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Akhtar W, Peterzan MA, Banya W, Olwell B, Aghouee FV, Brookes P, Dunning J, Dar O. Donor specific antibodies association with survival and adverse events after heart transplantation: A single center retrospective study between 2006 and 2021. Clin Transplant 2023; 37:e14914. [PMID: 36630276 DOI: 10.1111/ctr.14914] [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: 06/15/2022] [Revised: 12/23/2022] [Accepted: 01/08/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Newly detected donor HLA-specific antibodies (DSA) are historically known to be associated with reduced survival in heart transplant patients. Our objective is to clarify the modern incidence of DSA and determine its relationship with survival and MACE. METHODS This retrospective study included all patients undergoing orthotopic heart transplantation at Harefield Hospital, London between January 1, 2006 and May 31, 2021. We identified patients who developed DSA at any point post heart transplantation and its effect on survival and MACE (defined as rejection, coronary event, stroke, and arrhythmia. RESULTS In total of 232 patients were included with a median follow up time of 4.7 years post heart transplantation. 23.7% of patients included developed DSA post heart transplantation. There was a significantly increased risk of death in patients developing DSA versus not (sub distribution hazard ratio [SHR] 1.83, 95% confidence interval 1.03-3.24, p = .04). At the time of detection of DSA, 38.2% of the cohort had rejection necessitating treatment. A MACE event had occurred in 48.1% by 2 years and 53.7% by 3 years in the DSA cohort. There was a significantly increased risk of MACE in patients developing DSA versus not (SHR 2.48 [1.58-3.89, p < .0001]). CONCLUSIONS This study showed an increased risk of death and MACE in patients developing DSA post heart transplantation. Further research is required into the optimal management of these patients.
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Affiliation(s)
- Waqas Akhtar
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Mark A Peterzan
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Winston Banya
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Brian Olwell
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Farveh Vakilian Aghouee
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Paul Brookes
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - John Dunning
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
| | - Owais Dar
- Department of Advanced Heart Failure, Transplantation and Mechanical Support, Harefield Hospital, Harefield, UK
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Accommodation in allogeneic and xenogeneic organ transplantation: Prevalence, impact, and implications for monitoring and for therapeutics. Hum Immunol 2023; 84:5-17. [PMID: 36244871 DOI: 10.1016/j.humimm.2022.08.001] [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: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
Accommodation refers to acquired resistance of organs or tissues to immune or inflammatory reactions that might otherwise cause severe injury or rejection. As first observed in ABO-incompatible kidney transplants and heterotopic cardiac xenografts, accommodation was identified when organ transplants continued to function despite the presence of anti-graft antibodies and/or other reactants in the blood of recipients. Recent evidence suggests many and perhaps most organ transplants have accommodation, as most recipients mount B cell responses specific for the graft. Wide interest in the impact of graft-specific antibodies on the outcomes of transplants prompts questions about which mechanisms confer protection against such antibodies, how accommodation might be detected and whether and how rejection could be superimposed on accommodation. Xenotransplantation offers a unique opportunity to address these questions because immune responses to xenografts are easily detected and the pathogenic impact of immune responses is so severe. Xenotransplantation also provides a compelling need to apply these and other insights to decrease the intensity and toxicity of immunosuppression that otherwise could limit clinical application.
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Jaiswal A, Bell J, DeFilippis EM, Kransdorf EP, Patel J, Kobashigawa JA, Kittleson MM, Baran DA. Assessment and management of allosensitization following heart transplant in adults. J Heart Lung Transplant 2022; 42:423-432. [PMID: 36702686 DOI: 10.1016/j.healun.2022.12.011] [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: 09/23/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Immunological injury to the allograft, specifically by antibodies to de novo donor specific human leukocyte antigen (dnDSA) and antibody mediated injury and rejection are the major limitations to graft survival after heart transplantation (HT). As such, our approach to allosensitization remains limited by the inability of contemporaneous immunoassays to unravel pathogenic potential of dnDSA. Additionally, the role of dnDSA is continuously evaluated with emerging methods to detect rejection. Moreover, the timing and frequency of dnDSA monitoring for early detection and risk mitigation as well as management of dnDSA remain challenging. A strategic approach to dnDSA employs diagnostic assays to determine relevant antibodies in conjunction with clinical presentation and injury/rejection of allograft to tailor therapeutics. In this review, we aim to outline contemporary knowledge involving detection, monitoring and management of dnDSA after HT. Subsequently, we propose a diagnostic and therapeutic approach that may mitigate morbidity and mortality while balancing adverse reactions from pharmacotherapy.
