mario C Deng
- Advanced Heart Failure/Mechanical Support/Heart Transplant, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 100 Medical Plaza Drive, Suite 630, Los Angeles, CA 90095
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11
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Stoiber L, Schoenrath F, Knosalla C, Milting H, Klingel K, Tschöpe C, Tanacli R, Gebker R, Berger A, Pieske B, Kelle S. Case Report: Early Transplant Rejection of a Methanol-Intoxicated Donor Heart in a Young Female Patient. A Diagnostic Approach With CMR, Cardiac Biopsy, and Genetic Risk Assessment. Front Immunol 2021; 11:575635. [PMID: 33692775 PMCID: PMC7938323 DOI: 10.3389/fimmu.2020.575635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022] Open
Abstract
This case report describes the contributions of multimodality imaging, cardiac biopsy, and genetic sequencing to the diagnosis and management of heart transplant rejection in a 23-year old patient with dilated cardiomyopathy.
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Affiliation(s)
- Lukas Stoiber
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Hendrik Milting
- Erich and Hanna Klessmann Institute for Cardiovascular Research & Development (EHKI), Heart and Diabetes Center North Rine-Westphalia (NRW), University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Carsten Tschöpe
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
| | - Radu Tanacli
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Rolf Gebker
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Alexander Berger
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine Berlin, Berlin, Germany
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12
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[Pathology of heart transplantation: Where are we now?]. Ann Pathol 2021; 41:38-49. [PMID: 33413972 DOI: 10.1016/j.annpat.2020.12.001] [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: 11/07/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 11/23/2022]
Abstract
Pathology is still the gold standard for the diagnosis of rejection in heart transplantation. During the last decade, molecular pathology has emerged as a powerful tool for the understanding of the processes implicated in allograft rejection. Transcriptomic analysis of the allograft may also help the pathologist for diagnosis and accurate classification of rejection. This review will describe the recent advances and perspectives of molecular pathology in the field of heart transplantation.
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13
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Duong Van Huyen JP, Fedrigo M, Fishbein GA, Leone O, Neil D, Marboe C, Peyster E, von der Thüsen J, Loupy A, Mengel M, Revelo MP, Adam B, Bruneval P, Angelini A, Miller DV, Berry GJ. The XVth Banff Conference on Allograft Pathology the Banff Workshop Heart Report: Improving the diagnostic yield from endomyocardial biopsies and Quilty effect revisited. Am J Transplant 2020; 20:3308-3318. [PMID: 32476272 DOI: 10.1111/ajt.16083] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 01/25/2023]
Abstract
The XVth Banff Conference on Allograft Pathology meeting was held on September 23-27, 2019, in Pittsburgh, Pennsylvania, USA. During this meeting, two main topics in cardiac transplant pathology were addressed: (a) Improvement of endomyocardial biopsy (EMB) accuracy for the diagnosis of rejection and other significant injury patterns, and (b) the orphaned lesion known as Quilty effect or nodular endocardial infiltrates. Molecular technologies have evolved in recent years, deciphering pathophysiology of cardiac rejection. Diagnostically, it is time to integrate the histopathology of EMBs and molecular data. The goal is to incorporate molecular pathology, performed on the same paraffin block as a companion test for histopathology, to yield more accurate and objective EMB interpretation. Application of digital image analysis from hematoxylin and eosin (H&E) stain to multiplex labeling is another means of extracting additional information from EMBs. New concepts have emerged exploring the multifaceted significance of myocardial injury, minimal rejection patterns supported by molecular profiles, and lesions of arteriolitis/vasculitis in the setting of T cell-mediated rejection (TCMR) and antibody-mediated rejection (AMR). The orphaned lesion known as Quilty effect or nodular endocardial infiltrates. A state-of-the-art session with historical aspects and current dilemmas was reviewed, and possible pathogenesis proposed, based on advances in immunology to explain conflicting data. The Quilty effect will be the subject of a multicenter project to explore whether it functions as a tertiary lymphoid organ.
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Affiliation(s)
- Jean-Paul Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, INSERM U970 and Université de Paris, Paris, France.,Department of Pathology, Necker Hospital, Paris, France
| | - Marny Fedrigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gregory A Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ornella Leone
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Desley Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Charles Marboe
- Department of Pathology and Cell Biology, Columbia University, New York, New York, USA
| | - Eliot Peyster
- Cardiovascular Research Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM U970 and Université de Paris, Paris, France.,Department of Nephrology and Transplantation, Necker-Enfants Hospital, Paris, France
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Monica P Revelo
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Benjamin Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick Bruneval
- Paris Translational Research Center for Organ Transplantation, INSERM U970 and Université de Paris, Paris, France
| | - Annalisa Angelini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA
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14
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Mengel M, Loupy A, Haas M, Roufosse C, Naesens M, Akalin E, Clahsen‐van Groningen MC, Dagobert J, Demetris AJ, Duong van Huyen J, Gueguen J, Issa F, Robin B, Rosales I, Von der Thüsen JH, Sanchez‐Fueyo A, Smith RN, Wood K, Adam B, Colvin RB. Banff 2019 Meeting Report: Molecular diagnostics in solid organ transplantation-Consensus for the Banff Human Organ Transplant (B-HOT) gene panel and open source multicenter validation. Am J Transplant 2020; 20:2305-2317. [PMID: 32428337 PMCID: PMC7496585 DOI: 10.1111/ajt.16059] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/19/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
This meeting report from the XV Banff conference describes the creation of a multiorgan transplant gene panel by the Banff Molecular Diagnostics Working Group (MDWG). This Banff Human Organ Transplant (B-HOT) panel is the culmination of previous work by the MDWG to identify a broadly useful gene panel based on whole transcriptome technology. A data-driven process distilled a gene list from peer-reviewed comprehensive microarray studies that discovered and validated their use in kidney, liver, heart, and lung transplant biopsies. These were supplemented by genes that define relevant cellular pathways and cell types plus 12 reference genes used for normalization. The 770 gene B-HOT panel includes the most pertinent genes related to rejection, tolerance, viral infections, and innate and adaptive immune responses. This commercially available panel uses the NanoString platform, which can quantitate transcripts from formalin-fixed paraffin-embedded samples. The B-HOT panel will facilitate multicenter collaborative clinical research using archival samples and permit the development of an open source large database of standardized analyses, thereby expediting clinical validation studies. The MDWG believes that a pathogenesis and pathway based molecular approach will be valuable for investigators and promote therapeutic decision-making and clinical trials.
