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Steggerda JA, Heeger PS. The Promise of Complement Therapeutics in Solid Organ Transplantation. Transplantation 2024; 108:1882-1894. [PMID: 38361233 DOI: 10.1097/tp.0000000000004927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Transplantation is the ideal therapy for end-stage organ failure, but outcomes for all transplant organs are suboptimal, underscoring the need to develop novel approaches to improve graft survival and function. The complement system, traditionally considered a component of innate immunity, is now known to broadly control inflammation and crucially contribute to induction and function of adaptive T-cell and B-cell immune responses, including those induced by alloantigens. Interest of pharmaceutical industries in complement therapeutics for nontransplant indications and the understanding that the complement system contributes to solid organ transplantation injury through multiple mechanisms raise the possibility that targeting specific complement components could improve transplant outcomes and patient health. Here, we provide an overview of complement biology and review the roles and mechanisms through which the complement system is pathogenically linked to solid organ transplant injury. We then discuss how this knowledge has been translated into novel therapeutic strategies to improve organ transplant outcomes and identify areas for future investigation. Although the clinical application of complement-targeted therapies in transplantation remains in its infancy, the increasing availability of new agents in this arena provides a rich environment for potentially transformative translational transplant research.
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Affiliation(s)
- Justin A Steggerda
- Division of Abdominal Transplant Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Peter S Heeger
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Nephrology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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2
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Gramkow AM, Baatrup JH, Gramkow ET, Thiesson HC, Koefoed-Nielsen P. Association of HLA B- and T-cell molecular mismatches with HLA antibodies, rejection, and graft survival in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14773. [PMID: 38808702 DOI: 10.1111/petr.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/01/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Optimizing graft survival and diminishing human leukocyte antigen (HLA) sensitization are essential for pediatric kidney transplant recipients. More precise HLA matching predicting epitope mismatches could reduce alloreactivity. We investigated the association of predicted HLA B- and T-cell molecular mismatches with the formation of de novo donor-specific antibodies, HLA antibodies, rejection, and graft survival. METHODS Forty-nine pediatric kidney transplant recipients transplanted from 2009 to 2020 were retrospectively studied. Donors and recipients were high-resolution HLA typed, and recipients were screened for HLA antibodies posttransplant. HLA-EMMA (HLA Epitope MisMatch Algorithm) and PIRCHE-II (Predicted Indirectly ReCognizable HLA Epitopes) predicted the molecular mismatches. The association of molecular mismatches and the end-points was explored with logistic regression. RESULTS Five recipients (11%) developed de novo donor-specific antibodies. All five had de novo donor-specific antibodies against HLA class II, with four having HLA-DQ antibodies. We found no associations between PIRCHE-II or HLA-EMMA with de novo donor-specific antibodies, HLA sensitization, graft loss, or rejection. However, we did see a tendency towards an increased odds ratio in PIRCHE-II predicting de novo donor-specific antibodies formation, with an odds ratio of 1.12 (95% CI: 0.99; 1.28) on HLA class II. CONCLUSION While the study revealed no significant associations between the number of molecular mismatches and outcomes, a notable trend was observed - indicating a reduced risk of dnDSA formation with improved molecular match. It is important to acknowledge, however, that the modest population size and limited observed outcomes preclude us from making definitive conclusions.
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Affiliation(s)
- Ann-Maria Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne H Baatrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Emilie T Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine - Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Helle C Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Pan X, Peng J, Zhu R, An N, Pei J. Non-invasive biomarkers of acute rejection in pediatric kidney transplantation: New targets and strategies. Life Sci 2024; 348:122698. [PMID: 38710278 DOI: 10.1016/j.lfs.2024.122698] [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: 02/01/2024] [Revised: 04/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Kidney transplantation is the preferred treatment for pediatric end-stage renal disease. However, pediatric recipients face unique challenges due to their prolonged need for kidney function to accommodate growth and development. The continual changes in the immune microenvironment during childhood development and the heightened risk of complications from long-term use of immunosuppressive drugs. The overwhelming majority of children may require more than one kidney transplant in their lifetime. Acute rejection (AR) stands as the primary cause of kidney transplant failure in children. While pathologic biopsy remains the "gold standard" for diagnosing renal rejection, its invasive nature raises concerns regarding potential functional impairment and the psychological impact on children due to repeated procedures. In this review, we outline the current research status of novel biomarkers associated with AR in urine and blood after pediatric kidney transplantation. These biomarkers exhibit superior diagnostic and prognostic performance compared to conventional ones, with the added advantages of being less invasive and highly reproducible for long-term graft monitoring. We also integrate the limitations of these novel biomarkers and propose a refined monitoring model to optimize the management of AR in pediatric kidney transplantation.
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Affiliation(s)
- Xingyu Pan
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jinpu Peng
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Rong Zhu
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Nini An
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jun Pei
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China.
