1
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Latorre-Rodríguez AR, Razia D, Omar A, Bremner RM, Mittal SK. Pulmonary and esophageal function in lung transplantation: Fundamental principles and clinical application. Transplant Rev (Orlando) 2024; 38:100796. [PMID: 37840002 DOI: 10.1016/j.trre.2023.100796] [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: 07/18/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023]
Abstract
The lungs and esophagus have a close anatomical and physiological relationship. Over the years, reflux-induced pulmonary injury has gained wider recognition, but the full effects of pulmonary disease on esophageal function are still unknown. Intrathoracic pressure dynamics potentially affect esophageal function, especially in patients with end-stage lung disease, both obstructive and restrictive. Lung transplantation is the only viable option for patients with end-stage pulmonary disease and has provided us with a unique opportunity to study these effects as transplantation restores the intrathoracic environment. Esophageal and foregut functional testing before and after transplantation provide insights into the pathophysiology of the foregut-pulmonary axis, such as how underlying pulmonary disease and intrathoracic pressure changes affect esophageal physiology. This review summarizes the available literature and shares the research experience of a lung transplant center, covering topics such as pre- and posttransplant foregut function, esophageal motility in lung transplant recipients, immune-mediated mechanisms of graft rejection associated with gastroesophageal reflux, and the role of antireflux surgery in this population.
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Affiliation(s)
| | - Deepika Razia
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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2
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Yang W, Lecuona E, Wu Q, Liu X, Sun H, Alam H, Nadig SN, Bharat A. The role of lung-restricted autoantibodies in the development of primary and chronic graft dysfunction. FRONTIERS IN TRANSPLANTATION 2023; 2:1237671. [PMID: 38993924 PMCID: PMC11235341 DOI: 10.3389/frtra.2023.1237671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/18/2023] [Indexed: 07/13/2024]
Abstract
Lung transplantation is a life-saving treatment for both chronic end-stage lung diseases and acute respiratory distress syndrome, including those caused by infectious agents like COVID-19. Despite its increasing utilization, outcomes post-lung transplantation are worse than other solid organ transplants. Primary graft dysfunction (PGD)-a condition affecting more than half of the recipients post-transplantation-is the chief risk factor for post-operative mortality, transplant-associated multi-organ dysfunction, and long-term graft loss due to chronic rejection. While donor-specific antibodies targeting allogenic human leukocyte antigens have been linked to transplant rejection, the role of recipient's pre-existing immunoglobulin G autoantibodies against lung-restricted self-antigens (LRA), like collagen type V and k-alpha1 tubulin, is less understood in the context of lung transplantation. Recent studies have found an increased risk of PGD development in lung transplant recipients with LRA. This review will synthesize past and ongoing research-utilizing both mouse models and human subjects-aimed at unraveling the mechanisms by which LRA heightens the risk of PGD. Furthermore, it will explore prospective approaches designed to mitigate the impact of LRA on lung transplant patients.
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Affiliation(s)
- Wenbin Yang
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Emilia Lecuona
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Qiang Wu
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Xianpeng Liu
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Haiying Sun
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Hasan Alam
- Division of Trauma & Acute Care Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Satish N. Nadig
- Division of Abdominal Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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3
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Khan MA, Lau CL, Krupnick AS. Monitoring regulatory T cells as a prognostic marker in lung transplantation. Front Immunol 2023; 14:1235889. [PMID: 37818354 PMCID: PMC10561299 DOI: 10.3389/fimmu.2023.1235889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Lung transplantation is the major surgical procedure, which restores normal lung functioning and provides years of life for patients suffering from major lung diseases. Lung transplant recipients are at high risk of primary graft dysfunction, and chronic lung allograft dysfunction (CLAD) in the form of bronchiolitis obliterative syndrome (BOS). Regulatory T cell (Treg) suppresses effector cells and clinical studies have demonstrated that Treg levels are altered in transplanted lung during BOS progression as compared to normal lung. Here, we discuss levels of Tregs/FOXP3 gene expression as a crucial prognostic biomarker of lung functions during CLAD progression in clinical lung transplant recipients. The review will also discuss Treg mediated immune tolerance, tissue repair, and therapeutic strategies for achieving in-vivo Treg expansion, which will be a potential therapeutic option to reduce inflammation-mediated graft injuries, taper the toxic side effects of ongoing immunosuppressants, and improve lung transplant survival rates.
