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Paraskeva MA, Snell GI. Advances in lung transplantation: 60 years on. Respirology 2024; 29:458-470. [PMID: 38648859 DOI: 10.1111/resp.14721] [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: 02/11/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.
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Affiliation(s)
- Miranda A Paraskeva
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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2
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Benden C, Wikenheiser-Brokamp KA. Antibody-mediated rejection (AMR) in pediatric lung transplantation-Current state and future directions. Pediatr Transplant 2024; 28:e14739. [PMID: 38436533 DOI: 10.1111/petr.14739] [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: 11/01/2023] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
Lung transplantation is considered as the ultimate therapy for children with advanced pulmonary disease. International data show a median conditional 1-year post-transplantation survival of 9.1 years. Recently, antibody-mediated rejection (AMR) has increasingly been recognized as an important cause of allograft dysfunction although pediatric reports are still scarce. Donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) are known to play a role in AMR development post-transplant but AMR pathogenesis is still poorly understood. Central to the concept of pulmonary AMR is immune activation with the production of allo-specific B-cells and plasma cells directed against donor lung antigens. The frequency of pulmonary AMR in children is currently unknown. Due to the lack of AMR data in children, the diagnostic approach for pediatric pulmonary AMR is solely based on adult literature. This personal viewpoint article evaluates the rational for the creation of age-based thresholds for different diagnostic categories of pulmonary AMR and data on the management of pulmonary AMR in children. To the authors' knowledge, there have been no randomized controlled trials comparing different management regimes in pulmonary AMR, and thus, management and treatment algorithms for pulmonary AMR in children are only extrapolated from adults. To advance the knowledge of AMR in children, the authors propose that children be included in collaborative, multi-center trials. It is vital that future decisions on internationally agreed upon guidelines for pulmonary AMR take its impact on children into consideration. Research is needed to fill the current knowledge gaps in the field of pulmonary AMR in children focused on optimizing outcomes.
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Affiliation(s)
| | - Kathryn A Wikenheiser-Brokamp
- Division of Pathology and Laboratory Medicine, Perinatal Institute, Division of Pulmonary Biology, and Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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3
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Pradère P, Zajacova A, Bos S, Le Pavec J, Fisher A. Molecular monitoring of lung allograft health: is it ready for routine clinical use? Eur Respir Rev 2023; 32:230125. [PMID: 37993125 PMCID: PMC10663940 DOI: 10.1183/16000617.0125-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
Maintenance of long-term lung allograft health in lung transplant recipients (LTRs) requires a fine balancing act between providing sufficient immunosuppression to reduce the risk of rejection whilst at the same time not over-immunosuppressing individuals and exposing them to the myriad of immunosuppressant drug side-effects that can cause morbidity and mortality. At present, lung transplant physicians only have limited and rather blunt tools available to assist them with this task. Although therapeutic drug monitoring provides clinically useful information about single time point and longitudinal exposure of LTRs to immunosuppressants, it lacks precision in determining the functional level of immunosuppression that an individual is experiencing. There is a significant gap in our ability to monitor lung allograft health and therefore tailor optimal personalised immunosuppression regimens. Molecular diagnostics performed on blood, bronchoalveolar lavage or lung tissue that can detect early signs of subclinical allograft injury, differentiate rejection from infection or distinguish cellular from humoral rejection could offer clinicians powerful tools in protecting lung allograft health. In this review, we look at the current evidence behind molecular monitoring in lung transplantation and ask if it is ready for routine clinical use. Although donor-derived cell-free DNA and tissue transcriptomics appear to be the techniques with the most immediate clinical potential, more robust data are required on their performance and additional clinical value beyond standard of care.
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Affiliation(s)
- Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrea Zajacova
- Prague Lung Transplant Program, Department of Pneumology, Motol University Hospital and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Jérôme Le Pavec
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrew Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
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4
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Gauthier PT, Mackova M, Hirji A, Weinkauf J, Timofte IL, Snell GI, Westall GP, Havlin J, Lischke R, Zajacová A, Simonek J, Hachem R, Kreisel D, Levine D, Kubisa B, Piotrowska M, Juvet S, Keshavjee S, Jaksch P, Klepetko W, Halloran K, Halloran PF. Defining a natural killer cell-enriched molecular rejection-like state in lung transplant transbronchial biopsies. Am J Transplant 2023; 23:1922-1938. [PMID: 37295720 DOI: 10.1016/j.ajt.2023.06.003] [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: 02/17/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
In lung transplantation, antibody-mediated rejection (AMR) diagnosed using the International Society for Heart and Lung Transplantation criteria is uncommon compared with other organs, and previous studies failed to find molecular AMR (ABMR) in lung biopsies. However, understanding of ABMR has changed with the recognition that ABMR in kidney transplants is often donor-specific antibody (DSA)-negative and associated with natural killer (NK) cell transcripts. We therefore searched for a similar molecular ABMR-like state in transbronchial biopsies using gene expression microarray results from the INTERLUNG study (#NCT02812290). After optimizing rejection-selective transcript sets in a training set (N = 488), the resulting algorithms separated an NK cell-enriched molecular rejection-like state (NKRL) from T cell-mediated rejection (TCMR)/Mixed in a test set (N = 488). Applying this approach to all 896 transbronchial biopsies distinguished 3 groups: no rejection, TCMR/Mixed, and NKRL. Like TCMR/Mixed, NKRL had increased expression of all-rejection transcripts, but NKRL had increased expression of NK cell transcripts, whereas TCMR/Mixed had increased effector T cell and activated macrophage transcripts. NKRL was usually DSA-negative and not recognized as AMR clinically. TCMR/Mixed was associated with chronic lung allograft dysfunction, reduced one-second forced expiratory volume at the time of biopsy, and short-term graft failure, but NKRL was not. Thus, some lung transplants manifest a molecular state similar to DSA-negative ABMR in kidney and heart transplants, but its clinical significance must be established.