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Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Alexandre Loupy
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Mark Haas
- Department of Pathology and Laboratory MedicineCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Candice Roufosse
- Department of Immunology and InflammationImperial College London and North West London PathologyLondonUK
| | - Maarten Naesens
- Department of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium,Department of NephrologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Enver Akalin
- Montefiore‐Einstein Center for TransplantationMontefiore Medical CenterBronxNew YorkUSA
| | | | - Jessy Dagobert
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Anthony J. Demetris
- Department of PathologyUniversity of Pittsburgh Medical CenterMontefiore, PittsburghPennsylvaniaUSA
| | - Jean‐Paul Duong van Huyen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Juliette Gueguen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Fadi Issa
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Blaise Robin
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity of ParisParisFrance
| | - Ivy Rosales
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Rex N. Smith
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Kathryn Wood
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Benjamin Adam
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - Robert B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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15
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Levitsky J, Asrani SK, Schiano T, Moss A, Chavin K, Miller C, Guo K, Zhao L, Kandpal M, Bridges N, Brown M, Armstrong B, Kurian S, Demetris AJ, Abecassis M. Discovery and validation of a novel blood-based molecular biomarker of rejection following liver transplantation. Am J Transplant 2020; 20:2173-2183. [PMID: 32356368 PMCID: PMC7496674 DOI: 10.1111/ajt.15953] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/28/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Noninvasive biomarker profiles of acute rejection (AR) could affect the management of liver transplant (LT) recipients. Peripheral blood was collected following LT for discovery (Northwestern University [NU]) and validation (National Institute of Allergy and Infectious Diseases Clinical Trials in Organ Transplantation [CTOT]-14 study). Blood gene profiling was paired with biopsies showing AR or ADNR (acute dysfunction no rejection) as well as stable graft function samples (Transplant eXcellent-TX). CTOT-14 subjects had serial collections prior to AR, ADNR, TX, and after AR treatment. NU cohort gene expression (46 AR, 45 TX) was analyzed using random forest models to generate a classifier training set (36 gene probe) distinguishing AR vs TX (area under the curve 0.92). The algorithm and threshold were locked and tested on the CTOT-14 validation cohort (14 AR, 50 TX), yielding an accuracy of 0.77, sensitivity 0.57, specificity 0.82, positive predictive value (PPV) 0.47, and negative predictive value (NPV) 0.87 for AR vs TX. The probability score line slopes were positive preceding AR, and negative preceding TX and non-AR (TX + ADNR) (P ≤ .001) and following AR treatment. In conclusion, we have developed a blood biomarker diagnostic for AR that can be detected prior to AR-associated graft injury as well a normal graft function (non-AR). Further studies are needed to evaluate its utility in precision-guided immunosuppression optimization following LT.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIllinois,Division of Gastroenterology and HepatologyDepartment of MedicineNorthwestern University Feinberg School of MedicineChicagoIllinois
| | - Sumeet K. Asrani
- Annette C. and Harold C. Simmons Transplant InstituteBaylor University Medical CenterDallasTexas
| | | | | | | | | | - Kexin Guo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIllinois,Biostatistics Collaboration CenterDepartment of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIllinois
| | - Lihui Zhao
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIllinois,Biostatistics Collaboration CenterDepartment of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIllinois
| | - Manoj Kandpal
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineChicagoIllinois,Biostatistics Collaboration CenterDepartment of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIllinois
| | - Nancy Bridges
- Division of Allergy, Immunology, and TransplantationNational Institute of Allergy and Infectious DiseasesBethesdaMaryland
| | - Merideth Brown
- Division of Allergy, Immunology, and TransplantationNational Institute of Allergy and Infectious DiseasesBethesdaMaryland
| | | | - Sunil Kurian
- The Scripps Research InstituteLa JollaCalifornia
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16
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Madill-Thomsen K, Abouljoud M, Bhati C, Ciszek M, Durlik M, Feng S, Foroncewicz B, Francis I, Grąt M, Jurczyk K, Klintmalm G, Krasnodębski M, McCaughan G, Miquel R, Montano-Loza A, Moonka D, Mucha K, Myślak M, Pączek L, Perkowska-Ptasińska A, Piecha G, Reichman T, Sanchez-Fueyo A, Tronina O, Wawrzynowicz-Syczewska M, Więcek A, Zieniewicz K, Halloran PF. The molecular diagnosis of rejection in liver transplant biopsies: First results of the INTERLIVER study. Am J Transplant 2020; 20:2156-2172. [PMID: 32090446 DOI: 10.1111/ajt.15828] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 01/25/2023]
Abstract
Molecular diagnosis of rejection is emerging in kidney, heart, and lung transplant biopsies and could offer insights for liver transplant biopsies. We measured gene expression by microarrays in 235 liver transplant biopsies from 10 centers. Unsupervised archetypal analysis based on expression of previously annotated rejection-related transcripts identified 4 groups: normal "R1normal " (N = 129), T cell-mediated rejection (TCMR) "R2TCMR " (N = 37), early injury "R3injury " (N = 61), and fibrosis "R4late " (N = 8). Groups differed in median time posttransplant, for example, R3injury 99 days vs R4late 3117 days. R2TCMR biopsies expressed typical TCMR-related transcripts, for example, intense IFNG-induced effects. R3injury displayed increased expression of parenchymal injury transcripts (eg, hypoxia-inducible factor EGLN1). R4late biopsies showed immunoglobulin transcripts and injury-related transcripts. R2TCMR correlated with histologic rejection although with many discrepancies, and R4late with fibrosis. R2TCMR , R3injury , and R4late correlated with liver function abnormalities. Supervised classifiers trained on histologic rejection showed less agreement with histology than unsupervised R2TCMR scores. No confirmed cases of clinical antibody-mediated rejection (ABMR) were present in the population, and strategies that previously revealed ABMR in kidney and heart transplants failed to reveal a liver ABMR phenotype. In conclusion, molecular analysis of liver transplant biopsies detects rejection, has the potential to resolve ambiguities, and could assist with immunosuppressive management.
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Affiliation(s)
| | | | - Chandra Bhati
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michał Ciszek
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Sandy Feng
- University of California San Francisco, San Francisco, California, USA
| | - Bartosz Foroncewicz
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | | | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Jurczyk
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, Poland
| | | | - Maciej Krasnodębski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Geoff McCaughan
- Centenary Research Institute, Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
| | | | | | | | - Krzysztof Mucha
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Marek Myślak
- Department of Clinical Interventions, Department of Nephrology and Kidney, Transplantation, SPWSZ Hospital, Pomeranian Medical University, Szczecin, Poland
| | - Leszek Pączek
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | | | - Grzegorz Piecha
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | | | | | - Olga Tronina
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Marta Wawrzynowicz-Syczewska
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Alberta, Canada
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17
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Dallaire F, Greenway SC. Advancing Heart Transplantation and the Detection of Rejection, Bit by BiT. Can J Cardiol 2020; 36:1189-1190. [PMID: 32553816 DOI: 10.1016/j.cjca.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Frederic Dallaire
- Department of Pediatrics, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Steven C Greenway
- Departments of Pediatrics, Cardiac Sciences, Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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18
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Shannon CP, Hollander Z, Dai DLY, Chen V, Assadian S, Lam KK, McManus JE, Zarzycki M, Kim Y, Kim JYV, Balshaw R, Gidlöf O, Öhman J, Smith JG, Toma M, Ignaszewski A, Davies RA, Delgado D, Haddad H, Isaac D, Kim D, Mui A, Rajda M, West L, White M, Zieroth S, Tebbutt SJ, Keown PA, McMaster WR, Ng RT, McManus BM. HEARTBiT: A Transcriptomic Signature for Excluding Acute Cellular Rejection in Adult Heart Allograft Patients. Can J Cardiol 2019; 36:1217-1227. [PMID: 32553820 DOI: 10.1016/j.cjca.2019.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Nine mRNA transcripts associated with acute cellular rejection (ACR) in previous microarray studies were ported to the clinically amenable NanoString nCounter platform. Here we report the diagnostic performance of the resulting blood test to exclude ACR in heart allograft recipients: HEARTBiT. METHODS Blood samples for transcriptomic profiling were collected during routine post-transplantation monitoring in 8 Canadian transplant centres participating in the Biomarkers in Transplantation initiative, a large (n = 1622) prospective observational study conducted between 2009 and 2014. All adult cardiac transplant patients were invited to participate (median age = 56 [17 to 71]). The reference standard for rejection status was histopathology grading of tissue from endomyocardial biopsy (EMB). All locally graded ISHLT ≥ 2R rejection samples were selected for analysis (n = 36). ISHLT 1R (n = 38) and 0R (n = 86) samples were randomly selected to create a cohort approximately matched for site, age, sex, and days post-transplantation, with a focus on early time points (median days post-transplant = 42 [7 to 506]). RESULTS ISHLT ≥ 2R rejection was confirmed by EMB in 18 and excluded in 92 samples in the test set. HEARTBiT achieved 47% specificity (95% confidence interval [CI], 36%-57%) given ≥ 90% sensitivity, with a corresponding area under the receiver operating characteristic curve of 0.69 (95% CI, 0.56-0.81). CONCLUSIONS HEARTBiT's diagnostic performance compares favourably to the only currently approved minimally invasive diagnostic test to rule out ACR, AlloMap (CareDx, Brisbane, CA) and may be used to inform care decisions in the first 2 months post-transplantation, when AlloMap is not approved, and most ACR episodes occur.
