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Salinas T, Li C, Snopkowski C, Sharma VK, Dadhania DM, Suhre K, Muthukumar T, Suthanthiran M. Urinary Cell Gene Signature of Acute Rejection in Kidney Allografts. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.18.23300165. [PMID: 38196644 PMCID: PMC10775338 DOI: 10.1101/2023.12.18.23300165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Introduction A kidney allograft biopsy may display acute T cell-mediated rejection (TCMR), antibody-mediated rejection (ABMR), or concurrent TCMR + ABMR (MR). Development of noninvasive biomarkers diagnostic of all three types of acute rejection is a useful addition to the diagnostic armamentarium. Methods We developed customized RT-qPCR assays and measured urinary cell mRNA copy number in 145 biopsy-matched urine samples from 126 kidney allograft recipients and calculated urinary cell three-gene signature score from log 10 -transformed values for the 18S-normalized CD3E mRNA, 18S-normalized CXCL10 mRNA and 18S rRNA. We determined whether the signature score in biopsy-matched urine specimens discriminates biopsies without rejection (NR, n=50) from biopsies displaying TCMR (n=47), ABMR (n=28) or MR (n=20). Results Urinary cell three-gene signature discriminated TCMR, ABMR or MR biopsies from NR biopsies (P <0.0001, One-way ANOVA). Dunnett's multiple comparisons test yielded P<0.0001 for NR vs. TCMR; P <0.001 for NR vs. ABMR; and P <0.0001 for NR vs. MR. By bootstrap resampling, optimism-corrected area under the receiver operating characteristic curve (AUC) was 0.749 (bias-corrected 95% confidence interval [CI], 0.638 to 0.840) for NR vs. TCMR (P<0.0001); 0.780 (95% CI, 0.656 to 0.878) for NR vs. ABMR (P<0.0001); and 0.857 (95% CI, 0.727 to 0.947) for NR vs. MR (P<0.0001). All three rejection biopsy categories were distinguished from NR biopsies with similar accuracy (all AUC comparisons P>0.05). Conclusion Urinary cell three-gene signature score may serve as a universal diagnostic signature of acute rejection due to TCMR, ABMR or MR in human kidney allografts with similar performance characteristics.
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Mubarak M, Raza A, Rashid R, Shakeel S. Evolution of human kidney allograft pathology diagnostics through 30 years of the Banff classification process. World J Transplant 2023; 13:221-238. [PMID: 37746037 PMCID: PMC10514746 DOI: 10.5500/wjt.v13.i5.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 09/15/2023] Open
Abstract
The second half of the previous century witnessed a tremendous rise in the number of clinical kidney transplants worldwide. This activity was, however, accompanied by many issues and challenges. An accurate diagnosis and appropriate management of causes of graft dysfunction were and still are, a big challenge. Kidney allograft biopsy played a vital role in addressing the above challenge. However, its interpretation was not standardized for many years until, in 1991, the Banff process was started to fill this void. Thereafter, regular Banff meetings took place every 2 years for the past 30 years. Marked changes have taken place in the interpretation of kidney allograft biopsies, diagnosis, and classification of rejection and other non-rejection pathologies from the original Banff 93 classification. This review attempts to summarize those changes for increasing the awareness and understanding of kidney allograft pathology through the eyes of the Banff process. It will interest the transplant surgeons, physicians, pathologists, and allied professionals associated with the care of kidney transplant patients.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Amber Raza
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Rahma Rashid
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Shaheera Shakeel
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
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Gaiffe E, Colladant M, Desmaret M, Bamoulid J, Leroux F, Laheurte C, Brouard S, Giral M, Saas P, Courivaud C, Degauque N, Ducloux D. Pre-transplant immune profile defined by principal component analysis predicts acute rejection after kidney transplantation. Front Immunol 2023; 14:1192440. [PMID: 37497224 PMCID: PMC10367005 DOI: 10.3389/fimmu.2023.1192440] [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] [Received: 03/23/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Background Acute rejection persists as a frequent complication after kidney transplantation. Defining an at-risk immune profile would allow better preventive approaches. Methods We performed unsupervised hierarchical clustering analysis on pre-transplant immunological phenotype in 1113 renal transplant recipients from the ORLY-EST cohort. Results We identified three immune profiles correlated with clinical phenotypes. A memory immune cluster was defined by memory CD4+T cell expansion and decreased naïve CD4+T cell. An activated immune cluster was characterized by an increase in CD8+T cells and a decreased CD4/CD8 ratio. A naïve immune cluster was mainly defined by increased naïve CD4+T cells. Patients from the memory immune profile tend to be older and to have diabetes whereas those from the activated immune profile were younger and more likely to have pre-transplant exposure to CMV. Patients from the activated immune profile were more prone to experience acute rejection than those from other clusters [(HR=1.69, 95%IC[1.05-2.70], p=0.030) and (HR=1.85; 95%IC[1.16-3.00], p=0.011). In the activated immune profile, those without previous exposure to CMV (24%) were at very high risk of acute rejection (27 vs 16%, HR=1.85; 95%IC[1.04-3.33], p=0.039). Conclusion Immune profile determination based on principal component analysis defines clinically different sub-groups and discriminate a population at high-risk of acute rejection.
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Affiliation(s)
- Emilie Gaiffe
- Besançon University Hospital, INSERM CIC-1431, Besançon, France
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Mathilde Colladant
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
- Besançon University Hospital, Department of Nephrology, Besançon, France
| | - Maxime Desmaret
- Besançon University Hospital, INSERM CIC-1431, Besançon, France
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Jamal Bamoulid
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
- Besançon University Hospital, Department of Nephrology, Besançon, France
| | - Franck Leroux
- Besançon University Hospital, INSERM CIC-1431, Besançon, France
| | - Caroline Laheurte
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Sophie Brouard
- Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche (UMR) 1064, Institut de Transplantation Université de Nantes (ITUN), Nantes, France
| | - Magali Giral
- Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche (UMR) 1064, Institut de Transplantation Université de Nantes (ITUN), Nantes, France
| | - Philippe Saas
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
| | - Cécile Courivaud
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
- Besançon University Hospital, Department of Nephrology, Besançon, France
| | - Nicolas Degauque
- Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche (UMR) 1064, Institut de Transplantation Université de Nantes (ITUN), Nantes, France
| | - Didier Ducloux
- Besançon University Hospital, INSERM CIC-1431, Besançon, France
- Univ. Franche-Comté, INSERM, Etablissement Français du Sang Bourgogne Franche-Comté, Unité Mixte de Recherche (UMR) 1098, RIGHT Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France
- Besançon University Hospital, Department of Nephrology, Besançon, France
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Oto ÖA, Mirioğlu Ş, Yazıcı H, Dirim AB, Güller N, Şafak S, Demir E, Artan AS, Özlük MY, Türkmen A, Çalışkan YK, Lentine KL. Outcomes of kidney transplantation in patients with congenital anomalies of the kidney and urinary tract: a propensity-score-matched analysis with case-control design. Turk J Med Sci 2023; 53:526-535. [PMID: 37476885 PMCID: PMC10387911 DOI: 10.55730/1300-0144.5613] [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: 10/03/2022] [Accepted: 02/01/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND We compared long-term outcomes after kidney transplantation (KTx) in patients with and without congenital anomalies of the kidney and urinary tract (CAKUT). METHODS KTx recipients (KTRs) with CAKUT in 1980-2016 were identified; their hard copy and electronic medical records were reviewed and compared to a propensity-score-matched control group (non-CAKUT) from the same period. The primary outcomes were graft loss or death with a functioning graft; secondary outcomes included posttransplant urinary tract infections (UTIs) and biopsy-proven rejection (BPR). RESULTS : We identified 169 KTRs with CAKUT and 169 matched controls. Median follow-up was 132 (IQR: 75.0-170.0) months. UTIs were more common in CAKUT patients compared to non-CAKUT group (20.7% vs 10.7%; p = 0.01). Rates of BPR were similar between the two groups. In Kaplan-Meier analysis, 10-year graft survival rates were significantly higher in the CAKUT group than in the non-CAKUT group (87.6% vs 69.2%; p < 0.001), while patient survival rates were similar. In multivariate Cox regression analyses, CAKUT (HR: 0.469; 95% CI: 0.320-0.687; p < 0.001) and PRA positivity before transplantation (HR: 3.756; 95% CI: 1.507-9.364; p = 0.005) predicted graft loss. DISCUSSION Graft survival in KTRs with CAKUT appears superior to KTRs without CAKUT. Transplant centers should develop multidisciplinary educational and social working groups to support and encourage CAKUT patients with kidney failure to seek for transplants.
