1
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Mang Y, Gao Y, Yang Y, Dong M, Yang Q, Li H, Ran J, Li L, Ma J, Chen G, Yang B, Xie Y, Wu Y, Zhao Y, Zhang S. Experience on AMR Diagnosis and Treatment Following Liver Transplantation: Case Series. Transplant Direct 2024; 10:e1598. [PMID: 38464427 PMCID: PMC10923386 DOI: 10.1097/txd.0000000000001598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 03/12/2024] Open
Affiliation(s)
- Yuanyi Mang
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Yang Gao
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Yan Yang
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Mei Dong
- Hemodialysis Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Qian Yang
- Department of Pathology, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Hong Li
- Department of Ultrasonic Medicine, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Jianghua Ran
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Li Li
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Jun Ma
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Guoyu Chen
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Bin Yang
- Medical Imaging Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Ying Xie
- Medical Imaging Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Yunsong Wu
- Hemodialysis Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Kunming, China
| | - Yingpeng Zhao
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
| | - Shengning Zhang
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Center, The Calmette Affiliated Hospital of Kunming Medical University, The First People’s Hospital of Kunming, Clinical Medical Center for Organ Transplantation of Yunnan Province, Kunming, China
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Kosuta I, Kelava T, Ostojic A, Sesa V, Mrzljak A, Lalic H. Immunology demystified: A guide for transplant hepatologists. World J Transplant 2024; 14:89772. [PMID: 38576757 PMCID: PMC10989464 DOI: 10.5500/wjt.v14.i1.89772] [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: 11/12/2023] [Revised: 01/24/2024] [Accepted: 02/29/2024] [Indexed: 03/15/2024] Open
Abstract
Liver transplantation has become standard practice for treating end-stage liver disease. The success of the procedure relies on effective immunosuppressive medications to control the host's immune response. Despite the liver's inherent capacity to foster tolerance, the early post-transplant period is marked by significant immune reactivity. To ensure favorable outcomes, it is imperative to identify and manage various rejection types, encompassing T-cell-mediated, antibody-mediated, and chronic rejection. However, the approach to prescribing immunosuppressants relies heavily on clinical judgment rather than evidence-based criteria. Given that the majority of patients will require lifelong immuno suppression as the mechanisms underlying operational tolerance are still being investigated, healthcare providers must possess an understanding of immune responses, rejection mechanisms, and the pathways targeted by immunosuppressive drugs. This knowledge enables customization of treatments and improved patient care, even though a consensus on an optimal immunosuppressive regimen remains elusive.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Tomislav Kelava
- Department of Physiology, School of Medicine, Univeristy of Zagreb, Zagreb 10000, Croatia
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, Zagreb 10000, Croatia
| | - Ana Ostojic
- Department of Gastroenterology and Hepatology, Liver Transplant Center, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Vibor Sesa
- Department of Gastroenterology and Hepatology, Liver Transplant Center, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Centre Zagreb, Zagreb 10000, Croatia
- Department of Medicine, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Hrvoje Lalic
- Department of Physiology, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Laboratory for Cell Biology, Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Department of Laboratory Immunology, Clinical Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb 10000, Croatia
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3
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Kanamori H, Yamada Y, Ito Y, Shirosaki K, Yamagishi S, Maeda Y, Kudo Y, Umeyama T, Takahashi N, Kato M, Hasegawa Y, Matsubara K, Shinoda M, Obara H, Irie R, Tsujikawa H, Okita H, Nguyen PT, Saigo K, Mitsunaga S, Inoue I, Kitagawa Y, Kuroda T. Noninvasive graft monitoring using donor-derived cell-free DNA in Japanese liver transplantation. Hepatol Res 2024; 54:300-314. [PMID: 37850337 DOI: 10.1111/hepr.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/06/2023] [Accepted: 10/13/2023] [Indexed: 10/19/2023]
Abstract
