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The Histological Spectrum and Clinical Significance of T Cell-mediated Rejection of Kidney Allografts. Transplantation 2022; 107:1042-1055. [PMID: 36584369 DOI: 10.1097/tp.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
T cell-mediated rejection (TCMR) remains a significant cause of long-term kidney allograft loss, either indirectly through induction of donor-specific anti-HLA alloantibodies or directly through chronic active TCMR. Whether found by indication or protocol biopsy, Banff defined acute TCMR should be treated with antirejection therapy and maximized maintenance immunosuppression. Neither isolated interstitial inflammation in the absence of tubulitis nor isolated tubulitis in the absence of interstitial inflammation results in adverse outcomes, and neither requires antirejection treatment. RNA gene expression analysis of biopsy material may supplement conventional histology, especially in ambiguous cases. Lesser degrees of tubular and interstitial inflammation (Banff borderline) may portend adverse outcomes and should be treated when found on an indication biopsy. Borderline lesions on protocol biopsies may resolve spontaneously but require close follow-up if untreated. Following antirejection therapy of acute TCMR, surveillance protocol biopsies should be considered. Minimally invasive blood-borne assays (donor-derived cell-free DNA and gene expression profiling) are being increasingly studied as a means of following stable patients in lieu of biopsy. The clinical benefit and cost-effectiveness require confirmation in randomized controlled trials. Treatment of acute TCMR is not standardized but involves bolus corticosteroids with lymphocyte depleting antibodies for severe, refractory, or relapsing cases. Arteritis may be found with acute TCMR, active antibody-mediated rejection, or mixed rejections and should be treated accordingly. The optimal treatment ofchronic active TCMR is uncertain. Randomized controlled trials are necessary to optimally define therapy.
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How Should Acute T-cell Mediated Rejection of Kidney Transplants Be Treated: Importance of Follow-up Biopsy. Transplant Direct 2022; 8:e1305. [PMID: 35372674 PMCID: PMC8963842 DOI: 10.1097/txd.0000000000001305] [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: 11/02/2021] [Revised: 01/20/2022] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background. Limited published data exist to guide patient monitoring after the treatment of T-cell mediated rejection (TCMR) of kidney allografts. Methods. We reviewed the kidney function and histological outcomes after treatment of 163 first episodes of biopsy-proven TCMR between January 1‚ 2015‚ and July 31‚ 2020. Results. Of the 146 patients treated with steroid pulse alone, complete histological response was seen in 83% of patients with borderline rejection, 82.5% with grade 1A, 67% with grade 1B, and 50% with grade IIA. Of the 17 patients treated with steroids plus antithymocyte globulin, the complete histological response rate was 100% with grade 1A, 75% with grade 1B, 100% with grade IIA, and 57% with grade IIB. Among the patients with complete response as assessed by kidney function, 14% only had a partial or no response histologically. Among patients with no kidney function response, 68% had a complete response histologically. Conclusion. We thus find that responses based on kidney function alone do not correlate well with histological responses. If further treatment had been based solely on changes in estimated glomerular filtration rate, a significant number of patients would have been subsequently undertreated or overtreated. These results support the use of protocol follow-up biopsies after the treatment of TCMR.
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The Pathological and Clinical Diversity of Acute Vascular Rejection in Kidney Transplantation. Transplantation 2022; 106:1666-1676. [PMID: 35266923 DOI: 10.1097/tp.0000000000004071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascular rejection (VR) is characterized by arteritis, steroid resistance, and increased graft loss but is poorly described using modern diagnostics. METHODS We screened 3715 consecutive biopsies and retrospectively evaluated clinical and histological phenotypes of VR (n = 100) against rejection without arteritis (v0REJ, n = 540) and normal controls (n = 1108). RESULTS Biopsy sample size affected the likelihood of arterial sampling, VR diagnosis, and final Banff v scores (P < 0.001). Local v and cv scores were greatest in larger arteries (n = 258). VR comprised 15.6% of all rejection episodes, presented earlier (median 1.0 mo, interquartile range, 0.4-8 mo) with higher serum creatinine levels and inferior graft survival, versus v0REJ (P < 0.001). Early VR (≤1 mo) was common (54%) and predicted by sensitization, delayed function, and prior corticosteroid use, with associated acute dysfunction and optimal therapeutic response, independent of Banff v score. Late VR followed under-immunosuppression in 71.4% (noncompliance 38.8%, iatrogenic 32.6%), and was associated with chronic interstitial fibrosis, incomplete renal functional recovery and persistent inflammation using sequential histopathology. The etiology was "pure" antibody-mediated VR (n = 21), mixed VR (n = 36), and "pure" T cell-mediated VR (n = 43). Isolated VR (n = 34, Banff i < 1 without tubulitis) comprised 24 T cell-mediated VR and 10 antibody-mediated VR, presenting with mild renal dysfunction, minimal Banff acute scores, and better graft survival compared with inflamed VR. Interstitial inflammation influenced acute renal dysfunction and early treatment response, whereas chronic tubulointerstitial damage determined long-term graft loss. CONCLUSIONS VR is a heterogenous entity influenced by time-of-onset, pathophysiology, accompanying interstitial inflammation and fibrosis. Adequate histological sampling is essential for its accurate diagnostic classification and treatment.