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Affiliation(s)
- Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Jennifer Bell
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan P Kransdorf
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart, Vascular and Thoracic Institute, Advanced Heart Failure Program, Weston, Florida
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Rao PN, Deo DD, Gaur A, Baran DA, Zucker MJ, Kapoor S, Marchioni MA, Almendral J, Kandula P, Patel A. A new flow cytometry assay identifies recipient IgG subtype antibodies binding donor cells: increasing donor availability for highly sensitised patients. Clin Transl Immunology 2022; 11:e1415. [PMID: 36092480 PMCID: PMC9446897 DOI: 10.1002/cti2.1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives There are four immunoglobulin (IgG) subtypes that have varying complement‐activating ability: strong (IgG3 and IgG1) and weak (IgG2 and IgG4). The standard flow cytometric crossmatch (FCM) assay does not distinguish between the various subtypes of the IgG molecule. This study outlines the development and use of a novel cell‐based IgG subtype‐specific FCM assay that is able to detect the presence of and quantitate the IgG subtypes bound to donor cells. Methods A six‐colour lyophilised reagent was designed that specifically detects the four IgG subtypes, as well as distinguishes between T cells and B cells in the lymphocyte population. To test the efficacy of this reagent, a retrospective evaluation of a group of highly sensitised patients awaiting heart and kidney transplant was carried out, who, because of positive standard FCM results, had been deemed incompatible with numerous prior potential donors. Results Observations in this study demonstrate that the positive standard FCM results were mainly because of the presence of noncomplement‐activating IgG2 or IgG4 antibodies. The results were supported by the absence of C3d‐binding donor‐specific antibodies (DSA) and a negative complement‐dependent cytotoxicity crossmatch (CDC). Conclusion Preliminary data presented in this study demonstrate the reliability of the novel IgG subtype assay to detect the presence of pretransplant, complement‐activating antibodies bound to donor cells. The knowledge gained from the IgG subtype assay and the C3d‐binding specificities of DSAs provides improved identification of donor suitability in pretransplant patients, potentially increasing the number of transplants.
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Affiliation(s)
- Prakash N Rao
- Personalized Transplant Medicine Institute New Providence NJ USA
| | - Dayanand D Deo
- Personalized Transplant Medicine Institute New Providence NJ USA
| | | | | | | | | | | | | | | | - Anup Patel
- Robert Wood Johnson Barnabas Health Livingston NJ USA
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The First Successful Combined Full Face and Bilateral Hand Transplant. Plast Reconstr Surg 2022; 150:414-428. [PMID: 35674521 DOI: 10.1097/prs.0000000000009369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.
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Frequency, reactivity and evolution of human leukocyte antigen and human platelet antigen antibodies in the setting of hematopoietic cell transplantation. Transfus Apher Sci 2021; 61:103301. [PMID: 34774441 DOI: 10.1016/j.transci.2021.103301] [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: 07/22/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Antibodies (Ab) against HLA and HPA antigens play an important role in HCT. In this prospective study we evaluated prevalence and kinetics of HLA- and HPA-Ab after HCT, including a possible donor-recipient transfer and their clinical relevance in respect to platelet transfusion refractoriness (PTR). MATERIALS AND METHODS Patients were consecutively recruited. Ab were determined by microbead assay technique and a mean fluorescence intensity cut-off of 1,000. RESULTS At baseline, 21 donors (42 %) and 27 patients (54 %) had HLA-Ab with a mean panel reactivity (cPRA) of 34.9 ± 29.4 % and 46.1 ± 36.5 %, respectively. We observed a significant higher number of HLA-Ab specificities in female donors and patients and a predominance of HLA-class I Ab. At day 0 we detected an increase of HLA-Ab (from 526 to 673) and cPRA (55.2 ± 31.9 %). Thirty-six patients (72 %) developed new HLA-Ab, mainly 3 weeks after HCT. In 7 patients an HLA-Ab with the same specificity as detected in the corresponding donor emerged, suggesting a possible transfer from the donor to the recipient. Overall, MFI showed a high variation. Type and number of transfusions were not associated with number and intensity of HLA-Ab (ρ: -0.05 - 0.02). Number of HLA-Ab, cPRA and intensity were not associated with PTR, which occurred in 9 patients (18 %) and none had bleeding WHO > 2. CONCLUSIONS Although a considerable number of patients have and develop HLA-Ab before and early after HCT, we found no association with PTR and bleeding and management should be individualized.