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Laroche C, Engen RM. Immune monitoring in pediatric kidney transplant. Pediatr Transplant 2024; 28:e14785. [PMID: 38766986 DOI: 10.1111/petr.14785] [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: 03/09/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Long-term outcomes in pediatric kidney transplantation remain suboptimal, largely related to chronic rejection. Creatinine is a late marker of renal injury, and more sensitive, early markers of allograft injury are an active area of current research. METHODS This is an educational review summarizing existing strategies for monitoring for rejection in kidney transplant recipients. RESULTS We summarize supporting currently available clinical tests, including surveillance biopsy, donor specific antibodies, and donor-derived cell free DNA, as well as the potential limitations of these studies. In addition, we review the current avenues of active research, including transcriptomics, proteomics, metabolomics, and torque tenovirus levels. CONCLUSION Advancing the use of noninvasive immune monitoring will depend on well-designed multicenter trials that include patients with stable graft function, include biopsy results on all patients, and can demonstrate both association with a patient-relevant clinical endpoint such as graft survival or change in glomerular filtration rate and a potential timepoint for intervention.
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Affiliation(s)
| | - Rachel M Engen
- University of Wisconsin Madison, Madison, Wisconsin, USA
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Fan H, Liu J, Sun J, Wang J, Pang X, Shang W, Feng G, Li J. Clinical characteristics of 15 cases of renal transplantation with pre -exsiting donor -specific antibody. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:1583-1591. [PMID: 38432887 PMCID: PMC10929897 DOI: 10.11817/j.issn.1672-7347.2023.230144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 03/05/2024]
Abstract
OBJECTIVES Currently, patients with pre-exsiting donor-specific antibody (DSA) are prone to antibody-mediated rejection (AMR) after surgery and are at a relatively high risk of postoperative complications and graft failure. The risk of postoperative complications and graft failure is relatively high. This study aims to discuss the clinical outcome of DSA-positive kidney transplantation and analyze the role and safety of preoperative pretreatment in DSA-positive kidney transplantation, providing single-center treatment experience for DSA-positive kidney transplantation. METHODS We retrospectively analyzed the clinical data of 15 DSA-positive kidney transplants in the Department of Renal Transplantation of First Affiliated Hospital of Zhengzhou University from August 2017 to July 2022. Eight cases were organ donation after citizen's death (DCD) kidney transplant recipients, of which 3 cases in the early stage were not treated with preoperative desensitisation therapy (DCD untreated group, n=3), and 5 recipients were treated with preoperative rituximab desensitisation (DCD preprocessing group, n=5). The remaining 7 cases were living related donors recipients (LRD) who received preoperative desensitisation treatment with rituximab and plasma exchange (LRD preprocessing group, n=7). We observed and recorded the incidence of complications with changes in renal function and DSA levels in the recipients and the survival of the recipients and transplanted kidneys at 1, 3 and 5 years, and to compare the differences in recovery and postoperative complications between 3 groups. RESULTS All 15 recipients were positive for preoperative panel reactive antibody (PRA) and DSA and were treated with methylprednisolone+rabbit anti-human thymocyte immunoglobulin induction before kidney transplantation. DCD untreated group all suffered from DSA level rebound, delayed renal graft function (DGF) and rejection reaction after surgery. After the combined treatment, DSA level was reduced and the graft renal function returned to normal. The DCD preprocessing group were all without antibody rebound, 1 recipient developed DGF and the renal function returned to normal after plasmapheresis, and the remaining 4 recipients recovered their renal function to normal within 2 weeks after the operation. In the LRD preprocessing group, 2 cases had antibody rebound and 1 case had rejection, but all of them recovered to normal after treatment, and DSA was maintained at a low level or even disappeared. The incidence of DGF and rejection in the DCD untreated group were significantly higher than that in the DCD preprocessing group and the LRD preprocessing group; and there were no significant difference in the incidence of postoperative haematuria, proteinuria, bacterial and fungal infections, and BK virus infection between the 3 groups (all P>0.05). A total of 11 of the 15 recipients were followed up for more than 1 year, 6 for more than 3 years, and 1 for more than 5 years, and the survival rates of both the recipients and the transplanted kidneys were 100%. CONCLUSIONS Effective preoperative pretreatment with desensitization therapy can effectively prevent antibody rebound in DSA-positive kidney transplantation and reduce perioperative complications.
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Affiliation(s)
- Hongzhao Fan
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052.
| | - Jia Liu
- Teaching and Research Department of Diagnostics, Henan Higher Institute of Medical Sciences, Zhengzhou 451100, China
| | - Jiajia Sun
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052
| | - Junxiang Wang
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052
| | - Xinlu Pang
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052
| | - Wenjun Shang
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052
| | - Guiwen Feng
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052
| | - Jinfeng Li
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052.