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Affiliation(s)
| | | | - Alim Hirji
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Greg I Snell
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | - Glen P Westall
- Alfred Hospital Lung Transplant Service, Melbourne, Victoria, Australia
| | - Jan Havlin
- University Hospital Motol, Prague, Czech Republic
| | | | | | - Jan Simonek
- University Hospital Motol, Prague, Czech Republic
| | - Ramsey Hachem
- Washington University in St Louis, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Washington University in St Louis, St. Louis, Missouri, USA
| | | | - Bartosz Kubisa
- Pomeranian Medical University of Szczecin, Szczecin, Poland
| | | | - Stephen Juvet
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
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5
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Matsumoto H, Suzuki H, Yamanaka T, Kaiho T, Hata A, Inage T, Ito T, Kamata T, Tanaka K, Sakairi Y, Motohashi S, Yoshino I. Anti-CD20 Antibody and Calcineurin Inhibitor Combination Therapy Effectively Suppresses Antibody-Mediated Rejection in Murine Orthotopic Lung Transplantation. Life (Basel) 2023; 13:2042. [PMID: 37895424 PMCID: PMC10608275 DOI: 10.3390/life13102042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Antibody-mediated rejection (AMR) is a risk factor for chronic lung allograft dysfunction, which impedes long-term survival after lung transplantation. There are no reports evaluating the efficacy of the single use of anti-CD20 antibodies (aCD20s) in addition to calcineurin inhibitors in preventing AMR. Thus, this study aimed to evaluate the efficacy of aCD20 treatment in a murine orthotopic lung transplantation model. Murine left lung transplantation was performed using a major alloantigen strain mismatch model (BALBc (H-2d) → C57BL/6 (BL/6) (H-2b)). There were four groups: isograft (BL/6→BL/6) (Iso control), no-medication (Allo control), cyclosporine A (CyA) treated, and CyA plus murine aCD20 (CyA+aCD20) treated groups. Severe neutrophil capillaritis, arteritis, and positive lung C4d staining were observed in the allograft model and CyA-only-treated groups. These findings were significantly improved in the CyA+aCD20 group compared with those in the Allo control and CyA groups. The B cell population in the spleen, lymph node, and graft lung as well as the levels of serum donor-specific IgM and interferon γ were significantly lower in the CyA+aCD20 group than in the CyA group. Calcineurin inhibitor-mediated immunosuppression combined with aCD20 therapy effectively suppressed AMR in lung transplantation by reducing donor-specific antibodies and complement activation.
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Affiliation(s)
- Hiroki Matsumoto
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
- Department of Thoracic Surgery, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu 292-8535, Japan
| | - Hidemi Suzuki
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Takahiro Yamanaka
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Taisuke Kaiho
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Atsushi Hata
- Department of General Thoracic Surgery, Chiba Cancer Center, Chiba 260-8717, Japan; (A.H.); (T.I.)
| | - Terunaga Inage
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Takamasa Ito
- Department of General Thoracic Surgery, Chiba Cancer Center, Chiba 260-8717, Japan; (A.H.); (T.I.)
| | - Toshiko Kamata
- Department of Thoracic Surgery, International University of Health and Welfare Atami Hospital, Shizuoka 413-0012, Japan;
| | - Kazuhisa Tanaka
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Yuichi Sakairi
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
| | - Shinichiro Motohashi
- Department of Medical Immunology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan;
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan; (H.M.); (T.Y.); (T.K.); (T.I.); (K.T.); (Y.S.); (I.Y.)
- Department of General Thoracic Surgery, International University of Health and Welfare Narita Hospital, Chiba 286-8520, Japan
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Giraudo C, Modugno A, Negro G, Dell'Amore A, Cecchin D, Motta R, Balestro E, Boscolo A, Calabrese F, Faccioli E, Navalesi P, Vianello A, Rea F, Stramare R. Radiomics of spinal muscles: toward a radiological biomarker for allograft rejection in lung transplant. LA RADIOLOGIA MEDICA 2023; 128:1070-1078. [PMID: 37458906 PMCID: PMC10474186 DOI: 10.1007/s11547-023-01674-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 06/29/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE To assess the role of muscle composition and radiomics in predicting allograft rejection in lung transplant. MATERIAL AND METHODS The last available HRCT before surgery of lung transplant candidates referring to our tertiary center from January 2010 to February 2020 was retrospectively examined. Only scans with B30 kernel reconstructions and 1 mm slice thickness were included. One radiologist segmented the spinal muscles of each patient at the level of the 11th dorsal vertebra by an open-source software. The same software was used to extract Hu values and 72 radiomic features of first and second order. Factor analysis was applied to select highly correlating features and then their prognostic value for allograft rejection was investigated by logistic regression analysis (level of significance p < 0.05). In case of significant results, the diagnostic value of the model was computed by ROC curves. RESULTS Overall 200 patients had a HRCT prior to the transplant but only 97 matched the inclusion criteria (29 women; mean age 50.4 ± 13 years old). Twenty-one patients showed allograft rejection. The following features were selected by the factor analysis: cluster prominence, Imc2, gray level non-uniformity normalized, median, kurtosis, gray level non-uniformity, and inverse variance. The radiomic-based model including also Hu demonstrated that only the feature Imc2 acts as a predictor of allograft rejection (p = 0.021). The model showed 76.6% accuracy and the Imc2 value of 0.19 demonstrated 81% sensitivity and 64.5% specificity in predicting lung transplant rejection. CONCLUSION The radiomic feature Imc2 demonstrated to be a predictor of allograft rejection in lung transplant.
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Affiliation(s)
- Chiara Giraudo
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, University of Padova, Padua, Italy.
| | - Antonella Modugno
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Giacomo Negro
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Andrea Dell'Amore
- Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Raffaella Motta
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Elisabetta Balestro
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Annalisa Boscolo
- Anesthesiology and Intensive Care Unit, Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Fiorella Calabrese
- Pathological Anatomy Section, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Eleonora Faccioli
- Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Paolo Navalesi
- Anesthesiology and Intensive Care Unit, Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Roberto Stramare
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, University of Padova, Padua, Italy
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7
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Ennis SL, Olsen N, Tong WWY, Goddard L, Watson N, Weston L, Iqbal A, Patel P, Malouf MA, Plit ML, Darley DR. Specific HLA-DQ risk epitope mismatches are associated with chronic lung allograft dysfunction after lung transplantation. Am J Transplant 2023:S1600-6135(23)00401-X. [PMID: 37054889 DOI: 10.1016/j.ajt.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Abstract
A high-risk epitope mismatch (REM) (found in DQA1*05 + DQB1*02/DQB1*03:01) is associated with de novo donor-specific antibodies (dn-DSA) after lung transplant (LTx). Chronic lung allograft dysfunction (CLAD) remains a barrier to LTx survival. The aims of this study were to measure the association between DQ REM and risk of CLAD and death after LTx. A retrospective analysis of LTx recipients at a single centre was conducted between Jan-2014 and Apr-2019. Molecular typing at HLA-DQA/DBQ identified DQ REM. Multivariable competing risk and Cox regression models were used to measure the association between DQ REM and time-to-CLAD and time-to-death. DQ REM was detected in 96/268(35.8%) and DQ REM dn-DSA detected in 34/96(35.4%). CLAD occurred in 78(29.1%) and 98(36.6%) recipients died during follow-up. When analysed as a baseline predictor, DQ REM status was associated with CLAD (SHR 2.19 95%CI 1.40-3.43; p=0.001). After adjustment for time dependent variables, dn-DQ-REM DSA (SHR 2.43 95%CI 1.10-5.38; p=0.029) and A-grade rejection score (SHR 1.22 95%CI 1.11-1.35; p=<0.001), but not DQ REM status was associated with CLAD. DQ REM was not associated with death (HR 1.18 95%CI 0.72-1.93; p=0.51). Classification of DQ REM may identify patients at risk of poor outcomes and should be incorporated into clinical decision-making.
