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Kim PJ, Cusi V, Cardenas A, Tada Y, Vaida F, Wettersten N, Chak J, Bijlani P, Pretorius V, Urey MA, Morris GP, Lin G. Antibody Mediated Rejection is not Associated with Worse Survival in Adherent Heart Transplant Patients in the Contemporary Era. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.01.23299311. [PMID: 38106112 PMCID: PMC10723500 DOI: 10.1101/2023.12.01.23299311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background C4d immunostaining of surveillance endomyocardial biopsies (EMB) and testing for donor specific antibodies (DSA) are routinely performed in the first year of heart transplantation (HTx) in adult patients. C4d and DSA positivity have not been evaluated together with respect to clinical outcomes in the contemporary era (2010-current). Methods This was a single center, retrospective study of consecutive EMBs performed between November 2010 and April 2023. The primary objective was to determine whether history of C4d and/or DSA positivity could predict death, cardiac death, or retransplant. Secondary analyses included cardiac allograft dysfunction and cardiac allograft vasculopathy. Cox proportional hazards models were used for single predictor and multipredictor analyses. Results A total of 6,033 EMBs from 519 HTx patients were reviewed for the study. There was no significant difference (p = 0.110) in all-cause mortality or cardiac retransplant between four groups: C4d+/DSA+, C4d+/DSA-, C4d-/DSA+, and C4d-/DSA-. The risk for cardiac mortality or retransplant was significantly higher in C4d+/DSA+ versus C4d-/DSA- patients (HR = 4.73; pc = 0.042) but not significantly different in C4d+/DSA- versus C4d-/DSA- patients (pc = 1.000). Similarly, the risk for cardiac allograft dysfunction was significantly higher in C4d+/DSA+ versus C4d-/DSA- patients (HR 3.26; pc = 0.001) but not significantly different in C4d+/DSA- versus C4d-/DSA- patients (pc = 1.000). Accounting for nonadherence, C4d/DSA status continued to predict cardiac allograft dysfunction but no longer predicted cardiac death or retransplant. Conclusions Medically adherent C4d+/DSA+ HTx patients show significantly greater risk for cardiac allograft dysfunction but not cardiac mortality or retransplant. In contrast, C4d+/DSA- patients represent a new immunopathologic group with a clinical course similar to that of HTx patients without antibody mediated rejection.
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Affiliation(s)
| | | | - Ashley Cardenas
- Department of Pathology, University of California, San Diego, California, USA
| | | | - Florin Vaida
- Department of Family Medicine and Public Health, UC San Diego, La Jolla, CA
| | - Nicholas Wettersten
- Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | | | | | - Victor Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California, USA
| | | | - Gerald P Morris
- Department of Pathology, University of California, San Diego, California, USA
| | - Grace Lin
- Department of Pathology, University of California, San Diego, California, USA
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Ghaleb S, Wittekind SG, Martinez H, Kasten J, Gao Z, Hengehold T, Chin C. Antithymocyte globulin induction therapy and myocardial complement deposition in pediatric heart transplantation. Pediatr Transplant 2021; 25:e13998. [PMID: 33704881 DOI: 10.1111/petr.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/11/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antithymocyte globulin (ATG) consists of polyclonal antibodies directed primarily against human T lymphocytes but may contain antibodies with affinity for other tissues in the transplanted organ, resulting in complement (C4d) deposition. This phenomenon has been demonstrated in endomyocardial biopsies (EMBs) of adult cardiac transplants. We examined the relationship of induction immunosuppression with ATG and C4d deposition in EMB of pediatric cardiac transplants. METHODS Results of C4d immunohistochemistry were available from all EMB of patients transplanted at our center between June 2012 and April 2018 (n = 48) who received induction immunosuppression with either ATG (n = 20) or basiliximab (n = 28) as the standard of care. RESULTS C4d deposition in the first year post-heart transplant was more commonly seen among patients who received ATG induction (20% of EMBs in ATG group vs 1% of EMBs in basiliximab group; p < .0001). C4d deposition related to ATG was observed early post-transplant (50% ATG vs 0% basiliximab on first EMB; p < .0001 and 35% ATG vs 0% basiliximab on the second EMB; p = .0012). While this difference waned by the third EMB (5% ATG vs 0% basiliximab; p = .41), positive C4d staining persisted to the sixth EMB in the ATG group only (6%). CONCLUSION C4d deposition is common on EMB up to 1 year post-pediatric cardiac transplant following ATG induction. This high rate of positive C4d staining in the absence of histologic AMR after ATG induction therapy must be accounted for in making clinical decisions regarding cardiac allograft rejection diagnosis and treatment.