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Gniewkiewicz M, Czerwinska K, Zielniok K, Durlik M. Association of Circulating Anti-HLA Donor-Specific Antibodies and Their Characteristics, including C1q-Binding Capacity, in Kidney Transplant Recipients with Long-Term Renal Graft Outcomes. J Clin Med 2023; 12:jcm12041312. [PMID: 36835848 PMCID: PMC9962721 DOI: 10.3390/jcm12041312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
Post-transplant antihuman leukocyte antigen donor-specific antibodies (anti-HLA DSAs) monitoring in kidney transplant recipients remains unclear and is currently under investigation. The pathogenicity of anti-HLA DSAs is determined by antibody classes, specificity, mean fluorescent intensity (MFI), C1q-binding capacity, and IgG subclasses. The aim of this study was to investigate the association of circulating DSAs and their characteristics with renal allograft long-term outcomes. The study included 108 consecutive patients from our transplant center who underwent kidney allograft biopsy between November 2018 and November 2020, 3 to 24 months after kidney transplantation. At the time of biopsy, patients' sera were collected for analysis of anti-HLA DSAs. Patients were followed for a median time of 39.0 months (Q1-Q3, 29.8-45.0). Detection of anti-HLA DSAs at the time of biopsy (HR = 5.133, 95% CI 2.150-12.253, p = 0.0002) and their C1q-binding capacity (HR = 14.639, 95% CI 5.320-40.283, p ≤ 0.0001) were independent predictors of the composite of sustained 30% reduction from estimated glomerular filtration rate or death-censored graft failure. Identification of anti-HLA DSAs and their C1q-binding capacity could be useful in identifying kidney transplant recipients at risk for inferior renal allograft function and graft failure. Analysis of C1q is noninvasive, accessible, and should be considered in clinical practice in post-transplant monitoring.
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Affiliation(s)
- Michal Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
- Correspondence:
| | - Katarzyna Czerwinska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Katarzyna Zielniok
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
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Piburn KH, Sigurjonsdottir VK, Indridason OS, Maestretti L, Patton MV, McGrath A, Palsson R, Gallo A, Chaudhuri A, Grimm PC. Patterns in Tacrolimus Variability and Association with De Novo Donor-Specific Antibody Formation in Pediatric Kidney Transplant Recipients. Clin J Am Soc Nephrol 2022; 17:1194-1203. [PMID: 35882506 PMCID: PMC9435976 DOI: 10.2215/cjn.16421221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES High tacrolimus intrapatient variability has been associated with inferior graft outcomes in patients with kidney transplants. We studied baseline patterns of tacrolimus intrapatient variability in pediatric patients with kidney transplants and examined these patterns in relation to C1q-binding de novo donor-specific antibodies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All tacrolimus levels in participants who underwent kidney-only transplantation at a single pediatric center from 2004 to 2018 (with at least 12-month follow-up, followed until 2019) were analyzed to determine baseline variability. Intrapatient variability was defined using the coefficient of variation (SD/mean ×100%) of all samples in a 6-month moving window. Routine de novo donor-specific antibody measurements were available for a subgroup of patients transplanted in 2010-2018. Cox proportional hazards models using tacrolimus intrapatient variability as a time-varying variable were used to examine the association between intrapatient variability and graft outcomes. The primary outcome of interest was C1q-binding de novo donor-specific antibody formation. RESULTS Tacrolimus intrapatient variability developed a steady-state baseline of 30% at 10 months post-transplant in 426 patients with a combined 31,125 tacrolimus levels. Included in the outcomes study were 220 patients, of whom 51 developed C1q-binding de novo donor-specific antibodies. De novo donor-specific antibody formers had higher intrapatient variability, with a median of 38% (interquartile range, 28%-48%) compared with 28% (interquartile range, 20%-38%) for nondonor-specific antibody formers (P<0.001). Patients with high tacrolimus intrapatient variability (coefficient of variation >30%) had higher risk of de novo donor-specific antibody formation (hazard ratio, 5.35; 95% confidence interval, 2.45 to 11.68). Patients in the top quartile of tacrolimus intrapatient variability (coefficient of variation >41%) had the strongest association with C1q-binding de novo donor-specific antibody formation (hazard ratio, 11.81; 95% confidence interval, 4.76 to 29.27). CONCLUSIONS High tacrolimus intrapatient variability was strongly associated with de novo donor-specific antibody formation.
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Affiliation(s)
- Kim H. Piburn
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Vaka K. Sigurjonsdottir
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California,Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland,Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Olafur S. Indridason
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland
| | - Lynn Maestretti
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Mary Victoria Patton
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Anne McGrath
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Runolfur Palsson
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland,Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Amy Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Palo Alto, California
| | - Abanti Chaudhuri
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Paul C. Grimm
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
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