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4
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Khatri A, Todd JL, Kelly FL, Nagler A, Ji Z, Jain V, Gregory SG, Weinhold KJ, Palmer SM. JAK-STAT activation contributes to cytotoxic T cell-mediated basal cell death in human chronic lung allograft dysfunction. JCI Insight 2023; 8:167082. [PMID: 36946463 PMCID: PMC10070100 DOI: 10.1172/jci.insight.167082] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/01/2023] [Indexed: 03/23/2023] Open
Abstract
Chronic lung allograft dysfunction (CLAD) is the leading cause of death in lung transplant recipients. CLAD is characterized clinically by a persistent decline in pulmonary function and histologically by the development of airway-centered fibrosis known as bronchiolitis obliterans. There are no approved therapies to treat CLAD, and the mechanisms underlying its development remain poorly understood. We performed single-cell RNA-Seq and spatial transcriptomic analysis of explanted tissues from human lung recipients with CLAD, and we performed independent validation studies to identify an important role of Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling in airway epithelial cells that contributes to airway-specific alloimmune injury. Specifically, we established that activation of JAK-STAT signaling leads to upregulation of major histocompatibility complex 1 (MHC-I) in airway basal cells, an important airway epithelial progenitor population, which leads to cytotoxic T cell-mediated basal cell death. This study provides mechanistic insight into the cell-to-cell interactions driving airway-centric alloimmune injury in CLAD, suggesting a potentially novel therapeutic strategy for CLAD prevention or treatment.
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Affiliation(s)
- Aaditya Khatri
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jamie L Todd
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Fran L Kelly
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew Nagler
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Zhicheng Ji
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vaibhav Jain
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
| | - Simon G Gregory
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kent J Weinhold
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott M Palmer
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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5
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Halverson LP, Hachem RR. Antibody-Mediated Rejection: Diagnosis and Treatment. Clin Chest Med 2023; 44:95-103. [PMID: 36774172 PMCID: PMC10148231 DOI: 10.1016/j.ccm.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Antibody-mediated rejection (AMR) is a form of lung allograft rejection that is emerging as an important risk factor for chronic lung allograft dysfunction and decreased long-term survival. In this review, we provide a brief overview of our current understanding of its pathophysiology with an emphasis on donor-specific antibodies before moving on to focus on the current diagnostic criteria and treatment strategies. Our goal is to discuss the limitations of our current knowledge and explore how novel diagnostic and therapeutic options aim to improve outcomes through earlier definitive diagnosis and preemptive targeted treatment.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA.
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA
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6
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Razia D, Mittal SK, Bansal S, Ravichandran R, Giulini L, Smith MA, Walia R, Mohanakumar T, Bremner RM. Association Between Antibodies Against Lung Self-Antigens and Gastroesophageal Reflux in Lung Transplant Candidates. Semin Thorac Cardiovasc Surg 2023; 35:177-186. [PMID: 35181441 DOI: 10.1053/j.semtcvs.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/09/2022] [Indexed: 11/11/2022]
Abstract
Gastroesophageal reflux (GER) and pretransplant antibodies against lung self-antigens (SAbs) collagen-V and/or k-alpha 1 tubulin are both independently associated with allograft dysfunction after lung transplantation (LTx). The role of GER in inducing lung injury and SAbs is unknown. We aimed to study the association between pre-LTx GER and SAbs. After IRB approval, we retrieved SAb assays conducted between 2015 and 2019 and collected 24 hour GER data for these patients. Patients were divided into 2 groups: no reflux (GER-) and pathologic reflux (GER+) to compare the prevalence of SAbs. Multivariate analysis was used to study the association between GER and SAbs in the whole cohort and in restrictive lung disease (RLD) and obstructive lung disease (OLD) subsets. Proximal esophageal reflux (PER) events ≥5 was considered abnormal. Patients (n = 134; 73 men) were divided into groups: GER- (54.5%, n = 73) and GER+ (45.5%, n = 61). The prevalence of GER was higher in the RLD than in the OLD subset (p < 0.001). The overall prevalence of SAbs was 53.7% (n = 72), higher in the GER+ than the GER- group (65.6% vs 43.8%, p = 0.012), but comparable between RLD and OLD subsets. Overall, SAbs were associated with GER (p = 0.012) and abnormal PER (p = 0.017). GER and abnormal PER increased the odds of SAbs in the RLD subset (OR [95% CI]: 2.825 [1.033-7.725], p = 0.040 and OR [95% CI]: 3.551 [1.271-9.925], p = 0.014, respectively) but not in the OLD subset. LTx candidates have a high prevalence of SAbs, which are significantly associated with GER and abnormal PER in patients with RLD.