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Affiliation(s)
- Samantha Louse Ennis
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Nicholas Olsen
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Winnie W Y Tong
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Louise Goddard
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Narelle Watson
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Lyanne Weston
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Ayesha Iqbal
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Purvesh Patel
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Monique Anne Malouf
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Marshall L Plit
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - David Ross Darley
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
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8
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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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9
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Charya AV, Ponor IL, Cochrane A, Levine D, Philogene M, Fu YP, Jang MK, Kong H, Shah P, Bon AM, Krishnan A, Mathew J, Luikart H, Khush KK, Berry G, Marboe C, Iacono A, Orens JB, Nathan SD, Agbor-Enoh S. Clinical features and allograft failure rates of pulmonary antibody-mediated rejection categories. J Heart Lung Transplant 2023; 42:226-235. [PMID: 36319530 DOI: 10.1016/j.healun.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Pulmonary antibody-mediated rejection (AMR) consensus criteria categorize AMR by diagnostic certainty. This study aims to define the clinical features and associated outcomes of these recently defined AMR categories. METHODS Adjudication committees reviewed clinical data of 335 lung transplant recipients to define clinical or subclinical AMR based on the presence of allograft dysfunction, and the primary endpoints, time from transplant to allograft failure, a composite endpoint of chronic lung allograft dysfunction and/or death. Clinical AMR was subcategorized based on diagnostic certainty as definite, probable or possible AMR if 4, 3, or 2 characteristic features were present, respectively. Allograft injury was assessed via plasma donor-derived cell-free DNA (ddcfDNA). Risk of allograft failure and allograft injury was compared for AMR categories using regression models. RESULTS Over the 38.5 months follow-up, 28.7% of subjects developed clinical AMR (n = 96), 18.5% developed subclinical AMR (n = 62) or 58.3% were no AMR (n = 177). Clinical AMR showed higher risk of allograft failure and ddcfDNA levels compared to subclinical or no AMR. Clinical AMR included definite/probable (n = 21) or possible AMR (n = 75). These subcategories showed similar clinical characteristics, ddcfDNA levels, and risk of allograft failure. However, definite/probable AMR showed greater measures of AMR severity, including degree of allograft dysfunction and risk of death compared to possible AMR. CONCLUSIONS Clinical AMR showed greater risk of allograft failure than subclinical AMR or no AMR. Subcategorization of clinical AMR based on diagnostic certainty correlated with AMR severity and risk of death, but not with the risk of allograft failure.
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Affiliation(s)
- Ananth V Charya
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Ileana L Ponor
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland; Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Adam Cochrane
- Advanced Lung Disease and Lung Transplantation Program, Inova Fairfax Hospital, Fairfax, Virginia
| | - Deborah Levine
- Lung Transplantation Program, University of Texas, San Antonio, Texas
| | - Mary Philogene
- Histocompatibility and Molecular Genetics Laboratory, Philadelphia, Pennsylvania
| | - Yi-Ping Fu
- Biostatistics, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Moon K Jang
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Hyesik Kong
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ann Mary Bon
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Joby Mathew
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Helen Luikart
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Gerald Berry
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Charles Marboe
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Department of Pathology, New York Presbyterian University Hospital of Cornell and Columbia, New York, New York
| | - Aldo Iacono
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Advanced Lung Disease and Lung Transplantation Program, Inova Fairfax Hospital, Fairfax, Virginia.
| | - Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laboratory of Applied Precision Omics, Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland; Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.
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10
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Calabrese F, Roden AC, Pavlisko E, Lunardi F, Neil D, Adam B, Hwang D, Goddard M, Berry GJ, Ivanovic M, Thüsen JVD, Gibault L, Lin CY, Wassilew K, Glass C, Westall G, Zeevi A, Levine DJ, Roux A. LUNG ALLOGRAFT STANDARDIZED HISTOLOGICAL ANALYSIS (LASHA) TEMPLATE: A RESEARCH CONSENSUS PROPOSAL. J Heart Lung Transplant 2022; 41:1487-1500. [DOI: 10.1016/j.healun.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/10/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
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11
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Sorbini M, Togliatto G, Mioli F, Simonato E, Marro M, Cappuccio M, Arruga F, Caorsi C, Mansouri M, Magistroni P, Gambella A, Delsedime L, Papotti MG, Solidoro P, Albera C, Boffini M, Rinaldi M, Amoroso A, Vaisitti T, Deaglio S. Validation of a Simple, Rapid, and Cost-Effective Method for Acute Rejection Monitoring in Lung Transplant Recipients. Transpl Int 2022; 35:10546. [PMID: 35755857 PMCID: PMC9221674 DOI: 10.3389/ti.2022.10546] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/19/2022] [Indexed: 11/24/2022]
Abstract
Despite advances in immunosuppression therapy, acute rejection remains the leading cause of graft dysfunction in lung transplant recipients. Donor-derived cell-free DNA is increasingly being considered as a valuable biomarker of acute rejection in several solid organ transplants. We present a technically improved molecular method based on digital PCR that targets the mismatch between the recipient and donor at the HLA-DRB1 locus. Blood samples collected sequentially post-transplantation from a cohort of lung recipients were used to obtain proof-of-principle for the validity of the assay, correlating results with transbronchial biopsies and lung capacity tests. The results revealed an increase in dd-cfDNA during the first 2 weeks after transplantation related to ischemia-reperfusion injury (6.36 ± 5.36%, p < 0.0001). In the absence of complications, donor DNA levels stabilized, while increasing again during acute rejection episodes (7.81 ± 12.7%, p < 0.0001). Respiratory tract infections were also involved in the release of dd-cfDNA (9.14 ± 15.59%, p = 0.0004), with a positive correlation with C-reactive protein levels. Overall, the dd-cfDNA percentages were inversely correlated with the lung function values measured by spirometry. These results confirm the value of dd-cfDNA determination during post-transplant follow-up to monitor acute rejection in lung recipients, achieved using a rapid and inexpensive approach based on the HLA mismatch between donor and recipient.