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Affiliation(s)
- Özgür Akın Oto
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Şafak Mirioğlu
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey ; Division of Nephrology, School of Medicine, Bezmialem Vakif University, İstanbul, Turkey
| | - Halil Yazıcı
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Ahmet Burak Dirim
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Nurane Güller
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Seda Şafak
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Erol Demir
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Ayşe Serra Artan
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Mesude Yasemin Özlük
- Department of Pathology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Aydın Türkmen
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Yaşar Kerem Çalışkan
- Division of Nephrology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey ;Division of Nephrology and Hypertension, School of Medicine, Saint Louis University, Saint Louis, USA
| | - Krista L Lentine
- Division of Nephrology and Hypertension, School of Medicine, Saint Louis University, Saint Louis, USA
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Li W, Zhu X, Xu Y, Chen J, Zhang H, Yang Z, Qi Y, Hong J, Li Y, Wang G, Shen J, Qian C. Simultaneous editing of TCR, HLA-I/II and HLA-E resulted in enhanced universal CAR-T resistance to allo-rejection. Front Immunol 2022; 13:1052717. [PMID: 36532006 PMCID: PMC9757162 DOI: 10.3389/fimmu.2022.1052717] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction The major challenge for universal chimeric antigen receptor T cell (UCAR-T) therapy is the inability to persist for a long time in patients leading to inferior efficacy clinically. The objective of this study was to design a novel UCAR-T cell that could avoid the occurrence of allo-rejection and provide effective resistance to allogeneic Natural Killer (NK) cell rejection, together with the validation of its safety and efficacy ex vivo and in vivo. Methods We prepared T-cell receptor (TCR), Human leukocyte antigen (HLA)-I/II triple-edited (TUCAR-T) cells and evaluated the anti-tumor efficacy ex vivo and in vivo. We measured the resistance of exogenous HLA-E expressing TUCAR-T (ETUCAR-T) to NK rejection by using an enhanced NK. Furthermore, we established the safety and efficacy of this regimen by treating Nalm6 tumor-bearing mice with a repeated high-dose infusion of ETUCAR-T. Moreover, we analyzed the effects of individual gene deficiency CAR-T on treated mice and the changes in the transcriptional profiles of different gene-edited T cells via RNA-Seq. Results Data showed that HLA-II editing didn't impair the anti-tumor efficacy of TUCAR-T ex vivo and in vivo and we found for the first time that HLA-II deficiency could facilitate the persistence of CAR-T. Contrastively, as the most commonly eliminated target in UCAR-T, TCR deficiency was found to be a key disadvantageous factor for the shorter-term anti-tumor efficacy in vivo. Our study demonstrated ETUCAR-T could effectively resist allogeneic NK rejection ex vivo and in vivo. Discussion Our research provided a potential and effective strategy for promoting the persistence of UCAR-T cells in clinical application. And it reveals the potential key factors of the poor persistence of UCAR-T along with new insights for future development.
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Affiliation(s)
- Wuling Li
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
- Center for Precision Medicine of Cancer, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Xiuxiu Zhu
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
- Center for Precision Medicine of Cancer, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Yanmin Xu
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Jun Chen
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Hongtao Zhang
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Zhi Yang
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Yanan Qi
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Juan Hong
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Yunyan Li
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Guixue Wang
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, State and Local Joint Engineering Laboratory for Vascular Implants, Bioengineering College of Chongqing University, Chongqing, China
| | - Junjie Shen
- Chongqing Key Laboratory of Gene and Cell Therapy, Institute of Precision Medicine and Biotechnology, Chongqing Precision Biotech Co., Ltd., Chongqing, China
| | - Cheng Qian
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
- Center for Precision Medicine of Cancer, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
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Dandamudi R, Gu H, Goss CW, Walther L, Dharnidharka VR. Longitudinal Evaluation of Donor-Derived Cellfree DNA in Pediatric Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:1646-1655. [PMID: 36302566 PMCID: PMC9718036 DOI: 10.2215/cjn.03840322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Donor-derived cellfree DNA (cfDNA) is a less-invasive marker of allograft injury compared with kidney biopsy. However, donor-derived cfDNA has not yet been extensively tested in children, where the test may have different characteristics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We assayed donor-derived cfDNA (AlloSure; CareDx) from 290 stored plasma samples from a prospective biobank at our center, collected from 57 children monthly in the first year postkidney transplant between January 2013 and December 2019. We assessed the kinetic changes in donor-derived cfDNA levels within the first year post-transplant. We analyzed donor-derived cfDNA levels for associations with biopsy-proven acute rejection using area under the receiver operating characteristic curve to longitudinal plasma and urine BK viral loads using linear mixed models. We analyzed the prognostic effect of an elevated donor-derived cfDNA level on the eGFR 30 days after the assay via Kolmogorov-Smirnov two-sample tests or on measured GFR or interstitial fibrosis at 12 months post-transplant. RESULTS The donor-derived cfDNA levels in children remained persistently elevated for at least 4 months post-transplant, more so if there is greater disparity in size between the donor and the recipient, before reaching a steady low level. A donor-derived cfDNA level of >1% discriminated between biopsy-proven acute rejection with a receiver operating characteristic area under the curve of 0.82 (95% confidence interval, 0.71 to 0.93). During BK viruria or viremia, patients had a significantly higher median donor-derived cfDNA than before or after and a significant rise within the same patient. A donor-derived cfDNA of >0.5% predicted a wider spread in the eGFR over the next 30 days but not the 12-month outcomes. CONCLUSIONS In children, donor-derived cfDNA is a valuable, less invasive biomarker for assessment of allograft rejection and injury. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_10_27_CJN03840322.mp3.
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Affiliation(s)
- Raja Dandamudi
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Hongjie Gu
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles W. Goss
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Leslie Walther
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Etta DPK. Implications of Banff Classification Schema: A Journey of Three Decades. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:598-602. [PMID: 37929555 DOI: 10.4103/1319-2442.388196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Dr Praveen Kumar Etta
- Department of Nephrology and Renal Transplantation, TX Hospitals, Hyderabad, Telangana, India., India
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Nankivell BJ, Shingde M, P’Ng CH, Sharma A. The Clinical and Pathological Phenotype of Antibody-Mediated Vascular Rejection Diagnosed using Arterial C4d Immunoperoxidase. Kidney Int Rep 2022; 7:1653-1664. [PMID: 35812292 PMCID: PMC9263238 DOI: 10.1016/j.ekir.2022.04.097] [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: 02/22/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction The diagnosis of antibody-mediated vascular rejection (AM-VR) should be reliable and accurate. We hypothesized that arterial C4d (C4dart) immunoperoxidase deposition represents endothelial interaction with antibody. Methods From 3309 consecutive, kidney transplant biopsies from a single center, 100 vascular rejection (VR) cases were compared against rejection without arteritis (n = 540) and normal controls (n = 1108). The clinical utility of C4dart for diagnosis and classification of AM-VR was evaluated against an independent reference test. Results C4dart occurred in 20.4% of acute, 11.0% of subclinical, and 46% of VR episodes. Semiquantitative C4dart score significantly correlated with immunodominant donor-specific antibodies (DSAs) (rho = 0.500, P < 0.001), peritubular capillary C4d (C4dptc), microvascular inflammation, and Banff v scores. Banff v3 arteritis suggested AM-VR. Addition of C4dart to Banff antibody-mediated rejection (AMR) schema increased diagnostic sensitivity for AM-VR from 57.9% to 93.0%, accuracy 74.0% to 92.0%, and specificity 95.4% to 90.2% versus Banff 2019 (using C4dptc). Death-censored graft failure was associated with C4dart AM-VR criteria using Cox regression (adjusted hazard ratio [HR] 4.310, 95% CI 1.322–14.052, P = 0.015). VR was then etiologically classified into AM-VR (n = 57, including 36 mixed VR) or “pure” (TCM-VR, n = 43). AM-VR occurred within all post-transplant periods, characterized by greater total, interstitial, and microvascular inflammation, arterial and peritubular C4d, DSA levels, and graft failure rates compared with TCM-VR. Mixed VR kidneys had the greatest inflammatory burden and graft loss (P < 0.001). Conclusion C4dart is a suggestive biomarker of the humoral alloresponse toward muscular arteries. Inclusion of C4dart into the Banff schema improved its diagnostic performance for detection of AM-VR and etiologic classification of arteritis.
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Affiliation(s)
- Brian J. Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Correspondence: Brian J. Nankivell, Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales 2145, Australia.
| | - Meena Shingde
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, Australia
| | - Chow H. P’Ng
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, Australia
| | - Ankit Sharma
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
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Abstract
Blood vessel endothelial cells (ECs) have long been known to modulate inflammation by regulating immune cell trafficking, activation status and function. However, whether the heterogeneous EC populations in various tissues and organs differ in their immunomodulatory capacity has received insufficient attention, certainly with regard to considering them for alternative immunotherapy. Recent single-cell studies have identified specific EC subtypes that express gene signatures indicative of phagocytosis or scavenging, antigen presentation and immune cell recruitment. Here we discuss emerging evidence suggesting a tissue-specific and vessel type-specific immunomodulatory role for distinct subtypes of ECs, here collectively referred to as 'immunomodulatory ECs' (IMECs). We propose that IMECs have more important functions in immunity than previously recognized, and suggest that these might be considered as targets for new immunotherapeutic approaches.
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Gowrishankar S. Banff classification from 1991 to 2019. A significant contribution to our understanding and reporting of allograft renal biopsies. Indian J Nephrol 2022; 32:1-7. [PMID: 35283563 PMCID: PMC8916159 DOI: 10.4103/ijn.ijn_270_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/04/2020] [Accepted: 10/09/2020] [Indexed: 11/05/2022] Open
Abstract
The Banff schema of classification of renal allograft biopsies, first proposed at the meeting in Banff, Canada in 1991 has evolved through subsequent meetings held once in two years and is the internationally accepted scheme of classification which is consensual, current, validated and in clinical use. This review traces the evolution of the classification and our understanding of renal transplant pathology, with emphasis on alloimmune reactions. The proceedings of the meetings and the important studies which have shaped the classification are covered.
