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Mella A, Lavacca A, Dodoi DT, Presta R, Fop F, Campagna M, Manzione AM, Dolla C, Gallo E, Abbasciano I, Gai C, Camussi G, Barreca A, Caorsi C, Giovinazzo G, Biancone L. Absence of IL-6 Receptor Blockade Effect on the Outcomes of Transplant Glomerulopathy in the Absence of Anti-HLA Donor-specific Antibodies. Transplant Direct 2024; 10:e1638. [PMID: 38769985 PMCID: PMC11104724 DOI: 10.1097/txd.0000000000001638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 03/03/2024] [Accepted: 03/07/2024] [Indexed: 05/22/2024] Open
Abstract
Background Transplant glomerulopathy (TG) is the hallmark of chronic antibody-mediated rejection but often occurs without anti-HLA donor-specific antibodies (DSAs) in the assumption that other DSAs may be the effectors of the tissue injury. Recently, we reported a positive effect of interleukin-6 (IL-6) receptor blocker tocilizumab (TCZ) in TG/DSA+. In the present study, we investigate the effect of TCZ in a cohort of TG cases without detectable anti-HLA DSAs. Methods Single-center retrospective analysis of TG cases without anti-HLA DSAs (TG/DSA) treated with TCZ for chronic antibody-mediated rejection as first-line therapy evaluated through clinical, protocol biopsies, and gene expression analyses was included. Results Differently from TG/DSA+, TG/DSA- showed a progressive reduction in the estimated glomerular filtration rate at 12 mo and after that with no significant modification in microvascular inflammation or C4d+. No upregulation in tight junction protein-1, aldo-keto reductase family 1 member C3, and calcium/calmodulin-dependent serine protein kinase, documented in TG/DSA+, was noted in post-TCZ biopsies. The reduction of microvascular inflammation was associated with natural killer-cell reduction in TG/DSA+, whereas TG/DSA- tends to maintain or increase periglomerular/interstitial infiltration. Conclusions In the absence of anti-HLA DSAs, TG behavior seems not to be modified by IL-6 receptor blockade. These results are at variance with observational studies and previous trials with IL-6 inhibitors in TG associated with anti-HLA DSAs. These data may fuel the hypothesis of different mechanisms underlying TGs (including the potentially different roles of natural killer cells) and suggest carefully selecting patients with TG for clinical trials or off-label treatment based on their antidonor serologic status.
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Affiliation(s)
- Alberto Mella
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Lavacca
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Diana Teodora Dodoi
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberto Presta
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marco Campagna
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ana Maria Manzione
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Caterina Dolla
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ester Gallo
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Isabella Abbasciano
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Gai
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Camussi
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristiana Caorsi
- Immunogenetic and Transplant Biology Center, “Città Della Salute e Della Scienza” Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gloria Giovinazzo
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplantation Center, “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Città Della Salute e Della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
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2
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Mengel M, Adam BA. Emerging phenotypes in kidney transplant rejection. Curr Opin Organ Transplant 2024; 29:97-103. [PMID: 38032262 DOI: 10.1097/mot.0000000000001130] [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: 12/01/2023]
Abstract
PURPOSE OF REVIEW This review focuses on more recently emerging rejection phenotypes in the context of time post transplantation and the resulting differential diagnostic challenges. It also discusses how novel ancillary diagnostic tools can potentially increase the accuracy of biopsy-based rejection diagnosis. RECENT FINDINGS With advances in reducing immunological risk at transplantation and improved immunosuppression treatment renal allograft survival improved. However, allograft rejection remains a major challenge and represent a frequent course for allograft failure. With prolonged allograft survival, novel phenotypes of rejection are emerging, which can show complex overlap and transition between cellular and antibody-mediated rejection mechanisms as well as mixtures of acute/active and chronic diseases. With the emerging complexity in rejection phenotypes, it is crucial to achieve diagnostic accuracy in the individual patient. SUMMARY The prospective validation and adoption of novel molecular and computational diagnostic tools into well defined and appropriate clinical context of uses will improve our ability to accurately diagnose, stage, and grade allograft rejection.