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Affiliation(s)
- Monica Sorbini
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Fiorenza Mioli
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Erika Simonato
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Matteo Marro
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | | | - Francesca Arruga
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristiana Caorsi
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Morteza Mansouri
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Paola Magistroni
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | | | - Luisa Delsedime
- Pathology Unit, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Mauro Giulio Papotti
- Pathology Unit, Città Della Salute e Della Scienza University Hospital, Turin, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Paolo Solidoro
- Lung Transplantation and Advanced Airways Management, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Carlo Albera
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Antonio Amoroso
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Tiziana Vaisitti
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Silvia Deaglio
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
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12
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Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection (ACR), and antibody-mediated rejection (AMR) are risk factors for the subsequent development of chronic lung allograft dysfunction and worse outcomes after transplantation. Although ACR has well-defined histopathologic diagnostic criteria and grading, the diagnosis of AMR requires a multidisciplinary diagnostic approach. This article reviews the identification, clinical and pathologic features of, and therapeutic options for ACR and AMR.
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Affiliation(s)
- Deborah J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, 4523 Clayton Avenue, Mailstop 8052-0043-14, St Louis, MO 63110, USA.
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13
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Subramani MV, Pandit S, Gadre SK. Acute rejection and post lung transplant surveillance. Indian J Thorac Cardiovasc Surg 2022; 38:271-279. [PMID: 35340687 PMCID: PMC8938213 DOI: 10.1007/s12055-021-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose The purpose of this review is to summarize the current evidence on the evaluation and treatment of acute rejection after lung transplantation. Results Despite significant progress in the field of transplant immunology, acute rejection remains a frequent complication after transplantation. Almost 30% of lung transplant recipients experience at least one episode of acute cellular rejection (ACR) during the first year after transplant. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well-defined histopathologic diagnostic criteria and grading. The diagnosis of antibody-mediated rejection after lung transplantation requires a multidisciplinary approach. Antibody-mediated rejection may cause acute allograft failure. Conclusions Acute rejection is a risk factor for development of chronic rejection. Further investigations are required to better define risk factors, surveillance strategies, and optimal management strategies for acute allograft rejection.
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Affiliation(s)
| | - Sumir Pandit
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Shruti Kumar Gadre
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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14
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Wang A, Ribeiro RVP, Ali A, Brambate E, Abdelnour-Berchtold E, Michaelsen V, Zhang Y, Rahfeld P, Moon H, Gokhale H, Gazzalle A, Pal P, Liu M, Waddell TK, Cserti-Gazdewich C, Tinckam K, Kizhakkedathu JN, West L, Keshavjee S, Withers SG, Cypel M. Ex vivo enzymatic treatment converts blood type A donor lungs into universal blood type lungs. Sci Transl Med 2022; 14:eabm7190. [PMID: 35171649 DOI: 10.1126/scitranslmed.abm7190] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Donor organ allocation is dependent on ABO matching, restricting the opportunity for some patients to receive a life-saving transplant. The enzymes FpGalNAc deacetylase and FpGalactosaminidase, used in combination, have been described to effectively convert group A (ABO-A) red blood cells (RBCs) to group O (ABO-O). Here, we study the safety and preclinical efficacy of using these enzymes to remove A antigen (A-Ag) from human donor lungs using ex vivo lung perfusion (EVLP). First, the ability of these enzymes to remove A-Ag in organ perfusate solutions was examined on five human ABO-A1 RBC samples and three human aortae after static incubation. The enzymes removed greater than 99 and 90% A-Ag from RBCs and aortae, respectively, at concentrations as low as 1 μg/ml. Eight ABO-A1 human lungs were then treated by EVLP. Baseline analyses of A-Ag in lungs revealed expression predominantly in the endothelial and epithelial cells. EVLP of lungs with enzyme-containing perfusate removed over 97% of endothelial A-Ag within 4 hours. No treatment-related acute lung toxicity was observed. An ABO-incompatible transplant was then simulated with an ex vivo model of antibody-mediated rejection using ABO-O plasma as the surrogate for the recipient circulation using three donor lungs. The treatment of donor lungs minimized antibody binding, complement deposition, and antibody-mediated injury as compared with control lungs. These results show that depletion of donor lung A-Ag can be achieved with EVLP treatment. This strategy has the potential to expand ABO-incompatible lung transplantation and lead to improvements in fairness of organ allocation.
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Affiliation(s)
- Aizhou Wang
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Rafaela V P Ribeiro
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Edson Brambate
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Etienne Abdelnour-Berchtold
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Vinicius Michaelsen
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Yu Zhang
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Peter Rahfeld
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Haisle Moon
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, Life Science Institute, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Hemant Gokhale
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Anajara Gazzalle
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada
| | - Prodipto Pal
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON M5S 1A8, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Departments of Surgery, Medicine and Physiology and Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON M5T 1P5, Canada
| | - Thomas K Waddell
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | | | - Kathryn Tinckam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON M5S 1A8, Canada.,Department of Medicine, University Health Network and University of Toronto, Toronto, ON M5G 2C4, Canada
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, Life Science Institute, University of British Columbia, Vancouver, BC V6T 1Z3, Canada.,School of Biomedical Engineering, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Lori West
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada.,Canadian Donation and Transplantation Research Program, Edmonton AB T6G 1C9, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Stephen G Withers
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Ajmera Transplant Centre, Toronto General Hospital Research Institute, University Health Network, ON M5G 1L7, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
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15
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Shino MY, Zhang Q, Li N, Derhovanessian A, Ramsey A, Saggar R, Britton IN, Amubieya OO, Lari SM, Hickey M, Reed EF, Noble PW, Stripp BR, Fishbein GA, Lynch JP, Ardehali A, Sayah DM, Weigt SS, Belperio JA. The allograft injury marker CXCL9 determines prognosis of anti-HLA antibodies after lung transplantation. Am J Transplant 2022; 22:565-573. [PMID: 34464505 PMCID: PMC10826889 DOI: 10.1111/ajt.16827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 01/25/2023]
Abstract
Despite the common detection of non-donor specific anti-HLA antibodies (non-DSAs) after lung transplantation, their clinical significance remains unclear. In this retrospective single-center cohort study of 325 lung transplant recipients, we evaluated the association between donor-specific HLA antibodies (DSAs) and non-DSAs with subsequent CLAD development. DSAs were detected in 30% of recipients and were associated with increased CLAD risk, with higher HRs for both de novo and high MFI (>5000) DSAs. Non-DSAs were detected in 56% of recipients, and 85% of DSA positive tests had concurrent non-DSAs. In general, non-DSAs did not increase CLAD risk in multivariable models accounting for DSAs. However, non-DSAs in conjunction with high BAL CXCL9 levels were associated with increased CLAD risk. Multivariable proportional hazards models demonstrate the importance of the HLA antibody-CXCL9 interaction: CLAD risk increases when HLA antibodies (both DSAs and non-DSAs) are detected in conjunction with high CXCL9. Conversely, CLAD risk is not increased when HLA antibodies are detected with low CXCL9. This study supports the potential utility of BAL CXCL9 measurement as a biomarker to risk stratify HLA antibodies for future CLAD. The ability to discriminate between high versus low-risk HLA antibodies may improve management by allowing for guided treatment decisions.