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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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12
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Minnelli C, Riazy M, Ohashi R, Kowalewska J, Leca N, Najafian B, Smith KD, Nicosia RF, Alpers CE, Akilesh S. Early Transplant Arteriopathy in Kidney Transplantation. Transplant Proc 2021; 53:1554-1561. [PMID: 33962774 DOI: 10.1016/j.transproceed.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 12/15/2020] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early dysfunction of renal allografts may be associated with vascular injury, which raises the specter of active rejection processes that require medical intervention. In our practice, we have encountered patients who present with delayed graft function and demonstrate a unique pattern of endothelial cell injury that raises concern for rejection in their biopsy. Therefore, we sought to systematically determine the biopsy characteristics and outcome of these patients. METHODS During a 17-year period at the University of Washington in Seattle, United States, we identified 24 cases of a distinct arterial vasculopathy presenting in the first year posttransplantation. This early transplant arteriopathy (ETA) is characterized by endothelial cell swelling and intimal edema but without the intimal arteritis that defines vascular rejection. RESULTS Approximately 1% of transplant biopsies during the study period showed ETA, almost all of which were in deceased donor organs (96%), and most presented with delayed graft function (54%) or increased serum creatinine (38%) soon after transplantation (median 13 days; range, 5-139). In this study, 77% of patients were managed expectantly, with only 2 patients (7.6%) subsequently developing acute vascular rejection. Except for 1 patient who died, all patients had functioning allografts at 1 year follow-up. CONCLUSION Recognizing ETA and distinguishing it from vascular rejection is important to prevent over-treatment because most patients appear to recover allograft function rapidly with expectant management.
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Affiliation(s)
- Carrie Minnelli
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Maziar Riazy
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ryuji Ohashi
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology, Nippon Medical School, Tokyo, Japan
| | - Jolanta Kowalewska
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, Virginia
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Behzad Najafian
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Kelly D Smith
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Roberto F Nicosia
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Shreeram Akilesh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington.
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13
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Rush DN. Subclinical Rejection: a Universally Held Concept? CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00290-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Abstract
The standardization of renal allograft pathology began in 1991 at the first Banff Conference held in Banff, Alberta, Canada. The first task of transplant pathologists, clinicians, and surgeons was to establish diagnostic criteria for T-cell-mediated rejection (TCMR). The histological threshold for this diagnosis was arbitrarily set at "i2t2": a mononuclear interstitial cell infiltrate present in at least 25% of normal parenchyma and >4 mononuclear cells within the tubular basement membrane of nonatrophic tubules. TCMR was usually found in dysfunctional grafts with an elevation in the serum creatinine; however, our group and others found this extent of inflammation in "routine" or "protocol" biopsies of normally functioning grafts: "subclinical" TCMR. The prevalence of TCMR is higher in the early months posttransplant and has decreased with the increased potency of current immunosuppressive agents. However, the pathogenicity of lesser degrees of inflammation under modern immunosuppression and the relation between ongoing inflammation and development of donor-specific antibody has renewed our interest in subclinical alloreactivity. Finally, the advances in our understanding of pretransplant risk assessment, and our increasing ability to monitor patients less invasively posttransplant, promises to usher in the era of precision medicine.
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15
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Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection. BMC Nephrol 2019; 20:373. [PMID: 31623566 PMCID: PMC6796330 DOI: 10.1186/s12882-019-1563-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background Medication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown. Methods We conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome. Results A total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012]. Conclusions After adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.
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16
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Tajima S, Fu R, Shigematsu T, Noguchi H, Kaku K, Tsuchimoto A, Okabe Y, Masuda S. Urinary Human Epididymis Secretory Protein 4 as a Useful Biomarker for Subclinical Acute Rejection Three Months after Kidney Transplantation. Int J Mol Sci 2019; 20:ijms20194699. [PMID: 31546745 PMCID: PMC6801851 DOI: 10.3390/ijms20194699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
Kidney transplantation is the treatment of choice for patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD). However, acute rejection (AR) is a common complication in kidney transplantation and is associated with reduced graft survival. Current diagnosis of AR relies mainly on clinical monitoring including serum creatinine, proteinuria, and confirmation by histopathologic assessment in the biopsy specimen of graft kidney. Although an early protocol biopsy is indispensable for depicting the severity of pathologic lesions in subclinical acute rejection (subAR), it is not acceptable in some cases and cannot be performed because of its invasive nature. Therefore, we examined the detection of noninvasive biomarkers that are closely related to the pathology of subAR in protocol biopsies three months after kidney transplantation. In this study, the urinary level of microtubule-associated protein 1 light chain 3 (LC3), monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and human epididymis secretory protein 4 (HE4) were measured three months after kidney transplantation. Urine samples of 80 patients undergoing kidney transplantation between August 2014 to September 2016, were prospectively collected after three months. SubAR was observed in 11 patients (13.8%) in protocol biopsy. The urinary levels of LC3, MCP-1, NGAL, and HE4 were significantly higher in patients with subAR than in those without, while those of L-FABP did not differ between the two groups. Multivariate regression models, receiver-operating characteristics (ROC), and areas under ROC curves (AUC) were used to identify predicted values of subAR. Urinary HE4 levels were able to better identify subAR (AUC = 0.808) than the other four urinary biomarkers. In conclusion, urinary HE4 is increased in kidney transplant recipients of subAR three months after kidney transplantation, suggesting that HE4 has the potential to be used as a novel clinical biomarker for predicting subAR.
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Affiliation(s)
- Soichiro Tajima
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Rao Fu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Tomohiro Shigematsu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan.
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, International University of Health and Welfare Narita Hospital, Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan.
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17
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Xu M, Garcia-Aroz S, Banan B, Wang X, Rabe BJ, Zhou F, Nayak DK, Zhang Z, Jia J, Upadhya GA, Manning PT, Gaut JP, Lin Y, Chapman WC. Enhanced immunosuppression improves early allograft function in a porcine kidney transplant model of donation after circulatory death. Am J Transplant 2019; 19:713-723. [PMID: 30152136 DOI: 10.1111/ajt.15098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 01/25/2023]
Abstract
It remains controversial whether renal allografts from donation after circulatory death (DCD) have a higher risk of acute rejection (AR). In the porcine large animal kidney transplant model, we investigated the AR and function of DCD renal allografts compared to the non-DCD renal allografts and the effects of increased immunosuppression. We found that the AR was significantly increased along with elevated MHC-I expression in the DCD transplants receiving low-dose immunosuppression; however, AR and renal function were significantly improved when given high-dose immunosuppressive therapy postoperatively. Also, high-dose immunosuppression remarkably decreased the mRNA levels of ifn-g, il-6, tgf-b, il-4, and tnf-a in the allograft at day 5 and decreased serum cytokines levels of IFN-g and IL-17 at day 4 and day 5 after operation. Furthermore, Western blot analysis showed that higher immunosuppression decreased phosphorylation of signal transducer and activator of transcription 3 and nuclear factor kappa-light-chain-enhancer of activated B cells-p65, increased phosphorylation of extracellular-signal-regulated kinase, and reduced the expression of Bcl-2-associated X protein and caspase-3 in the renal allografts. These results suggest that the DCD renal allograft seems to be more vulnerable to AR; enhanced immunosuppression reduces DCD-associated AR and improves early allograft function in a preclinical large animal model.
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Affiliation(s)
- Min Xu
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Sandra Garcia-Aroz
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Babak Banan
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Xuanchuan Wang
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA.,Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Brian J Rabe
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Fangyu Zhou
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Deepak K Nayak
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Zhengyan Zhang
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Jianluo Jia
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - Gundumi A Upadhya
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Joseph P Gaut
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yiing Lin
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
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18
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Nankivell BJ, P'Ng CH, Chapman JR. Does tubulitis without interstitial inflammation represent borderline acute T cell mediated rejection? Am J Transplant 2019; 19:132-144. [PMID: 29687946 DOI: 10.1111/ajt.14888] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
Abstract
Tubulitis without interstitial inflammation (Banff i0), termed "isolated tubulitis" (ISO-T), has been controversially included within the Banff "borderline" category of acute T cell mediated rejection (TCMR). This single-center, retrospective, observational study of 2055 consecutive biopsies from 775 recipients, determined the clinical significance of ISO-T. ISO-T prevalence was 19.1%, comprising mild tubulitis (i0t1) in 97.2%. Independent clinical predictors of tubulitis were HLA mismatch, prior TCMR and antibody-mediated rejection, pulse corticosteroids, and BKVAN (P = .006 to P < .001 by multivariable analysis). Histological associations of tubulitis included interstitial inflammation, peritubular capillaritis, tubular atrophy, and SV40T (P = .005 to <.001). The dominant pathological diagnoses in ISO-T (n = 393) were interstitial fibrosis/tubular atrophy (IF/TA, 44.5%) or normal/minimal (31.8%). Subanalysis of ISO-T from indication biopsies (n = 107) found acute tubular injury (37.4%), IF/TA (28.0%), normal/minimal (12.1%), acute rejection (9.3%, vascular or antibody), chronic-active TCMR (2.8%), and BKVAN (5.6%). Allograft function of ISO-T frequently improved, affected by early biopsy timing and underlying disease diagnosis. Subsequent histology of 1197 ISO-T biopsy-pairs was generally benign. The 1- and 5-year death-censored graft survivals of ISO-T were 98.8% and 92.7%. In summary, tubulitis without inflammation does not represent borderline TCMR. We suggest its removal from the borderline category, and reinstatement of i1 as the diagnostic threshold.
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Affiliation(s)
| | - Chow H P'Ng
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Jeremy R Chapman
- Departments of Renal Medicine, Westmead Hospital, Sydney, Australia
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19
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Liu P, Tseng G, Wang Z, Huang Y, Randhawa P. Diagnosis of T-cell-mediated kidney rejection in formalin-fixed, paraffin-embedded tissues using RNA-Seq-based machine learning algorithms. Hum Pathol 2018; 84:283-290. [PMID: 30296518 DOI: 10.1016/j.humpath.2018.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/21/2018] [Accepted: 09/29/2018] [Indexed: 12/26/2022]
Abstract
Molecular diagnosis is being increasingly used in transplant pathology to render more objective and quantitative determinations that also provide mechanistic and prognostic insights. This study performed RNA-Seq on biopsies from kidneys with stable function (STA) and biopsies with classical findings of T-cell-mediated rejection (TCMR). Machine learning tools were used to develop prediction models for distinguishing TCMR and STA samples using the top genes identified by DSeq2. The prediction models were tested on 703 biopsies with Affymetrix chip gene expression profiles available in the public domain. Linear discriminant analysis predicted TCMR in 55 of 67 biopsies labeled TCMR, and 65 of 105 biopsies designated as antibody-mediated rejection. The random forest and support vector machine models showed comparable performance. These data illustrate the feasibility of using RNA-Seq for molecular diagnosis of TCMR in formalin-fixed tissue. Application of the derived diagnostic algorithms to publicly available data sets demonstrates frequent coexistence of TCMR in biopsies designated as antibody-mediated rejection. This underrecognition of TCMR in renal allograft biopsies has significant implications with respect to patient care.