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Affiliation(s)
- Michael Mengel
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
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3
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Cristoferi I, Varol H, van Baardwijk M, Rahiem L, Lila KA, van den Bosch TPP, Baan CC, Hesselink DA, Kramann R, Minnee RC, Mustafa DAM, Reinders MEJ, Roelen DL, Shahzad-Arshad SP, Smith RN, Stubbs AP, Colvin RB, Rosales IA, Clahsen-van Groningen MC. Multiomic profiling of transplant glomerulopathy reveals a novel T-cell dominant subclass. Kidney Int 2024; 105:812-823. [PMID: 38128610 DOI: 10.1016/j.kint.2023.11.026] [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: 06/13/2023] [Revised: 09/04/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
Kidney transplant (KTx) biopsies showing transplant glomerulopathy (TG) (glomerular basement membrane double contours (cg) > 0) and microvascular inflammation (MVI) in the absence of C4d staining and donor-specific antibodies (DSAs) do not fulfill the criteria for chronic active antibody-mediated rejection (CA-AMR) diagnosis and do not fit into any other Banff category. To investigate this, we initiated a multicenter intercontinental study encompassing 36 cases, comparing the immunomic and transcriptomic profiles of 14 KTx biopsies classified as cg+MVI DSA-/C4d- with 22 classified as CA-AMR DSA+/C4d+ through novel transcriptomic analysis using the NanoString Banff-Human Organ Transplant (B-HOT) panel and subsequent orthogonal subset analysis using two innovative 5-marker multiplex immunofluorescent panels. Nineteen genes were differentially expressed between the two study groups. Samples diagnosed with CA-AMR DSA+/C4d+ showed a higher glomerular abundance of natural killer cells and higher transcriptomic cell type scores for macrophages in an environment characterized by increased expression of complement-related genes (i.e., C5AR1) and higher activity of angiogenesis, interstitial fibrosis tubular atrophy, CA-AMR, and DSA-related pathways when compared to samples diagnosed with cg+MVI DSA-/C4d-. Samples diagnosed with cg+MVI DSA-/C4d- displayed a higher glomerular abundance and activity of T cells (CD3+, CD3+CD8+, and CD3+CD8-). Thus, we show that using novel multiomic techniques, KTx biopsies with cg+MVI DSA-/C4d- have a prominent T-cell presence and activity, putting forward the possibility that these represent a more T-cell dominant phenotype.
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Affiliation(s)
- Iacopo Cristoferi
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands; Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Rotterdam, the Netherlands.
| | - Hilal Varol
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Myrthe van Baardwijk
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands; Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Layla Rahiem
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Karishma A Lila
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Thierry P P van den Bosch
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Rafael Kramann
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, Rotterdam, the Netherlands; Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany; Department of Nephrology and Clinical Immunology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Dana A M Mustafa
- Department of Pathology and Clinical Bioinformatics, the Tumor Immuno-Pathology Laboratory, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Shazia P Shahzad-Arshad
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Rex N Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew P Stubbs
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, Rotterdam, the Netherlands; Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany.
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4
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Sarwal MM, Naesens M. Urine trumps the protocol biopsy for subclinical rejection surveillance. Kidney Int 2023; 104:432-439. [PMID: 37599018 DOI: 10.1016/j.kint.2023.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Minnie M Sarwal
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California, USA.
