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Chang SH, Park CG. Comparing the Benefits and Drawbacks of Stem Cell Therapy Based on the Cell Origin or Manipulation Process: Addressing Immunogenicity. Immune Netw 2023; 23:e44. [PMID: 38188600 PMCID: PMC10767552 DOI: 10.4110/in.2023.23.e44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/12/2023] [Indexed: 01/09/2024] Open
Abstract
Mesenchymal stem cells (MSCs) are effective in treating autoimmune diseases and managing various conditions, such as engraftment of allogeneic islets. Additionally, autologous and HLA-matched allogeneic MSCs can aid in the engraftment of human allogeneic kidneys with or without low doses of tacrolimus, respectively. However, HLA alloantigens are problematic because cell therapy uses more HLA-mismatched allogeneic cells than autologous for convenience and standardization. In particular, HLA-mismatched MSCs showed increased Ag-specific T/B cells and reduced viability faster than HLA-matched MSCs. In CRISPR/Cas9-based cell therapy, Cas9 induce T cell activation in the recipient's immune system. Interestingly, despite their immunogenicity being limited to the cells with foreign Ags, the accumulation of HLA alloantigen-sensitized T/B cells may lead to allograft rejection, suggesting that alloantigens may have a greater scope of adverse effects than foreign Ags. To avoid alloantigen recognition, the β2-microglobulin knockout (B2MKO) system, eliminating class-I MHC, was able to avoid rejection by alloreactive CD8 T cells compared to controls. Moreover, universal donor cells in which both B2M and Class II MHC transactivator (CIITA) were knocked out was more effective in avoiding immune rejection than single KO. However, B2MKO and CIITA KO system remain to be controlled and validated for adverse effects such as the development of tumorigenicity due to deficient Ag recognition by CD8 T and CD4 T cells, respectively. Overall, better HLA-matching or depletion of HLA alloantigens prior to cell therapy can reduce repetitive transplantation through the long-term survival of allogeneic cell therapy, which may be especially important for patients seeking allogeneic transplantation.
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Affiliation(s)
- Sung-Ho Chang
- Department of Immunology and Molecular Microbiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul 03080, Korea
| | - Chung Gyu Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 03080, Korea
- Transplantation Research Institute, Medical Research center, Seoul National University College of Medicine, Seoul 03080, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul 03080, Korea
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2
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Issa F, Cross AR. IL-21-producing Alloreactive T Cells Expand in Parallel to Donor-specific Antibodies. Transplantation 2023; 107:1019-1020. [PMID: 36814091 DOI: 10.1097/tp.0000000000004492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Fadi Issa
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Mendoza Rojas A, Verhoeven JG, de Kuiper R, Clahsen-van Groningen MC, Boer K, Hesselink DA, van Gelder T, van Besouw NM, Baan CC. Alloreactive T cells to Assess Acute Rejection Risk in Kidney Transplant Recipients. Transplant Direct 2023; 9:e1478. [PMID: 37096150 PMCID: PMC10121441 DOI: 10.1097/txd.0000000000001478] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/26/2023] [Indexed: 04/26/2023] Open
Abstract
Memory T cells are important mediators of transplant rejection but are not routinely measured before or after kidney transplantation. The aims of this study were as follows: (1) validate whether pretransplant donor-reactive memory T cells are reliable predictors of acute rejection (AR) (2) determine whether donor-reactive memory T cells can distinguish AR from other causes of transplant dysfunction. Methods Samples from 103 consecutive kidney transplant recipients (2018-2019) were obtained pretransplantation and at time of for-cause biopsy sampling within 6 mo of transplantation. The number of donor-reactive interferon gamma (IFN-γ) and interleukin (IL)-21-producing memory T cells was analyzed by enzyme-linked immunosorbent spot (ELISPOT) assay. Results Of the 63 patients who underwent a biopsy, 25 had a biopsy-proven acute rejection (BPAR; 22 aTCMR and 3 aAMR), 19 had a presumed rejection, and 19 had no rejection. Receiver operating characteristic analysis showed that the pretransplant IFN-γ ELISPOT assay distinguished between patients who later developed BPAR and patients who remained rejection-free (area under the curve [AUC] 0.73; sensitivity 96% and specificity 41%). Both the IFN-γ and IL-21 assays were able to discriminate BPAR from other causes of transplant dysfunction (AUC 0.81; sensitivity 87% and specificity 76% and AUC 0.81; sensitivity 93% and specificity 68%, respectively). Conclusions This study validates that a high number of donor-reactive memory T cells before transplantation is associated with the development of AR after transplantation. Furthermore, it demonstrates that the IFN-γ and IL-21 ELISPOT assays are able to discriminate between patients with AR and patients without AR at the time of biopsy sampling.
