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Gramkow AM, Baatrup JH, Gramkow ET, Thiesson HC, Koefoed-Nielsen P. Association of HLA B- and T-cell molecular mismatches with HLA antibodies, rejection, and graft survival in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14773. [PMID: 38808702 DOI: 10.1111/petr.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/01/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Optimizing graft survival and diminishing human leukocyte antigen (HLA) sensitization are essential for pediatric kidney transplant recipients. More precise HLA matching predicting epitope mismatches could reduce alloreactivity. We investigated the association of predicted HLA B- and T-cell molecular mismatches with the formation of de novo donor-specific antibodies, HLA antibodies, rejection, and graft survival. METHODS Forty-nine pediatric kidney transplant recipients transplanted from 2009 to 2020 were retrospectively studied. Donors and recipients were high-resolution HLA typed, and recipients were screened for HLA antibodies posttransplant. HLA-EMMA (HLA Epitope MisMatch Algorithm) and PIRCHE-II (Predicted Indirectly ReCognizable HLA Epitopes) predicted the molecular mismatches. The association of molecular mismatches and the end-points was explored with logistic regression. RESULTS Five recipients (11%) developed de novo donor-specific antibodies. All five had de novo donor-specific antibodies against HLA class II, with four having HLA-DQ antibodies. We found no associations between PIRCHE-II or HLA-EMMA with de novo donor-specific antibodies, HLA sensitization, graft loss, or rejection. However, we did see a tendency towards an increased odds ratio in PIRCHE-II predicting de novo donor-specific antibodies formation, with an odds ratio of 1.12 (95% CI: 0.99; 1.28) on HLA class II. CONCLUSION While the study revealed no significant associations between the number of molecular mismatches and outcomes, a notable trend was observed - indicating a reduced risk of dnDSA formation with improved molecular match. It is important to acknowledge, however, that the modest population size and limited observed outcomes preclude us from making definitive conclusions.
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Affiliation(s)
- Ann-Maria Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne H Baatrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Emilie T Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine - Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Helle C Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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2
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Hiho SJ, Levvey BJ, Diviney MB, Snell GI, Sullivan LC, Westall GP. Comparison of human leukocyte antigen immunologic risk stratification methods in lung transplantation. Am J Transplant 2024; 24:827-838. [PMID: 37981213 DOI: 10.1016/j.ajt.2023.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/21/2023]
Abstract
Outcomes after lung transplantation (LTx) remain poor, despite advances in sequencing technology and development of algorithms defining immunologic compatibility. Presently, there is no consensus regarding the best approach to define human leukocyte antigen (HLA) compatibility in LTx. In this study, we compared 5 different HLA compatibility tools in a high-resolution HLA-typed, clinically characterized cohort, to determine which approach predicts outcomes after LTx. In this retrospective single-center study, 277 donor-recipient transplant pairs were HLA-typed using next generation sequencing. HLA compatibility was defined using HLAMatchmaker, HLA epitope mismatch algorithm (HLA-EMMA), predicted indirectly recognizable HLA epitopes (PIRCHE), electrostatic mismatch score (EMS), and amino acid mismatches (AAMMs). Associations with HLA mismatching and survival, chronic lung allograft dysfunction (CLAD), and anti-HLA donor-specific antibody (DSA) were calculated using adjusted Cox proportional modeling. Lower HLA class II mismatching was associated with improved survival as defined by HLAMatchmaker (P < .01), HLA-EMMA (P < .05), PIRCHE (P < .05), EMS (P < .001), and AAMM (P < .01). All approaches demonstrated that HLA-DRB1345 matching was associated with freedom from restrictive allograft syndrome and HLA-DQ matching with reduced DSA development. Reducing the level of HLA mismatching, in T cell or B cell epitopes, electrostatic differences, or amino acid, can improve outcomes after LTx and potentially guide immunosuppression strategies.