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Qannus AA, Bracamonte E, Tanriover B. Isolated Vascular Lesions in Renal Allograft Biopsy: How Do I Treat it? COMPLICATIONS IN KIDNEY TRANSPLANTATION 2022:243-248. [DOI: 10.1007/978-3-031-13569-9_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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5
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Loupy A, Mengel M, Haas M. 30 years of the International Banff Classification for Allograft Pathology: The Past, Present and Future of Kidney Transplant Diagnostics. Kidney Int 2021; 101:678-691. [DOI: 10.1016/j.kint.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
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Early-Isolated V Lesion in Kidney Allograft: Acute Rejection or Ischemic Injury? A Case Report of Primary Nonfunction and Graft Loss. Transplant Proc 2021; 53:2536-2538. [PMID: 34465423 DOI: 10.1016/j.transproceed.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/02/2021] [Indexed: 01/25/2023]
Abstract
Intimal arteritis (v-lesion) is a negative prognostic factor for kidney allograft survival. Early isolated v-lesions do not always represent a pathologic marker of acute T cell- or antibody-mediated rejection. In particular, in the case of transplant negative for C4d and donor-specific antibodies, such a finding can suggest an ischemic-reperfusion injury. There is an intense debate in the literature concerning the origin of this histologic feature. In the present study, we analyze how this argument can have a clinical relevance. Here we report a case of a 61-year-old woman with end-stage renal disease due to autosomal dominant polycystic kidney disease. The patient underwent kidney transplant from expanded criteria donor. Organs from expanded criteria donors are more prone to ischemic-reperfusion injury. Postoperative course was characterized by primary nonfunction of the graft. A first biopsy showed early isolated v-lesion in otherwise normal renal parenchymal. Simultaneously, a computed tomography scan revealed stenosis of the main renal artery. An endovascular stent was placed. Despite improved vascularization of the graft, no clinical response was observed and the patient remained anuric. A second biopsy was performed, showing T-cell mediated rejection (Banff Classification 1A). Despite pulse steroid, the patient lost the graft.
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de Mattos Barbosa MG, Lefferts AR, Huynh D, Liu H, Zhang Y, Fu B, Barnes J, Samaniego M, Bram RJ, Geha R, Shikanov A, Luning Prak ET, Farkash EA, Platt JL, Cascalho M. TNFRSF13B genotypes control immune-mediated pathology by regulating the functions of innate B cells. JCI Insight 2021; 6:e150483. [PMID: 34283811 PMCID: PMC8492324 DOI: 10.1172/jci.insight.150483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/14/2021] [Indexed: 11/20/2022] Open
Abstract
Host genes define the severity of inflammation and immunity but specific loci doing so are unknown. Here we show that TNF receptor superfamily member 13B (TNFRSF13B) variants, which enhance defense against certain pathogens, also control immune-mediated injury of transplants, by regulating innate B cells’ functions. Analysis of TNFRSF13B in human kidney transplant recipients revealed that 33% of those with antibody-mediated rejection (AMR) but fewer than 6% of those with stable graft function had TNFRSF13B missense mutations. To explore mechanisms underlying aggressive immune responses, we investigated alloimmunity and rejection in mice. Cardiac allografts in Tnfrsf13b-mutant mice underwent early and severe AMR. The dominance and precocity of AMR in Tnfrsf13b-deficient mice were not caused by increased alloantibodies. Rather, Tnfrsf13b mutations decreased “natural” IgM and compromised complement regulation, leading to complement deposition in allografted hearts and autogenous kidneys. Thus, WT TNFRSF13B and Tnfrsf13b support innate B cell functions that limit complement-associated inflammation; in contrast, common variants of these genes intensify inflammatory responses that help clear microbial infections but allow inadvertent tissue injury to ensue. The wide variation in inflammatory reactions associated with TNFRSF13B diversity suggests polymorphisms could underlie variation in host defense and explosive inflammatory responses that sometimes enhance morbidity associated with immune responses.
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Affiliation(s)
| | - Adam R Lefferts
- Department of Surgery, University of Michigan, Ann Arbor, United States of America
| | - Daniel Huynh
- Department of Surgery, University of Michigan, Ann Arbor, United States of America
| | - Hui Liu
- Department of Surgery, University of Michigan, Ann Arbor, United States of America
| | - Yu Zhang
- Department of Surgery, University of Michigan, Ann Arbor, United States of America
| | - Beverly Fu
- Department of Surgery, University of Michigan, Ann Arbor, United States of America
| | - Jenna Barnes
- Department of Pathology, University of Michigan, Ann Arbor, United States of America
| | - Milagros Samaniego
- Department of Medicine, University of Michigan, Ann Arbor, United States of America
| | - Richard J Bram
- Department of Pediatric and Adolescent Medicine, Mayo Clinic/Foundation, Rochester, United States of America
| | - Raif Geha
- Division of Immunology, Department of Pediatrics, Harvard Medical School, Boston, United States of America
| | - Ariella Shikanov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, United States of America
| | - Eline T Luning Prak
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, United States of America
| | - Evan A Farkash
- Department of Pathology, University of Michigan, Ann Arbor, United States of America
| | - Jeffrey L Platt
- Transplantation Biology, University of Michigan, Ann Arbor, United States of America
| | - Marilia Cascalho
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, United States of America
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8
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Mikhail D, Chan E, Sharma H, Kleinsteuber D, Wei J, Rim C, Henein M, Sener A, Jevnikar AM, Gabril M, Moussa M, Luke PP. Clinical Significance of Isolated V1 Arteritis in Renal Transplantation. Transplant Proc 2021; 53:1570-1575. [PMID: 33994184 DOI: 10.1016/j.transproceed.2021.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/03/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The presence of intimal arteritis (v) in renal allograft biopsy specimens establishes the presence of acute T-cell mediated rejection (TCMR), Grade IIa-III, according to the Banff classification of rejection. The clinical significance of isolated v1 lesions (v1), characterized by arteritis alone, compared with lesions of arteritis with tubulointerstitial inflammation (i-t-v) has been controversial. METHODS We performed a retrospective review of 280 patients undergoing renal transplantation between 2005 and 2015 who received a "for cause" transplant biopsy using the Banff 2013 classification. Patients with TCMR grade IIa (n = 83) were subdivided into groups with isolated v1 arteritis and i-t-v. Pre- and postoperative renal function, graft survival, and overall survival were evaluated in all patients. RESULTS Donor and recipient demographics were similar between groups. One month following treatment of rejection, patients with v1 disease had superior recovery of glomerular filtration rate vs patients with i-t-v (P < .002). At a median follow-up of 41 months from transplant, death-censored graft survival was 92% vs 79% (P = .04), and overall survival was 98% vs 79% (P < .004) in the isolated v1 and i-t-v groups, respectively. CONCLUSION Despite having identical Banff classification of TCMR IIa, our results indicate that graft survival in patients with isolated v1 rejection is superior to those with i-t-v. Following corroboration with data from other centers, modification of the Banff classification scheme should be considered.