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Affiliation(s)
- Stephanie Ghaleb
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Samuel G Wittekind
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Hugo Martinez
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Jennifer Kasten
- Department of Pathology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Tricia Hengehold
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
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Fujino T, Kumai Y, Yang B, Kalantari S, Rodgers D, Henriksen K, Chang A, Husain A, Kim G, Sayer G, Uriel N. Discordance between immunofluorescence and immunohistochemistry C4d staining and outcomes following heart transplantation. Clin Transplant 2021; 35:e14242. [PMID: 33539043 DOI: 10.1111/ctr.14242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/17/2021] [Accepted: 01/25/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Capillary deposition of C4d is an important marker of antibody-mediated rejection (AMR) following heart transplantation (HT). There are two immunopathologic assay methods for detecting C4d: frozen-tissue immunofluorescence (IF) and paraffin immunohistochemistry (IHC). The clinical significance of discrepancy between the results of IF and IHC has not been understood. METHODS AND RESULTS We reviewed 2187 biopsies from 142 HT recipients who had biopsies with assessment of both IF and IHC staining. Among them, 103 (73%) patients had negative IF and IHC C4d staining (Negative Group) and 32 (23%) patients had positive IF but negative IHC staining (Discordant Group). At the time of positive biopsy, 6 (19%) Discordant patients had graft dysfunction, compared to 5 (5%) Negative patients (p = .022). Cumulative incidence of cellular rejection at 1 year was comparable (31% vs. 29%, p = .46); however, cumulative incidence of AMR was significantly higher in the Discordant group (21% vs. 4%, p = .004). Overall 1-year survival was comparable (90% vs. 96%, p = .24); however, freedom from heart failure (HF) was significantly lower in the Discordant group (70% vs. 96%, p < .001). CONCLUSION The Discordant group showed higher rates of graft dysfunction, AMR and HF admission than the Negative group.
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Affiliation(s)
- Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Yuto Kumai
- Cardiology Division, Columbia University, New York, NY, USA
| | - Benjamin Yang
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Anthony Chang
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Aliya Husain
- Department of Pathology, University of Chicago Medical Center, Chicago, IL, USA
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Gabriel Sayer
- Cardiology Division, Columbia University, New York, NY, USA
| | - Nir Uriel
- Cardiology Division, Columbia University, New York, NY, USA
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Bhagra S, Parameshwar J. Outcomes following cardiac transplantation in adults. Indian J Thorac Cardiovasc Surg 2020; 36:166-174. [DOI: 10.1007/s12055-019-00796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 10/27/2022] Open
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Cell-free DNA donor fraction analysis in pediatric and adult heart transplant patients by multiplexed allele-specific quantitative PCR: Validation of a rapid and highly sensitive clinical test for stratification of rejection probability. PLoS One 2020; 15:e0227385. [PMID: 31929557 PMCID: PMC6957190 DOI: 10.1371/journal.pone.0227385] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
Lifelong noninvasive rejection monitoring in heart transplant patients is a critical clinical need historically poorly met in adults and unavailable for children and infants. Cell-free DNA (cfDNA) donor-specific fraction (DF), a direct marker of selective donor organ injury, is a promising analytical target. Methodological differences in sample processing and DF determination profoundly affect quality and sensitivity of cfDNA analyses, requiring specialized optimization for low cfDNA levels typical of transplant patients. Using next-generation sequencing, we previously correlated elevated DF with acute cellular and antibody-mediated rejection (ACR and AMR) in pediatric and adult heart transplant patients. However, next-generation sequencing is limited by cost, TAT, and sensitivity, leading us to clinically validate a rapid, highly sensitive, quantitative genotyping test, myTAIHEART®, addressing these limitations. To assure pre-analytical quality and consider interrelated cfDNA measures, plasma preparation was optimized and total cfDNA (TCF) concentration, DNA fragmentation, and DF