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Affiliation(s)
- Steven J Hiho
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia; Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics Service, Melbourne, Victoria, Australia.
| | - Bronwyn J Levvey
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Mary B Diviney
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics Service, Melbourne, Victoria, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Lucy C Sullivan
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia; Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Australian Red Cross LifeBlood, South Australian Transplantation and Immunogenetics Service, Adelaide, South Australia, Australia
| | - Glen P Westall
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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Costa D, Picascia A, Grimaldi V, Amarelli C, Petraio A, Levi A, Di Donato M, Pirozzi AVA, Fiorito C, Moccia G, Gallo A, Strozziero M, Marra C, De Feo M, Cacciatore F, Maiello C, Napoli C. Role of HLA matching and donor specific antibody development in long-term survival, acute rejection and cardiac allograft vasculopathy. Transpl Immunol 2024; 83:102011. [PMID: 38403197 DOI: 10.1016/j.trim.2024.102011] [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: 11/15/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024]
Abstract
Although there are different data supporting benefits of HLA matching in kidney transplantation, its role in heart transplantation is still unclear. HLA mismatch (MM) between donor and recipient can lead to the development of donor-specific antibodies (DSA) which produces negative events on the outcome of heart transplantation. Moreover, DSAs are involved in the development of antibody-mediated rejection (AMR) and are associated with an increase in cardiac allograft vasculopathy (CAV). In this study it is analyzed retrospectively the influence of HLA matching and anti-HLA antibodies on overall survival, AMR and CAV in heart transplantation. For this retrospective study are recruited heart transplanted patients at the Cardiac Transplantation Centre of Naples between 2000 and 2019. Among the 155 heart transplant patients, the mean number of HLA-A, B, -DR MM (0 to 6) between donor and recipient was 4.5 ± 1.1. The results show a negative association between MM HLA-DR and survival (p = 0.01). Comparison of patients with 0-1 MM at each locus to all others with 2 MM, for both HLA class I and class II, has not showed significant differences in the development of CAV. Our analysis detected DSA in 38.1% of patients. The production of de novo DSA reveals that there is not an influence on survival (p = 0.72) and/or AMR (p = 0.39). Instead, there is an association between the production of DSA class II and the probability of CAV development (p = 0.03). Mean fluorescence intensity (MFI) values were significantly higher in CAV-positive patients that CAV-negative patients (p = 0.02). Prospective studies are needed to evaluate HLA class II matching as an additional parameter for heart allocation, especially considering the increment of waiting list time.
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Affiliation(s)
- Dario Costa
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Antonietta Picascia
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Vincenzo Grimaldi
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Cristiano Amarelli
- Cardiac Transplantation Unit, Department of Cardiac Surgery and Transplantation, Ospedali dei Colli, Naples, Italy
| | - Andrea Petraio
- Cardiac Transplantation Unit, Department of Cardiac Surgery and Transplantation, Ospedali dei Colli, Naples, Italy
| | - Anna Levi
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Mario Di Donato
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Anna Virginia Adriana Pirozzi
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Carmela Fiorito
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Giusi Moccia
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | - Aurora Gallo
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
| | | | - Claudio Marra
- Cardiac Transplantation Unit, Department of Cardiac Surgery and Transplantation, Ospedali dei Colli, Naples, Italy
| | - Marisa De Feo
- Cardiac Transplantation Unit, Department of Cardiac Surgery and Transplantation, Ospedali dei Colli, Naples, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Maiello
- Cardiac Transplantation Unit, Department of Cardiac Surgery and Transplantation, Ospedali dei Colli, Naples, Italy
| | - Claudio Napoli
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology. Regional Reference Laboratory of Transplant Immunology (LIT). Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli", Naples, Italy
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4