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Affiliation(s)
- David Mikhail
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Division of Urology, Department of Surgery, London Health Sciences Center, London, Ontario, Canada
| | - Ernest Chan
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Division of Urology, Department of Surgery, London Health Sciences Center, London, Ontario, Canada
| | - Hemant Sharma
- Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada
| | - Derek Kleinsteuber
- Department of Pathology and Laboratory Medicine, London Health Sciences Center, London, Ontario, Canada; Department of Medicine, London Health Sciences Center, London, Ontario, Canada
| | - James Wei
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Claire Rim
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marina Henein
- Department of Pathology and Laboratory Medicine, London Health Sciences Center, London, Ontario, Canada; Department of Medicine, London Health Sciences Center, London, Ontario, Canada
| | - Alp Sener
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Division of Urology, Department of Surgery, London Health Sciences Center, London, Ontario, Canada; Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada
| | - Anthony M Jevnikar
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada
| | - Manal Gabril
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, London Health Sciences Center, London, Ontario, Canada; Department of Medicine, London Health Sciences Center, London, Ontario, Canada
| | - Madeleine Moussa
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, London Health Sciences Center, London, Ontario, Canada; Department of Medicine, London Health Sciences Center, London, Ontario, Canada
| | - Patrick P Luke
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Division of Urology, Department of Surgery, London Health Sciences Center, London, Ontario, Canada; Multi-Organ Transplant Program, London Health Sciences Center, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, London Health Sciences Center, London, Ontario, Canada; Department of Medicine, London Health Sciences Center, London, Ontario, Canada.
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9
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Molecular Analysis of Renal Allograft Biopsies: Where Do We Stand and Where Are We Going? Transplantation 2021; 104:2478-2486. [PMID: 32150035 DOI: 10.1097/tp.0000000000003220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A renal core biopsy for histological evaluation is the gold standard for diagnosing renal transplant pathology. However, renal biopsy interpretation is subjective and can render insufficient precision, making it difficult to apply a targeted therapeutic regimen for the individual patient. This warrants a need for additional methods assessing disease state in the renal transplant. Significant research activity has been focused on the role of molecular analysis in the diagnosis of renal allograft rejection. The identification of specific molecular expression patterns in allograft biopsies related to different types of allograft injury could provide valuable information about the processes underlying renal transplant dysfunction and can be used for the development of molecular classifier scores, which could improve our diagnostic and prognostic ability and could guide treatment. Molecular profiling has the potential to be more precise and objective than histological evaluation and may identify injury even before it becomes visible on histology, making it possible to start treatment at the earliest time possible. Combining conventional diagnostics (histology, serology, and clinical data) and molecular evaluation will most likely offer the best diagnostic approach. We believe that the use of state-of-the-art molecular analysis will have a significant impact in diagnostics after renal transplantation. In this review, we elaborate on the molecular phenotype of both acute and chronic T cell-mediated rejection and antibody-mediated rejection and discuss the additive value of molecular profiling in the setting of diagnosing renal allograft rejection and how this will improve transplant patient care.
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10
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Jeong HJ. Diagnosis of renal transplant rejection: Banff classification and beyond. Kidney Res Clin Pract 2020; 39:17-31. [PMID: 32164120 PMCID: PMC7105630 DOI: 10.23876/j.krcp.20.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 12/20/2022] Open
Abstract
Diagnosis of renal transplant rejection is dependent on interpretation of renal allograft biopsies. The Banff Classification of Allograft Pathology, which was developed as a standardized working classification system in 1991, has contributed to the standardization of definitions for histologic injuries resulting from renal allograft rejections and provided a universal grading system for assessing these injuries. It has also helped to provide insight into the underlying pathogenic mechanisms that contribute to transplant rejection. In addition to histological and immunologic parameters, molecular tools are now being used to facilitate the diagnosis of rejection. In this review, I will discuss morphologic features of renal transplant rejections as well as major revisions and pitfalls of the Banff classification system, and provide future perspectives.