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Affiliation(s)
- Aleixandra Mendoza Rojas
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeroen G.H.P. Verhoeven
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ronella de Kuiper
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marian C. Clahsen-van Groningen
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Faculty of Medicine, Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Karin Boer
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A. Hesselink
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole M. van Besouw
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Carla C. Baan
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Al-Adra DP, Thangavelu G, Lin J, Chan WF, Ellestad KK, Boon L, Anderson CC. CD8 T Cells Target Antigen Cross-Presented by Bone Marrow Derived Cells to Induce Bystander Rejection of Grafts Lacking the Cognate Peptide-MHC. Cell Transplant 2022; 31:9636897221136149. [PMID: 36367048 PMCID: PMC9659770 DOI: 10.1177/09636897221136149] [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] [Indexed: 11/13/2022] Open
Abstract
CD8 T cells play a key role in cancer immunotherapy and allograft rejection. However, it is not clear how they kill cells and tissues that do not have the agonist peptide-major histocompatibility complex (MHC) on their surface, as in the settings of MHC class I deficient tumors and indirect rejection of MHC-mismatched transplants. CD8 T cells might respond to agonist antigen cross-presented on hematopoietic cells, leading to a "bystander" rejection. Alternatively, they may recognize agonist antigen cross-presented on recipient endothelial cells and kill the tissue's vital blood supply. The latter mechanism predicts that all non-vascularized grafts, grafts dependent on in-growth of recipient blood vessels, will be susceptible to CD8 T cell mediated indirect rejection. In contrast, we show here that non-vascularized transplants, bearing the same agonist antigen, are not universally susceptible to this rejection pathway. Non-vascularized skin, but not islet or heart tissue transplants were indirectly rejected by CD8 T cells. Furthermore, CD8 T cells were able to indirectly reject skin grafts when recipient MHC class I expression was restricted to bone marrow derived cells but not when it was restricted to radioresistant cells (e.g. endothelial cells). These findings argue against a major role for endothelial cell cross-presentation in killing of tissue that does not present the agonist peptide-MHC class I. Instead, the data suggests that cross-presentation by recipient hematopoietic cells underlies the CD8 T cell mediated killing of tissue that is unable to directly present the target peptide-MHC class I.
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Affiliation(s)
- David P. Al-Adra
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Govindarajan Thangavelu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
| | - Jiaxin Lin
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
| | - William F.N. Chan
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada
| | - Kristofor K. Ellestad
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada,Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | | | - Colin C. Anderson
- Department of Surgery, University of Alberta, Edmonton, AB, Canada,Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, AB, Canada,Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada,Colin C. Anderson, Department of Surgery, University of Alberta, Edmonton, AB T6G 2E1, Canada.
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Schaenman J, Rossetti M, Pickering H, Sunga G, Wilhalme H, Elashoff D, Zhang Q, Hickey M, Reddy U, Danovitch G, Reed EF, Bunnapradist S. Preservation of Antiviral Immunologic Efficacy Without Alloimmunity After Switch to Belatacept in Calcineurin Inhibitor-Intolerant Patients. Kidney Int Rep 2022; 8:126-140. [PMID: 36644348 PMCID: PMC9832066 DOI: 10.1016/j.ekir.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Belatacept has shown potential for prevention of rejection after kidney transplantation, given its demonstration of reduced nephrotoxicity in combination with absence of significant incidence of rejection. However, concerns have been raised regarding increased risk of viral infection. Methods We set out to explore the impact of the switch to belatacept on alloimmune and antiviral immunity through the study of patients switched from calcineurin inhibitor (CNI) to belatacept within 3 months of kidney transplantation compared with a matched cohort of control patients on a CNI-based regimen. Results After the switch to belatacept, immune phenotyping demonstrated a decrease in naive and an increase in terminally differentiated effector memory (TMRA) T cells, with no significant difference compared with control patients. Donor-specific immune response, measured by intracellular cytokine staining (ICS), did not change significantly either by single or double cytokine secretion, but it was associated with the appearance of donor-specific antibody (DSA) in the control but not the belatacept cohort (P = 0.039 for naive and P = 0.002 for TMRA subtypes). Increased incidence of de novo DSA development was observed in the control group (P = 0.035). Virus-specific immune response, as measured by ICS in response to cytomegalovirus (CMV) or Epstein-Barr virus (EBV), was similar in both groups and stable over time. Conclusion We found that belatacept use was associated with an absence of alloreactivity without impact on immune phenotype, while preserving the antiviral immune response, for patients switched from a CNI-based regimen. In parallel, the antiviral immune response against CMV and EBV was preserved after the belatacept switch (clinicaltrials.gov: NCT01953120).
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Disease, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gemalene Sunga
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Holly Wilhalme
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - David Elashoff
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Michelle Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Uttam Reddy
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gabriel Danovitch
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Suphamai Bunnapradist
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA,Correspondence: Suuphamai Bunnapradist, 200 UCLA Medical Plaza, Suite 565, Los Angeles, CA 90095, USA.