AIM To evaluate the use of donor-derived cell-free DNA (dd-cfDNA) in diagnosing graft injuries in Japanese liver transplantation (LTx), including family-related living donors. METHODS A total of 321 samples from 10 newly operated LTx recipients were collected to monitor the early dynamics of dd-cfDNA levels after LTx. Fifty-five samples from 55 recipients were collected during protocol biopsies (PB), whereas 36 samples from 27 recipients were collected during event biopsies, consisting of 11 biopsy-proven acute rejection (AR), 20 acute dysfunctions without rejection (ADWR), and 5 chronic rejections. The levels of dd-cfDNA were quantified using a next-generation sequencer based on single nucleotide polymorphisms. RESULTS The dd-cfDNA levels were elevated significantly after LTx, followed by a rapid decline to the baseline in patients without graft injury within 30 days post-LTx. The dd-cfDNA levels were significantly higher in the 11 samples obtained during AR than those obtained during PB (p < 0.0001), which decreased promptly after treatment. The receiver operator characteristic curve analysis of diagnostic ability yielded areas under the curve of 0.975 and 0.897 for AR (rejection activity index [RAI] ≥3) versus PB and versus non-AR (ADWR + PB). The dd-cfDNA levels during AR were elevated earlier and correlated more strongly with the RAI (r = 0.740) than aspartate aminotransferase/alanine aminotransferase. The dd-cfDNA levels were neither associated with graft fibrosis based on histology nor the status of donor-specific antibodies in PB samples. CONCLUSIONS Donor-derived cell-free DNA serves as a sensitive biomarker for detecting graft injuries in LTx. Further large-scale cohort studies are warranted to optimize its use in differentiating various post-LTx etiologies.
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Affiliation(s)
- Hiroki Kanamori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ito
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Shirosaki
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoko Yamagishi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yutaro Maeda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yumi Kudo
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoshige Umeyama
- Department of Pediatric Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Nobuhiro Takahashi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Digestive Diseases Center, International University of Health and Welfare School of Medicine, Mita Hospital, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rie Irie
- Department of Diagnostic Pathology, Nippon Koukan Hospital, Kawasaki, Japan
| | - Hanako Tsujikawa
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Okita
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | | | - Kenichi Saigo
- Department of Transplantation Surgery, Japan Community Health Care Organization, Chiba Hospital, Chiba, Japan
| | - Shigeki Mitsunaga
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Ituro Inoue
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Children's Medical Center, Kanagawa, Japan
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4
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Nabulsi S, Otunla AA, Salciccioli J, Marshall DC, Villani V, Shanmugarajah K, Shalhoub J. HLA matching between donors and recipients improves clinical liver transplant graft survival. Liver Int 2024; 44:411-421. [PMID: 38010995 DOI: 10.1111/liv.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/03/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS The importance of human leukocyte antigen (HLA) matching between liver transplant donors and recipients on graft survival remains unclear and is not a clinical consideration in liver transplantation. This study aimed to determine the relationship between HLA matching and liver graft survival using a large-scale multi-centre database (UNOS/OPTN) and multivariate logistic analysis. The secondary aim was to determine whether this relationship was influenced by transplant indication and donor status. METHODS This retrospective observational analysis was performed using 22 702 liver transplant recipients from the UNOS/OPTN database. Patients were divided into two groups based on number of HLA mismatches (0-3 mismatches vs. 4-6 mismatches) and then subcategorized by indication and donor status. Risk-adjusted outcomes were assessed by multivariate Cox analysis adjusting for donor and recipient characteristics and visualized using Kaplan-Meier survival curves. RESULTS Allograft survival and risk of acute rejection were associated with degree of HLA mismatch. This association between HLA mismatch and graft survival persisted in individuals who underwent transplant for hepatitis, metabolic, drug toxicity, and congenital indications. Donor status also influenced the relationship between HLA mismatch and graft survival. Graft survival in DBD recipients was longer than in DCD in the 4-6 HLA mismatch group, whereas no significant difference was found in the 0-3 HLA mismatch group. CONCLUSION HLA mismatch significantly reduced graft survival and increased risk of acute rejection. This association was noted only in specific indications. These findings are of potential clinical relevance to organ allocation, allograft matching algorithms, immunosuppression protocols, and transplant surveillance.