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Abstract
Purpose of review Since the discovery of human leukocyte antigen (HLA) in the 1950s, there has been great interest in the role of antibodies in posttransplant rejection. The development of the lymphocyte toxicity test by Terasaki et al. in the 1960s was the first step toward understanding the role of antibodies in posttransplant rejection. Recent findings Subsequently, various organs have been transplanted and improving posttransplant outcomes have become a focus of research. In particular, methods to measure antibodies that affect posttransplant outcomes, including anti-HLA antibodies, and methods to desensitize patients from specific antibodies have been explored. One recent method for measuring antibodies is called the solid-phase assay, which uses purified HLA fixed to microbeads. This assay does not use donor lymphocytes and allows clinicians to test the reactivity of patient serum against a panel of antibodies. It has also enabled the identification of specific anti-HLA antibodies using a single HLA. Summary In addition to advances in methods to measure and analyze anti-HLA antibodies, the clinical impact of non-HLA antibodies has also received much attention recently.
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The clinical impact of donor-specific antibodies on antibody-mediated rejection and long-term prognosis after heart transplantation. Curr Opin Organ Transplant 2020; 24:245-251. [PMID: 31090631 DOI: 10.1097/mot.0000000000000636] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Outcomes after cardiac transplantation have improved over past decades, but long-term graft survival remains limited in part because of uncertainty regarding clinical implications of donor-specific antibodies (DSAs). The purpose of this review is to consolidate recent advances in knowledge on the topic of DSA and their potential to impact long-term prognosis after heart transplantation. RECENT FINDINGS The presence of persistent DSA increases the risk of poor outcome after heart transplantation, including development of antibody-mediated rejection (AMR), graft failure, cardiac allograft vasculopathy, and mortality. Importantly, different DSA vary in clinical significance. DSA capable of activating the complement cascade portend a higher risk of developing AMR. human leukocyte antigen class I and class II antigens are expressed differently within the heart, and so, clinical manifestations of class I and class II DSA vary accordingly. Further, compared with class I, class II DSA carry an increased risk of graft loss and mortality. When comparing preexisting DSA with formation of de-novo DSA, de-novo DSA are associated with worse outcome. SUMMARY DSAs are generally associated worse long-term prognosis after heart transplantation but vary in their clinical significance. Recognition of specific risk profiles is essential for guiding posttransplant antibody management.
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Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) is a major contributor of impaired long-term survival after heart transplantation (HTx). The presence of circulating donor-specific antihuman leukocyte antigen (HLA) antibodies (DSAs) is considered as a mandatory criterion for AMR after HTx. DSA are known prognostic biomarkers of outcome, for example, recipients with de-novo DSA have a three-fold increased risk of mortality. RECENT FINDINGS Although the awareness of the impact and prognosis of DSA on the survival has been increased in the HTx community over the last decade, the management of DSA pre and posttransplant varies among centers and is mainly based on the experience of transplant physicians. Thus, firm consensus strategies for each HTx recipient should be established by a center advisory board of experts in the field of HLA genetics, transplantation immunology, and HTx to evaluate the immunological risk preoperatively and also continuously during the posttransplant course. Consequently, the recent advances of invasive and noninvasive diagnostic tools should be applied, according to the risk, laboratory findings, and clinical events of the recipient. Such individual strategy will result in tailored therapeutic options. SUMMARY Novel standards for the management of DSA in HTx recipients on the basis of an interdisciplinary approach of experts will improve diagnostics for personalized medicine.