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Affiliation(s)
- Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona.
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Thalachallour Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
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7
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Yang W, Cerier EJ, Núñez-Santana FL, Wu Q, Yan Y, Kurihara C, Liu X, Yeldandi A, Khurram N, Avella-Patino D, Sun H, Budinger GS, Kreisel D, Mohanakumar T, Lecuona E, Bharat A. IL-1β-dependent extravasation of preexisting lung-restricted autoantibodies during lung transplantation activates complement and mediates primary graft dysfunction. J Clin Invest 2022; 132:157975. [PMID: 36250462 PMCID: PMC9566897 DOI: 10.1172/jci157975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Preexisting lung-restricted autoantibodies (LRAs) are associated with a higher incidence of primary graft dysfunction (PGD), although it remains unclear whether LRAs can drive its pathogenesis. In syngeneic murine left lung transplant recipients, preexisting LRAs worsened graft dysfunction, which was evident by impaired gas exchange, increased pulmonary edema, and activation of damage-associated pathways in lung epithelial cells. LRA-mediated injury was distinct from ischemia-reperfusion injury since deletion of donor nonclassical monocytes and host neutrophils could not prevent graft dysfunction in LRA-pretreated recipients. Whole LRA IgG molecules were necessary for lung injury, which was mediated by the classical and alternative complement pathways and reversed by complement inhibition. However, deletion of Fc receptors in donor macrophages or mannose-binding lectin in recipient mice failed to rescue lung function. LRA-mediated injury was localized to the transplanted lung and dependent on IL-1β-mediated permeabilization of pulmonary vascular endothelium, which allowed extravasation of antibodies. Genetic deletion or pharmacological inhibition of IL-1R in the donor lungs prevented LRA-induced graft injury. In humans, preexisting LRAs were an independent risk factor for severe PGD and could be treated with plasmapheresis and complement blockade. We conclude that preexisting LRAs can compound ischemia-reperfusion injury to worsen PGD for which complement inhibition may be effective.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - G.R. Scott Budinger
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel Kreisel
- Departments of Surgery, Pathology & Immunology, Washington University, St. Louis, Missouri, USA
| | | | | | - Ankit Bharat
- Division of Thoracic Surgery
- Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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8
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Santos J, Calabrese DR, Greenland JR. Lymphocytic Airway Inflammation in Lung Allografts. Front Immunol 2022; 13:908693. [PMID: 35911676 PMCID: PMC9335886 DOI: 10.3389/fimmu.2022.908693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplant remains a key therapeutic option for patients with end stage lung disease but short- and long-term survival lag other solid organ transplants. Early ischemia-reperfusion injury in the form of primary graft dysfunction (PGD) and acute cellular rejection are risk factors for chronic lung allograft dysfunction (CLAD), a syndrome of airway and parenchymal fibrosis that is the major barrier to long term survival. An increasing body of research suggests lymphocytic airway inflammation plays a significant role in these important clinical syndromes. Cytotoxic T cells are observed in airway rejection, and transcriptional analysis of airways reveal common cytotoxic gene patterns across solid organ transplant rejection. Natural killer (NK) cells have also been implicated in the early allograft damage response to PGD, acute rejection, cytomegalovirus, and CLAD. This review will examine the roles of lymphocytic airway inflammation across the lifespan of the allograft, including: 1) The contribution of innate lymphocytes to PGD and the impact of PGD on the adaptive immune response. 2) Acute cellular rejection pathologies and the limitations in identifying airway inflammation by transbronchial biopsy. 3) Potentiators of airway inflammation and heterologous immunity, such as respiratory infections, aspiration, and the airway microbiome. 4) Airway contributions to CLAD pathogenesis, including epithelial to mesenchymal transition (EMT), club cell loss, and the evolution from constrictive bronchiolitis to parenchymal fibrosis. 5) Protective mechanisms of fibrosis involving regulatory T cells. In summary, this review will examine our current understanding of the complex interplay between the transplanted airway epithelium, lymphocytic airway infiltration, and rejection pathologies.