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Han J, Rushakoff J, Moayedi Y, Henricksen E, Lee R, Luikart H, Shalakhti O, Gragert L, Benck L, Malinoski D, Kobashigawa J, Teuteberg J, Khush KK, Patel J, Kransdorf E. HLA sensitization is associated with an increased risk of primary graft dysfunction after heart transplantation. J Heart Lung Transplant 2024; 43:387-393. [PMID: 37802261 DOI: 10.1016/j.healun.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 08/30/2023] [Accepted: 09/24/2023] [Indexed: 10/08/2023] Open
Abstract
Primary graft dysfunction (PGD) is a leading cause of early morbidity and mortality following heart transplantation (HT). We sought to determine the association between pretransplant human leukocyte antigen (HLA) sensitization, as measured using the calculated panel reactive antibody (cPRA) value, and the risk of PGD. METHODS Consecutive adult HT recipients (n = 596) from 1/2015 to 12/2019 at 2 US centers were included. Severity of PGD was based on the 2014 International Society for Heart and Lung Transplantation consensus statement. For each recipient, unacceptable HLA antigens were obtained and locus-specific cPRA (cPRA-LS) and pre-HT donor-specific antibodies (DSA) were assessed. RESULTS Univariable logistic modeling showed that peak cPRA-LS for all loci and HLA-A was associated with increased severity of PGD as an ordinal variable (all loci: OR 1.78, 95% CI: 1.01-1.14, p = 0.025, HLA-A: OR 1.14, 95% CI: 1.03-1.26, p = 0.011). Multivariable analysis showed peak cPRA-LS for HLA-A, recipient beta-blocker use, total ischemic time, donor age, prior cardiac surgery, and United Network for Organ Sharing status 1 or 2 were associated with increased severity of PGD. The presence of DSA to HLA-B was associated with trend toward increased risk of mild-to-moderate PGD (OR 2.56, 95% CI: 0.99-6.63, p = 0.053), but DSA to other HLA loci was not associated with PGD. CONCLUSIONS Sensitization for all HLA loci, and specifically HLA-A, is associated with an increased severity of PGD. These factors should be included in pre-HT risk stratification to minimize the risk of PGD.
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Affiliation(s)
- Jiho Han
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Josh Rushakoff
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yasbanoo Moayedi
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Erik Henricksen
- Department of Transplant, Stanford Health Care, Stanford, California
| | - Roy Lee
- Department of Transplant, Stanford Health Care, Stanford, California
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Omar Shalakhti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Lillian Benck
- Division of Cardiology, NorthShore University Health System, Chicago, Illinois
| | - Darren Malinoski
- Critical Care and Acute Care Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Jon Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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5
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Firoz A, Geier S, Yanagida R, Hamad E, Rakita V, Zhao H, Kashem M, Toyoda Y. Heart Transplant Human Leukocyte Antigen Matching in the Modern Era. J Card Fail 2024; 30:362-372. [PMID: 37422273 DOI: 10.1016/j.cardfail.2023.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Although numerous reports have studied the consequences of human leukocyte antigen (HLA) mismatching in renal transplantation, there are limited and outdated data analyzing this association in thoracic organ transplantation. Therefore, our study reviewed the impact of HLA mismatching at both the total and the loci levels in the modern-era heart-transplant procedure on survival and chronic rejection outcomes. METHODS We performed a retrospective analysis of adult patients after heart transplant by using the United Network for Organ Sharing database from January 2005-July 2021. Total HLA and HLA-A, HLA-B and HLA-DR mismatches were analyzed. Survival and cardiac allograft vasculopathy were the outcomes of interest during a 10-year follow-up period using Kaplan-Meier curves, log-rank tests and multivariable regression models. RESULTS A total of 33,060 patients were included in this study. Recipients with a high degree of HLA mismatching had increased incidences of acute organ rejection. There were no significant differences in mortality rates among any of the total or loci level groups. Similarly, there were no significant differences between total HLA mismatch groups in time to first cardiac allograft vasculopathy, though mismatching at the HLA-DR locus was associated with an increased risk of cardiac allograft vasculopathy. CONCLUSION Our analysis suggests that HLA mismatch is not a significant predictor of survival in the modern era. Overall, the clinical implications of this study provide reassuring data for the continued use of non-HLA-matched donors in an effort to increase the donor pool. If HLA matching is to be considered for heart transplant donor-recipient selection, matching at the HLA-DR locus should take priority due to its association with cardiac allograft vasculopathy.