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Affiliation(s)
- Michael Y. Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Qiuheng Zhang
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ning Li
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ian N. Britton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Olawale O. Amubieya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Shahrzad M. Lari
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michelle Hickey
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Elaine F. Reed
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Paul W. Noble
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Barry R. Stripp
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Gregory A. Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P. Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M. Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S. Sam Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A. Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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16
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Cone BD, Zhang JQ, Sosa RA, Calabrese F, Reed EF, Fishbein GA. Phosphorylated S6 ribosomal protein expression by immunohistochemistry correlates with de novo donor-specific HLA antibodies in lung allograft recipients. J Heart Lung Transplant 2021; 40:1164-1171. [PMID: 34330604 DOI: 10.1016/j.healun.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Per the ISHLT 2016 definition, a C4d-positive lung biopsy is required to meet criteria for definite antibody-mediated rejection (AMR). Unfortunately, C4d has poor sensitivity and specificity, and low inter-rater reliability. Phosphorylated S6 ribosomal protein (p-S6RP) expressed via the mTOR pathway has been shown to be a biomarker of AMR and correlates with donor-specific antibodies (DSA) in heart allografts. However, p-S6RP immunohistochemistry (IHC) in the setting of pulmonary AMR has yet to be evaluated. We sought to determine whether p-S6RP IHC performed on lung biopsies correlates with de novo DSA. METHODS IHC for p-S6RP performed on 26 biopsies from lung transplant recipients with de novo HLA DSA (DSA+) and 28 biopsies from patients with no DSA (DSA-) were evaluated by 3 pathologists who independently scored the degree of alveolar macrophage and pneumocyte staining. Staining in ≥50% of the biopsy as determined by at least 2 pathologists was considered positive. RESULTS Twenty-one (81%) DSA+ biopsies stained positive for p-S6RP in pneumocytes and 21 (81%) in macrophages. Six DSA- biopsies (21%) stained positive for p-S6RP in pneumocytes, 6 (21%) were positive in macrophages. Pneumocyte p-S6RP staining was 81% sensitive and 79% specific for DSA. Macrophage staining showed the same sensitivity and specificity but with lower inter-rater agreement (κ = 0.53 vs 0.68). CONCLUSIONS This study demonstrates a positive relationship between de novo DSA and p-S6RP expression in pneumocytes and macrophages using IHC. p-S6RP is relatively sensitive and specific, and has superior inter-rater reliability compared to C4d.
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Affiliation(s)
- Brian D Cone
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Q Zhang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rebecca A Sosa
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Elaine F Reed
- David Geffen School of Medicine at UCLA, Los Angeles, California
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17
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Halverson LP, Hachem RR. Antibody-Mediated Rejection and Lung Transplantation. Semin Respir Crit Care Med 2021; 42:428-435. [PMID: 34030204 DOI: 10.1055/s-0041-1728796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antibody-mediated rejection (AMR) is now a widely recognized form of lung allograft rejection, with mounting evidence for AMR as an important risk factor for the development of chronic lung allograft dysfunction and markedly decreased long-term survival. Despite the recent development of the consensus diagnostic criteria, it remains a challenging diagnosis of exclusion. Furthermore, even after diagnosis, treatment directed at pulmonary AMR has been nearly exclusively derived from practices with other solid-organ transplants and other areas of medicine, such that there is a significant lack of data regarding the efficacy for these in pulmonary AMR. Lastly, outcomes after AMR remain quite poor despite aggressive treatment. In this review, we revisit the history of AMR in lung transplantation, describe our current understanding of its pathophysiology, discuss the use and limitations of the consensus diagnostic criteria, review current treatment strategies, and summarize long-term outcomes. We conclude with a synopsis of our most pressing gaps in knowledge, introduce recommendations for future directions, and highlight promising areas of active research.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, Missouri
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18
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Werlein C, Seidel A, Warnecke G, Gottlieb J, Laenger F, Jonigk D. Lung Transplant Pathology: An Overview on Current Entities and Procedures. Surg Pathol Clin 2020; 13:119-140. [PMID: 32005428 DOI: 10.1016/j.path.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alloimmune reactions are, besides various infections, the major cause for impaired lung allograft function following transplant. Acute cellular rejection is not only a major trigger of acute allograft failure but also contributes to development of chronic lung allograft dysfunction. Analogous to other solid organ transplants, acute antibody-mediated rejection has become a recognized entity in lung transplant pathology. Adequate sensitivity and specificity in the diagnosis of alloimmune reactions in the lung can only be achieved by synoptic analysis of histopathologic, clinical, and radiological findings together with serologic and microbiologic findings.
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Affiliation(s)
- Christopher Werlein
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
| | - Allison Seidel
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Gregor Warnecke
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Jens Gottlieb
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Pneumology, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Florian Laenger
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Danny Jonigk
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
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19
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The impact of C4d testing on tissue adequacy in lung transplant surveillance. Ann Diagn Pathol 2020; 48:151564. [PMID: 32659621 DOI: 10.1016/j.anndiagpath.2020.151564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/21/2020] [Accepted: 06/21/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surveillance transbronchial biopsies are routinely used to assess lung allograft rejection. While the criteria for diagnosing acute cellular rejection have been well-established, the morphological findings associated with antibody mediated rejection are variable. To increase the sensitivity for antibody mediated rejection, a portion of a biopsy can be used for C4d immunofluorescence testing, along with histologic findings and donor specific antibodies. When the number of alveolar pieces in a biopsy is small, the relative utility of sending one piece for C4d testing is unclear. METHODS Pathology reports of 1400 surveillance transbronchial lung biopsies from 2008 to 2017 were reviewed to obtain the number of pieces of alveolar parenchyma in each case. Based on a standard definition of adequacy as five pieces of well-expanded alveolar parenchyma, reports with five fragments were grouped as "adequate", four pieces as a "marginal" sample, and three or less were considered an "inadequate" sample. RESULTS Of the 1400 biopsies, 653 specimens had 5 or more pieces of alveolar parenchyma.747 specimens were submitted with less than 5 pieces and 290 of those were considered marginal. In all marginal cases, a piece was withheld for C4d immunofluorescence testing. CONCLUSIONS About 21% of specimens would have the recommended 5 pieces of alveolar parenchyma if not for the withholding of pieces for C4d IF testing. Over the span of 10 years, 290 such cases were recorded at our institution. Given this nontrivial impact, it is unclear if C4d immunofluorescence testing should be performed on surveillance transbronchial biopsies when the number of pieces in the specimen is marginal.