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Affiliation(s)
- Peng Liu
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - George Tseng
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Zijie Wang
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Yuchen Huang
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Parmjeet Randhawa
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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20
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Saygılı ES, Seyahi N, Durak H, Soylu H, Cengiz M, Altıparmak MR. Greft sağkalımını etkileyen faktörlerin transplant böbrek biyopsileriyle değerlendirilmesi. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.457229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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21
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Watson AM, Bhutiani N, Philips P, Davis EG, Eng M, Cannon RM, Jones CM. The role of FDG-PET in detecting rejection after liver transplantation. Surgery 2018; 164:257-261. [DOI: 10.1016/j.surg.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 01/20/2023]
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22
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Whittier WL, Gashti C, Saltzberg S, Korbet S. Comparison of native and transplant kidney biopsies: diagnostic yield and complications. Clin Kidney J 2018; 11:616-622. [PMID: 30289130 PMCID: PMC6165758 DOI: 10.1093/ckj/sfy051] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/18/2018] [Indexed: 01/20/2023] Open
Abstract
Background The safety and adequacy are established for the native percutaneous renal biopsy (PRB) but no prospective studies exist that directly compare these with transplant PRB. Methods From 1995 to 2015, 1705 adults underwent percutaneous native [native renal biopsy (NRB)] or transplant renal biopsy (TRB) by the Nephrology service. Real-time ultrasound and automated biopsy needles (NRB, 14 or 16 gauge; TRB, 16 gauge) were used. Patients were observed for 24 h (NRB) or 8 h (TRB) post-procedure. Adequacy was defined as tissue required for diagnosis plus glomerular yield. Complications were defined as those resulting in the need for an intervention, such as surgery, interventional radiologic procedure, readmission, blood transfusion and death. Data were collected prospectively in all biopsies. Results At the time of biopsy, NRB patients were younger (mean ± SD, 47 ± 17 versus 50 ± 14 years, P < 0.0001) and more often female (62 versus 48%, P < 0.0001) compared with TRB. A fellow supervised by an attending performed the procedure in 91% of NRB compared with 63% of TRB (P < 0.0001). TRB patients were more hypertensive [systolic blood pressure (SBP) 140 ± 22 versus 133 ± 18 mmHg, P < 0.0001] and had a higher serum creatinine (3.1 ± 1.8 versus 2.3 ± 2.2 mg/dL, P < 0.0001), activated partial thromboplastin time (28 ± 4.3 versus 27 ± 5 s, P < 0.0001) as well as lower hemoglobin (Hgb) (11.2 ± 1.8 versus 11.7 ± 2.1 g/dL, P < 0.0001) compared with NRB. Adequate tissue for diagnosis was obtained in > 99% of NRB and TRB (P = 0.71). Compared with TRB, NRB had a greater drop in Hgb after the biopsy (0.97 ± 1.1 versus 0.73 ± 1.3 g/dL, P < 0.0001), a higher complication rate (6.5 versus 3.9%, P = 0.02) and higher transfusion rate (5.2 versus 3.3%, P = 0.045). There was one death in each group attributed to the biopsy. Conclusions Although death is equally rare, the complication rate is higher in NRB compared with TRB despite TRB having more of the traditional risk factors for bleeding. Differences in technique, operator (fellow or attending) or needle gauge may explain this variability.
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Affiliation(s)
- William L Whittier
- Division of Nephrology, Rush University Medical Center, Chicago, IL, USA
| | - Casey Gashti
- Division of Nephrology, Rush University Medical Center, Chicago, IL, USA
| | - Samuel Saltzberg
- Division of Nephrology, Rush University Medical Center, Chicago, IL, USA
| | - Stephen Korbet
- Division of Nephrology, Rush University Medical Center, Chicago, IL, USA
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23
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Joelsons G, Domenico T, Gonçalves L, Manfro R. Non-invasive messenger RNA transcriptional evaluation in human kidney allograft dysfunction. Braz J Med Biol Res 2018; 51:e6904. [PMID: 29791589 PMCID: PMC5972022 DOI: 10.1590/1414-431x20186904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/19/2018] [Indexed: 11/21/2022] Open
Abstract
The aim of the present study was to evaluate messenger RNA expression in kidney allograft recipients. Forty-four kidney transplant recipients were evaluated up to three months after grafting. After transplantation, peripheral blood samples were drawn sequentially for real-time polymerase chain reaction analyses of perforin and TIM-3 genes. Biopsies were obtained to evaluate acute graft dysfunction and interpreted according to the Banff classification. Eight patients presented episodes of acute rejection. Recipients with rejection had significantly higher levels of TIM-3 mRNA transcripts compared to those without rejection (median gene expression 191.2 and 36.9 mRNA relative units, respectively; P<0.0001). Also, perforin gene expression was higher in patients with rejection (median gene expression 362.0 and 52.8 mRNA relative units; P<0.001). Receiver operating characteristic curves showed that the area under the curve (AUC) for the TIM-3 gene was 0.749 (95%CI: 0.670-0.827). Perforin gene mRNA expression provided an AUC of 0.699 (95%CI: 0.599 to 0.799). Overall accuracy of gene expression was 67.9% for the TIM-3 gene and 63.6% for the perforin gene. Combined accuracy was 76.8%. Negative predictive values were 95.3% for the TIM-3 gene, 95.5% for the perforin gene, and 95.4% in the combined analyses. Gene expression was significantly modulated by rejection treatment decreasing 64.1% (TIM-3) and 90.9% (perforin) compared to the median of pre-rejection samples. In conclusion, the longitudinal approach showed that gene profiling evaluation might be useful in ruling out the diagnosis of acute rejection and perhaps evaluating the efficacy of treatment.
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Affiliation(s)
- G. Joelsons
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
| | - T. Domenico
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
| | - L.F. Gonçalves
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre,
Porto Alegre, RS, Brasil
| | - R.C. Manfro
- Programa de Pós-Graduação em Medicina: Ciências Médicas,
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre,
RS, Brasil
- Serviço de Nefrologia, Hospital de Clínicas de Porto Alegre,
Porto Alegre, RS, Brasil
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24
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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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25
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Nickeleit V, Singh HK, Randhawa P, Drachenberg CB, Bhatnagar R, Bracamonte E, Chang A, Chon WJ, Dadhania D, Davis VG, Hopfer H, Mihatsch MJ, Papadimitriou JC, Schaub S, Stokes MB, Tungekar MF, Seshan SV. The Banff Working Group Classification of Definitive Polyomavirus Nephropathy: Morphologic Definitions and Clinical Correlations. J Am Soc Nephrol 2017; 29:680-693. [PMID: 29279304 DOI: 10.1681/asn.2017050477] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/11/2017] [Indexed: 01/24/2023] Open
Abstract
Polyomavirus nephropathy (PVN) is a common viral infection of renal allografts, with biopsy-proven incidence of approximately 5%. A generally accepted morphologic classification of definitive PVN that groups histologic changes, reflects clinical presentation, and facilitates comparative outcome analyses is lacking. Here, we report a morphologic classification scheme for definitive PVN from the Banff Working Group on Polyomavirus Nephropathy, comprising nine transplant centers in the United States and Europe. This study represents the largest systematic analysis of definitive PVN undertaken thus far. In a retrospective fashion, clinical data were collected from 192 patients and correlated with morphologic findings from index biopsies at the time of initial PVN diagnosis. Histologic features were centrally scored according to Banff guidelines, including additional semiquantitative histologic assessment of intrarenal polyomavirus replication/load levels. In-depth statistical analyses, including mixed effects repeated measures models and logistic regression, revealed two independent histologic variables to be most significantly associated with clinical presentation: intrarenal polyomavirus load levels and Banff interstitial fibrosis ci scores. These two statistically determined histologic variables formed the basis for the definition of three PVN classes that correlated strongest with three clinical parameters: presentation at time of index biopsy, serum creatinine levels/renal function over 24 months of follow-up, and graft failure. The PVN classes 1-3 as described here can easily be recognized in routine renal biopsy specimens. We recommend using this morphologic PVN classification scheme for diagnostic communication, especially at the time of index diagnosis, and in scientific studies to improve comparative data analysis.