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Affiliation(s)
- Casey P Shannon
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada.
| | - Zsuzsanna Hollander
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Darlene L Y Dai
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Virginia Chen
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Sara Assadian
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Karen K Lam
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet E McManus
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Marek Zarzycki
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - YoungWoong Kim
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ji-Young V Kim
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Balshaw
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Gidlöf
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Öhman
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - J Gustav Smith
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mustafa Toma
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Ignaszewski
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ross A Davies
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Diego Delgado
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Haissam Haddad
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Debra Isaac
- Department of Medicine, University of Alberta, Calgary, Aberta, Canada
| | - Daniel Kim
- Department of Medicine, University of Alberta, Calgary, Aberta, Canada
| | - Alice Mui
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Miroslaw Rajda
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lori West
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Shelley Zieroth
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott J Tebbutt
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul A Keown
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Robert McMaster
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond T Ng
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Computer Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce M McManus
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada.
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19
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Wolfson AM, Kobashigawa JA. Genetic and Genomic Approaches to Predict Cardiac Allograft Rejection. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0626-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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21
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An integrated molecular diagnostic report for heart transplant biopsies using an ensemble of diagnostic algorithms. J Heart Lung Transplant 2019; 38:636-646. [PMID: 30795962 DOI: 10.1016/j.healun.2019.01.1318] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We previously reported a microarray-based diagnostic system for heart transplant endomyocardial biopsies (EMBs), using either 3-archetype (3AA) or 4-archetype (4AA) unsupervised algorithms to estimate rejection. In the present study we examined the stability of machine-learning algorithms in new biopsies, compared 3AA vs 4AA algorithms, assessed supervised binary classifiers trained on histologic or molecular diagnoses, created a report combining many scores into an ensemble of estimates, and examined possible automated sign-outs. METHODS We studied 889 EMBs from 454 transplant recipients at 8 centers: the initial cohort (N = 331) and a new cohort (N = 558). Published 3AA algorithms derived in Cohort 331 were tested in Cohort 558, the 3AA and 4AA models were compared, and supervised binary classifiers were created. RESULTS A`lgorithms derived in Cohort 331 performed similarly in new biopsies despite differences in case mix. In the combined cohort, the 4AA model, including a parenchymal injury score, retained correlations with histologic rejection and DSA similar to the 3AA model. Supervised molecular classifiers predicted molecular rejection (areas under the curve [AUCs] >0.87) better than histologic rejection (AUCs <0.78), even when trained on histology diagnoses. A report incorporating many AA and binary classifier scores interpreted by 1 expert showed highly significant agreement with histology (p < 0.001), but with many discrepancies, as expected from the known noise in histology. An automated random forest score closely predicted expert diagnoses, confirming potential for automated signouts. CONCLUSIONS Molecular algorithms are stable in new populations and can be assembled into an ensemble that combines many supervised and unsupervised estimates of the molecular disease states.
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22
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Halloran PF, Reeve J, Aliabadi AZ, Cadeiras M, Crespo-Leiro MG, Deng M, Depasquale EC, Goekler J, Jouven X, Kim DH, Kobashigawa J, Loupy A, Macdonald P, Potena L, Zuckermann A, Parkes MD. Exploring the cardiac response to injury in heart transplant biopsies. JCI Insight 2018; 3:123674. [PMID: 30333303 DOI: 10.1172/jci.insight.123674] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/11/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Because injury is universal in organ transplantation, heart transplant endomyocardial biopsies present an opportunity to explore response to injury in heart parenchyma. Histology has limited ability to assess injury, potentially confusing it with rejection, whereas molecular changes have potential to distinguish injury from rejection. Building on previous studies of transcripts associated with T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), we explored transcripts reflecting injury. METHODS Microarray data from 889 prospectively collected endomyocardial biopsies from 454 transplant recipients at 14 centers were subjected to unsupervised principal component analysis and archetypal analysis to detect variation not explained by rejection. The resulting principal component and archetype scores were then examined for their transcript, transcript set, and pathway associations and compared to the histology diagnoses and left ventricular function. RESULTS Rejection was reflected by principal components PC1 and PC2, and by archetype scores S2TCMR, and S3ABMR, with S1normal indicating normalness. PC3 and a new archetype score, S4injury, identified unexplained variation correlating with expression of transcripts inducible in injury models, many expressed in macrophages and associated with inflammation in pathway analysis. S4injury scores were high in recent transplants, reflecting donation-implantation injury, and both S4injury and S2TCMR were associated with reduced left ventricular ejection fraction. CONCLUSION Assessment of injury is necessary for accurate estimates of rejection and for understanding heart transplant phenotypes. Biopsies with molecular injury but no molecular rejection were often misdiagnosed rejection by histology.TRAIL REGISTRATION. ClinicalTrials.gov NCT02670408FUNDING. Roche Organ Transplant Research Foundation, the University of Alberta Hospital Foundation, and Alberta Health Services.
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Affiliation(s)
- Philip F Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Martin Cadeiras
- Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | | | - Mario Deng
- Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | | | | | | | - Daniel H Kim
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Peter Macdonald
- The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Luciano Potena
- Cardiovascular Department, University of Bologna, Bologna, Italy
| | | | - Michael D Parkes
- Alberta Transplant Applied Genomics Centre, Edmonton, Alberta, Canada
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23
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Epailly E, Chenard MP, Van Huyen JPD. Biopsy-Negative Rejection: a Rare but Difficult Issue in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dorr CR, Oetting WS, Jacobson PA, Israni AK. Genetics of acute rejection after kidney transplantation. Transpl Int 2017; 31:263-277. [PMID: 29030886 DOI: 10.1111/tri.13084] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/07/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
Abstract
Treatment of acute rejection (AR) following kidney transplantation has improved in recent years, but there are still limitations to successful outcomes. This review article covers literature in regard to recipient and donor genetics of AR kidney and secondarily of liver allografts. Many candidate gene and some genome-wide association studies (GWASs) have been conducted for AR in kidney transplantation. Genetic associations with AR in kidney and liver are mostly weak, and in most cases, the associations have not been reproducible. A limitation in the study of AR is the lack of sufficiently large populations that account for population stratification to study the AR phenotype which in this era occurs in <10% of transplants. Furthermore, the AR phenotype has been difficult to define and the definitions of classifications have evolved over time. Literature related to the pharmacogenomics of tacrolimus is robust and has been validated in many studies. Associations between gene expression and AR are emerging as markers of outcomes and AR classification. In the future, combinations of pretransplant genotype for AR risk prediction, genotype-based immune suppressant dosing, and pharmacogenomic markers to select AR maintenance or treatment and expression markers from biopsies may provide valuable clinical tools for guiding treatment.