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Affiliation(s)
- Sarah Nabulsi
- Department of Life Sciences, Imperial College London, London, UK
| | | | - Justin Salciccioli
- Department of Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Vincenzo Villani
- Department of Transplantation, Memorial Hermann Health System, Houston, Texas, USA
| | | | - Joseph Shalhoub
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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5
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Battle R, Pritchard D, Peacock S, Hastie C, Worthington J, Jordan S, McCaughlan JA, Barnardo M, Cope R, Collins C, Diaz-Burlinson N, Rosser C, Foster L, Kallon D, Shaw O, Briggs D, Turner D, Anand A, Akbarzad-Yousefi A, Sage D. BSHI and BTS UK guideline on the detection of alloantibodies in solid organ (and islet) transplantation. Int J Immunogenet 2023; 50 Suppl 2:3-63. [PMID: 37919251 DOI: 10.1111/iji.12641] [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: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
Solid organ transplantation represents the best (and in many cases only) treatment option for patients with end-stage organ failure. The effectiveness and functioning life of these transplants has improved each decade due to surgical and clinical advances, and accurate histocompatibility assessment. Patient exposure to alloantigen from another individual is a common occurrence and takes place through pregnancies, blood transfusions or previous transplantation. Such exposure to alloantigen's can lead to the formation of circulating alloreactive antibodies which can be deleterious to solid organ transplant outcome. The purpose of these guidelines is to update to the previous BSHI/BTS guidelines 2016 on the relevance, assessment, and management of alloantibodies within solid organ transplantation.
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Affiliation(s)
- Richard Battle
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | | | - Sarah Peacock
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Sue Jordan
- National Blood Service Tooting, London, UK
| | | | - Martin Barnardo
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebecca Cope
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Luke Foster
- Birmingham Blood Donor Centre, Birmingham, UK
| | | | - Olivia Shaw
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David Turner
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Arthi Anand
- Imperial College Healthcare NHS Trust, London, UK
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6
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Sharma P, Arora A. Basic Understanding of Liver Transplant Immunology. J Clin Exp Hepatol 2023; 13:1091-1102. [PMID: 37975047 PMCID: PMC10643508 DOI: 10.1016/j.jceh.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/14/2023] [Indexed: 11/19/2023] Open
Abstract
The liver is a specialized organ and plays an important role in our immune system. The liver constitutes parenchymal cells which are hepatocytes and cholangiocytes (60-80%) and non-parenchymal cells like liver sinusoidal endothelial cells (LSECs), hepatic satellite/Ito cells, Kupffer cells, neutrophils, mononuclear cells, T and B lymphocytes (conventional and non-conventional), natural killer cells, and natural killer T (NKT) cells. The liver mounts a rapid and strong immune response, under unfavorable conditions and acts as an immune tolerance to a variety of non-pathogenic antigens. This delicate and dynamic interaction between different kinds of immune cells in the liver maintains a balance between immune screening and immune tolerance. The liver allografts are privileged immunologically; however, allograft rejection is not uncommon and is classified as cell or antibody-mediated. Advancements in transplant immunology help in the prevention of allografts rejection by immune reactions of the host thus leading to better graft and host survival. Fewer patients may not require immunosuppression due to systemic donor-specific T-cell tolerance. The liver tolerance mechanism is poorly studied, and LSEC and unconventional lymphocytes play an important role that dampens T cell response either by inducing apoptosis of cells or inhibiting co-stimulatory pathways. Newer cell-based therapy based on Treg, dendritic cells, and mesenchymal stromal cells will probably change the future of immunosuppression. Various invasive and non-invasive biomarkers and artificial intelligence have also been investigated to predict graft survival, post-transplant complications, and immunotolerance in the future.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