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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5
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van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [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: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
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Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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6
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Buxeda A, Llinàs-Mallol L, Gimeno J, Redondo-Pachón D, Arias-Cabrales C, Burballa C, Puche A, López-Botet M, Yélamos J, Vilches C, Naesens M, Pérez-Sáez MJ, Pascual J, Crespo M. Microvascular inflammation in the absence of human leukocyte antigen-donor-specific antibody and C4d: An orphan category in Banff classification with cytotoxic T and natural killer cell infiltration. Am J Transplant 2023; 23:464-474. [PMID: 36710135 DOI: 10.1016/j.ajt.2022.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
Isolated microvascular inflammation (iMVI) without HLA donor-specific antibodies or C4d deposition in peritubular capillaries remains an enigmatic phenotype that cannot be categorized as antibody-mediated rejection (ABMR) in recent Banff classifications. We included 221 kidney transplant recipients with biopsies with ABMR (n = 73), iMVI (n = 32), and normal (n = 116) diagnoses. We compared peripheral blood leukocyte distribution by flow cytometry and inflammatory infiltrates in kidney transplant biopsies among groups. Flow cytometry showed fewer lymphocytes and total, CD4+, and CD8+ peripheral T cells in iMVI compared with ABMR and normal cases. ABMR and iMVI had fewer total natural Killer (NK) cells but more NKG2A+ NK cells. Immunohistochemistry indicated that ABMR and iMVI had greater CD3+ and CD68+ glomerular infiltration than normal biopsies, whereas CD8+ and TIA1+ cells showed only increased iMVI, suggesting they are cytotoxic T cells. Peritubular capillaries displayed more CD3+, CD56+, TIA1+, and CD68+ cells in both ABMR and iMVI. In contrast, iMVI had less plasma cell infiltration in peritubular capillaries and interstitial aggregates than ABMR. iMVI displayed decreased circulating T and NK cells mirrored by T cell and NK cell infiltration in the renal allograft, similar to ABMR. However, the lesser plasma cell infiltration in iMVI may suggest an antibody-independent underlying stimulus.
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Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Javier Gimeno
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Dolores Redondo-Pachón
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carlos Arias-Cabrales
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Carla Burballa
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Adrián Puche
- Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Miguel López-Botet
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain
| | - José Yélamos
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Immunology, Hospital del Mar, Barcelona, Spain
| | - Carlos Vilches
- Immunogenetics-HLA, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Madrid, Spain
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Julio Pascual
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
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7
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Nickerson PW. Rationale for the IMAGINE study for chronic active antibody-mediated rejection (caAMR) in kidney transplantation. Am J Transplant 2022; 22 Suppl 4:38-44. [PMID: 36453707 DOI: 10.1111/ajt.17210] [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: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
Chronic active antibody-mediated rejection (caAMR) in kidney transplantation is a major cause of late graft loss and despite all efforts to date, there is no proven effective therapy. Indeed, the Transplant Society (TTS) consensus opinion called for a conservative approach optimizing baseline immunosuppression and supportive care focused on blood pressure, blood glucose, and lipid control. This review provides the rationale and early evidence in kidney transplant recipients with caAMR that supported the design of the IMAGINE study whose goal is to evaluate the potential impact of targeting the IL6/IL6R pathway.
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Affiliation(s)
- Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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8
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Vaulet T, Divard G, Thaunat O, Koshy P, Lerut E, Senev A, Aubert O, Van Loon E, Callemeyn J, Emonds MP, Van Craenenbroeck A, De Vusser K, Sprangers B, Rabeyrin M, Dubois V, Kuypers D, De Vos M, Loupy A, De Moor B, Naesens M. Data-Driven Chronic Allograft Phenotypes: A Novel and Validated Complement for Histologic Assessment of Kidney Transplant Biopsies. J Am Soc Nephrol 2022; 33:2026-2039. [PMID: 36316096 PMCID: PMC9678036 DOI: 10.1681/asn.2022030290] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/24/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND No validated system currently exists to realistically characterize the chronic pathology of kidney transplants that represents the dynamic disease process and spectrum of disease severity. We sought to develop and validate a tool to describe chronicity and severity of renal allograft disease and integrate it with the evaluation of disease activity. METHODS The training cohort included 3549 kidney transplant biopsies from an observational cohort of 937 recipients. We reweighted the chronic histologic lesions according to their time-dependent association with graft failure, and performed consensus k-means clustering analysis. Total chronicity was calculated as the sum of the weighted chronic lesion scores, scaled to the unit interval. RESULTS We identified four chronic clusters associated with graft outcome, based on the proportion of ambiguous clustering. The two clusters with the worst survival outcome were determined by interstitial fibrosis and tubular atrophy (IFTA) and by transplant glomerulopathy. The chronic clusters partially overlapped with the existing Banff IFTA classification (adjusted Rand index, 0.35) and were distributed independently of the acute lesions. Total chronicity strongly associated with graft failure (hazard ratio [HR], 8.33; 95% confidence interval [CI], 5.94 to 10.88; P<0.001), independent of the total activity scores (HR, 5.01; 95% CI, 2.83 to 7.00; P<0.001). These results were validated on an external cohort of 4031 biopsies from 2054 kidney transplant recipients. CONCLUSIONS The evaluation of total chronicity provides information on kidney transplant pathology that complements the estimation of disease activity from acute lesion scores. Use of the data-driven algorithm used in this study, called RejectClass, may provide a holistic and quantitative assessment of kidney transplant injury phenotypes and severity.