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Role of the Immune System in Renal Transplantation, Types of Response, Technical Approaches and Current Challenges. IMMUNO 2022. [DOI: 10.3390/immuno2040035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advances over the last decades have made renal transplantation an important therapy for patients with end-stage renal disease, as the incidences of acute rejection and short-term transplant loss have been significantly reduced. However, long-term transplant survival remains a challenge in the renal transplantation community. The main causes of long-term graft loss are acute and chronic rejection, as well as the complications related to immunosuppression therapy. In spite of the breakthroughs achieved in recent years, histology is the gold standard technique to confirm the activation of the immune system against the graft with all the ensuing problems that taking biopsies brings to immunosuppressed patients. For this reason, several assays have been developed to try to monitor the immune function, but they show serious constraints owing to the fact that they require substantial laboratory work, they are not clinically available and they provide controversial results, so the combination of multiple assays is often needed to obtain a reliable diagnosis. Thus, the aim of this review is to perform a retrospective study of the immune system in renal transplantation, with special emphasis on the cutting-edge technological developments for monitoring, classification and early detection of rejection episodes in order to contribute to a better adjustment of immunosuppressive therapies and, hence, to a more personalized medicine that improves the quality of life of patients.
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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Karahan GE, de Vaal Y, Bakker K, Roelen D, Claas FHJ, Heidt S. Comparison of different luminex single antigen bead kits for memory B cell-derived HLA antibody detection. HLA 2021; 98:200-206. [PMID: 34216435 PMCID: PMC8456970 DOI: 10.1111/tan.14356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 12/02/2022]
Abstract
Detection of HLA‐specific memory B cells can provide additional information on sensitization of alloantigen‐exposed individuals and refine immunological risk assessment. We have recently developed an assay enabling profiling of memory B cell‐derived HLA antibodies using luminex single antigen bead (SAB) assay. Here, we compared the performance of the SAB kits from two vendors for memory B cell‐derived HLA antibody detection. IgG was isolated from culture supernatants of polyclonally activated B cells from alloantigen‐exposed (n = 7) or nonexposed (n = 5) individuals, using our previously established method. Eluates containing isolated IgG from culture supernatants were tested for the presence of HLA antibodies using luminex SAB analysis from both One Lambda and Lifecodes (Immucor). In contrast to Lifecodes, high mean fluorescence intensity (MFI) signals were found for negative control beads in One Lambda (median MFI for class I:1730 and for class II:728), accompanied by high MFI values for self HLA‐coated beads, especially for HLA‐C. Despite high background in the One Lambda assays, 91% concordance for HLA class I and 85% concordance for HLA class II were found between the specificities detected using SAB kits from the two vendors. Our results show that HLA‐specific memory B cells can be profiled using kits from both vendors. However, when analyzing One Lambda results one should be aware of the restrictions related to nonspecific binding particularly in HLA‐C‐coated beads, and pay attention to self HLA‐coated beads in order to accurately identify the reactivities leading to the definition of the actual HLA antibody specificities.
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Affiliation(s)
- Gonca E Karahan
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvonne de Vaal
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim Bakker
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dave Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans H J Claas
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
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Pre-transplant donor-reactive IL-21 producing T cells as a tool to identify an increased risk for acute rejection. Sci Rep 2021; 11:12445. [PMID: 34127739 PMCID: PMC8203783 DOI: 10.1038/s41598-021-91967-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022] Open
Abstract
Pre-transplant screening focuses on the detection of anti-HLA alloantibodies. Previous studies have shown that IFN-γ and IL-21 producing T cells are associated with the development of acute rejection (AR). The aim of this study, was to assess whether pre-transplant donor-reactive T cells and/or B cells are associated with increased rejection risk. Samples from 114 kidney transplant recipients (transplanted between 2010 and 2013) were obtained pre-transplantation. The number of donor-reactive IFN-γ and IL-21 producing cells was analyzed by ELISPOT assay. The presence of donor specific antibodies (DSA) was also determined before transplantation. Numbers of donor-reactive IFN-γ producing cells were similar in patients with or without AR whereas those of IL-21 producing cells were higher in patients with AR (p = 0.03). Significantly more patients with AR [6/30(20%)] had detectable DSA compared to patients without AR [5/84(5.9%), p = 0.03]. Multivariate logistic regression showed that donor age (OR 1.06), pre-transplant DSA (OR 5.61) and positive IL-21 ELISPOT assay (OR 2.77) were independent predictors of an increased risk for the development of AR. Aside from an advanced donor-age and pre-transplant DSA, also pre-transplant donor-reactive IL-21 producing cells are associated with the development of AR after transplantation.
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