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Affiliation(s)
- Jesse Santos
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R. Calabrese
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - John R. Greenland
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
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9
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Ravichandran R, Bansal S, Rahman M, Sureshbabu A, Sankpal N, Fleming T, Bharat A, Mohanakumar T. Extracellular Vesicles Mediate Immune Responses to Tissue-Associated Self-Antigens: Role in Solid Organ Transplantations. Front Immunol 2022; 13:861583. [PMID: 35572510 PMCID: PMC9094427 DOI: 10.3389/fimmu.2022.861583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Transplantation is a treatment option for patients diagnosed with end-stage organ diseases; however, long-term graft survival is affected by rejection of the transplanted organ by immune and nonimmune responses. Several studies have demonstrated that both acute and chronic rejection can occur after transplantation of kidney, heart, and lungs. A strong correlation has been reported between de novo synthesis of donor-specific antibodies (HLA-DSAs) and development of both acute and chronic rejection; however, some transplant recipients with chronic rejection do not have detectable HLA-DSAs. Studies of sera from such patients demonstrate that immune responses to tissue-associated antigens (TaAgs) may also play an important role in the development of chronic rejection, either alone or in combination with HLA-DSAs. The synergistic effect between HLA-DSAs and antibodies to TaAgs is being established, but the underlying mechanism is yet to be defined. We hypothesize that HLA-DSAs damage the transplanted donor organ resulting in stress and leading to the release of extracellular vesicles, which contribute to chronic rejection. These vesicles express both donor human leukocyte antigen (HLA) and non-HLA TaAgs, which can activate antigen-presenting cells and lead to immune responses and development of antibodies to both donor HLA and non-HLA tissue-associated Ags. Extracellular vesicles (EVs) are released by cells under many circumstances due to both physiological and pathological conditions. Primarily employing clinical specimens obtained from human lung transplant recipients undergoing acute or chronic rejection, our group has demonstrated that circulating extracellular vesicles display both mismatched donor HLA molecules and lung-associated Ags (collagen-V and K-alpha 1 tubulin). This review focuses on recent studies demonstrating an important role of antibodies to tissue-associated Ags in the rejection of transplanted organs, particularly chronic rejection. We will also discuss the important role of extracellular vesicles released from transplanted organs in cross-talk between alloimmunity and autoimmunity to tissue-associated Ags after solid organ transplantation.
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Affiliation(s)
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohammad Rahman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Narendra Sankpal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ankit Bharat
- Department of Surgery-Thoracic, Northwestern University, Chicago, IL, United States
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10
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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11
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Abstract
Lung transplantation improves survival and quality of life in patients with advanced pulmonary disease. Over the past several decades, the volume of lung transplants has grown substantially, with increasing transplantation of older and acutely ill individuals facilitated by improved utilization and preservation of available donor organs. Other advances include improvements in the diagnosis and mechanistic understanding of frequent post-transplant complications, such as primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction (CLAD). CLAD occurs as a result of the host immune response to the allograft and is the principal factor limiting long-term survival after lung transplantation. Two distinct clinical phenotypes of CLAD have emerged, bronchiolitis obliterans syndrome and restrictive allograft syndrome, and this distinction has enabled further understanding of underlying immune mechanisms. Building on these advances, ongoing studies are exploring novel approaches to diagnose, prevent, and treat CLAD. Such studies are necessary to improve long-term outcomes for lung transplant recipients.