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Affiliation(s)
- Volker Nickeleit
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina;
| | - Harsharan K Singh
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center-Montefiore, Pittsburgh, Pennsylvania
| | - Cinthia B Drachenberg
- Department of Pathology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Ramneesh Bhatnagar
- Department of Pathology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Erika Bracamonte
- Department of Pathology, The University of Arizona College of Medicine, Tucson, Arizona
| | - Anthony Chang
- Department of Pathology, The University of Chicago, Chicago, Illinois
| | - W James Chon
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri
| | - Darshana Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Vicki G Davis
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - John C Papadimitriou
- Department of Pathology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Stefan Schaub
- Transplantation Immunology and Nephrology, University Hospital of Basel, Basel, Switzerland
| | - Michael B Stokes
- Department of Pathology, Columbia Presbyterian Medical Center, New York, New York
| | - Mohammad F Tungekar
- Histopathology Department, St. Thomas' Hospital, Guy's and St. Thomas Foundation Trust and King's College London, London, United Kingdom; and
| | - Surya V Seshan
- Department of Pathology, Weill Cornell Medicine, New York, New York
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26
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Serón D, Roman A. Lorraine Racusen and Kim Solez Awarded the Gold Medal of the Catalan Transplant Society. Transplant Proc 2017; 49:2240-2242. [PMID: 29198652 DOI: 10.1016/j.transproceed.2017.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In March 2017, a joint meeting between The Catalan Society of Transplantation and the Banff Foundation was held at the University of Barcelona. This was an opportunity for the Catalan Society of Transplantation to recognize the crucial contributions to transplant pathology made by Lorraine Racusen and Kim Solez, who created and actively contributed to the development of the International Banff Classification System. The ceremony of the Gold Medal took place on March 31 at the University of Barcelona; it consisted of a presentation of the contributions of Lorraine Racusen and Kim Solez to the development of transplant pathology. In this article, the presentation of these awardees with the Gold Medal of the Catalan Society of Transplantation is summarized.
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Affiliation(s)
- D Serón
- Nephrology Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - A Roman
- Pneumology Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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27
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Oates A, Ahuja S, Lee MM, Phelps AS, Mackenzie JD, Courtier JL. Pediatric renal transplant biopsy with ultrasound guidance: the 'core' essentials. Pediatr Radiol 2017; 47:1572-1579. [PMID: 28573315 DOI: 10.1007/s00247-017-3905-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/03/2017] [Accepted: 05/11/2017] [Indexed: 12/16/2022]
Abstract
This review provides a comprehensive and practical approach to pediatric percutaneous renal transplant biopsies, highlighting techniques and strategies to optimize adequate sample yield and ensure patient safety. In children with end-stage renal disease, transplantation is the preferred choice of therapy, providing for overall lower long-term morbidity and mortality compared with dialysis. In the ongoing management of renal transplant patients, core tissue sampling via a percutaneous renal biopsy remains the gold standard when transplant dysfunction is suspected. Indications for renal transplant biopsy and techniques/tools for adequate sample yield are discussed. Strategies for common challenges such as poor visualization and renal transplant mobility are addressed. We discuss the clinical signs, techniques and imaging findings for common complications including hematomas, arteriovenous fistulas and pseudoaneurysms. Although the percutaneous renal transplant biopsy procedure is generally safe with rare complications, care must be taken to ensure major complications are promptly recognized and treated. Adequate tissue samples obtained via renal biopsy are imperative to promptly identify transplant rejection to provide valuable information for patient diagnosis, treatment and outcomes. Radiologist and nephrologist attention to proper ultrasound techniques and optimal biopsy tools are critical to ensure tissue adequacy and minimize complications.
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Affiliation(s)
- Aris Oates
- Division of Nephrology, Department of Pediatrics, University of California, 550 16th St., 5th floor, Mailstop 3214, San Francisco, CA, 94143- 3214, USA.
| | - Saveen Ahuja
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Marsha M Lee
- Division of Nephrology, Department of Pediatrics, University of California, 550 16th St., 5th floor, Mailstop 3214, San Francisco, CA, 94143- 3214, USA
| | - Andrew S Phelps
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - John D Mackenzie
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Jesse L Courtier
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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28
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Abstract
Kidney biopsies are conducted under varying scenarios, presenting variables that could potentially influence yield and adequacy of tissue collected. We retrospectively reviewed 636 native and allograft kidney biopsies, and compared tissue collected between differing practitioners performing the biopsy (nephrologists or radiologists), imaging modalities for guidance (ultrasound or computed tomography), gauge needle used (18 or 16 G), and between on-site evaluators of biopsy adequacy conducted at the time of biopsy (general pathologists, renal pathologists, nephrologists). For radiologists using ultrasound guidance and 18 G needles, those using on-site evaluation of adequacy collected more glomeruli and glomeruli per length of tissue core than those not using on-site evaluation. Radiologists not using on-site evaluation but who used a larger bore needle (16 vs. 18 G) could generally collect comparable tissue as other biopsy performers who used on-site evaluation. Radiologists performing ultrasound-guided biopsies with 18 G needles without on-site evaluation consistently provided poorer tissue yield and had a higher rate of providing insufficient tissue so that a diagnosis could not be rendered. Nephrologists collected less total length of tissue cores, glomeruli, and arteries per case (whether performing the biopsy and/or performing on-site adequacy) compared with other groups using on-site evaluation, however, providing comparable density of glomeruli and arteries. Complication rates did not differ between compared groups using 18 G needles. It is our observation that the various conditions by which a kidney biopsy is obtained influences the yield of tissue collected and the subsequent ability for a pathologist to effectively provide a diagnosis.
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Affiliation(s)
- Miroslav Sekulic
- *Department of Laboratory Medicine and Pathology, University of Minnesota †Department of Pathology, Hennepin County Medical Center, Minneapolis, MN
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29
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Chien CC, Yan YH, Juan HT, Cheng TJ, Liao JB, Lee HP, Wang JS. Sustained renal inflammation following 2 weeks of inhalation of occupationally relevant levels of zinc oxide nanoparticles in Sprague Dawley rats. J Toxicol Pathol 2017; 30:307-314. [PMID: 29097840 PMCID: PMC5660952 DOI: 10.1293/tox.2017-0025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022] Open
Abstract
Exposure to zinc oxide (ZnO) has been linked to adverse health effects, but the renal effects of ZnO nanoparticles (ZnONPs) remain unclear. The objective of this study was to determine the renal toxicity of inhaled ZnONPs. Sprague Dawley (SD) rats were exposed to occupationally relevant levels of 1.1 (low dose) and 4.9 mg/m3 (high dose) ZnONPs or high-efficiency particulate arresting-filtered air (HEPA-FA) via inhalation for 2 weeks. Histopathological examinations of rat kidneys were performed at 24 hours, 7 days, and 1 month after exposure. A significant increase in microscopic inflammatory foci with pronounced periglomerular inflammation and interstitial lymphocytic infiltration was found in rats exposed to low and high doses of ZnONPs compared with rats exposed to HEPA-FA at the three time points following 2 weeks of exposure. Tubulitis featuring lymphocytic infiltrate within the tubular epithelium was found after 24 hours but had disappeared at 7 and 30 days in both the low- and high-dose exposure groups. Our findings demonstrate that inhaled ZnONPs cause sustained renal periglomerular and interstitial inflammation through lymphocytic infiltration. These findings provide histopathological evidence regarding sustained renal inflammation of nanoparticle exposure in rats and may provide some insight into the occupational health effects of ZnONPs on exposed workers.
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Affiliation(s)
- Chu-Chun Chien
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan.,Department of Nursing, Meiho University, Pingtung, No. 23, Pingguang Rd., Neipu Township, Pingtung County 912, Taiwan
| | - Yuan-Horng Yan
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, No. 17, Xuzhou Rd., Zhongzheng Dist., Taipei City 100, Taiwan.,Department of Medical Research, Kuang Tien General Hospital, No. 117, Shatian Rd., Shalu Dist., Taichung City 433, Taiwan.,Department of Internal Medicine, Kuang Tien General Hospital, No. 117, Shatian Rd., Shalu Dist., Taichung City 433, Taiwan.,Department of Nutrition and Institute of Biomedical Nutrition, Hung Kuang University, No. 1018, Sec. 6, Taiwan Blvd., Shalu Dist., Taichung City 433, Taiwan
| | - Hung-Tzu Juan
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, No. 17, Xuzhou Rd., Zhongzheng Dist., Taipei City 100, Taiwan
| | - Tsun-Jen Cheng
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, No. 17, Xuzhou Rd., Zhongzheng Dist., Taipei City 100, Taiwan.,Department of Public Health, College of Public Health, National Taiwan University, No. 17, Xuzhou Rd., Zhongzheng Dist., Taipei City 100, Taiwan
| | - Jia-Bin Liao
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan
| | - Huai-Pao Lee
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan.,Department of Nursing, Meiho University, Pingtung, No. 23, Pingguang Rd., Neipu Township, Pingtung County 912, Taiwan
| | - Jyh-Seng Wang
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan
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30
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Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol 2017; 18:174. [PMID: 28571571 PMCID: PMC5455080 DOI: 10.1186/s12882-017-0553-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 02/08/2023] Open
Abstract
These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on.
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Affiliation(s)
- Richard J Baker
- Renal Unit, St. James's University Hospital, Leeds, England.
| | - Patrick B Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Rajan K Patel
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Kate K Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
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31
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Ozluk Y, Caliskan Y, Sevinc M, Bayram A, Arikan EA, Turkmen A, Akgul S, Savran FO, Sever MS, Kilicaslan I. Re-evaluation of glomerulitis using occlusion criteria based on the Banff 2013 revision: a retrospective study. Transpl Int 2017; 30:579-588. [PMID: 28236636 DOI: 10.1111/tri.12943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/11/2017] [Accepted: 02/20/2017] [Indexed: 12/26/2022]
Abstract
The presence of occlusion/near-occlusion of glomerular capillaries was recently added to the existing definition of glomerulitis (g). We retrospectively re-evaluated 135 renal allograft biopsies regarding g to ensure no antibody-damaged grafts were missed. Previous and revised g scores (pg and rg, respectively) were compared for clinicopathologic correlations. The g score did not change in 100 (74.1%) biopsies. Thirty-five (25.9%) biopsies were changed to a lower score. Sensitivity and specificity of pg and rg for the presence of donor-specific antibodies (DSA) were 76% vs. 58% and 70% vs. 79%, respectively. Pg score indicated graft loss with 65% sensitivity and 63% specificity, whereas rg showed 46% sensitivity and 71% specificity. Area under the curve (AUC) values in ROC analysis for DSA and graft loss were as follows: pg, 0.773; rg, 0.693; and pg, 0.635; rg, 0.577, respectively. A comparison of the two AUC values revealed a significant difference between pg and rg only for DSA (P = 0.0076). Pg and post-transplant time of biopsy independently predicted graft loss, whereas rg did not. In conclusion, revised g scores showed lesser sensitivity but higher specificity for DSA and graft loss. Recent definition of g missed antibody-mediated rejection in few cases, and it was not an independent predictor for graft loss.