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Corelattions Between CD31, CD68, MMP-2 and MMP-9 Expression in Allograft Cardiac Rejection – Immunohistochemical Study. ARS MEDICA TOMITANA 2020. [DOI: 10.2478/arsm-2019-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction. The cardiac allograft rejections from the post-transplant period are attributable to the acute cellular rejection monitored by multiple endomyocardial biopsies. Compared to this, humoral rejection remains a matter of debate, with multiple therapeutic strategies, poor prognosis, and persisting uncertainty about diagnostic criteria. Acute allograft rejection is associated with significant modifications of the extracellular matrix compartment mainly regulated by matrix metalloproteinases (MMPs). In this context, the aim of this study was to evaluate the expression of MMP-2 and -9 and CD31, CD68 (endothelial and histiocytic markers) and the correlations between them using immunohistochemistry, in patients with cardiac allografts.
Materials and methods. Tissue fragments were obtained by endomyocardial biopsy from 5 patients with allograft heart transplant, 2 in the medium post-transplant phase and 2 in late phase. After identifying and characterizing the morphological context the probes were processed by standard immunohistochemical technique using anti-MMP-2 and anti-MMP-9 antibodies (Santa Cruz Biotechnology, Inc.) and anti-CD31, anti-CD68 antibodies (Sigma). The samples were examined using the Olympus BX40 microscope with an Olympus E330 camera attached.
Results and discussions. Sample examination revealed in all 4 cases the lack of IR (-) for CD31 and weak IR (+) for CD68 compared to MMPs, where we found moderate IR (++) for MMP-9 and weak IR (+) for MMP-2. These aspects complets the histological lesional aspects of these cases, indicating the lack of acute rejection. In conclusion, CD31 and CD68 IR correlated with MMPs IR (especially MMP-9) appear to represent predictive markers for cardiac allograft rejection and require further studies.
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12
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Platt JL, Cascalho M. Non-canonical B cell functions in transplantation. Hum Immunol 2019; 80:363-377. [PMID: 30980861 PMCID: PMC6544480 DOI: 10.1016/j.humimm.2019.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 12/18/2022]
Abstract
B cells are differentiated to recognize antigen and respond by producing antibodies. These activities, governed by recognition of ancillary signals, defend the individual against microorganisms and the products of microorganisms and constitute the canonical function of B cells. Despite the unique differentiation (e.g. recombination and mutation of immunoglobulin gene segments) toward this canonical function, B cells can provide other, "non-canonical" functions, such as facilitating of lymphoid organogenesis and remodeling and fashioning T cell repertoires and modifying T cell responses. Some non-canonical functions are exerted by antibodies, but most are mediated by other products and/or direct actions of B cells. The diverse set of non-canonical functions makes the B cell as much as any cell a central organizer of innate and adaptive immunity. However, the diverse products and actions also confound efforts to weigh the importance of individual non-canonical B cell functions. Here we shall describe the non-canonical functions of B cells and offer our perspective on how those functions converge in the development and governance of immunity, particularly immunity to transplants, and hurdles to advancing understanding of B cell functions in transplantation.
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Affiliation(s)
- Jeffrey L Platt
- Departments of Surgery and of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States.
| | - Marilia Cascalho
- Departments of Surgery and of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States
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Abstract
PURPOSE OF REVIEW Posttransplant donor-specific human leukocyte antigen (HLA) antibodies (DSA) represent a complex area in heart transplantation with nonstandardized practice and paucity of clinical data to guide optimal management. RECENT FINDINGS De novo DSA after heart transplantation is common and associated with rejection, cardiac allograft vasculopathy, allograft failure, and mortality. Advances in methods for HLA antibody detection have enabled identification of DSA with high precision and sensitivity. The detection of HLA antibodies must, however, be interpreted within appropriate laboratory and clinical contexts; it remains unclear which DSA are associated with greatest clinical risk. Increased antibody and clinical surveillance as well as optimization of maintenance immunosuppression are required for all patients with DSA. Antibody-directed therapies are reserved for patients with allograft dysfunction or rejection. Treatment of DSA may also be considered in asymptomatic high-risk patients including those in whom DSA arise de novo posttransplant, is persistent, high titer, or complement activating. The impact of DSA reduction and removal on long-term clinical outcomes remains unknown. SUMMARY Despite improvements in DSA detection, identification, and characterization, best therapeutic strategies are unclear. Prospective multicenter studies are needed to develop effective standardized approaches for DSA management in heart transplantation.