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Affiliation(s)
- Aparna C Swaminathan
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA; , , .,Duke Clinical Research Institute, Durham, North Carolina 27710, USA
| | - Jamie L Todd
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA; , , .,Duke Clinical Research Institute, Durham, North Carolina 27710, USA
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA; , , .,Duke Clinical Research Institute, Durham, North Carolina 27710, USA
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12
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Collins MK, Shotland AM, Wade MF, Atif SM, Richards DK, Torres-Llompart M, Mack DG, Martin AK, Fontenot AP, McKee AS. A role for TNF-α in alveolar macrophage damage-associated molecular pattern release. JCI Insight 2020; 5:134356. [PMID: 32255768 DOI: 10.1172/jci.insight.134356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/01/2020] [Indexed: 01/22/2023] Open
Abstract
Chronic beryllium disease (CBD) is a metal hypersensitivity/autoimmune disease in which damage-associated molecular patterns (DAMPs) promote a break in T cell tolerance and expansion of Be2+/self-peptide-reactive CD4+ T cells. In this study, we investigated the mechanism of cell death induced by beryllium particles in alveolar macrophages (AMs) and its impact on DAMP release. We found that phagocytosis of Be led to AM cell death independent of caspase, receptor-interacting protein kinases 1 and 3, or ROS activity. Before cell death, Be-exposed AMs secreted TNF-α that boosted intracellular stores of IL-1α followed by caspase-8-dependent fragmentation of DNA. IL-1α and nucleosomal DNA were subsequently released from AMs upon loss of plasma membrane integrity. In contrast, necrotic AMs released only unfragmented DNA and necroptotic AMs released only IL-1α. In mice exposed to Be, TNF-α promoted release of DAMPs and was required for the mobilization of immunogenic DCs, the expansion of Be-reactive CD4+ T cells, and pulmonary inflammation in a mouse model of CBD. Thus, early autocrine effects of particle-induced TNF-α on AMs led to a break in peripheral tolerance. This potentially novel mechanism may underlie the known relationship between fine particle inhalation, TNF-α, and loss of peripheral tolerance in T cell-mediated autoimmune disease and hypersensitivities.
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Affiliation(s)
- Morgan K Collins
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | - Abigail M Shotland
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | - Morgan F Wade
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | - Shaikh M Atif
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | | | | | - Douglas G Mack
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | - Allison K Martin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine
| | - Andrew P Fontenot
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine.,Department of Immunology and Microbiology, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy S McKee
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine.,Department of Immunology and Microbiology, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Bharat A. Does Foxp3+ T cell-mediated lung transplant tolerance depend on BALT formation? Am J Transplant 2020; 20:1219-1220. [PMID: 31919975 DOI: 10.1111/ajt.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/10/2019] [Accepted: 01/03/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Ius F, Salman J, Knoefel AK, Sommer W, Nakagiri T, Verboom M, Siemeni T, Poyanmehr R, Bobylev D, Kuehn C, Avsar M, Erdfelder C, Hallensleben M, Boethig D, Hecker H, Schwerk N, Mueller C, Welte T, Falk C, Preissler G, Haverich A, Tudorache I, Warnecke G. Increased frequency of CD4 + CD25 high CD127 low T cells early after lung transplant is associated with improved graft survival - a retrospective study. Transpl Int 2020; 33:503-516. [PMID: 31903646 DOI: 10.1111/tri.13568] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/04/2019] [Accepted: 12/20/2019] [Indexed: 12/30/2022]
Abstract
In this retrospective study, we analyzed the presence of any association of three CD4+ CD25high regulatory T-cell subpopulations at 3 weeks after lung transplantation with the later incidence of chronic lung allograft dysfunction and graft survival. Among lung-transplanted patients between January 2009 and April 2018, only patients with sufficient T-cell measurements at 3 weeks after transplantation were included into the study. Putative regulatory T cells were defined as CD4+ CD25high T cells, detected in peripheral blood and further analyzed for CD127low , FoxP3+ , and CD152+ using fluorescence-activated cell sorting (FACS) analysis. Associations of regulatory T cells with chronic lung allograft dysfunction (CLAD) and graft survival were evaluated using Cox analysis. During the study period, 724 (71%) patients were included into the study. Freedom from chronic lung allograft dysfunction (CLAD) and graft survival amounted to 66% and 68% at 5 years. At the multivariable analysis, increasing frequencies of CD127low were associated with better freedom from CLAD (hazard ratio for each 1% increase of %CD127low , HR = 0.989, 95% CI = 0.981-0.996, P = 0.003) and better graft survival (HR = 0.991, 95% CI = 0.984-0.999, P = 0.026). A higher frequency of CD127low regulatory T cells in peripheral blood early after lung transplantation estimated a protective effect against chronic lung allograft dysfunction, mortality, and re-transplantation.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ann-Kathrin Knoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
| | - Tomoyuki Nakagiri
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Caroline Erdfelder
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hartmut Hecker
- Institute for Biometry, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Carsten Mueller
- Department of pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Christine Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Gerhard Preissler