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Affiliation(s)
- Ahad Firoz
- Lewis Katz School of Medicine at Temple University, Philadelphia PA.
| | - Steven Geier
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia PA
| | - Roh Yanagida
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia PA
| | - Eman Hamad
- Heart and Vascular Institute, Temple University Hospital, Philadelphia PA
| | - Val Rakita
- Heart and Vascular Institute, Temple University Hospital, Philadelphia PA
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Lewis Katz School of Medicine, Philadelphia PA
| | - Mohammed Kashem
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia PA
| | - Yoshiya Toyoda
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia PA.
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6
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Karpov DS, Sosnovtseva AO, Pylina SV, Bastrich AN, Petrova DA, Kovalev MA, Shuvalova AI, Eremkina AK, Mokrysheva NG. Challenges of CRISPR/Cas-Based Cell Therapy for Type 1 Diabetes: How Not to Engineer a "Trojan Horse". Int J Mol Sci 2023; 24:17320. [PMID: 38139149 PMCID: PMC10743607 DOI: 10.3390/ijms242417320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Type 1 diabetes mellitus (T1D) is an autoimmune disease caused by the destruction of insulin-producing β-cells in the pancreas by cytotoxic T-cells. To date, there are no drugs that can prevent the development of T1D. Insulin replacement therapy is the standard care for patients with T1D. This treatment is life-saving, but is expensive, can lead to acute and long-term complications, and results in reduced overall life expectancy. This has stimulated the research and development of alternative treatments for T1D. In this review, we consider potential therapies for T1D using cellular regenerative medicine approaches with a focus on CRISPR/Cas-engineered cellular products. However, CRISPR/Cas as a genome editing tool has several drawbacks that should be considered for safe and efficient cell engineering. In addition, cellular engineering approaches themselves pose a hidden threat. The purpose of this review is to critically discuss novel strategies for the treatment of T1D using genome editing technology. A well-designed approach to β-cell derivation using CRISPR/Cas-based genome editing technology will significantly reduce the risk of incorrectly engineered cell products that could behave as a "Trojan horse".
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Affiliation(s)
- Dmitry S. Karpov
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (D.S.K.); (A.O.S.); (M.A.K.); (A.I.S.)
| | - Anastasiia O. Sosnovtseva
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (D.S.K.); (A.O.S.); (M.A.K.); (A.I.S.)
| | - Svetlana V. Pylina
- Endocrinology Research Centre, 115478 Moscow, Russia; (S.V.P.); (A.N.B.); (D.A.P.); (A.K.E.)
| | - Asya N. Bastrich
- Endocrinology Research Centre, 115478 Moscow, Russia; (S.V.P.); (A.N.B.); (D.A.P.); (A.K.E.)
| | - Darya A. Petrova
- Endocrinology Research Centre, 115478 Moscow, Russia; (S.V.P.); (A.N.B.); (D.A.P.); (A.K.E.)
| | - Maxim A. Kovalev
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (D.S.K.); (A.O.S.); (M.A.K.); (A.I.S.)
| | - Anastasija I. Shuvalova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (D.S.K.); (A.O.S.); (M.A.K.); (A.I.S.)
| | - Anna K. Eremkina
- Endocrinology Research Centre, 115478 Moscow, Russia; (S.V.P.); (A.N.B.); (D.A.P.); (A.K.E.)
| | - Natalia G. Mokrysheva
- Endocrinology Research Centre, 115478 Moscow, Russia; (S.V.P.); (A.N.B.); (D.A.P.); (A.K.E.)
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7
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Marco I, López-Azor García JC, González Martín J, Severo Sánchez A, García-Cosío Carmena MD, Mancebo Sierra E, de Juan Bagudá J, Castrodeza Calvo J, Hernández Pérez FJ, Delgado JF. De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians. J Clin Med 2023; 12:7474. [PMID: 38068526 PMCID: PMC10707043 DOI: 10.3390/jcm12237474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 04/12/2024] Open
Abstract
Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.