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Affiliation(s)
- Hyeon Joo Jeong
- Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
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11
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Bangaru V, Uppin M, Yadla M, Gudithi S, Taduri G, Raju S. Isolated Vascular Lesions (IVL) in Early Allograft Biopsies: A Case Series. Indian J Nephrol 2019; 29:364-367. [PMID: 31571746 PMCID: PMC6755935 DOI: 10.4103/ijn.ijn_345_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This case series includes five patients diagnosed as isolated vascular lesion (IVL) on allograft biopsy in an early post-transplant period. These patients presented with graft dysfunction. The biopsies satisfied the criteria for IVL as laid down by Banff 2009. Four of these patients were treated with corticosteroids and other anti rejection measures. C4d and DSA were negative in all. The patients showed good response to treatment with stable graft function at the longest follow-up of one year. We have also reviewed the literature about IVL as a specific entity. There are differences between the molecular and clinical data of IVL. It is difficult to differentiate whether IVL is a rejection or non-rejection process. This study aims to highlight the importance of a rare entity.
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Affiliation(s)
| | - Megha Uppin
- Department of Pathology, NIMS, Hyderabad, Telangana, India
| | - Manjusha Yadla
- Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
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12
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Yadla M, Pradeep K, Harke M. Successful treatment of isolated vascular arteritis in renal allograft recipients: A treatable new histological entity. INDIAN JOURNAL OF TRANSPLANTATION 2019. [DOI: 10.4103/ijot.ijot_86_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Early isolated V-lesion may not truly represent rejection of the kidney allograft. Clin Sci (Lond) 2018; 132:2269-2284. [PMID: 30287520 PMCID: PMC6365629 DOI: 10.1042/cs20180745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/26/2023]
Abstract
Intimal arteritis is known to be a negative prognostic factor for kidney allograft survival. Isolated v-lesion (IV) is defined as intimal arteritis with minimal tubulointerstitial inflammation (TI). Although the Banff classification assesses IV as T cell-mediated rejection (TCMR), clinical, and prognostic significance of early IV (early IV, eIV) with negative C4d and donor-specific antibodies (DSA) remains unclear. To help resolve if such eIV truly represents acute rejection, a molecular study was performed. The transcriptome of eIV (n=6), T cell-mediated vascular rejection with rich TI (T cell-mediated vascular rejection, TCMRV, n=4) and non-rejection histologic findings (n=8) was compared using microarrays. A total of 310 genes were identified to be deregulated in TCMRV compared with eIV. Gene enrichment analysis categorized deregulated genes to be associated primarily with T-cells associated biological processes involved in an innate and adaptive immune and inflammatory response. Comparison of deregulated gene lists between the study groups and controls showed only a 1.7% gene overlap. Unsupervised hierarchical cluster analysis revealed clear distinction of eIV from TCMRV and showed similarity with a control group. Up-regulation of immune response genes in TCMRV was validated using RT-qPCR in a different set of eIV (n=12) and TCMRV (n=8) samples. The transcriptome of early IV (< 1 month) with negative C4d and DSA is associated with a weak immune signature compared with TCMRV and shows similarity with normal findings. Such eIV may feature non-rejection origin and reflect an injury distinct from an alloimmune response. The present study supports use of molecular methods when interpreting kidney allograft biopsy findings.
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14
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Novotny M, Hruba P, Vichova P, Maluskova J, Honsova E, Viklicky O, Wohlfahrtova M. Isolated v-lesion represents a benign phenotype of vascular rejection of the kidney allograft - a retrospective study. Transpl Int 2018; 31:1153-1163. [PMID: 29855106 DOI: 10.1111/tri.13286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/19/2018] [Accepted: 05/25/2018] [Indexed: 12/01/2022]
Abstract
While the detrimental impact of the humoral acute vascular rejection (AVR) phenotype is recognized, the prognostic significance of isolated v-lesion (IV) remains unclear. In this retrospective single-centre study, AVR was found in 98 of 1015 patients (9.7%) who had undergone kidney transplantation in 2010-2014, with donor-specific antibodies (DSA) evaluated in all of them. The outcome of four AVR phenotypes was evaluated during median follow-up of 59 months; in 25 patients with IV, 18 with T-cell-mediated vascular rejection (TCMVR), 19 with antibody-mediated vascular rejection (AMVR) and 36 with suspected antibody-mediated rejection (sAMVR). AVR was diagnosed mainly by for-cause biopsy (81%) early after transplantation (median 19 POD) and appeared as mild-grade intimal arteritis. IV occurred in low-sensitized patients after the first transplantation (96%) in the absence of DSA. IV responded satisfactorily to treatment (88%), showed no persistence of rejection in surveillance biopsy, and had stable graft function, minimal proteinuria and excellent DCGS (96%). Contrary to that, Kaplan-Meier estimate of 3-year DCGS of AMVR was 66% (log-rank = 0.0004). Early IV represents a benign phenotype of AVR with a favourable outcome. This study prompts further research to evaluate the nature of IV before considering any change in the classification and management.