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Colvin MM, Cook JL, Chang PP, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller DV, Rodriguez ER, Tyan DB, Zeevi A. Sensitization in Heart Transplantation: Emerging Knowledge: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e553-e578. [DOI: 10.1161/cir.0000000000000598] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sensitization, defined as the presence of circulating antibodies, presents challenges for heart transplant recipients and physicians. When present, sensitization can limit a transplantation candidate’s access to organs, prolong wait time, and, in some cases, exclude the candidate from heart transplantation altogether. The management of sensitization is not yet standardized, and current therapies have not yielded consistent results. Although current strategies involve antibody suppression and removal with intravenous immunoglobulin, plasmapheresis, and antibody therapy, newer strategies with more specific targets are being investigated.
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Dipchand AI, Webber S, Mason K, Feingold B, Bentlejewski C, Mahle WT, Shaddy R, Canter C, Blume ED, Lamour J, Zuckerman W, Diop H, Morrison Y, Armstrong B, Ikle D, Odim J, Zeevi A. Incidence, characterization, and impact of newly detected donor-specific anti-HLA antibody in the first year after pediatric heart transplantation: A report from the CTOTC-04 study. Am J Transplant 2018; 18:2163-2174. [PMID: 29442424 PMCID: PMC6092243 DOI: 10.1111/ajt.14691] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 01/30/2018] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Data on the clinical importance of newly detected donor-specific anti-HLA antibodies (ndDSAs) after pediatric heart transplantation are lacking despite mounting evidence of the detrimental effect of de novo DSAs in solid organ transplantation. We prospectively tested 237 pediatric heart transplant recipients for ndDSAs in the first year posttransplantation to determine their incidence, pattern, and clinical impact. One-third of patients developed ndDSAs; when present, these were mostly detected within the first 6 weeks after transplantation, suggesting that memory responses may predominate over true de novo DSA production in this population. In the absence of preexisting DSAs, patients with ndDSAs had significantly more acute cellular rejection but not antibody-mediated rejection, and there was no impact on graft and patient survival in the first year posttransplantation. Risk factors for ndDSAs included common sensitizing events. Given the early detection of the antibody response, memory responses may be more important in the first year after pediatric heart transplantation and patients with a history of a sensitizing event may be at risk even with a negative pretransplantation antibody screen. The impact on late graft and patient outcomes of first-year ndDSAs is being assessed in an extended cohort of patients.
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Affiliation(s)
- A. I. Dipchand
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - S. Webber
- Vanderbilt University Medical Center, Nashville, TN
| | | | - B. Feingold
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | - W. T. Mahle
- Children’s Healthcare of Atlanta, Atlanta, GA
| | - R. Shaddy
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - C. Canter
- St Louis Children’s Hospital, St Louis, MO
| | | | - J. Lamour
- Montefiore Children’s Hospital, New York, NY
| | | | - H. Diop
- National Institutes of Health, Bethesda, MD
| | | | | | | | - J. Odim
- National Institutes of Health, Bethesda, MD
| | - A. Zeevi
- Department of Pathology, UPMC, Pittsburgh, PA
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Hollander SA, Peng DM, Mills M, Berry GJ, Fedrigo M, McElhinney DB, Almond CS, Rosenthal DN. Pathological antibody-mediated rejection in pediatric heart transplant recipients: Immunologic risk factors, hemodynamic significance, and outcomes. Pediatr Transplant 2018; 22:e13197. [PMID: 29729067 DOI: 10.1111/petr.13197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 12/31/2022]
Abstract
Biopsy-diagnosed pAMR has been observed in over half of pediatric HT recipients within 6 years of transplantation. We report the incidence and outcomes of pAMR at our center. All endomyocardial biopsies for all HT recipients transplanted between 2010 and 2015 were reviewed and classified using contemporary ISHLT guidelines. Graft dysfunction was defined as a qualitative decrement in systolic function by echocardiogram or an increase of ≥3 mm Hg in atrial filling pressure by direct measurement. Among 96 patients, pAMR2 occurred in 7 (7%) over a median follow-up period of 3.1 years, while no cases of pAMR3 occurred. A history of CHD, DSA at transplant, and elevated filling pressures were associated with pAMR2. Five-sixths (83%) of patients developed new C1q+ DSA at the time of pAMR diagnosis. There was a trend toward reduced survival, with 43% of patients dying within 2.3 years of pAMR diagnosis.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David M Peng