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7
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Betjes MGH, De Weerd A. Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and clinical dots. Front Med (Lausanne) 2023; 10:1215167. [PMID: 37502354 PMCID: PMC10368955 DOI: 10.3389/fmed.2023.1215167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
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Narita S, Miuma S, Okudaira S, Koga Y, Fukushima M, Sasaki R, Haraguchi M, Soyama A, Hidaka M, Miyaaki H, Futakuchi M, Nagai K, Ichikawa T, Eguchi S, Nakao K. Regular protocol liver biopsy is useful to adjust immunosuppressant dose after adult liver transplantation. Clin Transplant 2023; 37:e14873. [PMID: 36443801 DOI: 10.1111/ctr.14873] [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: 03/01/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adjusting immunosuppression to minimal levels post-adult liver transplantation (LT) is critical; however, graft rejection has been reported in LT recipients with normal liver function evaluated by liver biopsy (LBx). Continual protocol liver biopsy (PLB) is performed regularly in LT recipients with normal liver function in some centers; however, its usefulness remains inadequately evaluated. This study aimed to assess retrospectively the usefulness of late PLB after adult LT. METHODS LBx evaluations of LT recipients with normal liver function and hepatitis B and C virus seronegativity were defined as PLB. The cases requiring immunosuppressive therapy for rejection findings based on Banff criteria were extracted from the PLBs, and pathological data collected before and after immunosuppressive dosage adjustment (based on modified histological activity index [HAI] score) were compared. RESULTS Among 548 LBx cases, 213 LBx in 110 recipients fulfilled the inclusion criteria for PLB. Immunosuppressive therapy after PLB was intensified in 14 LBx (6.6%) recipients (12.7%); of these, nine had late-onset acute rejection, three had isolated perivenular inflammation, one had plasma cell-rich rejection, and one had early chronic rejection. Follow-up LBx after immunosuppressive dose adjustment showed improvement in the modified HAI score grading in 10 of 14 cases (71.4%). No clinical background and blood examination data, including those from the post-LT period, immunosuppressant trough level, or examination for de novo DSA, predicted rejection in PLB. Complications of PLB were found in only three cases. CONCLUSION PLB is useful in the management of seemingly stable LT recipients, to discover subclinical rejection and allow for appropriate immunosuppressant dose adjustment.
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Affiliation(s)
- Shohei Narita
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sadayuki Okudaira
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshito Koga
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Masanori Fukushima
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masafumi Haraguchi
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuru Futakuchi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuki Ichikawa
- Nagasaki Harbor Medical Center, Department of Gastroenterology, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University of Graduate School of Biomedical Sciences, Nagasaki, Japan
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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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10
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El Sabagh A, Mohamed IB, Aloor FZ, Abdelwahab A, Hassan MM, Jalal PK. Current Status of Biomarkers and Molecular Diagnostic Tools for Rejection in Liver Transplantation: Light at the End of the Tunnel? J Clin Exp Hepatol 2023; 13:139-148. [PMID: 36647415 PMCID: PMC9840072 DOI: 10.1016/j.jceh.2022.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/24/2022] [Indexed: 01/19/2023] Open
Abstract
Strategies to minimize immune-suppressive medications after liver transplantation are limited by allograft rejection. Biopsy of liver is the current standard of care in diagnosing rejection. However, it adds to physical and economic burden to the patient and has diagnostic limitations. In this review, we aim to highlight the different biomarkers to predict and diagnose acute rejection. We also aim to explore recent advances in molecular diagnostics to improve the diagnostic yield of liver biopsies.