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Affiliation(s)
- Marek Novotny
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Hruba
- Transplant Laboratory, Centre for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Vichova
- Department of Immunogenetics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Maluskova
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Eva Honsova
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Transplant Laboratory, Centre for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Mariana Wohlfahrtova
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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15
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Stevenson HL, Prats MM, Isse K, Zeevi A, Avitzur Y, Ng VL, Demetris AJ. Isolated vascular "v" lesions in liver allografts: How to approach this unusual finding. Am J Transplant 2018; 18:1534-1543. [PMID: 29464837 DOI: 10.1111/ajt.14708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 01/25/2023]
Abstract
According to the Banff criteria for kidney allografts, isolated vascular or "v" lesions are defined as intimal inflammation, age-inappropriate fibro-intimal hyperplasia, or both, without the presence of associated interstitial T cell-mediated rejection (TCMR). In general, these lesions portend a worse outcome for kidney allografts, particularly in those where the "v" lesions are identified in patients with coexistent donor specific antibodies (DSA) or later after transplantation. Although affected arteries are rarely sampled in liver allograft biopsies, we identified nine patients at a mean of 1805 days posttransplantation and compared these to matched controls. Almost half (4 of 9) of the study patient biopsies showed inflammatory arteritis associated with focal or diffuse C4d positivity, which was not observed in matched controls. One "v" lesion patient progressed to rejection-related graft failure and two developed moderate/severe TCMR in subsequent biopsies, whereas only one rejection episode occurred in follow-up biopsies, and no rejection-related deaths or graft failures were detected in controls. In conclusion, patients with liver allograft isolated "v" lesions should undergo further evaluation and closer follow-up for impending TCMR and/or underlying co-existent chronic antibody-mediated rejection (AMR).
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Affiliation(s)
- H L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - M M Prats
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - K Isse
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A Zeevi
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Y Avitzur
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - V L Ng
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - A J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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16
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Rabant M, Boullenger F, Gnemmi V, Pellé G, Glowacki F, Hertig A, Brocheriou I, Suberbielle C, Taupin JL, Anglicheau D, Legendre C, Duong Van Huyen JP, Buob D. Isolated v-lesion in kidney transplant recipients: Characteristics, association with DSA, and histological follow-up. Am J Transplant 2018; 18:972-981. [PMID: 29206350 DOI: 10.1111/ajt.14617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/24/2017] [Accepted: 11/25/2017] [Indexed: 01/25/2023]
Abstract
Isolated v-lesion (IvL) represents a rare and challenging situation in renal allograft biopsies because it is unknown whether IvL truly represents rejection, antibody- or T cell-mediated, or not. This multicentric retrospective study describes the clinicopathological features of IvL with an emphasis on the donor-specific antibody (DSA) status, histological follow-up, and graft survival. Inclusion criteria were the presence of v-lesion with minimal interstitial (i ≤ 1) and microvascular inflammation (g + ptc≤1). C4d-positive biopsies were excluded. We retrospectively found 33 IvL biopsies in 33 patients, mainly performed in the early posttransplantation period (median time 27 days) and clinically indicated in 66.7%. A minority of recipients (5/33, 15.2%) had DSA at the time of biopsy. IvL was treated by anti-rejection therapy in 21 cases (63.6%), whereas 12 (36.4%) were untreated. Seventy percent of untreated patients and 66% of treated patients showed favorable histological evolution on subsequent biopsy. Kidney graft survival in IvL was significantly higher than in a matched cohort of antibody-mediated rejection with arteritis. In conclusion, IvL is not primarily antibody-mediated and may show a favorable evolution. The heterogeneity of IvL pathophysiology on early biopsies should prompt DSA testing as well as close clinical and histological follow-up in all patients with IvL.
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Affiliation(s)
- Marion Rabant
- Pathology Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris,, France.,Paris Descartes, Sorbonne Paris Cité University, Paris, France
| | - Fanny Boullenger
- Nephrology department, Centre hospitalier intercommunal André Grégoire, Montreuil, France
| | - Viviane Gnemmi
- Pathology department, CHRU Lille, Lille 2 University, Lille, France
| | - Gaëlle Pellé
- Kidney transplant department, Foch Hospital, Suresnes, France
| | - François Glowacki
- Kidney transplant department, CHRU Lille, Lille 2 University, Lille, France
| | - Alexandre Hertig
- Kidney transplant department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Isabelle Brocheriou
- Pathology department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Paris 06, Paris, France.,Inserm, UMR S 1155, Paris, France
| | - Caroline Suberbielle
- Histocompatibility department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Luc Taupin
- Histocompatibility department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dany Anglicheau
- Paris Descartes, Sorbonne Paris Cité University, Paris, France.,Department of Nephrology and Kidney transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Paris Descartes, Sorbonne Paris Cité University, Paris, France.,Department of Nephrology and Kidney transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Paul Duong Van Huyen
- Pathology Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris,, France.,Paris Descartes, Sorbonne Paris Cité University, Paris, France.,Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - David Buob
- Pathology department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Paris 06, Paris, France.,Inserm, UMR S 1155, Paris, France
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17
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Iwai T, Uchida J, Kabei K, Nishide S, Kuwabara N, Naganuma T, Kumada N, Takemoto Y, Nakatani T. Isolated V-Lesion in an ABO-Incompatible Kidney Transplant Recipient Receiving Rituximab. EXP CLIN TRANSPLANT 2017; 17:678-680. [PMID: 29137592 DOI: 10.6002/ect.2017.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report an ABO-incompatible kidney transplant performed on a 69-year-old female patient, whose donor was her 69-year-old husband. The patient received an immunosuppressive protocol using rituximab without splenectomy. Renal biopsy was done on posttransplant day 8 due to poor early graft function, and an isolated v-lesion was found, which responded to steroid pulse therapy and gusperimus hydrochloride administration. Our results indicate that isolated v-lesions can occur in ABO-incompatible kidney transplant recipients receiving rituximab and that this finding should be treated as acute rejection. To our knowledge, this is the first report of an isolated v-lesion in an ABO-incompatible kidney transplant recipient who had been administered rituximab.