- Department of Pediatrics (Cardiology), University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Marcos Mills
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald J Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Marny Fedrigo
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, LPCH Heart Center Clinical and Translational Research Program, Stanford University, Stanford, CA, USA
| | - Christopher S Almond
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
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Keating BJ, Pereira AC, Snyder M, Piening BD. Applying genomics in heart transplantation. Transpl Int 2018; 31:278-290. [PMID: 29363220 PMCID: PMC5990370 DOI: 10.1111/tri.13119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/18/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
While advances in patient care and immunosuppressive pharmacotherapies have increased the lifespan of heart allograft recipients, there are still significant comorbidities post-transplantation and 5-year survival rates are still significant, at approximately 70%. The last decade has seen massive strides in genomics and other omics fields, including transcriptomics, with many of these advances now starting to impact heart transplant clinical care. This review summarizes a number of the key advances in genomics which are relevant for heart transplant outcomes, and we highlight the translational potential that such knowledge may bring to patient care within the next decade.
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Affiliation(s)
- Brendan J. Keating
- Division of Transplantation, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandre C. Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - Michael Snyder
- Department of Genetics, Stanford University, Stanford, CA, USA
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Moncharmont P. Platelet component transfusion and alloimmunization: Where do we stand? Transfus Clin Biol 2018; 25:172-178. [PMID: 29478960 DOI: 10.1016/j.tracli.2018.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/23/2018] [Indexed: 11/27/2022]
Abstract
Platelet transfusion in patients, particularly in onco-haematology, is frequent and can become chronic in some cases. Post-transfusion alloimmunization is often seen, in practice. The risk of this is significantly improved in multitransfused patients. Several classes of antigens binding on platelets (HLA and HPA) are involved and also red blood cell antigens (residual red blood cells in platelet concentrates). Platelet alloimmunization causes a poor transfusion response, refractoriness and, more rarely, post-transfusion purpura. In an alloimmunized recipient, the efficiency of platelet transfusion is based on the selection of compatible products. Significant technical progress means that several methods are currently available to ensure a good post-transfusion platelet count and a satisfactory clinical outcome for the patient.
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Affiliation(s)
- P Moncharmont
- Hémovigilance, département des vigilances, site de Décines, Établissement français du sang Auvergne-Rhône-Alpes, 111, rue Élisée-Reclus CS 20617, 69153 Décines-Charpieu cedex, France.
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Application and interpretation of histocompatibility data in liver transplantation. Curr Opin Organ Transplant 2018; 22:499-504. [PMID: 28708813 DOI: 10.1097/mot.0000000000000450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW There has been a resurgence of interest in histocompatibility as it applies to liver transplantation. The association of persistent and de-novo donor specific antibody (DSA) and outcomes after liver transplantation continues to be investigated. RECENT FINDINGS Consensus continues to evolve regarding the existence of acute and chronic antibody-mediated rejection (AMR) and pathogenicity of DSA and associated pathologic findings after liver transplantation. The presence of persistent high level, complement fixing DSA or emergence of de novo, Class II DSA has been associated with rejection and worse long-term graft and patient survival. Significant adverse associations of DSA extend to patients after simultaneous liver kidney (SLK) transplant as well as in pediatric recipients of liver transplantation. A higher degree of HLA incompatibility has been recently associated with worse outcomes in living donor liver transplant. SUMMARY In summary, recent consensus guidelines describe and recognize the existence of acute and chronic AMR and provide a basis upon which to build further investigation. Important adverse outcomes including decreased survival, allograft failure and liver fibrosis have been linked to the presence of DSA. Routine donor and recipient HLA typing and DSA assessment will facilitate diagnosis and provide for baseline data, which may help guide future management. Future investigations may help to clarify the role of therapeutic interventions.