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Affiliation(s)
- Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasar Caliskan
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Sevinc
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aysel Bayram
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Evsen A Arikan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sebahat Akgul
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatma O Savran
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet S Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Isin Kilicaslan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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32
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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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33
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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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34
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Becker JU, Chang A, Nickeleit V, Randhawa P, Roufosse C. Banff Borderline Changes Suspicious for Acute T Cell-Mediated Rejection: Where Do We Stand? Am J Transplant 2016; 16:2654-60. [PMID: 26988137 DOI: 10.1111/ajt.13784] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
The definition of Banff Borderline became ambiguous when the Banff 2005 consensus modified the lower threshold from i1t1 (10-25% interstitial inflammation with mild tubulitis) to i0t1 (0-10% interstitial inflammation with mild tubulitis). We conducted a worldwide survey among members of the Renal Pathology Society about their approach to this diagnostic category. A web-based survey was sent out to all 503 current members (153 respondents). A database search yielded which threshold for Banff i was applied in the most influential manuscripts about Borderline. Among the 139 nephropathologists using the Borderline category, 67% use the Banff 1997 definition, requiring Banff i1. Thirty-seven percent admitted to sometimes exaggerating Banff i in the presence of tubulitis, to reach a diagnosis of Borderline. Forty-eight percent were dissatisfied with the definition of Borderline. The majority of the most influential manuscripts used the 1997 definition, contrary to the current one. There is considerable dissatisfaction with Borderline, and practice in Banff i thresholds is variable. Until additional studies inform a revision, we suggest leaving it to each pathologist's discretion whether to use i0 or i1 as the minimal threshold. In order to avoid future ambiguity, a web-based synopsis of all scattered current Banff definitions and rules should be created.
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Affiliation(s)
- J U Becker
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - A Chang
- The University of Chicago Medicine, Chicago, IL
| | - V Nickeleit
- Division of Nephropathology, Department of Pathology, The University of North Carolina, Chapel Hill, NC
| | - P Randhawa
- Department of Pathology, Thomas E Starzl Txn Institute, University of Pittsburgh, UPMC-Montefiore, Pittsburgh, PA
| | - C Roufosse
- Department of Cellular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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35
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Arias-Cabrales C, Redondo-Pachón D, Pérez-Sáez MJ, Gimeno J, Sánchez-Güerri I, Bermejo S, Sierra A, Burballa C, Mir M, Crespo M, Pascual J. Renal graft survival according to Banff 2013 classification in indication biopsies. Nefrologia 2016; 36:660-666. [PMID: 27595515 DOI: 10.1016/j.nefro.2016.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 04/08/2016] [Accepted: 05/10/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The impact of acute rejection in kidney graft survival is well known, but the prognosis of other diagnoses is uncertain. We evaluated the frequency and impact on graft survival of different diagnostic categories according to the Banff 2013 classification in a cohort of renal transplant recipients. MATERIAL AND METHODS Retrospective study of 495 renal biopsies by indication in 322 patients from 1990-2014. Two independent observers reviewed the histological reports, reclassifying according to the Banff 2013 classification. RESULTS Of 495 biopsies, 28 (5.7%) were not diagnostic. Of the remaining 467, 10.3% were «normal» (category 1), 19.6% antibody-mediated changes (category 2), 5.9% «borderline» changes (category 3), 8.7% T-cell-mediated rejection (category 4), 23.4% interstitial fibrosis/tubular atrophy (IFTA) (category 5) and 26.5% with other diagnoses (category 6). As time after transplantation increases, diagnoses of categories 1, 3 and 4 decrease, while categories 5 and 2 increase. Worse graft survival with category 2 diagnosis was observed (45% at 7.5 years, HR 4.29 graft loss [95% CI, 2.39-7.73]; P≤.001, compared to category 1). Grafts with «unfavourable histology» (chronic antibody-mediated rejection, moderate-severe IFTA) presented worse survival that grafts with «favourable histology» (normal, acute tubular necrosis, mild IFTA). CONCLUSIONS The Banff 2013 classification facilitates a histological diagnosis in 95% of indication biopsies. While diagnostic category 6 is the most common, a change in the predominant histopathology was observed according to time elapsed since transplantation. Antibody-mediated changes are associated with worse graft survival.
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Affiliation(s)
| | | | | | - Javier Gimeno
- Anatomía Patológica, Hospital del Mar, Barcelona, España
| | | | - Sheila Bermejo
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
| | - Adriana Sierra
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
| | - Carla Burballa
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
| | - Marisa Mir
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Barcelona, España.
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36
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Burghuber CK, Kwun J, Page EJ, Manook M, Gibby AC, Leopardi FV, Song M, Farris AB, Hong JJ, Villinger F, Adams AB, Iwakoshi NN, Knechtle SJ. Antibody-Mediated Rejection in Sensitized Nonhuman Primates: Modeling Human Biology. Am J Transplant 2016; 16:1726-38. [PMID: 26705099 PMCID: PMC4874845 DOI: 10.1111/ajt.13688] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 01/25/2023]
Abstract
We have established a model of sensitization in nonhuman primates and tested two immunosuppressive regimens. Animals underwent fully mismatched skin transplantation, and donor-specific antibody (DSA) response was monitored by flow cross-match. Sensitized animals subsequently underwent kidney transplantation from their skin donor. Immunosuppression included tacrolimus, mycophenolate, and methylprednisolone. Three animals received basiliximab induction; compared with nonsensitized animals, they showed a shorter mean survival time (4.7 ± 3.1 vs. 187 ± 88 days). Six animals were treated with T cell depletion (anti-CD4/CD8 mAbs), which prolonged survival (mean survival time 21.6 ± 19.0 days). All presensitized animals showed antibody-mediated rejection (AMR). In two of three basiliximab-injected animals, cellular rejection (ACR) was prominent. After T cell depletion, three of six monkeys experienced early acute rejection within 8 days with histological evidence of thrombotic microangiopathy and AMR. The remaining three monkeys survived 27-44 days, with mixed AMR and ACR. Most T cell-depleted animals experienced a rebound of DSA that correlated with deteriorating kidney function. We also found an increase in proliferating memory B cells (CD20(+) CD27(+) IgD(-) Ki67(+) ), lymph node follicular helper T cells (ICOS(+) PD-1(hi) CXCR5(+) CD4(+) ), and germinal center (GC) response. Depletion controlled cell-mediated rejection in sensitized nonhuman primates better than basiliximab, yet grafts were rejected with concomitant DSA rise. This model provides an opportunity to test novel desensitization strategies.
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Affiliation(s)
- Christopher K. Burghuber
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jean Kwun
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
- Duke Transplant Center, Department of Surgery, Duke University, Durham, North Carolina
| | - Eugenia J Page
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
| | - Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University, Durham, North Carolina
| | - Adriana C Gibby
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
| | - Frank V Leopardi
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
- Duke Transplant Center, Department of Surgery, Duke University, Durham, North Carolina
| | - Minqing Song
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
- Duke Transplant Center, Department of Surgery, Duke University, Durham, North Carolina
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Jung Joo Hong
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Georgia
- National Primate Research Center (NPRC), Korea Research Institute of Bioscience and Biotechnology (KRIBB), Ochang, Korea
| | - Francois Villinger
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Georgia
| | - Andrew B. Adams
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
| | - Neal N Iwakoshi
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
| | - Stuart J Knechtle
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia
- Duke Transplant Center, Department of Surgery, Duke University, Durham, North Carolina
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Abrahimi P, Qin L, Chang WG, Bothwell ALM, Tellides G, Saltzman WM, Pober JS. Blocking MHC class II on human endothelium mitigates acute rejection. JCI Insight 2016; 1. [PMID: 26900601 DOI: 10.1172/jci.insight.85293] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Acute allograft rejection is mediated by host CD8+ cytotoxic T lymphocytes (CTL) targeting graft class I major histocompatibility complex (MHC) molecules. In experimental rodent models, rejection requires differentiation of naive CD8+ T cells into alloreactive CTL within secondary lymphoid organs, whereas in humans, CTL may alternatively develop within the graft from circulating CD8+ effector memory T cells (TEM) that recognize class I MHC molecules on graft endothelial cells (EC). This latter pathway is poorly understood. Here, we show that host CD4+ TEM, activated by EC class II MHC molecules, provide critical help for this process. First, blocking HLA-DR on EC lining human artery grafts in immunodeficient mice reduces CD8+ CTL development within and acute rejection of the artery by adoptively transferred allogeneic human lymphocytes. Second, siRNA knockdown or CRISPR/Cas9 ablation of class II MHC molecules on EC prevents CD4+ TEM from helping CD8+ TEM to develop into CTL in vitro. Finally, implanted synthetic microvessels, formed from CRISPR/Cas9-modified EC lacking class II MHC molecules, are significantly protected from CD8+ T cell-mediated destruction in vivo. We conclude that human CD8+ TEM-mediated rejection targeting graft EC class I MHC molecules requires help from CD4+ TEM cells activated by recognition of class II MHC molecules.