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Affiliation(s)
- Tomoaki Iwai
- From the Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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18
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Evaluation of Microvascular Inflammation in ABO-Incompatible Kidney Transplantation. Transplantation 2017; 101:1423-1432. [PMID: 27495756 DOI: 10.1097/tp.0000000000001403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In ABO-incompatible kidney transplantation, the diagnostic criteria for antibody-mediated rejection remain controversial because C4d deposition is commonly observed. Thus, we investigated microvascular inflammation (MVI score ≥ 2) within 1 year as a predictor of graft outcome. METHODS A total of 148 recipients without preformed or de novo donor-specific anti-HLA antibody were stratified based on MVI score less than 2 (n = 117) and MVI score of 2 or greater (n = 31). RESULTS We found that 5-year graft survival was significantly lower (P = 0.0129) in patients with MVI (89.8%) than in patients without MVI (97.0%). Graft function, as characterized by serum estimated glomerular filtration rate, was also significantly worse for patients with MVI than it was for patients without MVI, between 3 months and 10 years after transplantation (P = 0.048). Multivariate analysis indicated that HLA class II mismatch (P = 0.0085) was an independent marker of MVI. CONCLUSIONS Microvascular inflammation score of 2 or greater is significantly associated with poor graft outcome after ABO-incompatible kidney transplantation. We suggest that MVI score of 2 or greater in ABOi transplantation be used as a basis to diagnose antibody-mediated rejection.
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19
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Current status of pediatric renal transplant pathology. Pediatr Nephrol 2017; 32:425-437. [PMID: 27221522 DOI: 10.1007/s00467-016-3381-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 03/07/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
Histopathology is still an indispensable tool for the diagnosis of kidney transplant dysfunction in adult and pediatric patients. This review presents consolidated knowledge, recent developments and future prospects on the biopsy procedure, the diagnostic work-up, classification schemes, the histopathology of rejection, including antibody-mediated forms, ABO-incompatible transplants, protocol biopsies, recurrent and de novo disease, post-transplant lymphoproliferative disorder, infectious complications and drug-induced toxicity. It is acknowledged that frequently the correct diagnosis can only be reached in consensus with clinical, serological, immunogenetical, bacteriological and virological findings. This review shall enhance the understanding of the pediatric nephrologist for the thought processes of nephropathologists with the aim to facilitate teamwork between these specialist groups for the benefit of the patient.
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20
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Katsuma A, Yamakawa T, Nakada Y, Yamamoto I, Yokoo T. Histopathological findings in transplanted kidneys. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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21
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Loupy A, Haas M, Solez K, Racusen L, Glotz D, Seron D, Nankivell BJ, Colvin RB, Afrouzian M, Akalin E, Alachkar N, Bagnasco S, Becker JU, Cornell L, Drachenberg C, Dragun D, de Kort H, Gibson IW, Kraus ES, Lefaucheur C, Legendre C, Liapis H, Muthukumar T, Nickeleit V, Orandi B, Park W, Rabant M, Randhawa P, Reed EF, Roufosse C, Seshan SV, Sis B, Singh HK, Schinstock C, Tambur A, Zeevi A, Mengel M. The Banff 2015 Kidney Meeting Report: Current Challenges in Rejection Classification and Prospects for Adopting Molecular Pathology. Am J Transplant 2017; 17:28-41. [PMID: 27862883 PMCID: PMC5363228 DOI: 10.1111/ajt.14107] [Citation(s) in RCA: 486] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 01/25/2023]
Abstract
The XIII Banff meeting, held in conjunction the Canadian Society of Transplantation in Vancouver, Canada, reviewed the clinical impact of updates of C4d-negative antibody-mediated rejection (ABMR) from the 2013 meeting, reports from active Banff Working Groups, the relationships of donor-specific antibody tests (anti-HLA and non-HLA) with transplant histopathology, and questions of molecular transplant diagnostics. The use of transcriptome gene sets, their resultant diagnostic classifiers, or common key genes to supplement the diagnosis and classification of rejection requires further consensus agreement and validation in biopsies. Newly introduced concepts include the i-IFTA score, comprising inflammation within areas of fibrosis and atrophy and acceptance of transplant arteriolopathy within the descriptions of chronic active T cell-mediated rejection (TCMR) or chronic ABMR. The pattern of mixed TCMR and ABMR was increasingly recognized. This report also includes improved definitions of TCMR and ABMR in pancreas transplants with specification of vascular lesions and prospects for defining a vascularized composite allograft rejection classification. The goal of the Banff process is ongoing integration of advances in histologic, serologic, and molecular diagnostic techniques to produce a consensus-based reporting system that offers precise composite scores, accurate routine diagnostics, and applicability to next-generation clinical trials.