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Affiliation(s)
- Irene Marco
- Cardiology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Juan Carlos López-Azor García
- Cardiology Department, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain; (J.C.L.-A.G.); (F.J.H.P.)
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Javier González Martín
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - María Dolores García-Cosío Carmena
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Esther Mancebo Sierra
- Immunology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier de Juan Bagudá
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- School of Medicine, Universidad Europea de Madrid, 28670 Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Javier Castrodeza Calvo
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | | | - Juan Francisco Delgado
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain; (J.G.M.); (M.D.G.-C.C.); (J.d.J.B.); (J.C.C.)
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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8
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Hiho S, Bowman S, Hudson F, Sullivan L, Carroll R, Diviney M. Impact of assigning 2-field HLA alleles from real-time PCR on deceased donor assessments and conformance with high resolution alleles. HLA 2023; 102:570-577. [PMID: 37128703 DOI: 10.1111/tan.15083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
Waitlisted sensitised transplant recipients with HLA allele level antibodies to their own HLA antigen family are disadvantaged by current deficiencies in HLA typing for deceased donors. This is primarily because at time of organ allocation, HLA typing is provided at antigen level whereas solid phase assays provide allele level antibody definition. The gold standard for HLA allele typing is next generation sequencing (NGS), however time limitations with established NGS systems prevent NGS use for deceased donors. Instead, many labs use a real-time PCR (qPCR) antigen level result for deceased donors, which can disadvantage sensitised patients. Here, we compared assigning qPCR 2-field alleles to qPCR antigen level to determine the impact on virtual crossmatch (VXM) and discuss impact on donor-specific antibody (DSA) assignments. 244 consecutive deceased donors were HLA typed to allelic level by qPCR (LinkSeq SABR) and subsequently by NGS (One Lambda Alltype). The impact of qPCR allele assignments on potential DSA identification was investigated, by retrospectively investigating all 3904 VXMs, where recipient DSA assessments were assessed against donor HLA, was performed within the cohort. There was 96.3% concordance between qPCR and NGS for all allele level loci, with HLA-A; DQB1; and DPB1 having best agreement (99.4%, 98.4% and 99.4% respectively). Of the 3904 VXMs with qPCR allele assignment, there were 13 (<1%) occasions where the potential DSA assignment was impacted, with DQA1 having the most impact. Assigning alleles derived from qPCR to define unacceptable antigens for VXMs, can allow improved access to donor offers for sensitised patients by better defining alleles.
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Affiliation(s)
- Steven Hiho
- Victorian Transplantation and Immunogenetics, Australian Red Cross LifeBlood, Melbourne, Victoria, Australia
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Sue Bowman
- Victorian Transplantation and Immunogenetics, Australian Red Cross LifeBlood, Melbourne, Victoria, Australia
| | - Fiona Hudson
- Victorian Transplantation and Immunogenetics, Australian Red Cross LifeBlood, Melbourne, Victoria, Australia
| | - Lucy Sullivan
- South Australian Transplantation and Immunogenetics Service, Australian Red Cross LifeBlood, Adelaide, South Australia, Australia
| | - Robert Carroll
- South Australian Transplantation and Immunogenetics Service, Australian Red Cross LifeBlood, Adelaide, South Australia, Australia
- Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mary Diviney
- Victorian Transplantation and Immunogenetics, Australian Red Cross LifeBlood, Melbourne, Victoria, Australia
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9