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20
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Tejada S, Campogiani L, Mazo C, Romero A, Peña Y, Pont T, Gómez A, Román A, Rello J. Acute respiratory failure among lung transplant adults requiring intensive care: Changing spectrum of causative organisms and impact of procalcitonin test in the diagnostic workup. Transpl Infect Dis 2020; 22:e13346. [PMID: 32473604 DOI: 10.1111/tid.13346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim was to identify the causing organisms and assess the association of procalcitonin (PCT) with bacterial pneumonia within 24 hours of intensive care unit admission (ICU-A) among lung transplant (LT) adult recipients. METHODS Secondary analysis from a prospective cohort study. All LT adults admitted to ICU for acute respiratory failure (ARF) over 5 years were included. Patients were followed until hospital discharge or death. RESULTS Fifty-eight consecutive LT patients were enrolled. The most important cause of ICU-A due to ARF was pneumonia 29 (50%) followed by acute rejection 3 (5.2%) and bronchiolitis obliterans syndrome exacerbation 3 (5.2%). Microorganisms were isolated from 22/29 cases with pneumonia (75.9%): 17 (77.2%) bacterial, 4 (18.2%) viral, 1 (4.5%) Aspergillus fumigates, with Pseudomonas aeruginosa being the most common cause (45.5%) of pneumonia, with 10 patients presenting chronic colonization by P aeruginosa. Median [Interquartile range (IQR)] PCT levels within 24 hours after admission were higher in pneumonia (1.5 µg/L; IQR:0.3-22.0), than in non-pneumonia cases (0.2 µg/L; IQR:0.1-0.7) (P = .019) and PCT levels within 24 hours helped to discriminate bacterial pneumonia (8.2 µg/L; IQR:0.2-43.0) from viral pneumonia and non-pneumonia cases (0.2 µg/L; IQR:0.1-0.7). The overall negative predictive value for bacterial pneumonia was 85.1%, increasing to 91.6% among episodes after 6 months of LT. CONCLUSIONS Causes of severe pneumonia in LT are changing, with predominant role of P aeruginosa and respiratory viruses. PCT ≤ 0.5 μg/L within 24 hours helps to exclude bacterial pneumonia diagnosis in LT adults requiring ICU-A. A negative PCT test allows antimicrobial de-escalation and requires an alternative diagnostic to bacterial pneumonia.
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Affiliation(s)
- Sofia Tejada
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Laura Campogiani
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy
| | - Cristopher Mazo
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Anabel Romero
- ONCOBELL Program - Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Yolanda Peña
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Teresa Pont
- Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Aroa Gómez
- Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antonio Román
- Respiratory Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Rello
- CIBER de Enfermedades Respiratorias (CIBERES), Instituo Salud Carlos III, Madrid, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain.,Anesthesia Department, Clinical Research in the ICU, CHU Nimes, Universite de Nimes-Montpellier, Nimes, France
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21
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Benazzo A, Worel N, Schwarz S, Just U, Nechay A, Lambers C, Böhmig G, Fischer G, Koren D, Muraközy G, Knobler R, Klepetko W, Hoetzenecker K, Jaksch P. Outcome of Extracorporeal Photopheresis as an Add-On Therapy for Antibody-Mediated Rejection in Lung Transplant Recipients. Transfus Med Hemother 2020; 47:205-213. [PMID: 32595425 DOI: 10.1159/000508170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/26/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction The diagnosis and treatment of antibody-mediated rejection (AMR) after lung transplantation has recently gained recognition within the transplant community. Extracorporeal photopheresis (ECP), currently used to treat chronic lung allograft dysfunction, modulates various pathways of the immune system known to be involved in AMR. We hypothesize that adding ECP to established AMR treatments could prevent the rebound of donor-specific antibodies (DSA). Objectives This study aimed to analyze the role of ECP as an add-on therapy to prevent the rebound of DSA. Methods Lung transplant recipients who received ECP as an add-on therapy for pulmonary AMR between January 2010 and January 2019 were included in this single-center retrospective analysis. Baseline demographics of the patients, as well as their immunological characteristics and long-term transplant outcomes, were analyzed. Results A total of 41 patients developed clinical AMR during the study period. Sixteen patients received ECP as an add-on therapy after first-line AMR treatment. Among the 16 patients, 2 (13%) had pretransplant DSA, both against human leukocyte antigen (HLA) class I (B38, B13, and C06). Fifteen patients (94%) developed de novo DSA (dnDSA), i.e., 10 (63%) against class I and 14 (88%) against class II. The median time to dnDSA after lung transplantation was 361 days (range 25-2,548). According to the most recent International Society of Heart and Lung Transplantation (ISHLT) consensus report, 2 (13%) patients had definite clinical AMR, 6 (38%) had probable AMR, and 7 (44%) had possible AMR. The median mean fluorescence intensity (MFI) of dnDSA at the time of clinical diagnosis was 4,220 (range 1,319-10,552) for anti-HLA class I and 10,953 (range 1,969-27,501) for anti-HLA class II antibodies. ECP was performed for a median of 14 cycles (range 1-64). MFI values of dnDSA against HLA classes I and II were significantly reduced over the treatment period (for anti-class I: 752; range 70-2,066; for anti-class II: 5,612; range 1,689-21,858). The 1-year survival rate was 55%. No adverse events related to ECP were reported in any of the patients. Conclusions ECP is associated with a reduction of dnDSA in lung transplant recipients affected by AMR. Prospective studies are warranted to confirm the beneficial effects of ECP in the setting of AMR.