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Affiliation(s)
- Parwiz Abrahimi
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lingfeng Qin
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William G Chang
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alfred L M Bothwell
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - George Tellides
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - W Mark Saltzman
- Department of Biomedical Engineering, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jordan S Pober
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
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Phillips S, Kapp M, Crowe D, Garces J, Fogo AB, Giannico GA. Endothelial activation, lymphangiogenesis, and humoral rejection of kidney transplants. Hum Pathol 2016; 51:86-95. [PMID: 27067786 DOI: 10.1016/j.humpath.2015.12.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/04/2015] [Accepted: 12/10/2015] [Indexed: 11/18/2022]
Abstract
Antibody-mediated rejection (ABMR) is implicated in 45% of renal allograft failure and 57% of late allograft dysfunction. Peritubular capillary C4d is a specific but insensitive marker of ABMR. The 2013 Banff Conference ABMR revised criteria included C4d-negative ABMR with evidence of endothelial-antibody interaction. We hypothesized that endothelial activation and lymphangiogenesis are increased with C4d-negative ABMR and correlate with intragraft T-regulatory cells and T-helper 17. Seventy-four renal transplant biopsies were selected to include (a) ABMR with C4d Banff scores ≥2 (n = 35), (b) variable microvascular injury and C4d score 0-1 (n = 24), and (c) variable microvascular injury and C4d score = 0 (n = 15). Controls included normal preimplantation donor kidneys (n = 5). Immunohistochemistry for endothelial activation (P- and E-selectins [SEL]), lymphangiogenesis (D2-40), T-regulatory cells (FOXP3), and T-helper 17 (STAT3) was performed. Microvessel and inflammatory infiltrate density was assessed morphometrically in interstitium and peritubular capillaries. All transplants had significantly higher microvessel and lymph vessel density compared with normal. Increased expression of markers of endothelial activation predicted transplant glomerulopathy (P-SEL, P = .003). Increased P-SEL and D2-40 were associated with longer interval from transplant to biopsy (P = .005). All 3 markers were associated with increased interstitial fibrosis, tubular atrophy, and graft failure (P-SEL, P < .001; E-SEL, P = .0011; D2-40, P = .012). There was no association with the intragraft FOXP3/STAT3 ratio. We conclude that endothelial activation and lymphangiogenesis could represent a late response to injury leading to fibrosis and progression of kidney damage, and are independent of the intragraft FOXP3/STAT3 ratio. Our findings support the therapeutic potential of specifically targeting endothelial activation.
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Affiliation(s)
- Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Meghan Kapp
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Deborah Crowe
- DCI Transplant Immunology Laboratory, Nashville, TN 37203.
| | - Jorge Garces
- Ochsner Abdominal Transplant Center, New Orleans, LA 70121.
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Giovanna A Giannico
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232.
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Early and Sustained Reduction in Donor-Specific Antibodies in Desensitized Living Donor Kidney Transplant Recipients: A 3-Year Prospective Study. Transplant Direct 2016; 2:e62. [PMID: 27500255 PMCID: PMC4946491 DOI: 10.1097/txd.0000000000000570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/19/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Desensitization with IVIG and rituximab allows acceptable graft survival in sensitized kidney transplant recipients with preexisting donor-specific antibodies (DSAs) and a positive crossmatch. There is little published data reporting the durability of DSA removal in kidney transplant recipients treated with IVIG and rituximab. METHODS We conducted a 3-year prospective DSA monitoring study in living donor kidney recipients with preexisting DSA to assess the durability of DSA removal after a perioperative protocol of IVIG and rituximab. All recipients had flow crossmatch titers less than 1:32. Data were analyzed using linear mixed effects models and Kaplan-Meier survival methods. RESULTS The longitudinal database comprised 210 mean fluorescence intensity (MFI) determinations. Forty-two DSAs were identified in 29 patients. Pretreatment MFI averaged 4715 ± 3962 (range, 947-20 129). At 1 month posttransplant, 18 patients (62%) had a complete response (MFI < 1000) and an additional 9 patients (31%) had a partial response (MFI reduced but >1000). There was a 46% reduction (P < 0.001) in DSA MFI at 1 month posttransplant that was sustained throughout the 3-year follow-up period and was observed for both class I and II DSAs regardless of pretreatment MFI levels. With a mean posttransplant follow-up of 1048 ± 574 days, 3-year patient and graft survivals were 95% and 90%. Four patients (14%) had acute rejection between days 125 and 560. CONCLUSIONS Desensitization with IVIG and rituximab results in early and sustained DSA removal over a 3-year posttransplant period in living donor kidney transplant recipients with pretransplant DSA and a positive crossmatch, excellent patient and graft survivals and a low incidence of acute rejection.
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40
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Yamada Y, Nadazdin O, Boskovic S, Lee S, Zorn E, Smith RN, Colvin RB, Madsen JC, Cosimi AB, Kawai T, Benichou G. Repeated Injections of IL-2 Break Renal Allograft Tolerance Induced via Mixed Hematopoietic Chimerism in Monkeys. Am J Transplant 2015; 15:3055-66. [PMID: 26190648 PMCID: PMC4654979 DOI: 10.1111/ajt.13382] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/20/2015] [Accepted: 05/11/2015] [Indexed: 01/25/2023]
Abstract
Tolerance of allografts achieved in mice via stable mixed hematopoietic chimerism relies essentially on continuous elimination of developing alloreactive T cells in the thymus (central deletion). Conversely, while only transient mixed chimerism is observed in nonhuman primates and patients, it is sufficient to ensure tolerance of kidney allografts. In this setting, it is likely that tolerance depends on peripheral regulatory mechanisms rather than thymic deletion. This implies that, in primates, upsetting the balance between inflammatory and regulatory alloimmunity could abolish tolerance and trigger the rejection of previously accepted renal allografts. In this study, six monkeys that were treated with a mixed chimerism protocol and had accepted a kidney allograft for periods of 1-10 years after withdrawal of immunosuppression received subcutaneous injections of IL-2 cytokine (0.6-3 × 10(6) IU/m(2) ). This resulted in rapid rejection of previously tolerated renal transplants and was associated with an expansion and reactivation of alloreactive pro-inflammatory memory T cells in the host's lymphoid organs and in the graft. This phenomenon was prevented by anti-CD8 antibody treatment. Finally, this process was reversible in that cessation of IL-2 administration aborted the rejection process and restored normal kidney graft function.
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Affiliation(s)
- Y. Yamada
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - O. Nadazdin
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - S. Boskovic
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - S. Lee
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - E. Zorn
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - R. N. Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R. B. Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J. C. Madsen
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - A. B. Cosimi
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - T. Kawai
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA
| | - G. Benichou
- Department of Surgery, Center for Transplantation Sciences, Harvard Medical School, Boston, MA,Corresponding author: Gilles Benichou,
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41
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T-cell-mediated rejection of the kidney in the era of donor-specific antibodies: diagnostic challenges and clinical significance. Curr Opin Organ Transplant 2015; 20:325-32. [PMID: 25944230 DOI: 10.1097/mot.0000000000000189] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Burgeoning literature on antibody-mediated rejection (ABMR) has led to a perception that T-cell-mediated rejection (TCMR) is no longer a significant problem. This premise needs to be carefully appraised. RECENT FINDINGS A review of the literature indicates that TCMR remains an independent-risk factor for graft loss. Importantly, it can occur as a sensitizing event that triggers ABMR, and adversely affects its outcome. Moreover, T cells are regularly present in lesions used to diagnose ABMR, and these lesions can also develop in the absence of donor-specific antibodies (DSA). Conversely, patients with DSA are at risk for mixed ABMR-TCMR, which is quite common in many studies, and may require a combined anti-T-cell and anti-B-cell strategy for the best outcome. SUMMARY T-cell-based clinical monitoring and therapy is still relevant for prophylaxis of both cellular and humoral rejection, treatment of steroid refractory TCMR, which occurs in up to 20% of patients, and optimization of clinical outcome in mixed TCMR-ABMR, which is more frequently encountered than generally appreciated, and still associated with unacceptably high rates of graft loss.
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Abstract
PURPOSE OF REVIEW Inflammation of the arterial wall has been recognized as a key element of rejection since the early studies of pathologic changes in transplanted organs. Better elucidation of the mechanisms involved in endothelial injury has brought increasing complexity to the diagnostic classification of this lesion in the context of transplantation, and has affected the clinical management of patients with allograft rejection. Here, we examine how our understanding of the significance of intimal arteritis in renal graft biopsies has evolved in the past decades. RECENT FINDINGS Recognition that antidonor antibody may cause intimal arteritis has prompted revision of histologic classifications of transplant rejection. Although molecular signatures/biomarkers are being developed and proposed as new tools for aiding in the identification of cell-mediated and antibody-mediated types of rejection, histological examination is still needed to identify intimal arteritis in allograft biopsies. Outcome studies are contributing to clarify the prognostic significance of intimal arteritis in transplant rejection. SUMMARY Intimal arteritis remains an important histologic feature of allograft rejection, which comes in different nuances requiring tailored therapeutic approaches.
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43
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Abrahimi P, Liu R, Pober JS. Blood Vessels in Allotransplantation. Am J Transplant 2015; 15:1748-54. [PMID: 25807965 DOI: 10.1111/ajt.13242] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 12/23/2014] [Accepted: 01/23/2015] [Indexed: 01/25/2023]
Abstract
Human vascularized allografts are perfused through blood vessels composed of cells (endothelium, pericytes, and smooth muscle cells) that remain largely of graft origin and are thus subject to host alloimmune responses. Graft vessels must be healthy to maintain homeostatic functions including control of perfusion, maintenance of permselectivity, prevention of thrombosis, and participation in immune surveillance. Vascular cell injury can cause dysfunction that interferes with these processes. Graft vascular cells can be activated by mediators of innate and adaptive immunity to participate in graft inflammation contributing to both ischemia/reperfusion injury and allograft rejection. Different forms of rejection may affect graft vessels in different ways, ranging from thrombosis and neutrophilic inflammation in hyperacute rejection, to endothelialitis/intimal arteritis and fibrinoid necrosis in acute cell-mediated or antibody-mediated rejection, respectively, and to diffuse luminal stenosis in chronic rejection. While some current therapies targeting the host immune system do affect graft vascular cells, direct targeting of the graft vasculature may create new opportunities for preventing allograft injury and loss.