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Affiliation(s)
- Thibaut Vaulet
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
| | - Gillian Divard
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Olivier Thaunat
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, Lyon, France
- Department of Transplantation, Nephrology, and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Priyanka Koshy
- Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross–Flanders, Mechelen, Belgium
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Elisabet Van Loon
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross–Flanders, Mechelen, Belgium
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Katrien De Vusser
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maud Rabeyrin
- Department of Pathology, Hospices Civils de Lyon, Bron, France
| | - Valérie Dubois
- Human Leukocyte Antigen (HLA) Laboratory, French National Blood Service (EFS), Décines-Charpieu, France
| | - Dirk Kuypers
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten De Vos
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Université de Paris, INSERM, PARCC, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bart De Moor
- ESAT Stadius Center for Dynamical Systems, Signal Processing, and Data Analytics, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
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Delpire B, Van Loon E, Naesens M. The Role of Fc Gamma Receptors in Antibody-Mediated Rejection of Kidney Transplants. Transpl Int 2022; 35:10465. [PMID: 35935272 PMCID: PMC9346079 DOI: 10.3389/ti.2022.10465] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/08/2022] [Indexed: 11/25/2022]
Abstract
For the past decades, complement activation and complement-mediated destruction of allograft cells were considered to play a central role in anti-HLA antibody-mediated rejection (AMR) of kidney transplants. However, also complement-independent mechanisms are relevant in the downstream immune activation induced by donor-specific antibodies, such as Fc-gamma receptor (FcγR)-mediated direct cellular activation. This article reviews the literature regarding FcγR involvement in AMR, and the potential contribution of FcγR gene polymorphisms to the risk for antibody mediated rejection of kidney transplants. There is large heterogeneity between the studies, both in the definition of the clinical phenotypes and in the technical aspects. The study populations were generally quite small, except for two larger study cohorts, which obviates drawing firm conclusions regarding the associations between AMR and specific FcγR polymorphisms. Although FcγR are central in the pathophysiology of AMR, it remains difficult to identify genetic risk factors for AMR in the recipient’s genome, independent of clinical risk factors, independent of the donor-recipient genetic mismatch, and in the presence of powerful immunosuppressive agents. There is a need for larger, multi-center studies with standardised methods and endpoints to identify potentially relevant FcγR gene polymorphisms that represent an increased risk for AMR after kidney transplantation.
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Affiliation(s)
- Boris Delpire
- University Hospitals Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Elisabet Van Loon
- University Hospitals Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- University Hospitals Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Kidney Transplantation, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
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Borski A, Kainz A, Kozakowski N, Regele H, Kläger J, Strassl R, Fischer G, Faé I, Wenda S, Kikić Ž, Bond G, Reindl-Schwaighofer R, Mayer KA, Eder M, Wahrmann M, Haindl S, Doberer K, Böhmig GA, Eskandary F. Early Estimated Glomerular Filtration Rate Trajectories After Kidney Transplant Biopsy as a Surrogate Endpoint for Graft Survival in Late Antibody-Mediated Rejection. Front Med (Lausanne) 2022; 9:817127. [PMID: 35530045 PMCID: PMC9069161 DOI: 10.3389/fmed.2022.817127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Late antibody-mediated rejection (ABMR) after kidney transplantation is a major cause of long-term allograft loss with currently no proven treatment strategy. Design for trials testing treatment for late ABMR poses a major challenge as hard clinical endpoints require large sample sizes. We performed a retrospective cohort study applying commonly used selection criteria to evaluate the slope of the estimated glomerular filtration rate (eGFR) within an early and short timeframe after biopsy as a surrogate of future allograft loss for clinical trials addressing late ABMR. Methods Study subjects were identified upon screening of the Vienna transplant biopsy database. Main inclusion criteria were (i) a solitary kidney transplant between 2000 and 2013, (ii) diagnosis of ABMR according to the Banff 2015 scheme at >12 months post-transplantation, (iii) age 15-75 years at ABMR diagnosis, (iv) an eGFR > 25 mL/min/1.73 m2 at ABMR diagnosis, and (v) a follow-up for at least 36 months after ABMR diagnosis. The primary