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Affiliation(s)
- Alberto Benazzo
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulrike Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Anna Nechay
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Lambers
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniela Koren
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Gabriela Muraközy
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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22
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Bery AI, Hachem RR. Antibody-mediated rejection after lung transplantation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:411. [PMID: 32355855 PMCID: PMC7186640 DOI: 10.21037/atm.2019.11.86] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibody-mediated rejection (AMR) has been identified as a significant form of acute allograft dysfunction in lung transplantation. The development of consensus diagnostic criteria has created a uniform definition of AMR; however, significant limitations of these criteria have been identified. Treatment modalities for AMR have been adapted from other areas of medicine and data on the effectiveness of these therapies in AMR are limited. AMR is often refractory to these therapies, and graft failure and death are common. AMR is associated with increased rates of chronic lung allograft dysfunction (CLAD) and poor long-term survival. In this review, we discuss the history of AMR and describe known mechanisms, application of the consensus diagnostic criteria, data for current treatment strategies, and long-term outcomes. In addition, we highlight current gaps in knowledge, ongoing research, and future directions to address these gaps. Promising diagnostic techniques are actively being investigated that may allow for early detection and treatment of AMR. We conclude that further investigation is required to identify and define chronic and subclinical AMR, and head-to-head comparisons of currently used treatment protocols are necessary to identify an optimal treatment approach. Gaps in knowledge regarding the epidemiology, mechanisms, diagnosis, and treatment of AMR continue to exist and future research should focus on these aspects.
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Affiliation(s)
- Amit I Bery
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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23
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Agbor-Enoh S. 2018 ATS BEAR Cage Winning Proposal: Cell-Free DNA to Improve Lung Transplant Outcomes. Am J Respir Crit Care Med 2020; 199:1058-1060. [PMID: 30884244 PMCID: PMC6515866 DOI: 10.1164/rccm.201902-0458ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sean Agbor-Enoh
- 1 Division of Intramural Research National Heart, Lung, and Blood Institute Bethesda, Maryland and.,2 Division of Pulmonary and Critical Care Medicine Johns Hopkins School of Medicine Baltimore, Maryland
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24
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Alexander MP, Bentall A, Aleff PCA, Gandhi MJ, Scott JP, Roden AC. Ultrastructural changes in pulmonary allografts with antibody-mediated rejection. J Heart Lung Transplant 2019; 39:165-175. [PMID: 31870771 DOI: 10.1016/j.healun.2019.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/02/2019] [Accepted: 11/27/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is an important cause of lung allograft loss in some patients. Challenges with current diagnostic criteria limit timely detection. Ultrastructural studies of endothelia allow the early detection of AMR in kidney allografts. This study aimed to define the ultrastructural changes of the endothelium in lung allografts in the setting of AMR and determine its specificity for AMR. METHODS Ultrastuctural studies were performed on lung allograft biopsies of 12 patients using glutaraldehyde-fixed or paraffin-embedded material. AMR had been classified according to the International Society of Heart and Lung Transplant 2016 consensus report criteria. Endothelial changes (swelling [ES], vacuolization [EV], surface irregularity, detachment, neutrophil margination [NM]) and basement membrane changes were graded semi quantitatively using electron microscopy (EM). Grades were compared between AMR, acute cellular rejection, and non-transplant controls. RESULTS Significant differences were found between AMR and acute cellular reaction biopsies, particularly in ES (p = 0.006), EV (p = 0.023) and NM (p = 0.038). Using a combined score of all categories of assessment, the total EM score was significantly higher in AMR (p = 0.007) and provided excellent sensitivity and specificity with a receiver operator characteristic curve of 1.0. C4d did not correlate with EM changes associated with AMR. The use of paraffin-embedded material samples did not significantly affect the analysis compared with glutaraldehyde-fixed tissue, although ES was reduced in the former. CONCLUSIONS Endothelial structural analysis using EM can facilitate improved diagnostic accuracy of AMR and needs to be validated in larger cohorts, but it also allows retrospective studies to be performed.
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Affiliation(s)
| | | | | | | | - John P Scott
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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25
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Mazo C, Pont T, Ballesteros MA, López E, Rellán L, Robles JC, Rello J. Pneumonia versus graft dysfunction as the cause of acute respiratory failure after lung transplant: a 4-year multicentre prospective study in 153 adults requiring intensive care admission. Eur Respir J 2019; 54:13993003.01512-2018. [PMID: 31346003 DOI: 10.1183/13993003.01512-2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 06/25/2019] [Indexed: 01/02/2023]
Abstract
We aimed to assess the main causes of intensive care unit (ICU) readmissions in lung transplant adults and to identify independent predictors of ICU mortality (primary end-point).This Spanish five-centre prospective cohort study enrolled all lung transplant adults with ICU readmissions after post-transplant ICU discharge between 2012 and 2016. Patients were followed until hospital discharge or death.153 lung transplant recipients presented 174 ICU readmissions at a median (interquartile range) of 6 (2-25) months post-transplant. Chronic lung allograft dysfunction was reported in 39 (25.5%) recipients, 13 of whom (all exitus) had restrictive allograft syndrome (RAS). Acute respiratory failure (ARF) (110 (71.9%)) was the main condition requiring ICU readmission. Graft rejection (six (5.4%) acute) caused only 12 (10.8%) readmissions whereas pneumonia (56 (36.6%)) was the main cause (50 admitted for ARF and six for shock), with Pseudomonas aeruginosa (50% multidrug resistant) being the predominant pathogen. 55 (35.9%) and 69 (45.1%) recipients died in the ICU and the hospital, respectively. Bronchiolitis obliterans syndrome (BOS) stage 2 (adjusted OR (aOR) 7.2 (95% CI 1.0-65.7)), BOS stage 3 (aOR 13.7 (95% CI 2.5-95.3)), RAS (aOR >50) and pneumonia at ICU readmission (aOR 2.5 (95% CI 1.0-7.1)) were identified in multivariate analyses as independent predictors of ICU mortality. Only eight (5.2%) patients had positive donor-specific antibodies prior to ICU readmission and this variable did not affect the model.ARF was the main condition requiring ICU readmission in lung transplant recipients and was associated with high mortality. Pneumonia was the main cause of death and was also an independent predictor. RAS should receive palliative care rather than ICU admission.