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22
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Current pathological perspectives on chronic rejection in renal allografts. Clin Exp Nephrol 2016; 21:943-951. [PMID: 27848058 DOI: 10.1007/s10157-016-1361-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/08/2016] [Indexed: 01/22/2023]
Abstract
Chronic rejection in renal transplantation clinically manifests as slow deterioration in allograft function and is a major contributor of late renal graft loss. Most cases of chronic rejection involve chronic antibody-mediated rejection (ABMR) triggered by the interaction of donor-specific alloantibodies with endothelial cells of the microcirculation. The evolution of the Banff classification involved a major revision of the ABMR criteria during the 2000s and led to the inclusion of detailed pathological characteristics of chronic ABMR in the 2013 Banff scheme, including microcirculation damage observed as newly formed basement membranes and arterial fibrous intimal proliferation. Inflammation of microvasculature including glomeruli and/or peritubular capillaries is also seen in substantial cases of chronic ABMR, defined as chronic active ABMR. Chronic active T cell-mediated rejection (TCMR) results from chronic T cell-mediated injury involving renal arteries but is less characterized under the current Banff classification, mainly due to the expanding histological criteria of chronic active ABMR. Characteristics shared by these two chronic rejection types can potentially cause diagnostic confusion. Hence, the diagnostic criteria or categories of chronic renal rejection require amendment of the current Banff classification. Assessment of rejection cases with molecular phenotyping advanced the mechanistic understanding of various dysfunctions in renal allograft, including ABMR and TCMR. Identification of disease-specific changes in gene expression by immunohistological studies, especially in chronic ABMR, has already been validated by several studies, warranting potential application to the pathological diagnostic process. This review provides an overview of current pathological perspectives on chronic rejection of renal allografts and future directions.
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23
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Efficacy of Acute Cellular Rejection Treatment According to Banff Score in Kidney Transplant Recipients: A Systematic Review. Transplant Direct 2016; 2:e115. [PMID: 27990480 PMCID: PMC5142362 DOI: 10.1097/txd.0000000000000626] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/25/2022] Open
Abstract
Supplemental digital content is available in the text. Background The poor prognosis classically associated with Banff grade 2 acute cell-mediated rejection (CMR) may be due to unrecognized antibody-mediated damage. We thus performed a systematic review of the literature to determine the rate of response to treatment in kidney transplant recipients with pure CMR, stratified by Banff class. Methods In addition to a manual search, databases interrogated included Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), Evidence-Based Medicine (EBM) databases, Central, PubMed and CINAHL. Studies providing functional and/or histological response rates to the treatment of CMR rejection by Banff class (1997 or more recent) were included. Results Among the 746 articles identified, 5 articles were included in the final review. Two studies excluded some, and 2 excluded all features of antibody-mediated rejection, while providing data on functional recovery. The absence of functional recovery was reported in 4% of borderline, 15% for Banff grade 1A and IB pooled, 0% to 25% of Banff grade 1B alone, 11% to 20% of Banff grade 2A, and 38% of Banff grade 2B rejections. Conclusions The rate of functional recovery of pure Banff IIA CMR overlapped with that of Banff grade 1 CMR, whereas Banff grade 2B showed worse prognosis. There was important heterogeneity in the definition of response to treatment and paucity of data describing the histological response to treatment stratified by Banff class. There is a pressing need to standardize outcome metrics for the reversibility of rejection in kidney transplant recipients in order to design high-quality trials for novel therapeutic alternatives.
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24
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Halloran PF, Famulski KS, Reeve J. Molecular assessment of disease states in kidney transplant biopsy samples. Nat Rev Nephrol 2016; 12:534-48. [DOI: 10.1038/nrneph.2016.85] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Early Posttransplant Isolated v1 Lesion Does Not Need to Be Treated and Does Not Lead to Increased Fibrosis. Case Rep Transplant 2016; 2016:4603014. [PMID: 27293950 PMCID: PMC4886071 DOI: 10.1155/2016/4603014] [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: 01/28/2016] [Revised: 04/20/2016] [Accepted: 05/03/2016] [Indexed: 11/18/2022] Open
Abstract
Acute vascular rejection (AVR) is characterized by intimal arteritis in addition to tubulitis and interstitial inflammation. It is associated with a poorer prognosis compared to tubulointerstitial rejection (AIR) and AVR is associated with a higher rate of graft loss than AIR. The prognosis and treatment of arteritis without tubulitis and interstitial inflammation (isolated v1 lesion) are still controversial. We report a case of a patient who had a biopsy of the kidney allograft for evaluation of slow graft function. The biopsy revealed an isolated v1 lesion. However, we chose not to augment immunosuppression. The patient's kidney allograft function improved over time with close monitoring. Repeat biopsy a year later showed no evidence of endothelialitis and relatively unchanged fibrosis and no other abnormalities. Although it is suggested that most cases of isolated v1 lesions will respond to corticosteroids or T cell depleting therapies, some cases will improve with conservative management. Further studies are needed to determine which cases could be managed conservatively.