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Han J, Moayedi Y, Henricksen EJ, Waddell K, Valverde-Twiggs J, Kim D, Luikart H, Zhang BM, Teuteberg J, Khush KK. Primary Graft Dysfunction Is Associated With Development of Early Cardiac Allograft Vasculopathy, but Not Other Immune-mediated Complications, After Heart Transplantation. Transplantation 2023; 107:1624-1629. [PMID: 36801852 DOI: 10.1097/tp.0000000000004551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND We investigated associations between primary graft dysfunction (PGD) and development of acute cellular rejection (ACR), de novo donor-specific antibodies (DSAs), and cardiac allograft vasculopathy (CAV) after heart transplantation (HT). METHODS A total of 381 consecutive adult HT patients from January 2015 to July 2020 at a single center were retrospectively analyzed. The primary outcome was incidence of treated ACR (International Society for Heart and Lung Transplantation grade 2R or 3R) and de novo DSA (mean fluorescence intensity >500) within 1 y post-HT. Secondary outcomes included median gene expression profiling score and donor-derived cell-free DNA level within 1 y and incidence of cardiac allograft vasculopathy (CAV) within 3 y post-HT. RESULTS When adjusted for death as a competing risk, the estimated cumulative incidence of ACR (PGD 0.13 versus no PGD 0.21; P = 0.28), median gene expression profiling score (30 [interquartile range, 25-32] versus 30 [interquartile range, 25-33]; P = 0.34), and median donor-derived cell-free DNA levels was similar in patients with and without PGD. After adjusting for death as a competing risk, estimated cumulative incidence of de novo DSA within 1 y post-HT in patients with PGD was similar to those without PGD (0.29 versus 0.26; P = 0.10) with a similar DSA profile based on HLA loci. There was increased incidence of CAV in patients with PGD compared with patients without PGD (52.6% versus 24.8%; P = 0.01) within the first 3 y post-HT. CONCLUSIONS During the first year after HT, patients with PGD had a similar incidence of ACR and development of de novo DSA, but a higher incidence of CAV when compared with patients without PGD.
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Affiliation(s)
- Jiho Han
- Section of Cardiology, University of Chicago Medical Center, Chicago, IL
| | - Yasbanoo Moayedi
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Kian Waddell
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Julien Valverde-Twiggs
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Daniel Kim
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Bing M Zhang
- Department of Pathology, Stanford University, Stanford, CA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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10
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Ellison M, Mangiola M, Marrari M, Bentlejewski C, Sadowski J, Zern D, Kramer CSM, Heidt S, Niemann M, Xu Q, Dipchand AI, Mahle WT, Rossano JW, Canter CE, Singh TP, Zuckerman WA, Hsu DT, Feingold B, Webber SA, Zeevi A. Immunologic risk stratification of pediatric heart transplant patients by combining HLA-EMMA and PIRCHE-II. Front Immunol 2023; 14:1110292. [PMID: 36999035 PMCID: PMC10043167 DOI: 10.3389/fimmu.2023.1110292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
Human leukocyte antigen (HLA) molecular mismatch is a powerful biomarker of rejection. Few studies have explored its use in assessing rejection risk in heart transplant recipients. We tested the hypothesis that a combination of HLA Epitope Mismatch Algorithm (HLA-EMMA) and Predicted Indirectly Recognizable HLA Epitopes (PIRCHE-II) algorithms can improve risk stratification of pediatric heart transplant recipients. Class I and II HLA genotyping were performed by next-generation sequencing on 274 recipient/donor pairs enrolled in the Clinical Trials in Organ Transplantation in Children (CTOTC). Using high-resolution genotypes, we performed HLA molecular mismatch analysis with HLA-EMMA and PIRCHE-II, and correlated these findings with clinical outcomes. Patients without pre-formed donor specific antibody (DSA) (n=100) were used for correlations with post-transplant DSA and antibody mediated rejection (ABMR). Risk cut-offs were determined for DSA and ABMR using both algorithms. HLA-EMMA cut-offs alone predict the risk of DSA and ABMR; however, if used in combination with PIRCHE-II, the population could be further stratified into low-, intermediate-, and high-risk groups. The combination of HLA-EMMA and PIRCHE-II enables more granular immunological risk stratification. Intermediate-risk cases, like low-risk cases, are at a lower risk of DSA and ABMR. This new way of risk evaluation may facilitate individualized immunosuppression and surveillance.