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Affiliation(s)
- Casey R Dorr
- Department of Nephrology, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Ajay K Israni
- Department of Nephrology, Minneapolis Medical Research Foundation, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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Halloran PF, Potena L, Van Huyen JPD, Bruneval P, Leone O, Kim DH, Jouven X, Reeve J, Loupy A. Building a tissue-based molecular diagnostic system in heart transplant rejection: The heart Molecular Microscope Diagnostic (MMDx) System. J Heart Lung Transplant 2017; 36:1192-1200. [DOI: 10.1016/j.healun.2017.05.029] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 01/08/2023] Open
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Kransdorf EP, Kobashigawa JA. Novel molecular approaches to the detection of heart transplant rejection. Per Med 2017; 14:293-297. [DOI: 10.2217/pme-2017-0024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Antibody-mediated rejection in the cardiac allograft: diagnosis, treatment and future considerations. Curr Opin Cardiol 2017; 32:326-335. [PMID: 28212151 DOI: 10.1097/hco.0000000000000390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the latest publications dealing with antibody-mediated rejection (AMR) and defines areas of controversy and future steps that may improve the outcome for patients with this virulent form of rejection. RECENT FINDINGS Recent progress includes publication of standardized pathologic criteria for acute AMR by the International Society for Heart and Lung Transplantation (ISHLT) and guidelines for treatment of acute AMR by the American Heart Association, endorsed by ISHLT as well. Recently published review articles emphasize the important role of innate immune mechanisms, clarify the role of viral infection and provide insights into vascular biology and the role of innate effector populations, macrophages and dendritic cells. SUMMARY Strategies for future studies are discussed in the context of these new findings and similar efforts undertaken by renal and liver allograft investigators.
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Afzali B, Chapman E, Racapé M, Adam B, Bruneval P, Gil F, Kim D, Hidalgo L, Campbell P, Sis B, Duong Van Huyen JP, Mengel M. Molecular Assessment of Microcirculation Injury in Formalin-Fixed Human Cardiac Allograft Biopsies With Antibody-Mediated Rejection. Am J Transplant 2017; 17:496-505. [PMID: 27401781 DOI: 10.1111/ajt.13956] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/06/2016] [Accepted: 06/26/2016] [Indexed: 01/25/2023]
Abstract
Precise diagnosis of antibody-mediated rejection (AMR) in cardiac allograft endomyocardial biopsies (EMBs) remains challenging. This study assessed molecular diagnostics in human EMBs with AMR. A set of 34 endothelial, natural killer cell and inflammatory genes was quantified in 106 formalin-fixed, paraffin-embedded EMBs classified according to 2013 International Society for Heart and Lung Transplantation (ISHLT) criteria. The gene set expression was compared between ISHLT diagnoses and correlated with donor-specific antibody (DSA), endothelial injury by electron microscopy (EM) and prognosis. Findings were validated in an independent set of 57 EMBs. In the training set (n = 106), AMR cases (n = 70) showed higher gene set expression than acute cellular rejection (ACR; n = 21, p < 0.001) and controls (n = 15, p < 0.0001). Anti-HLA DSA positivity was associated with higher gene set expression (p = 0.01). Endothelial injury by electron microscopy strongly correlated with gene set expression, specifically in AMR cases (r = 0.62, p = 0.002). Receiver operating characteristic curve analysis for diagnosing AMR showed greater accuracy with gene set expression (area under the curve [AUC] = 79.88) than with DSA (AUC = 70.47) and C4d (AUC = 70.71). In AMR patients (n = 17) with sequential biopsies, increasing gene set expression was associated with inferior prognosis (p = 0.034). These findings were confirmed in the validation set. In conclusion, biopsy-based molecular assessment of antibody-mediated microcirculation injury has the potential to improve diagnosis of AMR in human cardiac transplants.
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Affiliation(s)
- B Afzali
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.,Institute for Pathology, University of Duisburg-Essen, Essen, Germany
| | - E Chapman
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - M Racapé
- Paris Translational Research Centre for Organ Transplantation, Paris Descartes University, Paris, France
| | - B Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - P Bruneval
- Paris Translational Research Centre for Organ Transplantation, Paris Descartes University, Paris, France
| | - F Gil
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - D Kim
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - L Hidalgo
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - P Campbell
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - B Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - J P Duong Van Huyen
- Paris Translational Research Centre for Organ Transplantation, Paris Descartes University, Paris, France
| | - M Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
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29
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Loupy A, Duong Van Huyen JP, Hidalgo L, Reeve J, Racapé M, Aubert O, Venner JM, Falmuski K, Bories MC, Beuscart T, Guillemain R, François A, Pattier S, Toquet C, Gay A, Rouvier P, Varnous S, Leprince P, Empana JP, Lefaucheur C, Bruneval P, Jouven X, Halloran PF. Gene Expression Profiling for the Identification and Classification of Antibody-Mediated Heart Rejection. Circulation 2017; 135:917-935. [PMID: 28148598 DOI: 10.1161/circulationaha.116.022907] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 01/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) contributes to heart allograft loss. However, an important knowledge gap remains in terms of the pathophysiology of AMR and how detection of immune activity, injury degree, and stage could be improved by intragraft gene expression profiling. METHODS We prospectively monitored 617 heart transplant recipients referred from 4 French transplant centers (January 1, 2006-January 1, 2011) for AMR. We compared patients with AMR (n=55) with a matched control group of 55 patients without AMR. We characterized all patients using histopathology (ISHLT [International Society for Heart and Lung Transplantation] 2013 grades), immunostaining, and circulating anti-HLA donor-specific antibodies at the time of biopsy, together with systematic gene expression assessments of the allograft tissue, using microarrays. Effector cells were evaluated with in vitro human cell cultures. We studied a validation cohort of 98 heart recipients transplanted in Edmonton, AB, Canada, including 27 cases of AMR and 71 controls. RESULTS A total of 240 heart transplant endomyocardial biopsies were assessed. AMR showed a distinct pattern of injury characterized by endothelial activation with microcirculatory inflammation by monocytes/macrophages and natural killer (NK) cells. We also observed selective changes in endothelial/angiogenesis and NK cell transcripts, including CD16A signaling and interferon-γ-inducible genes. The AMR-selective gene sets accurately discriminated patients with AMR from those without and included NK transcripts (area under the curve=0.87), endothelial activation transcripts (area under the curve=0.80), macrophage transcripts (area under the curve=0.86), and interferon-γ transcripts (area under the curve=0.84; P<0.0001 for all comparisons). These 4 gene sets showed increased expression with increasing pathological AMR (pAMR) International Society for Heart and Lung Transplantation grade (P<0.001) and association with donor-specific antibody levels. The unsupervised principal components analysis demonstrated a high proportion of molecularly inactive pAMR1(I+), and there was significant molecular overlap between pAMR1(H+) and full-blown pAMR2/3 cases. Endothelial activation transcripts, interferon-γ, and NK transcripts showed association with chronic allograft vasculopathy. The molecular architecture and selective AMR transcripts, together with gene set discrimination capacity for AMR identified in the discovery set, were reproduced in the validation cohort. CONCLUSIONS Tissue-based measurements of specific pathogenesis-based transcripts reflecting NK burden, endothelial activation, macrophage burden, and interferon-γ effects accurately classify AMR and correlate with degree of injury and disease activity. This study illustrates the clinical potential of a tissue-based analysis of gene transcripts to refine diagnosis of heart transplant rejection.