- German Center for Lung Research (DZL), Hannover, Germany.,Department of Surgery, Munich Lung Transplant Group, Ludwig-Maximilian's University, Munich, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL), Hannover, Germany
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15
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Gauthier JM, Harrison MS, Krupnick AS, Gelman AE, Kreisel D. The emerging role of regulatory T cells following lung transplantation. Immunol Rev 2019; 292:194-208. [PMID: 31536165 DOI: 10.1111/imr.12801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/27/2019] [Indexed: 12/13/2022]
Abstract
Regulatory T cells (Treg) have proven to be a powerful immunologic force in nearly every organ system and hold therapeutic potential for a wide range of diseases. Insights gained from non-transplant pathologies, such as infection, cancer, and autoimmunity, are now being translated to the field of solid organ transplantation, particularly for livers and kidneys. Recent insights from animal models of lung transplantation have established that Tregs play a vital role in suppressing rejection and facilitating tolerance of lung allografts, and such discoveries are being validated in human studies and preclinical trials. Given that long-term outcomes following lung transplantation remain profoundly limited by chronic rejection, Treg therapy holds the potential to significantly improve patient outcomes and should be aggressively investigated.
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Affiliation(s)
- Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, MO, USA
| | - M Shea Harrison
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, MO, USA
| | - Alexander S Krupnick
- Division of Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA.,Carter Immunology Center, University of Virginia, Charlottesville, VA, USA
| | - Andrew E Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, MO, USA.,Department of Pathology & Immunology, Washington University, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, MO, USA.,Department of Pathology & Immunology, Washington University, Saint Louis, MO, USA
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16
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Sureshbabu A, Fleming T, Mohanakumar T. Autoantibodies in lung transplantation. Transpl Int 2019; 33:41-49. [PMID: 31393646 DOI: 10.1111/tri.13487] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/12/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) comprises both bronchiolitis obliterans syndrome and restrictive allograft syndrome as subtypes. After lung transplantation, CLAD remains a major limitation for long-term survival, and lung transplant recipients therefore have poorer outcomes compared with recipients of other solid organ transplants. Although the number of lung transplants continues to increase globally, the field demands detailed understanding of immunoregulatory mechanisms and more effective individualized therapies to combat CLAD. Emerging evidence suggests that CLAD is multifactorial and involves a complex, delicate interplay of multiple factors, including perioperative donor characteristics, inflammation induced immediately following transplant, post-transplant infection and interplay between allo- and autoimmunity directed to donor antigens. Recently, identification of stress-induced exosome release from the transplanted organ has emerged as an underlying mechanism in the development of chronic rejection and promises to prompt novel strategies for future therapeutic interventions. In this review, we will discuss recent studies and ongoing research into the mechanisms for the development of CLAD, with emphasis on immune responses to lung-associated self-antigens-that is, autoimmunity.
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Affiliation(s)
- Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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17
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Viruses and Autoimmunity: A Review on the Potential Interaction and Molecular Mechanisms. Viruses 2019; 11:v11080762. [PMID: 31430946 PMCID: PMC6723519 DOI: 10.3390/v11080762] [Citation(s) in RCA: 297] [Impact Index Per Article: 59.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 07/27/2019] [Accepted: 07/31/2019] [Indexed: 02/06/2023] Open
Abstract
For a long time, viruses have been shown to modify the clinical picture of several autoimmune diseases, including type 1 diabetes (T1D), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjögren’s syndrome (SS), herpetic stromal keratitis (HSK), celiac disease (CD), and multiple sclerosis (MS). Best examples of viral infections that have been proposed to modulate the induction and development of autoimmune diseases are the infections with enteric viruses such as Coxsackie B virus (CVB) and rotavirus, as well as influenza A viruses (IAV), and herpesviruses. Other viruses that have been studied in this context include, measles, mumps, and rubella. Epidemiological studies in humans and experimental studies in animal have shown that viral infections can induce or protect from autoimmunopathologies depending on several factors including genetic background, host-elicited immune responses, type of virus strain, viral load, and the onset time of infection. Still, data delineating the clear mechanistic interaction between the virus and the immune system to induce autoreactivity are scarce. Available data indicate that viral-induced autoimmunity can be activated through multiple mechanisms including molecular mimicry, epitope spreading, bystander activation, and immortalization of infected B cells. Contrarily, the protective effects can be achieved via regulatory immune responses which lead to the suppression of autoimmune phenomena. Therefore, a better understanding of the immune-related molecular processes in virus-induced autoimmunity is warranted. Here we provide an overview of the current understanding of viral-induced autoimmunity and the mechanisms that are associated with this phenomenon.