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Affiliation(s)
- M. Ellison
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
- *Correspondence: M. Ellison,
| | - M. Mangiola
- Transplant Institute, NYU Langone Health, New York University, New York, NY, United States
| | - M. Marrari
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - C. Bentlejewski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - J. Sadowski
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
| | - D. Zern
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
| | | | - S. Heidt
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - M. Niemann
- Research and Development, PIRCHE AG, Berlin, Germany
| | - Q. Xu
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - A. I. Dipchand
- Labatt Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - W. T. Mahle
- Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - J. W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - C. E. Canter
- Division of Cardiology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, United States
| | - T. P. Singh
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - W. A. Zuckerman
- Columbia University, Irving Medical Center, New York, NY, United States
| | - D. T. Hsu
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, NY, United States
| | - B. Feingold
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - S. A. Webber
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - A. Zeevi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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11
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Hiho S, Levvey B, Holdsworth R, Sullivan L, Westall G, Snell G. Major technological advances will enhance Australian donor-recipient matching and improve transplant outcomes. Intern Med J 2023; 53:140-144. [PMID: 36693637 DOI: 10.1111/imj.15991] [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: 05/12/2022] [Accepted: 08/26/2022] [Indexed: 01/26/2023]
Abstract
In recent times, numerous and significant technological and supportive changes have taken place in Australian transplantation. These changes are often deployed without the wider clinical community having a full understanding of what has brought about these changes and the impacts they have. Here, we aim to clarify the reasoning behind these changes and shed light on potential future endeavours to improve patient outcomes.
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Affiliation(s)
- Steven Hiho
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia.,Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics Service, Melbourne, Victoria, Australia
| | - Bronwyn Levvey
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Rhonda Holdsworth
- Australian Red Cross LifeBlood, Victorian Transplantation and Immunogenetics Service, Melbourne, Victoria, Australia
| | - Lucy Sullivan
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Australian Red Cross LifeBlood, South Australian Transplantation and Immunogenetics Service, Adelaide, South Australia, Australia
| | - Glen Westall
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Greg Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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12
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Li C, Wang G. Liquid Biopsy, a Potential New Detection Method in Heart Allograft Rejection. Methods Mol Biol 2023; 2695:309-315. [PMID: 37450128 DOI: 10.1007/978-1-0716-3346-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Allografts rejection remains the most important reason causing allograft dysfunction in heart transplantation recipients. Currently, the golden standard for detecting graft rejection is endomyocardial biopsy (EMB). As a new noninvasive technique, liquid biopsy emerges along with the great developments of droplet-based digital PCR and the various optimizations of next-generation sequencing technologies, which is also cheaper than EMB. This review introduces several types of liquid biopsy and its application in heart transplantation.
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Affiliation(s)
- Chenghao Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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13
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Cardoso B, Wang J, Kiernan J, Dipchand AI. Eplet matching in pediatric heart transplantation: The SickKids experience. J Heart Lung Transplant 2022; 41:1470-1477. [DOI: 10.1016/j.healun.2022.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/11/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
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14
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Bedford A, Jervis S, Worthington J, Lowe M, Poulton K. Human leukocyte antigen epitope mismatch loads and the development of de novo donor-specific antibodies in cardiothoracic organ transplantation. Int J Immunogenet 2021; 49:30-38. [PMID: 34904369 DOI: 10.1111/iji.12563] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 12/30/2022]
Abstract