quantification were validated in parallel for integration into myTAIHEART reporting. Analytical validations employed individual and reconstructed mixtures of human blood-derived genomic DNA (gDNA), cfDNA, and gDNA sheared to apoptotic length. Precision, linearity, and limits of blank/detection/quantification were established for TCF concentration, DNA fragmentation ratio, and DF determinations. For DF, multiplexed high-fidelity amplification followed by quantitative genotyping of 94 SNP targets was applied to 1168 samples to evaluate donor options in staged simulations, demonstrating DF call equivalency with/without donor genotype. Clinical validation studies using 158 matched endomyocardial biopsy-plasma pairs from 76 pediatric and adult heart transplant recipients selected a DF cutoff (0.32%) producing 100% NPV for ≥2R ACR. This supports the assay’s conservative intended use of stratifying low versus increased probability of ≥2R ACR. myTAIHEART is clinically validated for heart transplant recipients ≥2 months old and ≥8 days post-transplant, expanding opportunity for noninvasive transplant rejection assessment to infants and children and to all recipients >1 week post-transplant.
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Zieliński T, Sobieszczańska-Małek M, Karczmarz M, Komuda K, Grajkowska W, Pronicki M, Szymańska S, Kluge P, Browarek A, Bekta P, Karcz M, Parulski A, Wójcik A, Klisiewicz A, Kuśmierczyk M, Różański J, Korewicki J. Lack of Impact of Presence of Positive C4d Staining in Capillaries in Myocardial Biopsies on Long-term Survival of Heart Transplant Patients. Transplant Proc 2017; 48:1767-9. [PMID: 27496488 DOI: 10.1016/j.transproceed.2016.02.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/28/2016] [Accepted: 02/18/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The long-term survival of 209 consecutive patients (mean age, 46 ± 15 years) from a single center with ≥1 diagnostic myocardial biopsy after heart transplantation was analyzed. METHODS Patients were considered as C4d positive if a capillary staining (immunohistochemistry in paraffin samples) was observed in ≥1 myocardial biopsy. Data were analyzed according to pathologic consensus of antibody mediated rejection definition of C4d+ positivity: 2004 definition in group A and the 2013 definition in group B and compared with their respective controls, composed of patients who do not meet those criteria. Age, follow-up time, and number of biopsies were comparable between patients with C4d+ and controls in both groups. Follow-up was 100% complete with mean of observation time 2143 days. RESULTS During the follow-up period, 62 patients died (group A: C4d+ 32% vs controls 29%; group B: C4d+ 36% vs controls 29% [P = NS]). There were no differences in survival between patients with positive staining and without C4d+ staining when Kaplan-Meier survival curves were compared. CONCLUSIONS The presence of C4d positive staining in myocardial capillaries of heart biopsies of patients after heart transplantation, as an isolated finding, was not related to worse long-term survival.
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Affiliation(s)
- T Zieliński
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland.
| | - M Sobieszczańska-Małek
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - M Karczmarz
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - K Komuda
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - W Grajkowska
- Department of Pathology, The Children's Memorial Health Hospital, Warsaw, Poland
| | - M Pronicki
- Department of Pathology, The Children's Memorial Health Hospital, Warsaw, Poland
| | - S Szymańska
- Department of Pathology, The Children's Memorial Health Hospital, Warsaw, Poland
| | - P Kluge
- Department of Pathology, The Children's Memorial Health Hospital, Warsaw, Poland
| | - A Browarek
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - P Bekta
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - M Karcz
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - A Parulski
- Department of Cardiosurgery and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - A Wójcik
- Department of Congenital Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | - A Klisiewicz
- Department of Congenital Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | - M Kuśmierczyk
- Department of Cardiosurgery and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - J Różański
- Department of Cardiosurgery and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - J Korewicki
- Department of Heart Failure and Transplantology, Institute of Cardiology, Warsaw, Poland
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