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Key Words
- 3BMBs, third bifurcation mucosal endo-bronchial biopsies
- AMR, antibody mediated rejection
- APC, antigen presenting cells
- AR, Acute rejection
- ATCMR, acute T-cell mediated rejection
- ATG, Anti-thymoglobulin
- AUC, area under curve
- AUROC, area under receiver operating characteristic curve
- B-HOT, Banff Human Organ Transplant
- CNI, Calcineurin inhibitors
- DSA, Donor specific antibodies
- FDA, Food and drug administration
- FFPE, formalin fixed paraffin embedded preparation
- GLUT-4, glucose transport-4
- HLA, human leukocyte antigens
- HNMR, high nuclear magnetic resonance
- ILTS, International liver transplantation society
- LT, Liver transplantation
- Liver transplantation
- MDWG, molecular diagnostic work group
- MFI, mean fluorescence intensity
- MHC, major histo–compatibility complex
- MMDX
- MMDX, Molecular microscopic diagnostic system
- MMF, Mycophenolate Mofetil
- MToR, Mechanistic target of Rapamycin
- NPV, Negative predictive value
- PPV, Positive predictive value
- RATs, rejection associated transcripts
- TBB, trans-bronchial biopsies
- UNOS, United network for organ sharing and procurement
- biomarker
- dd cfDNA, donor-derived cell-free DNA
- donor-derived cell-free DNA
- immune-suppression
- mRNA, messenger RNA
- miRNA, micro-RNA
- micro-RNA
- molecular diagnosis
- nano-string
- rejection
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Affiliation(s)
- Ahmed El Sabagh
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
- Department of Internal Medicine, Gastroenterology & Hepatology, Ain Shams University, Cairo, Egypt
| | - Islam B. Mohamed
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
- Department of Internal Medicine, Gastroenterology & Hepatology, Ain Shams University, Cairo, Egypt
| | - Fuad Z. Aloor
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed Abdelwahab
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Manal M. Hassan
- Department of Epidemiology, Division of Cancer Prevention and Population Sciences, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Prasun K. Jalal
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
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11
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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12
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Zhao K, Wang R, Kamoun M, Callans L, Bremner R, Rame E, McLean R, Cevasco M, Olthoff KM, Levine MH, Shaked A, Abt PL. Incidence of acute rejection and patient survival in combined heart-liver transplantation. Liver Transpl 2022; 28:1500-1508. [PMID: 35247292 DOI: 10.1002/lt.26448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 02/06/2022] [Accepted: 02/13/2022] [Indexed: 01/13/2023]
Abstract
Combined heart-liver transplantation (CHLT) is indicated for patients with concomitant end-stage heart and liver disease or patients with amyloid heart disease where liver transplantation mitigates progression. Limited data suggest that the liver allograft provides immunoprotection for heart and kidney allografts in combined transplantation from the same donor. We hypothesized that CHLT reduces the incidence of acute cellular rejection (ACR) and the development of de novo donor-specific antibodies (DSAs) compared with heart-alone transplantation (HA). We conducted a retrospective analysis of 32 CHLT and 280 HA recipients in a single-center experience. The primary outcome was incidence of ACR based on protocol and for-cause myocardial biopsy. Rejection was graded by the International Society of Heart and Lung Transplantation guidelines with Grade 2R and higher considered significant. Secondary outcomes included the development of new DSAs, cardiac function, and patient and cardiac graft survival rates. Of CHLT patients, 9.7% had ACR compared with 45.3% of HA patients (p < 0.01). Mean pretransplant calculated panel reactive antibody (cPRA) levels were similar between groups (CHLT 9.4% vs. HA 9.5%; p = 0.97). Among patients who underwent testing, 26.9% of the CHLT and 16.7% of HA developed DSA (p = 0.19). Despite the difference in ACR, patient and cardiac graft survival rates were similar at 5 years (CHLT 82.1% vs. HA 80.9% [p = 0.73]; CHLT 82.1% vs. HA 80.9% [p = 0.73]). CHLT reduced the incidence of ACR in the cardiac allograft, suggesting that the liver offers immunoprotection against cellular mechanisms of rejection without significant impacts on patient and cardiac graft survival rates. CHLT did not reduce the incidence of de novo DSA, possibly portending similar long-term survival among cardiac allografts in CHLT and HA.