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Affiliation(s)
- Alexandre Loupy
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France.
| | - Jean Paul Duong Van Huyen
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Luis Hidalgo
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Jeff Reeve
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Maud Racapé
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Olivier Aubert
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Jeffery M Venner
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Konrad Falmuski
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Marie Cécile Bories
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Thibaut Beuscart
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Romain Guillemain
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Arnaud François
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Sabine Pattier
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Claire Toquet
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Arnaud Gay
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Philippe Rouvier
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Shaida Varnous
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Pascal Leprince
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Jean Philippe Empana
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Carmen Lefaucheur
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Patrick Bruneval
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Xavier Jouven
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
| | - Philip F Halloran
- From Paris Descartes University and Hôpital Necker, Assistance Publique-Hôpitaux de Paris, France (A.L., J.P.D.V.H., M.R.); Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, France (A.L., J.P.D.V.H., O.A., T.B., J.P.E., C.L., P.B., X.J.); Pathology Department, Necker Hospital, Paris, France (J.P.D.V.H.); Alberta Transplant Applied Genomics Centre; University of Alberta, Edmonton, AB, Canada (L.H., J.R., J.M.V., K.F., P.F.H.); Cardiology Department and Intensive Care (M.C.B.), Cardiology and Heart Transplant Department (R.G., X.J.), and Pathology Department (P.B.), Georges Pompidou Hospital, Paris, France; Pathology (P.R.) and Cardiac Surgery Departments (S.V., P.L.), La Pitié Salpétrière Hospital, Paris; Pathology (C.T.) and Thoracic and Cardiovascular Surgery Departments (S.P), Laennec Hospital, Nantes; Pathology (A.F.) and Cardiovascular Surgery Departments (A.G), Charles Nicolle Hospital, Rouen, France
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Bodez D, Hocini H, Tchitchek N, Tisserand P, Benhaiem N, Barau C, Kharoubi M, Guellich A, Guendouz S, Radu C, Couetil JP, Ghaleh B, Dubois-Randé JL, Teiger E, Hittinger L, Levy Y, Damy T. Myocardial Gene Expression Profiling to Predict and Identify Cardiac Allograft Acute Cellular Rejection: The GET-Study. PLoS One 2016; 11:e0167213. [PMID: 27898719 PMCID: PMC5127573 DOI: 10.1371/journal.pone.0167213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 11/10/2016] [Indexed: 11/24/2022] Open
Abstract
Aims Serial invasive endomyocardial biopsies (EMB) remain the gold standard for acute cellular rejection (ACR) diagnosis. However histological grading has several limitations. We aimed to explore the value of myocardial Gene Expression Profiling (GEP) for diagnosing and identifying predictive biomarkers of ACR. Methods A case-control study nested within a retrospective heart transplant patients cohort included 126 patients with median (IQR) age 50 (41–57) years and 111 (88%) males. Among 1157 EMB performed, 467 were eligible (i.e, corresponding to either ISHLT grade 0 or ≥3A), among which 36 were selected for GEP according to the grading: 0 (CISHLT, n = 13); rejection ≥3A (RISHLT, n = 13); 0 one month before ACR (BRISHLT, n = 10). Results We found 294 genes differentially expressed between CISHLT and RISHLT, mainly involved in immune activation, and inflammation. Hierarchical clustering showed a clear segregation of CISHLT and RISHLT groups and heterogeneity of GEP within RISHLT. All EMB presented immune activation, but some RISHLT EMB were strongly subject to inflammation, whereas others, closer to CISHLT, were characterized by structural modifications with lower inflammation level. We identified 15 probes significantly different between BRISHLT and CISHLT, including the gene of the muscular protein TTN. This result suggests that structural alterations precede inflammation in ACR. Linear Discriminant Analysis based on these 15 probes was able to identify the histological status of every 36 samples. Conclusion Myocardial GEP is a helpful method to accurately diagnose ACR, and predicts rejection one month before its histological occurrence. These results should be considered in cardiac allograft recipients’ care.
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Affiliation(s)
- Diane Bodez
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
| | - Hakim Hocini
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- Vaccine Research Institute (VRI), Henri Mondor Teaching Hospital, Créteil, France
| | - Nicolas Tchitchek
- CEA, DSV/iMETI, Immunology of viral infections and autoimmune diseases research unit, Fontenay-aux-Roses, France
- UMR1184, IDMIT infrastructure, Fontenay-aux-Roses, France
| | - Pascaline Tisserand
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- Vaccine Research Institute (VRI), Henri Mondor Teaching Hospital, Créteil, France
| | - Nicole Benhaiem
- AP-HP, Department of Pathology, Henri Mondor Teaching Hospital, Créteil, France
| | - Caroline Barau
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- AP-HP, Platform of Biological Resources, Henri Mondor Teaching Hospital, Créteil, France
| | - Mounira Kharoubi
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- GRC Amyloid Research Institute, Henri Mondor Teaching Hospital, Créteil, France
| | - Aziz Guellich
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
- GRC Amyloid Research Institute, Henri Mondor Teaching Hospital, Créteil, France
| | - Soulef Guendouz
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
- GRC Amyloid Research Institute, Henri Mondor Teaching Hospital, Créteil, France
| | - Costin Radu
- AP-HP, Department of Cardiac Surgery, Henri Mondor Teaching Hospital, Créteil, France
| | - Jean-Paul Couetil
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- AP-HP, Department of Cardiac Surgery, Henri Mondor Teaching Hospital, Créteil, France
| | - Bijan Ghaleh
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- AP-HP, Platform of Biological Resources, Henri Mondor Teaching Hospital, Créteil, France
| | - Jean-Luc Dubois-Randé
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
| | - Emmanuel Teiger
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
| | - Luc Hittinger
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
| | - Yves Levy
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- Vaccine Research Institute (VRI), Henri Mondor Teaching Hospital, Créteil, France
- AP-HP, Clinical Immunology, Henri Mondor Teaching Hospital, Créteil, France
- * E-mail: (YL); (TD)
| | - Thibaud Damy
- AP-HP, Department of Cardiology, Henri Mondor Teaching Hospital, Créteil, France
- School of Medicine, Paris-Est-Créteil University (UPEC), Créteil, France
- IMRB INSERM U955, Paris-Est-Créteil University (UPEC), Créteil F-94000, France`
- DHU ATVB, Henri Mondor Teaching Hospital, Creteil, France
- GRC Amyloid Research Institute, Henri Mondor Teaching Hospital, Créteil, France
- * E-mail: (YL); (TD)
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Kalnins A, Thomas MN, Andrassy M, Müller S, Wagner A, Pratschke S, Rentsch M, Klussmann S, Kauke T, Angele MK, Bazhin AV, Fischereder M, Werner J, Guba M, Andrassy J. Spiegelmer Inhibition of MCP-1/CCR2--Potential as an Adjunct Immunosuppressive Therapy in Transplantation. Scand J Immunol 2015; 82:102-9. [PMID: 25970072 DOI: 10.1111/sji.12310] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/03/2015] [Indexed: 01/01/2023]
Abstract
The rejection process remains the key unsolved issue after transplantation of disparate tissue. The CC chemokine monocyte chemoattractant protein-1 (MCP-1/CCL2) has been reported to be involved in the process of alloimmune interaction. Spiegelmers are l-oligonucleotides that can be designed to bind to pharmacologically relevant target molecules. Here, we tested a high-affinity Spiegelmer-based MCP-1 inhibitor (mNOX-E36) in an allogeneic heart transplant model. Fully vascularized allogeneic heterotopic heart transplantations from BALB/c to C57BL/6 mice were performed. Mice were either treated with the anti-MCP-1-Spiegelmer (mNOX-E36) in monotherapy or in combination with subtherapeutic doses of cyclosporine A (CsA) (10 mg/kgBW/day) for 10 days. Controls received equivalent doses of a non-functional Spiegelmer (revmNOX-E36). Graft survival of allogeneic heart transplants was slightly but significantly prolonged under mNOX-E36 monotherapy (median graft survival 10 day ± 0.7) compared to revmNOX-E36 (median graft survival 7 day ± 0.3; P = 0.001). A synergistic beneficial effect could be seen when mNOX-E36 was administered in combination with subtherapeutic doses of CsA (18 day ± 2.8 versus 7 day ± 0.3; P < 0.0001). Levels of inflammatory cytokines and 'alarmins' were significantly reduced, and the number of F4/80(+) cells was lower under combination therapy (1.8% ± 1.3%; versus 14.6% ± 4.4%; P = 0.0002). This novel inhibitor of the MCP-1/CCR2 axis (mNOX-E36), which has already proven efficacy and tolerability in early clinical trials, alleviates acute rejection processes in allogeneic transplantation especially when combined with subtherapeutic doses of CsA. Thus, mNOX-E36 may have potential as an adjunct immunomodulatory agent.