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Feingold B, Picarsic J, Lesniak A, Popp BA, Wood-Trageser MA, Demetris AJ. Late graft dysfunction after pediatric heart transplantation is associated with fibrosis and microvasculopathy by automated, digital whole-slide analysis. J Heart Lung Transplant 2017; 36:1336-1343. [PMID: 29055602 DOI: 10.1016/j.healun.2017.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/23/2017] [Accepted: 09/26/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Histopathologic features of late graft dysfunction (LGD) in endomyocardial biopsies (EMBs) after pediatric heart transplantation (HT) have been incompletely described and rarely quantified. We employed automated, morphometric analysis of whole-slide EMB images to objectively quantify fibrosis and microvasculopathy after pediatric HT. METHODS Nine recipients with clinical LGD were matched with controls on age, listing diagnosis, crossmatch and time since HT. Fibrosis was quantified as percent tissue area with fibrosis and capillary density as capillaries per unit area, number of capillary "neighbors" within 30 μm of each myocyte and myocyte-to-nearest-capillary diffusion distance. Clinical data, including all EMB reports, were also reviewed. RESULTS The groups were well matched for age at HT (median 4.0 vs 3.1 years), listing diagnosis (50% congenital heart disease for each), positive crossmatch (11% each) and days post-HT (2,628 vs 2,894, p = 0.69). Despite a similar number of previous EMBs (median 23 each, p = 0.43), areas occupied by fibrosis were greater in LGD cases (44.5% vs 23.2%, p = 0.012). Capillary number/area data were not statistically different between LGD cases and controls (378/mm2 vs 559/mm2, p = 0.57), but LGD cases more commonly had zero capillary neighbors (35% vs 20%, p = 0.02) and greater myocyte-to-nearest-capillary distances (27.1 μm vs 18.7 μm, p = 0.005). Cumulative rejection history correlated with fibrosis (r = 0.49, p = 0.039) and myocyte-to-nearest-capillary distance (r = 0.5, p = 0.036). CONCLUSIONS LGD after pediatric HT is associated with previous rejection and characterized histologically by fibrosis and microvasculopathy, which are not readily appreciated by traditional semi-quantitative EMB analysis. Software-assisted EMB analysis may enable greater pathophysiologic understanding of LGD and identification of targets for future study and intervention.
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Affiliation(s)
- Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Jennifer Picarsic
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Lesniak
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Division of Transplant Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Benjamin A Popp
- Division of Transplant Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michelle A Wood-Trageser
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Division of Transplant Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anthony J Demetris
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Division of Transplant Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Broch K, Gude E, Andreassen AK, Gullestad L. Newer Immunosuppression and Strategies on the Horizon in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Delbos F, Cesbron A. [Caracterization of HLA allo-immunization and clinical impact in transfusion and organ transplantation]. Transfus Clin Biol 2017; 24:131-137. [PMID: 28757117 DOI: 10.1016/j.tracli.2017.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
Allo-immunizations against HLA antigens are known to be deleterious in transfusion and organ transplantation. The development of new tests based on solid phase assays for screening and identification of HLA antibodies in particular those using Luminex® bead based technology has completely changed the way of allo-immunization monitoring because of their extreme sensitivity. They allow a better characterization of these antibodies, identification of acceptable antigens and the use of virtual cross-matches. All these new possibilities improve the managing of patients before and after platelets transfusion or organ transplantation. However, this technology displays some limits that should be known in order to interpret correctly the results. Beside these bead based assays, cellular cross-matches based on Complement Dependent Cytotoxicity (CDC) and flow cytometry are still used and useful in organ transplantation since beads are produced in vitro and do not reflected exactly what happens physiologically. Moreover, differences of sensitivity between these methods make results interpretation and decision making difficult in some cases.
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Affiliation(s)
- F Delbos
- Établissement français du sang, Pays-de-la-Loire, 34, boulevard Jean-Monnet, 44000 Nantes, France
| | - A Cesbron
- Établissement français du sang, Pays-de-la-Loire, 34, boulevard Jean-Monnet, 44000 Nantes, France.
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