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18
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Compelling scientific and clinical evidence that non-HLA specific antibodies impact graft outcome independently and in concert with donor HLA specific antibodies. Hum Immunol 2019; 80:555-560. [PMID: 31279533 DOI: 10.1016/j.humimm.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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19
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Akbarpour M, Wu Q, Liu X, Sun H, Lecuona E, Tomic R, Bhorade S, Mohanakumar T, Bharat A. Clinical relevance of lung-restricted antibodies in lung transplantation. Hum Immunol 2019; 80:595-601. [PMID: 31078336 DOI: 10.1016/j.humimm.2019.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/01/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022]
Abstract
Lung transplant is a definitive treatment for several end-stage lung diseases. However, the high incidence of allograft rejection limits the overall survival following lung transplantation. Traditionally, alloimmunity directed against human leukocyte antigens (HLA) has been implicated in transplant rejection. Recently, the clinical impact of non-HLA lung-restricted antibodies (LRA) has been recognized and extensive research has demonstrated that they may play a dominant role in the development of lung allograft rejection. The immunogenic lung-restricted antigens that have been identified include amongst others, collagen type I, collagen type V, and k-alpha 1 tubulin. Pre-existing antibodies against these lung-restricted antigens are prevalent in patients undergoing lung transplantation and have emerged as one of the predominant risk factors for primary graft dysfunction which limits short-term survival following lung transplantation. Additionally, LRA have been shown to predispose to chronic lung allograft rejection, the predominant cause of poor long-term survival. This review will discuss ongoing research into the mechanisms of development of LRA as well as the pathogenesis of associated lung allograft injury.
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Affiliation(s)
- Mahzad Akbarpour
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Qiang Wu
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Xianpeng Liu
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Haiying Sun
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilia Lecuona
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rade Tomic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sangeeta Bhorade
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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20
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Bharat A. A Need for Targeted Immunosuppression after Lung Transplantation. Am J Respir Cell Mol Biol 2019; 61:279-280. [PMID: 30958700 PMCID: PMC6839934 DOI: 10.1165/rcmb.2019-0100ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Ankit Bharat
- Department of Surgeryand.,Department of MedicineNorthwestern University Feinberg School of MedicineChicago, Illinois
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21
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Bharat A, Kreisel D. Immunopathogenesis of Primary Graft Dysfunction After Lung Transplantation. Ann Thorac Surg 2019; 105:671-674. [PMID: 29455798 DOI: 10.1016/j.athoracsur.2017.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Ankit Bharat
- Department of Surgery, Northwestern University, Chicago, Illinois; Department of Medicine, Northwestern University, Chicago, Illinois.
| | - Daniel Kreisel
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri; Department of Pathology & Immunology, Washington University in St. Louis, St. Louis, Missouri
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22
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Akbarpour M, Bharat A. Lung Injury and Loss of Regulatory T Cells Primes for Lung-Restricted Autoimmunity. Crit Rev Immunol 2019; 37:23-37. [PMID: 29431077 DOI: 10.1615/critrevimmunol.2017024944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplantation is a life-saving therapy for several end-stage lung diseases. However, lung allografts suffer from the lowest survival rate predominantly due to rejection. The pathogenesis of alloimmunity and its role in allograft rejection has been extensively studied and multiple approaches have been described to induce tolerance. However, in the context of lung transplantation, dysregulation of mechanisms, which maintain tolerance against self-antigens, can lead to lung-restricted autoimmunity, which has been recently identified to drive the immunopathogenesis of allograft rejection. Indeed, both preexisting as well as de novo lung-restricted autoimmunity can play a major role in the development of lung allograft rejection. The three most widely studied lung-restricted self-antigens include collagen type I, collagen type V, and k-alpha 1 tubulin. In this review, we discuss the role of lung-restricted autoimmunity in the development of both early as well as late lung allograft rejection and recent literature providing insight into the development of lung-restricted autoimmunity through the dysfunction of immune mechanisms which maintain peripheral tolerance.