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Affiliation(s)
- A Kalnins
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M N Thomas
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M Andrassy
- Department of Medicine, Rupprecht-Karl's University, Heidelberg, Germany
| | - S Müller
- Department of Pathology, Ludwig-Maximilian's University, Munich, Germany
| | - A Wagner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - S Pratschke
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | | | - T Kauke
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - A V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M Fischereder
- Division of Nephrology, Department of Medicine, Med IV, Ludwig-Maximilian's University, Munich, Germany
| | - J Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - M Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
| | - J Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilian's-University Munich, Munich, Germany
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Daly KP. Circulating donor-derived cell-free DNA: a true biomarker for cardiac allograft rejection? ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:47. [PMID: 25861602 DOI: 10.3978/j.issn.2305-5839.2015.01.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/26/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Kevin P Daly
- 1 Transplant Research Program & Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA ; 2 Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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33
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Halloran B, Chang J, Shih DQ, McGovern D, Famulski K, Evaschesen C, Fedorak RN, Thiesen A, Targan S, Halloran PF. Molecular patterns in human ulcerative colitis and correlation with response to infliximab. Inflamm Bowel Dis 2014; 20:2353-63. [PMID: 25397893 PMCID: PMC4985265 DOI: 10.1097/mib.0000000000000239] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND As a T cell-mediated disease of the colonic epithelium, ulcerative colitis (UC) is likely to share pathogenic elements with other T cell-mediated inflammatory diseases. Recently, microarray analysis revealed large-scale molecular changes in T cell-mediated rejection of kidney and heart transplants. We hypothesized that similar disturbances might be operating in UC and could provide insights into responsiveness to therapy. METHODS We studied 56 colon biopsies from patients with colitis characterizing the clinical and histological features and using microarrays to define the messenger RNA phenotype. We expressed the microarray results using previously defined pathogenesis-based transcript sets. We also studied 48 published microarray files from human colon biopsies downloaded from the Gene Expression Omnibus database, classified by response to infliximab therapy, to examine whether the molecular measurements derived from our studies correlated with nonresponsiveness to treatment. RESULTS UC biopsies manifested coordinate transcript changes resembling rejecting transplants, with effector T cell, IFNG-induced, macrophage, and injury transcripts increasing while parenchymal transcripts decreased. The disturbance in gene expression, summarized as principal component 1 (PC1), correlated with conventional clinical and histologic assessments. When assessed in microarray results from published studies, the disturbance (PC1) predicted response to infliximab: patients with intense disturbance did not achieve clinical response, although quantitative improvement was seen even in many clinical nonresponders. Similar changes were seen in Crohn's colitis. CONCLUSIONS The molecular phenotype of UC manifests a large-scale coordinate disturbance reflecting changes in inflammatory cells and parenchymal elements that correlates with conventional features and predicts response to infliximab.
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Affiliation(s)
- Brendan Halloran
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
- F. Widjaja Foundation, Inflammatory Bowel & Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | - David Q. Shih
- F. Widjaja Foundation, Inflammatory Bowel & Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Dermot McGovern
- F. Widjaja Foundation, Inflammatory Bowel & Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Konrad Famulski
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Chad Evaschesen
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Richard N Fedorak
- Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Aducio Thiesen
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Stephan Targan
- F. Widjaja Foundation, Inflammatory Bowel & Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Philip F. Halloran
- Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, AB, Canada
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Fedrigo M, Feltrin G, Poli F, Frigo AC, Benazzi E, Gambino A, Tona F, Caforio ALP, Castellani C, Toscano G, Gerosa G, Thiene G, Angelini A. Intravascular macrophages in cardiac allograft biopsies for diagnosis of early and late antibody-mediated rejection. J Heart Lung Transplant 2013; 32:404-9. [PMID: 23498161 DOI: 10.1016/j.healun.2012.12.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 11/13/2012] [Accepted: 12/13/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of our study was to evaluate the role of intravascular macrophages in the diagnosis of early and late antibody-mediated rejection (AMR) on endomyocardial biopsies (EMBs). METHODS We reviewed 1,420 consecutive EMBs from 131 patients and selected 75 C4d+ EMBs. The C4d+ group was compared with a control group (66 patients) matched for age, gender, date of transplantation, follow-up, immunosuppressive regimen and primary heart disease. A total of 141 EMBs were evaluated. Immunoperoxidase staining for C4d and CD68 were performed. Post-transplant IgG anti-HLA reactivity was investigated by Luminex technology. Clinical data were also collected. Fourteen EMBs were available from 11 symptomatic AMR patients. RESULTS Of the 141 EMBs evaluated, 53 were positive for intravascular macrophages (CD68); among them, 32 were also positive for C4d (32 of 53, 60.4%). Of the 88 CD68- EMBs, 43 were also C4d+ (43 of 88, 48.9%). Of the 53 CD68+ EMBs, 30 EMBs were within the first year since transplantation (30 of 53, 57.8%), and among these 21 were also positive for C4d (21 of 30, 70.0%). In the late period, among the 23 CD68+ EMBs (23 of 53, 42.2%) 11 were also positive for C4d (11 of 23, 47.8%). In the early period, intravascular macrophages were more common in symptomatic (3 of 3, 100%) than asymptomatic (3 of 11, 27.3%) patients. Sensitivity and specificity of intravascular macrophages in predicting donor-specific antibodies (DSA) within the first year were 50.0% and 100.0%, respectively. CONCLUSIONS Intravascular macrophages predict C4d, DSA and symptoms early after transplantation; however, in the late period, they are unable to identify patients with circulating DSA, C4d and/or symptoms.
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Affiliation(s)
- Marny Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Pathologic classification of antibody-mediated rejection correlates with donor-specific antibodies and endothelial cell activation. J Heart Lung Transplant 2013; 32:769-76. [DOI: 10.1016/j.healun.2013.05.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 05/05/2013] [Accepted: 05/23/2013] [Indexed: 11/21/2022] Open
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Zhang G, Chen G, Liu L, Qiu J, Chen L. A novel accelerated rejection model for mouse cardiac transplantation involving presensitization with donor splenocytes. J Surg Res 2013; 181:146-55. [PMID: 22683077 DOI: 10.1016/j.jss.2012.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 04/27/2012] [Accepted: 05/08/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Accelerated rejection is a type of refractory rejection. Animal models of accelerated rejection are widely employed in research on transplant immunity. METHODS We divided 36 C57BL/6 mice into six groups that underwent heart transplant. To select the ideal number of splenocytes for the presensitization to induce accelerated rejection, were transferred 0.5 × 10(7), 1 × 10(7), 5 × 10(7), or 10 × 10(7) donor splenocytes 7 d before transplantation. We confirmed successful presensitization by increases in donor-reactive antibodies. We performed 12 additional heart transplants in the accelerated rejection group and the control groups for a histological examination, immunohistochemical staining for C3d, and a splenocyte test using flow cytometry. RESULTS The transfer of 5 × 10(7) donor splenocytes effectively and efficiently induced an accelerated rejection in the BALB/c→C57BL/6 heart transplant, with an allograft survival time that was decreased from 7.4 ± 0.5 d to 3.5 ± 0.8 d compared with the allogenic controls (P < 0.05, log-rank test). An analysis of this model indicated that compared with acute rejection, the number of donor-reactive antibodies was significantly increased, and the proportions of effector memory CD8(+) T cells and plasmacytes in the spleen were significantly increased (7.81% ± 1.2% versus 2.96% ± 1.0%, P = 0.006; 1.27% ± 0.13% versus 0.71% ± 0.22%, P = 0.018, respectively). We found the histological characteristics of both cellular and humoral rejection in the accelerated rejection model. CONCLUSIONS Presensitization via the transfer of donor splenocytes facilitates the establishment of an accelerated rejection model. Our findings with this model indicate that humoral rejection and cellular rejection are coexistent, and that the proportions of effector memory CD8(+) T cells and plasmacytes in the spleen increase significantly during accelerated rejection.