De novo donor-specific human leucocyte antigen (HLA) antibodies (dnDSA) are associated with increased risk of rejection and mortality in solid organ transplantation. Such dnDSA is produced in some recipients upon allorecognition of mismatched HLA post-transplant. HLA matching is not currently considered in the allocation of deceased donor hearts and lungs and pre-transplant immunological risk stratification is based entirely on the mean fluorescence intensity (MFI) of circulating donor-directed HLA antibodies. HLA epitope-based matching tools predict B-cell or T-cell HLA epitopes that are present in the donor's HLA but absent in the recipient's HLA. We hypothesized that patients with higher epitope mismatch loads would be at increased risk of dnDSA development. We retrospectively analysed 73 heart and/or lung transplant recipients who were tested for DSA between 2015 and 2020. HLAMatchmaker, PIRCHE-II and HLA epitope mismatch algorithm (HLA-EMMA) were used to calculate eplet mismatch (EpMM) loads, T-cell epitope mismatch (TEpMM) loads and solvent accessible amino acid mismatch (SAMM) loads, respectively. Multivariate analyses showed that HLA-EMMA was the only tool with a significant association between the total score for all HLA loci and dnDSA production [odds ratio (OR) 1.021, 95% confidence interval (CI) 1.003-1.042, p = .0225] though this increased risk was marginal. The majority of dnDSA were directed against HLA-DQ and patients with higher HLA-DQ TEpMM loads (OR = 1.008, CI = 1.002-1.014, p = .007), and HLA-DR+DQ SAMM loads (OR = 1.035, CI = 1.010-1.064, p = .0077) were most at risk of producing dnDSA. We also showed that patients with a risk epitope within the HLA molecule encoded for by HLA-DQA1*05 + HLA-DQB1*02/03:01 were significantly more likely to produce dnDSA. The use of HLA epitope-based matching tools could be used for cardiothoracic transplant risk stratification to enable early intervention and monitoring of patients at increased risk of producing dnDSA.
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Affiliation(s)
- Amy Bedford
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Steven Jervis
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Judith Worthington
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Marcus Lowe
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kay Poulton
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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15
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Epitope-Level Matching—A Review of the Novel Concept of Eplets in Transplant Histocompatibility. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The development of de novo donor-specific antibodies is related to the poor matching of the human leukocyte antigen (HLA) between donor and recipient, which leads to dismal clinical outcomes and graft loss. However, new approaches that stratify the risks of long-term graft failure in solid organ transplantation have emerged, changing the paradigm of HLA compatibility. In addition, advances in software development have given rise to a new structurally based algorithm known as HLA Matchmaker, which determines compatibility at the epitope rather than the antigen level. Although this technique still has limitations, plenty of research maintains that this assessment represents a more complete and detailed definition of HLA compatibility. This review summarizes recent aspects of eplet mismatches, highlighting the most recent advances and future research directions.
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16
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Osorio-Jaramillo E, Claas FHJ, Zuckermann A, Laufer G, Aliabadi-Zuckermann AZ. HLA-EMMA, a tool for molecular-level HLA matching after heart transplantation. Transpl Int 2020; 33:1821-1822. [PMID: 32986244 DOI: 10.1111/tri.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Frans H J Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Andreas Zuckermann
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Guenther Laufer
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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17
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Cacciatore F, Palmieri V, Amarelli C, Maiello C, Napoli C. Further evidence on HLA‐DR matching in determining heart transplantation outcomes. Transpl Int 2020; 33:1551-1552. [DOI: 10.1111/tri.13698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Francesco Cacciatore
- Cardiac Transplantation Unit Department of Cardiac Surgery and Transplantation Ospedali dei Colli Naples Italy
- Department of Translational Medical Sciences Federico II University of Naples Naples Italy
| | - Vittorio Palmieri
- Cardiac Transplantation Unit Department of Cardiac Surgery and Transplantation Ospedali dei Colli Naples Italy
| | - Cristiano Amarelli
- Cardiac Transplantation Unit Department of Cardiac Surgery and Transplantation Ospedali dei Colli Naples Italy
| | - Ciro Maiello
- Cardiac Transplantation Unit Department of Cardiac Surgery and Transplantation Ospedali dei Colli Naples Italy
| | - Claudio Napoli
- Clinical Department of Internal Medicine Specialistic Units and Regional Referring Centre for Clinical Immunology of Organ Transplantation (LIT) University Department of Advanced Medical and Surgical Sciences (DAMSS) University of Campania "Luigi Vanvitelli" Naples Italy
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