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Affiliation(s)
- P Abrahimi
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
| | - R Liu
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
| | - J S Pober
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
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44
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Giannico GA, Arnold S, Langone A, Schaefer H, Helderman JH, Shaffer D, Fogo AB. Non-immunoglobulin A mesangial immune complex glomerulonephritis in kidney transplants. Hum Pathol 2015; 46:1521-8. [PMID: 26245687 DOI: 10.1016/j.humpath.2015.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/29/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
Abstract
We have observed a predominantly mesangial non-immunoglobulin A immune complex mesangial glomerulopathy (MG) in renal transplants with mesangial deposits by immunofluorescence and electron microscopy. Clinicopathological features of 28 patients with MG were analyzed and compared with 28 transplant controls, matched for age, sex, ethnicity, donor type, estimated glomerular filtration rate, and interval from transplant to biopsy. Indications for biopsy in the MG group were allograft dysfunction in 64%, allograft dysfunction/proteinuria in 29%, and proteinuria in 7%. Biopsy indications in controls were allograft dysfunction (61%), allograft dysfunction/proteinuria (18%), proteinuria (14%), and delayed graft function (7%). Most MG cases had mild mesangial hypercellularity with endocapillary proliferation in 2 and crescents in 2 without fibrinoid necrosis. Immunoglobulin M-dominant deposits were present in 83%, and immunoglobulin G was dominant in 17% with mesangial deposits in 93% of cases by electron microscopy. Compared with controls, MG had higher Banff interstitial inflammation score (i) (P = .036) and was associated with concurrent acute T-cell-mediated rejection (P = .023), but not with acute or chronic antibody-mediated rejection. MG patients and controls had similar prevalence of polyomavirus nephropathy and Epstein-Barr virus infection. At follow-up, most MG patients had stable estimated glomerular filtration rate with no or stable proteinuria. Disease-specific graft survival was not different in MG versus controls. We conclude that, in view of the apparent self-limited nature of this lesion, additional treatment may not be required in these patients. Awareness of this lesion may thus spare patients unwarranted further intervention.
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Affiliation(s)
- Giovanna A Giannico
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Shanna Arnold
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232; Department of Veterans Affairs, Nashville, TN 37212.
| | - Anthony Langone
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Heidi Schaefer
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - J Harold Helderman
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - David Shaffer
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232.
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232.
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45
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Dos Santos DC, De Andrade LGM, De Carvalho MFC, Moraes Neto FA, Viero RM. Methods of analysis for peritubular capillaritis and glomerulitis in acute renal rejection: capillaritis in management of routine diagnosis. Transplant Proc 2015; 46:87-93. [PMID: 24507031 DOI: 10.1016/j.transproceed.2013.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 03/25/2013] [Accepted: 04/23/2013] [Indexed: 11/26/2022]
Abstract
Glomerulitis and peritubular capillaritis have been recognized as important lesions in acute renal rejection (AR). We studied glomerulitis and peritubular capillaritis in AR by 2 methods and investigated associations with C4d, type/grade of AR, and allograft survival time. Glomerulitis was measured according to Banff scores (glomerulitis by Banff Method [gBM]) and by counting the number of intraglomerular inflammatory cells (glomerulitis by Quantitative Method [gQM]). Capillaritis was classified by the Banff scoring system (peritubular capillaritis by Banff Method [ptcBM]) and by counting the number of cells in peritubular capillaries in 10 high-power fields (hpf; peritubular capillaritis by Quantitative Method [ptcQM]). These quantitative analyses were performed in an attempt to improve our understanding of the role played by glomerulitis and capillaritis in AR. The g0 + g1 group (gBM) associated with negative C4d (P = .02). In peritubular capillaritis, a larger number of cells per 10 hpf in peritubular capillaries (ptcQM) were observed in positive C4d cases (P = .03). The group g2 + g3 (gBM) correlated with graft loss (P = .01). Peritubular capillaritis was not significantly related to graft survival time. Our study showed that the Banff scoring system is the best method to study glomerulitis and observed that the evaluation of capillaritis in routine biopsies is difficult and additional studies are required for a better understanding of its meaning in AR biopsy specimens of renal allografts.
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Affiliation(s)
- D C Dos Santos
- Department of Pathology, Botucatu School of Medicine, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil.
| | - L G M De Andrade
- Department of Internal Medicine, Botucatu School of Medicine, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - M F C De Carvalho
- Department of Internal Medicine, Botucatu School of Medicine, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - F A Moraes Neto
- Department of Pathology, Amaral Carvalho Hospital, Jaú, São Paulo, Brazil
| | - R M Viero
- Department of Pathology, Botucatu School of Medicine, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
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46
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Broecker V, Mengel M. The significance of histological diagnosis in renal allograft biopsies in 2014. Transpl Int 2014; 28:136-43. [PMID: 25205033 DOI: 10.1111/tri.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 01/20/2023]
Abstract
In 2014, the renal allograft biopsy still represents the best available diagnostic 'gold' standard to assess reasons for allograft dysfunction. However, it is well recognized that histological lesion observed in the biopsy is of limited diagnostic specificity and that the Banff classification as the international diagnostic standard represents mere expert consensus. Here, we review the role of the renal allograft biopsy in different clinical and diagnostic settings. To increase diagnostic accuracy and to compensate for lack of specificity, the interpretation of biopsy pathology needs to be within the clinical context, primarily defined by time post-transplantation and patient-specific risk profile. With this in mind, similar histopathological patterns will lead to different conclusions with regard to diagnosis, disease grading and staging and thus to patient-specific clinical decision-making. Consensus generation for such integrated diagnostic approach, preferably including new molecular tools, represents the next challenge to the transplant community on its way to precision medicine in transplantation.
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Affiliation(s)
- Verena Broecker
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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47
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Bröcker V, Mengel M. Histopathological diagnosis of acute and chronic rejection in pediatric kidney transplantation. Pediatr Nephrol 2014; 29:1939-49. [PMID: 24141526 DOI: 10.1007/s00467-013-2640-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 09/05/2013] [Accepted: 09/13/2013] [Indexed: 01/05/2023]
Abstract
ABO-compatible as well as ABO-incompatible kidney transplantation are well established in the pediatric population. There are particularities in the histopathological evaluation of pediatric kidney transplant biopsies as for example the recurrence of certain diseases different from the adult population. Furthermore, the challenging transition of pediatric renal transplant recipients to adulthood is associated with an increased rate of non-adherence triggered rejection episodes. With modern immunosuppressive drugs, T-cell-mediated rejection of renal allografts is well controlled. In contrast, antibody-mediated rejection (AMR) is increasingly recognized as one of the major reasons for allograft loss. However, the 2001 diagnostic Banff criteria for antibody-mediated rejection require further refinement, as the morphological spectrum of AMR expands while effective therapeutic strategies are lacking. For example, endarteritis, which traditionally has been attributed to T-cell-mediated rejection, has recently been shown to be part of the AMR spectrum in some cases. Many findings in transplant renal biopsies are not specific for a certain disease but need consideration of differential diagnoses. To use the term "chronic allograft nephropathy" as a diagnostic entity is no longer appropriate. Therefore, the precise identification of specific diseases is paramount in the assessment of transplant renal biopsies in order to enable tailored therapeutic management.
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Affiliation(s)
- Verena Bröcker
- Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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48
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Troxell ML, Houghton DC. The Basics of Renal Allograft Pathology. Surg Pathol Clin 2014; 7:367-87. [PMID: 26837445 DOI: 10.1016/j.path.2014.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Renal allograft biopsy provides critical information in the management of renal transplant patients, and must be analyzed in close collaboration with the clinical team. The histologic correlates of acute T-cell mediated rejection are interstitial inflammation, tubulitis, and endothelialitis; polyomavirus nephropathy is a potential mimic. Evidence of antibody-mediated rejection includes C4d deposition; morphologic acute tissue injury; and donor specific antibodies. Acute tubular injury/necrosis is a reversible cause of impaired graft function, especially in the immediate post-transplant period. Drug toxicity, recurrent disease, chronic injury, and other entities affecting both native and transplant kidneys must also be evaluated.
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Affiliation(s)
- Megan L Troxell
- Department of Pathology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Donald C Houghton
- Department of Pathology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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49
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Abstract
Kidney diseases are morphologically heterogeneous. Pathologic classifications of renal disease permit standardization of diagnosis and may identify clinical-pathologic subgroups with different outcomes and/or responses to treatment. To date, classifications have been proposed for lupus nephritis, allograft rejection, IgA nephropathy, focal segmental glomerulosclerosis, antineutrophil cytoplasmic antibody -related glomerulonephritis, and diabetic glomerulosclerosis. These classifications share several limitations related to lack of specificity, reproducibility, validation, and relevance to clinical practice. They offer a standardized approach to diagnosis, however, which should facilitate communication and clinical research.
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Affiliation(s)
- M Barry Stokes
- Department of Pathology, Columbia University College of Physicians and Surgeons, 630 West 168th Street, VC14-224, New York, NY 10032, USA.
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50
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Serine Protease Inhibitor-6 Inhibits Granzyme B–Mediated Injury of Renal Tubular Cells and Promotes Renal Allograft Survival. Transplantation 2014; 98:402-10. [DOI: 10.1097/tp.0000000000000237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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