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Affiliation(s)
- Gang Zhang
- Department of Organ Transplantation, First Affiliated Hospital of Sun Yat-sen University, Guang Zhou, Guang Dong Province, China
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Molecular transplantation pathology: the interface between molecules and histopathology. Curr Opin Organ Transplant 2013; 18:354-62. [PMID: 23619514 DOI: 10.1097/mot.0b013e3283614c90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW In the last decade, high-throughput molecular screening methods have revolutionized the transplantation research. This article reviews the new knowledge that has emerged from transplant patient sample-derived 'omics data by examining the interface between molecular signals and allograft pathology. RECENT FINDINGS State-of-the-art molecular studies have shed light on the biology of organ transplant diseases and provided several potential molecular tests with diagnostic, prognostic, and theranostic applications for the implementation of personalized medicine in transplantation. By comprehensive molecular profiling of patient samples, we have learned numerous new insights into the effector mechanisms and parenchymal response during allograft diseases. It has become evident that molecular profiles are coordinated and move in patterns similar to histopathology lesions, and therefore lack qualitative specificity. However, molecular tests can empower precision diagnosis and prognostication through their objective and quantitative manner when they are integrated in a holistic approach with histopathology and clinical factors of patients. SUMMARY Despite clever science and large amounts of public money invested in transplant 'omics studies, multiparametric molecular testing has not yet been translated to patient care. There are serious challenges in the implementation of transplant molecular diagnostics that have increased frustration in transplant community. We appeal for a full collaboration between pathologists and researchers to accelerate transition from research to clinical practice in transplantation.
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Labarrere CA, Woods JR, Hardin JW, Campana GL, Ortiz MA, Jaeger BR, Baldridge LA, Pitts DE, Kirlin PC. Value of the first post-transplant biopsy for predicting long-term cardiac allograft vasculopathy (CAV) and graft failure in heart transplant patients. PLoS One 2012; 7:e36100. [PMID: 22558345 PMCID: PMC3338502 DOI: 10.1371/journal.pone.0036100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 03/29/2012] [Indexed: 11/18/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) is the principal cause of long-term graft failure following heart transplantation. Early identification of patients at risk of CAV is essential to target invasive follow-up procedures more effectively and to establish appropriate therapies. We evaluated the prognostic value of the first heart biopsy (median: 9 days post-transplant) versus all biopsies obtained within the first three months for the prediction of CAV and graft failure due to CAV. Methods and Findings In a prospective cohort study, we developed multivariate regression models evaluating markers of atherothrombosis (fibrin, antithrombin and tissue plasminogen activator [tPA]) and endothelial activation (intercellular adhesion molecule-1) in serial biopsies obtained during the first three months post-transplantation from 172 patients (median follow-up = 6.3 years; min = 0.37 years, max = 16.3 years). Presence of fibrin was the dominant predictor in first-biopsy models (Odds Ratio [OR] for one- and 10-year graft failure due to CAV = 38.70, p = 0.002, 95% CI = 4.00–374.77; and 3.99, p = 0.005, 95% CI = 1.53–10.40) and loss of tPA was predominant in three-month models (OR for one- and 10-year graft failure due to CAV = 1.81, p = 0.025, 95% CI = 1.08–3.03; and 1.31, p = 0.001, 95% CI = 1.12–1.55). First-biopsy and three-month models had similar predictive and discriminative accuracy and were comparable in their capacities to correctly classify patient outcomes, with the exception of 10-year graft failure due to CAV in which the three-month model was more predictive. Both models had particularly high negative predictive values (e.g., First-biopsy vs. three-month models: 99% vs. 100% at 1-year and 96% vs. 95% at 10-years). Conclusions Patients with absence of fibrin in the first biopsy and persistence of normal tPA in subsequent biopsies rarely develop CAV or graft failure during the next 10 years and potentially could be monitored less invasively. Presence of early risk markers in the transplanted heart may be secondary to ischemia/reperfusion injury, a potentially modifiable factor.
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Affiliation(s)
- Carlos A Labarrere
- Experimental Pathology, Methodist Research Institute, Indiana University Health Methodist Hospital, Indianapolis, Indiana, USA.
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Pascual-Figal DA, Garrido IP, Blanco R, Minguela A, Lax A, Ordoñez-Llanos J, Bayes-Genis A, Valdés M, Moore SA, Januzzi JL. Soluble ST2 Is a Marker for Acute Cardiac Allograft Rejection. Ann Thorac Surg 2011; 92:2118-24. [DOI: 10.1016/j.athoracsur.2011.07.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 07/10/2011] [Accepted: 07/18/2011] [Indexed: 11/24/2022]
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Spivey TL, Uccellini L, Ascierto ML, Zoppoli G, De Giorgi V, Delogu LG, Engle AM, Thomas JM, Wang E, Marincola FM, Bedognetti D. Gene expression profiling in acute allograft rejection: challenging the immunologic constant of rejection hypothesis. J Transl Med 2011; 9:174. [PMID: 21992116 PMCID: PMC3213224 DOI: 10.1186/1479-5876-9-174] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 10/12/2011] [Indexed: 02/06/2023] Open
Abstract
In humans, the role and relationship between molecular pathways that lead to tissue destruction during acute allograft rejection are not fully understood. Based on studies conducted in humans, we recently hypothesized that different immune-mediated tissue destruction processes (i.e. cancer, infection, autoimmunity) share common convergent final mechanisms. We called this phenomenon the "Immunologic Constant of Rejection (ICR)." The elements of the ICR include molecular pathways that are consistently described through different immune-mediated tissue destruction processes and demonstrate the activation of interferon-stimulated genes (ISGs), the recruitment of cytotoxic immune cells (primarily through CXCR3/CCR5 ligand pathways), and the activation of immune effector function genes (IEF genes; granzymes A/B, perforin, etc.). Here, we challenge the ICR hypothesis by using a meta-analytical approach and systematically reviewing microarray studies evaluating gene expression on tissue biopsies during acute allograft rejection. We found the pillars of the ICR consistently present among the studies reviewed, despite implicit heterogeneity. Additionally, we provide a descriptive mechanistic overview of acute allograft rejection by describing those molecular pathways most frequently encountered and thereby thought to be most significant. The biological role of the following molecular pathways is described: IFN-γ, CXCR3/CCR5 ligand, IEF genes, TNF-α, IL-10, IRF-1/STAT-1, and complement pathways. The role of NK cell, B cell and T-regulatory cell signatures are also addressed.