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26
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Haas M. The Revised (2013) Banff Classification for Antibody-Mediated Rejection of Renal Allografts: Update, Difficulties, and Future Considerations. Am J Transplant 2016; 16:1352-7. [PMID: 26696524 DOI: 10.1111/ajt.13661] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 01/25/2023]
Abstract
The Banff 2013 classification (Banff 2013) for antibody-mediated rejection (ABMR) in renal allografts represents the first major revision of the original Banff classification for ABMR that was published in 2003. The main impetus for this revision was the need to include C4d-negative ABMR, although this revised classification contains a number of additional features based on findings reported from 2007 to 2013. Since its publication, several studies have examined the validity of different aspects of Banff 2013 and compared it to earlier (2003, 2007) versions of the Banff ABMR classification. Recent evidence, albeit limited, indicates that Banff 2013 represents an improvement over the previous versions, enhancing our ability to accurately diagnose cases of acute/active and chronic active ABMR on renal allograft biopsy. Molecular studies appear to justify the threshold value of glomerulitis plus peritubular capillaritis score ≥2 required by Banff 2013 for the diagnosis of C4d-negative ABMR; however, other aspects of the classification, including its overall interobserver reproducibility, the clinical significance of the category of C4d staining without evidence of rejection, and whether surrogate markers might potentially substitute for the requirement for the presence of donor-specific antibodies, require additional investigation.
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Affiliation(s)
- M Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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27
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Reeve J, Chang J, Salazar IDR, Lopez MM, Halloran PF. Using Molecular Phenotyping to Guide Improvements in the Histologic Diagnosis of T Cell-Mediated Rejection. Am J Transplant 2016; 16:1183-92. [PMID: 26730747 DOI: 10.1111/ajt.13572] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/01/2015] [Accepted: 10/03/2015] [Indexed: 01/25/2023]
Abstract
Recognition that some lesions typical of T cell-mediated rejection (TCMR) also occur in antibody-mediated rejection requires revision of the histologic TCMR definition. To guide this process, we assessed the relative importance of various lesions and the performance of new histology diagnostic algorithms, using molecular TCMR scores as histology-independent estimates of true TCMR. In 703 indication biopsies, random forest analysis and logistic regression indicated that interstitial infiltrate (i-lesions) and tubulitis (t-lesions) were the key histologic predictors of molecular TCMR, with arteritis (v-lesions) having less importance. Histology predicted molecular TCMR more accurately when diagnoses were assigned by strictly applying the Banff rules to the lesion scores and redefining isolated v-lesion TCMR. This improved prediction from area under the curve (AUC) 0.70 with existing rules to AUC 0.80. Further improvements were achieved by introducing more categories to reflect inflammation (AUC 0.84), by summing the lesion scores (AUC 0.85) and by logistic regression (AUC 0.90). We concluded that histologic assessment of TCMR can be improved by placing more emphasis on i- and t-lesions and incorporating new algorithms for diagnosis. Nevertheless, some discrepancies between histologic and molecular diagnoses persist, partially due to the inherent nonspecificity of i- and t-lesions, and molecular methods will be required to help resolve these cases.
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Affiliation(s)
- J Reeve
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - J Chang
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - I D R Salazar
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, Viedma Hospital, Cochabamba, Bolivia
| | - M Merino Lopez
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - P F Halloran
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
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28
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Salazar IDR, Merino López M, Chang J, Halloran PF. Reassessing the Significance of Intimal Arteritis in Kidney Transplant Biopsy Specimens. J Am Soc Nephrol 2015; 26:3190-8. [PMID: 25918035 DOI: 10.1681/asn.2014111064] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/10/2015] [Indexed: 12/23/2022] Open
Abstract
Intimal arteritis (the presence of v-lesions) in kidney transplant biopsy specimens is believed to have major prognostic and diagnostic significance. We assessed the relationship of v-lesions to prognosis in 703 indication biopsy specimens and used microarray-based molecular tests to re-examine the relationship of v-lesions to rejection. v-Lesions were noted in 49 specimens (7%) and were usually mild (v1). The presence of v-lesions had no effect on graft survival compared with the absence of v-lesions. Pathologists using current conventions almost always interpreted v-lesions as reflecting T cell-mediated rejection (TCMR), either pure or mixed with antibody-mediated rejection (ABMR). The molecular scores questioned the conventional diagnoses in 29 of 49 specimens (59%), including ten that were conventional TCMR with no molecular rejection and nine that were conventional TCMR mixed with pure ABMR molecularly. The presence of tubulointerstitial inflammation (i-t) meeting TCMR criteria allowed subclassification of v-lesion specimens into 21 i-t-v-lesion specimens and 28 isolated v-lesion specimens. Molecular TCMR scores were positive in 95% of i-t-v-lesion specimens but only 21% of isolated v-lesion specimens. Molecular ABMR scores were often positive in isolated v-lesion biopsies (46%). Time of biopsy after transplantation was critical for understanding isolated v-lesions: most early isolated v-lesion specimens had no molecular rejection and were DSA negative, whereas most isolated >1 year after transplantation had positive DSA and ABMR scores. Therefore, v-lesions in indication biopsy specimens do not affect prognosis and can reflect TCMR, ABMR, or no rejection. Time after transplantation, DSA, and accompanying inflammation provide probabilistic basis for interpreting v-lesions.
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Affiliation(s)
- Israel D R Salazar
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada; Department of Medicine, Viedma Hospital, Cochabamba, Bolivia; Caja National Health Hospital, Cochabamba, Bolivia; and
| | | | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada; Department of Medicine, Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta, Canada
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29
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Racusen L, Lefaucheur C. Renal allograft rejection: pieces of the puzzle. J Am Soc Nephrol 2014; 26:1004-5. [PMID: 25381428 DOI: 10.1681/asn.2014090932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Lorraine Racusen
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland; and
| | - Carmen Lefaucheur
- Department of Nephrology and Transplantation, Saint-Louis Hospital, Paris, France
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