outcome variable was death-censored graft survival. A mixed effects model with linear splines was used for eGFR slope modeling and association of graft failure and eGFR slope was assessed applying a multivariate competing risk analysis with landmarks set at 12 and 24 months after index biopsy. Results A total of 70 allografts from 68 patients were included. An eGFR loss of 1 ml/min/1.73 m2 per year significantly increased the risk for allograft failure, when eGFR slopes were modeled over 12 months [HR 1.1 (95% CI: 1.01-1.3), p = 0.020] or over 24 months [HR 1.3 (95% CI: 1.1-1.4), p = 0.001] after diagnosis of ABMR with landmarks set at both time points. Covariables influencing graft loss in all models were histologic evidence of glomerulonephritis concurring with ABMR as well as the administration of anti-thymocyte globulin (ATG) at the time of transplantation. Conclusion Our study supports the use of the eGFR slope modeled for at least 12 months after biopsy-proven diagnosis of late ABMR, as a surrogate parameter for future allograft loss. The simultaneous occurrence of glomerulonephritis together with ABMR at index biopsy and the use of ATG at the time of transplantation-likely representing a confounder in pre-sensitized recipients-were strongly associated with worse transplant outcomes.
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Affiliation(s)
- Anita Borski
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Alexander Kainz
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | | | - Heinz Regele
- Department of Pathology, Medical University Vienna, Vienna, Austria
| | - Johannes Kläger
- Department of Pathology, Medical University Vienna, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - Ingrid Faé
- Department of Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - Sabine Wenda
- Department of Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - Željko Kikić
- Department of Urology, Medical University Vienna, Vienna, Austria
| | - Gregor Bond
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | | | - Katharina A. Mayer
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Michael Eder
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Markus Wahrmann
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Susanne Haindl
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Konstantin Doberer
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Georg A. Böhmig
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Farsad Eskandary
- Department of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
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Callemeyn J, Lamarthée B, Koenig A, Koshy P, Thaunat O, Naesens M. Allorecognition and the spectrum of kidney transplant rejection. Kidney Int 2021; 101:692-710. [PMID: 34915041 DOI: 10.1016/j.kint.2021.11.029] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022]
Abstract
Detection of mismatched human leukocyte antigens by adaptive immune cells is considered as the main cause of transplant rejection, leading to either T-cell mediated rejection or antibody-mediated rejection. This canonical view guided the successful development of immunosuppressive therapies and shaped the diagnostic Banff classification for kidney transplant rejection that is used in clinics worldwide. However, several observations have recently emerged that question this dichotomization between T-cell mediated rejection and antibody-mediated rejection, related to heterogeneity in the serology, histology, and prognosis of the rejection phenotypes. In parallel, novel insights were obtained concerning the dynamics of donor-specific anti-human leukocyte antigen antibodies, the immunogenicity of donor-recipient non-human leukocyte antigen mismatches, and the autoreactivity against self-antigens. Moreover, the potential of innate allorecognition was uncovered, as exemplified by natural killer cell-mediated microvascular inflammation through missing self, and by the emerging evidence on monocyte-driven allorecognition. In this review, we highlight the gaps in the current classification of rejection, provide an overview of the expanding insights into the mechanisms of allorecognition, and critically appraise how these could improve our understanding and clinical approach to kidney transplant rejection. We argue that consideration of the complex interplay of various allorecognition mechanisms can foster a more integrated view of kidney transplant rejection and can lead to improved risk stratification, targeted therapies, and better outcome after kidney transplantation.
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Affiliation(s)
- Jasper Callemeyn
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Baptiste Lamarthée
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Necker-Enfants Malades Institute, French National Institute of Health and Medical Research (INSERM) Unit 1151, Paris, France
| | - Alice Koenig
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Priyanka Koshy
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Thaunat
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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