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Affiliation(s)
- Kai Zhao
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Roy Wang
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Malek Kamoun
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lauren Callans
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Remy Bremner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo Rame
- Department of Medicine, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rhondalyn McLean
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abraham Shaked
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Vij M, Rammohan A, Rela M. Long-term liver allograft fibrosis: A review with emphasis on idiopathic post-transplant hepatitis and chronic antibody mediated rejection. World J Hepatol 2022; 14:1541-1549. [PMID: 36157865 PMCID: PMC9453462 DOI: 10.4254/wjh.v14.i8.1541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is a life-saving surgical procedure and the current standard of care for most patients with end stage liver disease. With improvements in organ preservation techniques, perioperative care, and immunosuppression, there is better patient and graft survival following LT, and assessment of the liver allograft in long-term survivors is becoming increasingly important. Recurrent or de novo viral or autoimmune injury remains the most common causes of chronic hepatitis and fibrosis following liver transplantation in adults. However, no obvious cause can be identified in many adults with controlled recurrent disease and the majority of pediatric LT recipients, as they have been transplanted for non-recurrent liver diseases. Serial surveillance liver biopsies post LT have been evaluated in several adult and pediatric centers to identify long-term pathological changes. Pathological findings are frequently present in liver biopsies obtained after a year post LT. The significance of these findings is uncertain as many of these are seen in protocol liver biopsies from patients with clinically good allograft function and normal liver chemistry parameters. This narrative review summaries the factors predisposing to long-term liver allograft fibrosis, highlighting the putative role of idiopathic post-LT hepatitis and chronic antibody mediated rejection in its pathogenesis.
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Affiliation(s)
- Mukul Vij
- Department of Pathology, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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14
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Dekeyser M, Taupin JL, Elias M, Ichaï P, Herr F, Boudon M, Brunel M, Sa cunha A, Coilly A, Saliba F, Durrbach A. Impact of DSA and immunosuppression minimization on rejection, graft, and patient survival after simultaneous liver–kidney transplantation. Front Med (Lausanne) 2022; 9:949833. [PMID: 36072942 PMCID: PMC9441637 DOI: 10.3389/fmed.2022.949833] [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: 05/21/2022] [Accepted: 07/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute rejection rate is low after simultaneous liver–kidney transplantation (SLKT), leading some groups to minimize immunosuppressive (IS) regimens. However, the impact of preformed (pDSA) or de novo donor-specific antibodies (dnDSA) on the graft remains unclear. Methods We performed a retrospective analysis of 102 consecutive SLKT patients to study the impact of anti-HLA antibodies. Results Anti-HLA antibodies were detected in 75 recipients (class I 23.8%, both classes I and II 23.8%, and class II 14.3%). In total, 42.8% of the patients had pDSA and 21.7% developed dnDSA. Overall patient survival at 1–3 and 5 years, was respectively 88, 84, and 80%. Acute rejection occurred respectively in 3 (2.9%) liver and 6 kidney (5.9%) recipients. pDSA with titers over 10,000 mean fluorescence intensity (14.3%) was associated with lower patient survival (40 vs. 82%) but not with acute rejection. In a multivariable Cox regression analysis, the risk of death was associated with maleness, the highest titer of pDSA (p < 0.0007) or the sum of pDSA >10,000. Renal function did not differ between patients with class I pDSA (p = 0.631) and those with class II pDSA (p = 0.112) or between patients with and without a positive cross-match (p = 0.842). dnDSA were not associated with acute rejection, graft dysfunction or patient survival. IS minimization was not associated with rejection, graft dysfunction or death. Conclusion In SLKT, high levels of pDSA >10,000 were associated with lower patient survival, but not rejection or graft survival. Minimization of maintenance immunosuppression regimen was not associated with a poorer outcome.