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Affiliation(s)
- Mahzad Akbarpour
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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23
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Ravichandran R, Bansal S, Rahman M, Sharma M, Liu W, Bharat A, Hachem R, Omar A, Smith MA, Mohanakumar T. The role of donor-derived exosomes in lung allograft rejection. Hum Immunol 2019; 80:588-594. [PMID: 30898684 DOI: 10.1016/j.humimm.2019.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/12/2019] [Accepted: 03/17/2019] [Indexed: 12/20/2022]
Abstract
Lung transplant recipients (LTxRs) with acute or chronic rejection release circulating exosomes that mostly originate from donor lung tissue and express mismatched human leucocyte antigens (HLA) and lung-associated self-antigens (SAgs), Collagen-V and K alpha 1 Tubulin. During lung transplant (LTx), donor lungs often undergo injuries that increase the antigenicity of the transplanted organ. 30% of LTxRs also have pre-transplant antibodies (Abs) to HLA and lung SAgs, which may induce conditions that increase the risk of chronic lung allograft dysfunction (CLAD). Post-transplant, some recipients experience de novo development of Abs to mismatched donor HLA (donor-specific antibody [DSA]) and Abs to lung SAgs, which have been implicated in CLAD pathogenesis. Because most LTxRs who develop DSA also develop Abs to SAgs, some have suggested a synergistic relationship between alloimmunity and autoimmunity in CLAD immunopathogenesis. These processes likely occur from stress-induced exosome release. Exosomes carry allo-antigens, lung SAgs, several micro RNAs, proteasome, co-stimulatory molecules, and pro-inflammatory transcription factors-resulting in efficient antigen presentation by direct, semidirect, and indirect pathways, leading to immune responses to both allo-antigens and lung-associated SAgs. This review summarizes recent findings on the role of exosomes, and processes triggering immune responses to allo-antigens and lung SAgs that ultimately culminate in CLAD.
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Affiliation(s)
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohammad Rahman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Monal Sharma
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Wei Liu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ankit Bharat
- Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Ramsey Hachem
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States.
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24
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Immune Responses to Tissue-Restricted Nonmajor Histocompatibility Complex Antigens in Allograft Rejection. J Immunol Res 2017; 2017:6312514. [PMID: 28164137 PMCID: PMC5253484 DOI: 10.1155/2017/6312514] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/06/2016] [Indexed: 01/02/2023] Open
Abstract
Chronic diseases that result in end-stage organ damage cause inflammation, which can reveal sequestered self-antigens (SAgs) in that organ and trigger autoimmunity. The thymus gland deletes self-reactive T-cells against ubiquitously expressed SAgs, while regulatory mechanisms in the periphery control immune responses to tissue-restricted SAgs. It is now established that T-cells reactive to SAgs present in certain organs (e.g., lungs, pancreas, and intestine) are incompletely eliminated, and the dysregulation of peripheral immuneregulation can generate immune responses to SAgs. Therefore, chronic diseases can activate self-reactive lymphocytes, inducing tissue-restricted autoimmunity. During organ transplantation, donor lymphocytes are tested against recipient serum (i.e., cross-matching) to detect antibodies (Abs) against donor human leukocyte antigens, which has been shown to reduce Ab-mediated hyperacute rejection. However, primary allograft dysfunction and rejection still occur frequently. Because donor lymphocytes do not express tissue-restricted SAgs, preexisting Abs against SAgs are undetectable during conventional cross-matching. Preexisting and de novo immune responses to tissue-restricted SAgs (i.e., autoimmunity) play a major role in rejection. In this review, we discuss the evidence that supports autoimmunity as a contributor to rejection. Testing for preexisting and de novo immune responses to tissue-restricted SAgs and treatment based on immune responses after organ transplantation may improve short- and long-term outcomes after transplantation.
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