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Affiliation(s)
- Tara L Spivey
- Infectious Disease and Immunogenetics Section (IDIS), Department of Transfusion Medicine, Clinical Center and trans-NIH Center for Human Immunology (CHI), National Institutes of Health, Bethesda, Maryland 20892, USA
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Baldwin WM, Halushka MK, Valujskikh A, Fairchild RL. B cells in cardiac transplants: from clinical questions to experimental models. Semin Immunol 2011; 24:122-30. [PMID: 21937238 DOI: 10.1016/j.smim.2011.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/24/2011] [Indexed: 12/31/2022]
Abstract
After many years of debate, there is now general agreement that B cells can participate in the immune response to cardiac transplants. Acute antibody-mediated rejection (AMR) is the best defined manifestation of B cell responses, but diagnostic and mechanistic questions still surround AMR. Many complement dependent mechanisms of antibody-mediated injury have been elucidated. C5 has become a therapeutic target that may not just truncate complement activation, but also may tip the balance away from inflammation by altering macrophage function. Additional complement independent effects have been identified. These may escape diagnosis and progress to chronic graft injury. The function of B cell infiltrates in cardiac transplants is even more enigmatic. Nodular endocardial infiltrates that contain B cells and plasma cells have been described in protocol biopsies of cardiac transplants for decades, but an understanding of their significance is still evolving based on more critical morphological and molecular evaluation of these infiltrates. A range of infiltrates containing B cells has also been described in the epicardial fat in transplants with advanced chronic rejection. B cells have been observed in endocardial and epicardial tertiary lymphoid nodules, but their impact on antigen presentation or antibody production remains to be determined. Experimental models in small and large animals suggest that B cells could be essential for the formation of lymphoid nodules through cytokine production. Similarly, the role of proinflammatory adipokines in the formation or function of epicardial lymphoid nodules has not been studied. These clinical observations provide critical questions to be addressed in experimental models.
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Affiliation(s)
- William M Baldwin
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH, USA.
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[Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation]. Rev Esp Cardiol 2011; 64:1109-13. [PMID: 21924812 DOI: 10.1016/j.recesp.2011.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 06/19/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.
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Loupy A, Cazes A, Guillemain R, Amrein C, Hedjoudje A, Tible M, Pezzella V, Fabiani JN, Suberbielle C, Nochy D, Hill GS, Empana JP, Jouven X, Bruneval P, Duong Van Huyen JP. Very late heart transplant rejection is associated with microvascular injury, complement deposition and progression to cardiac allograft vasculopathy. Am J Transplant 2011; 11:1478-87. [PMID: 21668629 DOI: 10.1111/j.1600-6143.2011.03563.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In heart transplants, the significance of very late rejection (after 7 years post-transplant, VLR) detected by routine endomyocardial biopsies (EMB) remains uncertain. Here, we assessed the prevalence, histopathological and immunological phenotype, and outcome of VLR in clinically stable patients. Between 1985 and 2009, 10 662 protocol EMB were performed at our institution in 398 consecutive heart transplants recipients. Among the 196 patients with >7-year follow-up, 20 (10.2%) presented subclinical ≥3A/2R-ISHLT rejection. The VLR group was compared to a matched control group of patients without rejection. All biopsies were stained for C4d/C3d/CD68 with sera screened for the presence of donor-specific antibodies (DSAs). In addition to cellular infiltrates with myocyte damage, 60% of VLR patients had evidence of intravascular macrophages. C4d and/or C3d-capillary deposition was found in 55% VLR EMB. All cases of VLR associated with microcirculation injury had DSAs (mean DSA(max) -MFI = 1751 ± 583). This entity was absent from the control group (p < 0.0001). Finally, after a similar follow-up postreference EMB of 6.4 ± 1 years, the mean of CAV grade was 0.76 ± 0.18 in the control group compared to 2.06 ± 0.26 in the VLR group respectively, p = 0.001). There was no difference in patient survival between study and control groups. In conclusion, VLR is frequently associated with complement-cascade activation, microvascular injury and DSA, suggesting an antibody-mediated process. VLR is associated with a dramatic progression to severe CAV in long-term follow-up.
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Affiliation(s)
- A Loupy
- Service de Transplantation Rénale et de Soins Intensifs, Hôpital Necker, APHP, Paris, F-75015, France
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Abstract
Immune-modulation therapy has had great success in various inflammatory diseases. Despite the promising results of preliminary studies in anti-tumor necrosis factor-α therapies, large randomized studies have lacked positive clinical outcomes in patients with heart failure. These results have led to the idea that therapies directed toward specific inflammatory mediators may not be the answer and lead us toward the development of novel anti-inflammatory strategies that may involve a broader spectrum of inflammatory mediators. Therapeutic plasma exchange has been demonstrated as a safe treatment, and preliminary outcomes led us to develop new treatment schemes.
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Holweg CTJ, Potena L, Luikart H, Yu T, Berry GJ, Cooke JP, Valantine HA, Mocarski ES. Identification and classification of acute cardiac rejection by intragraft transcriptional profiling. Circulation 2011; 123:2236-43. [PMID: 21555702 DOI: 10.1161/circulationaha.109.913921] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of acute rejection (AR) in heart transplantation relies on histopathological grading of endomyocardial biopsies according to International Society for Heart and Lung Transplantation guidelines. Intragraft gene expression profiling may be a way to complement histological evaluation. METHODS AND RESULTS Transcriptional profiling was performed on 26 endomyocardial biopsies, and expression patterns were compared with the 1990 International Society for Heart and Lung Transplantation AR grades. Importantly, transcriptional profiles from settings with an equivalent AR grade appeared the same. In addition, grade 0 profiles could not be distinguished from 1A profiles, and grade 3A profiles could not be distinguished from 3B profiles. Comparing the AR groupings (0+1A, 1B, and 3A+3B), 0+1A showed more striking differences from 1B than from 3A+3B. When these findings were extrapolated to the 2005 revised guidelines, the combination of 1A and 1B into a single category (1R) appears to have brought together endomyocardial biopsies with different underlying processes that are not evident from histological evaluation. Grade 1B was associated with upregulated immune response genes, as 1 categorical distinction from grade 1A. Although grade 1B was distinct from the clinically relevant AR grades 3A and 3B, all of these grades shared a small number of overlapping pathways consistent with common physiological underpinnings. CONCLUSION The gene expression similarities and differences identified here in different AR settings have the potential to revise the clinical perspective on acute graft rejection, pending the results of larger studies.
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Affiliation(s)
- Cécile T J Holweg
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Mengel M, Chang J, Kayser D, Gwinner W, Schwarz A, Einecke G, Broecker V, Famulski K, de Freitas DG, Guembes-Hidalgo L, Sis B, Haller H, Halloran PF. The molecular phenotype of 6-week protocol biopsies from human renal allografts: reflections of prior injury but not future course. Am J Transplant 2011; 11:708-18. [PMID: 21114657 DOI: 10.1111/j.1600-6143.2010.03339.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed the molecular phenotype of 107 6-week protocol biopsies from human renal allografts, using Affymetrix microarrays. Transcript changes were summarized as nonoverlapping pathogenesis-based transcript sets (PBTs) reflecting inflammation (T cells, macrophages, IFNG effects) and the injury-repair response of the parenchyma, stroma and microcirculation-increased ('injury-up') and decreased ('injury-down') transcripts. The molecular changes were highly correlated with each other, even when all rejection and borderline cases were excluded. Inflammation and injury-down PBTs correlated with histologic inflammation and tubulitis, and the inflammation transcripts were greater in kidneys diagnosed as T cell-mediated or borderline rejection. Injury-up PBTs did not correlate with histopathology but did correlate with kidney function: thus functional disturbances are represented in transcript changes but not in histopathology. PBT changes correlated with prior delayed graft function. However, there was little difference between live donor kidneys and deceased donor kidneys that had not shown delayed graft function. Molecular changes did not predict future biopsies for clinical indications, rejection episodes, functional deterioration or allograft loss. Thus while detecting T cell-mediated inflammation, the molecular phenotype of early protocol biopsies mostly reflects the injury-repair response to implantation stresses, and has little relationship to future events and outcomes.
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Affiliation(s)
- M Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada.
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