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Affiliation(s)
- Manon Dekeyser
- Nephrology and Transplantation Department, APHP, Henri Mondor Hospital, Créteil, France
- INSERM UMR 1186, Institut Gustave Roussy, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Jean-Luc Taupin
- HLA Laboratory, AP-HP Saint Louis Hospital, Paris, France
- University of Paris, Paris, France
| | - Michelle Elias
- Nephrology and Transplantation Department, APHP, Henri Mondor Hospital, Créteil, France
| | - Philippe Ichaï
- APHP, Paul Brousse Hospital, INSERM UMR 1193, Villejuif, France
| | - Florence Herr
- INSERM UMR 1186, Institut Gustave Roussy, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Marc Boudon
- APHP, Paul Brousse Hospital, INSERM UMR 1193, Villejuif, France
| | - Melanie Brunel
- Nephrology and Transplantation Department, APHP, Henri Mondor Hospital, Créteil, France
- INSERM UMR 1186, Institut Gustave Roussy, Villejuif, France
- Paris-Saclay University, Paris, France
| | - Antonio Sa cunha
- Paris-Saclay University, Paris, France
- APHP, Paul Brousse Hospital, INSERM UMR 1193, Villejuif, France
| | - Audrey Coilly
- Paris-Saclay University, Paris, France
- APHP, Paul Brousse Hospital, INSERM UMR 1193, Villejuif, France
| | - Faouzi Saliba
- Paris-Saclay University, Paris, France
- APHP, Paul Brousse Hospital, INSERM UMR 1193, Villejuif, France
| | - Antoine Durrbach
- Nephrology and Transplantation Department, APHP, Henri Mondor Hospital, Créteil, France
- INSERM UMR 1186, Institut Gustave Roussy, Villejuif, France
- Paris-Saclay University, Paris, France
- *Correspondence: Antoine Durrbach,
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15
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Beyzaei Z, Shojazadeh A, Geramizadeh B. The role of regulatory T cells in liver transplantation. Transpl Immunol 2021; 70:101512. [PMID: 34871717 DOI: 10.1016/j.trim.2021.101512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 12/18/2022]
Abstract
The liver is considered a tolerogenic organ that can induce peripheral tolerance. The exact mechanisms of tolerance in the liver remain undefined. Regulatory T cells (Tregs) have been demonstrated to be involved in inducing and maintaining peripheral tolerance. They play an important role in the prevention of immune responses and autoimmunity. The main focus of this review is the role of Tregs and their subpopulation in liver transplantation. More specifically, this manuscript will highlight the recent findings about using Treg cells as a biomarker in liver transplantation. There are some reports and animal models about the role of Tregs in the process of rejection of liver transplantation. Previous reports and studies have suggested that by increasing the number of Tregs better liver transplant outcomes will be accomplished by enhancing tolerance. It has been shown that the levels of CD4 + CD25 + FOXP3+ Treg cells correlate with the inhibition of acute allograft rejection in liver transplantation; however, further studies must be done to address the potential role of Treg cells in chronic rejection. Indeed, in the future, Treg cells may have potential use as a beneficial biomarker to screen long-term graft function.
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Affiliation(s)
- Zahra Beyzaei
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shojazadeh
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran.
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16
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Lee BT, Fiel MI, Schiano TD. Antibody-mediated rejection of the liver allograft: An update and a clinico-pathological perspective. J Hepatol 2021; 75:1203-1216. [PMID: 34343613 DOI: 10.1016/j.jhep.2021.07.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Antibody-mediated rejection after liver transplantation is an under-recognised cause of allograft injury. While definitions of acute and chronic antibody-mediated rejection have increased clinical awareness, timely identification and management of antibody-mediated rejection remain difficult because of complexities in diagnosis and histopathology, lack of treatment protocols, and unclear long-term outcomes. While recent cohort studies assessing the importance of donor-specific antibodies have aided in its diagnosis, literature on the treatment of antibody-mediated rejection in liver transplantation remain limited to case reports and small series. Further increasing the awareness and timely recognition of antibody-mediated rejection post-liver transplantation is crucial in order to stimulate future research and the development of protocols for its diagnosis and treatment. This review will summarise recent advances in the clinical diagnosis and treatment of antibody-mediated rejection in liver transplantation, as well as some of the histopathologic features (on liver biopsy tissue) of acute and chronic antibody-mediated rejection.
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Affiliation(s)
- Brian T Lee
- Division of Gastroenterology and Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas D Schiano
- Division of Liver Diseases, Department of Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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17
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Eguchi S. Available weapons in our arsenal for de novo antibody-mediated rejection following liver transplantation-Fighting an invisible foe. Hepatol Res 2021; 51:921-922. [PMID: 34469635 DOI: 10.1111/hepr.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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