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Affiliation(s)
- Cristopher Mazo
- Transplant Procurement Dept, Vall d'Hebron University Hospital, Barcelona, Spain .,Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Dept of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Pont
- Transplant Procurement Dept, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Maria A Ballesteros
- Intensive Care Medicine Dept, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Eloísa López
- Intensive Care Medicine Dept, 12 de Octubre University Hospital, Madrid, Spain
| | - Luzdivina Rellán
- Intensive Care Medicine Dept, A Coruña University Hospital, A Coruña, Spain
| | - Juan C Robles
- Intensive Care Medicine Dept, Reina Sofia University Hospital, Córdoba, Spain
| | - Jordi Rello
- Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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26
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Parulekar AD, Kao CC. Detection, classification, and management of rejection after lung transplantation. J Thorac Dis 2019; 11:S1732-S1739. [PMID: 31632750 DOI: 10.21037/jtd.2019.03.83] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well defined histopathologic diagnostic criteria and grading. Diagnosis of AMR requires a multidisciplinary approach. CLAD is the major barrier to long-term survival following lung transplantation. The most common phenotype of CLAD is bronchiolitis obliterans syndrome (BOS) which is defined by a persistent obstructive decline in lung function. Restrictive allograft dysfunction (RAS) is a second phenotype of CLAD and is associated with a worse prognosis. This article will review the diagnosis, staging, clinical presentation, and treatment of acute rejection, AMR, and CLAD following lung transplantation.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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27
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Wohlschlaeger J, Laenger F, Gottlieb J, Hager T, Seidel A, Jonigk D. Lungentransplantation. DER PATHOLOGE 2019; 40:281-291. [DOI: 10.1007/s00292-019-0598-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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28
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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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29
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Ngo C, Danel C, Duong-Quy S, Dauriat G, Castier Y, Lortat-Jacob B, Mal H, Brugière O, Cazes A. C4d detection and histological patterns in the diagnosis of antibody-mediated rejection after lung transplantation: a single-centre study. Histopathology 2019; 74:988-996. [PMID: 30636056 DOI: 10.1111/his.13823] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 01/10/2019] [Indexed: 12/27/2022]
Abstract
AIMS Antibody-mediated rejection (AMR) is an emerging and challenging issue in transplantation. Endothelial deposition of C4d and microvascular inflammation (MI) are reliable markers of AMR in renal and cardiac transplantation, but remain controversial in the lung. Our aim was to assess C4d immunohistochemistry and histological patterns for the diagnosis of lung AMR. METHODS AND RESULTS We reviewed 158 transbronchial biopsies (TBBs) (n = 85 clinically indicated, and n = 73 surveillance TBBs) from 48 recipients, blinded to clinical and serological data. C4d was scored as 0, 1+ (<10%), 2+ (10-50%) or 3+ (>50%). TBBs were reassessed for MI and acute lung injury (ALI). Donor-specific antibodies (DSAs), acute clinical graft dysfunction and chronic lung allograft graft dysfunction (CLAD) were recorded. C4d3+, C4d2+, C4d1+ and C4d0 occurred respectively in four (2.5%), six (3.8%), 28 (17.7%) and 120 (75.9%) TBBs. MI and ALI were rare but more frequent in C4d1-3+ TBBs than in the absence of C4d. C4d2+ was frequently observed with concomitant infection. Among the surveillance TBBs, only two (2.7%) showed MI. Neither ALI nor C4d3+ was diagnosed on surveillance TBBs. No significant association was found between histopathological findings and DSAs. All four patients with C4d3+ could retrospectively be diagnosed with AMR and developed CLAD. CONCLUSION Although rare, diffuse C4d deposition appears to be a strong indication of acute clinical AMR in lung transplant patients, whereas intermediate C4d2+ requires more investigations. In stable patients, histopathology and C4d may lack the sensitivity to diagnose subclinical AMR. This emphasises the need for a multidisciplinary evaluation of each suspected AMR case, and the need for complementary diagnostic tools.
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Affiliation(s)
- Carine Ngo
- Département de Pathologie, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claire Danel
- Département de Pathologie, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U1152, Paris Diderot University, Paris, France
| | - Sy Duong-Quy
- Department of Lung Function Testing, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Gaëlle Dauriat
- Service de Pneumologie B et Transplantation, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yves Castier
- INSERM U1152, Paris Diderot University, Paris, France.,Service de Chirurgie Vasculaire et Thoracique, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Brice Lortat-Jacob
- Service de Réanimation Chirurgicale, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Hervé Mal
- INSERM U1152, Paris Diderot University, Paris, France.,Service de Pneumologie B et Transplantation, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Brugière
- INSERM U1152, Paris Diderot University, Paris, France.,Service de Pneumologie B et Transplantation, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Pneumologie et Transplantation, Hôpital Foch, Suresnes, France
| | - Aurélie Cazes
- Département de Pathologie, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U1152, Paris Diderot University, Paris, France
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30
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Halloran KM, Parkes MD, Chang J, Timofte IL, Snell GI, Westall GP, Hachem R, Kreisel D, Trulock E, Roux A, Juvet S, Keshavjee S, Jaksch P, Klepetko W, Halloran PF. Molecular assessment of rejection and injury in lung transplant biopsies. J Heart Lung Transplant 2019; 38:504-513. [PMID: 30773443 DOI: 10.1016/j.healun.2019.01.1317] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Improved understanding of lung transplant disease states is essential because failure rates are high, often due to chronic lung allograft dysfunction. However, histologic assessment of lung transplant transbronchial biopsies (TBBs) is difficult and often uninterpretable even with 10 pieces. METHODS We prospectively studied whether microarray assessment of single TBB pieces could identify disease states and reduce the amount of tissue required for diagnosis. By following strategies successful for heart transplants, we used expression of rejection-associated transcripts (annotated in kidney transplant biopsies) in unsupervised machine learning to identify disease states. RESULTS All 242 single-piece TBBs produced reliable transcript measurements. Paired TBB pieces available from 12 patients showed significant similarity but also showed some sampling variance. Alveolar content, as estimated by surfactant transcript expression, was a source of sampling variance. To offset sampling variation, for analysis, we selected 152 single-piece TBBs with high surfactant transcripts. Unsupervised archetypal analysis identified 4 idealized phenotypes (archetypes) and scored biopsies for their similarity to each: normal; T-cell‒mediated rejection (TCMR; T-cell transcripts); antibody-mediated rejection (ABMR)-like (endothelial transcripts); and injury (macrophage transcripts). Molecular TCMR correlated with histologic TCMR. The relationship of molecular scores to histologic ABMR could not be assessed because of the paucity of ABMR in this population. CONCLUSIONS Molecular assessment of single-piece TBBs can be used to classify lung transplant biopsies and correlated with rejection histology. Two or 3 pieces for each TBB will probably be needed to offset sampling variance.
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Affiliation(s)
- Kieran M Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Parkes
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Jessica Chang
- Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada
| | - Irina L Timofte
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland at Baltimore, Baltimore, Maryland, USA
| | - Gregory I Snell
- Lung Transplant Service, Alfred Hospital, Monash University, Melbourne, Australia
| | - Glen P Westall
- Lung Transplant Service, Alfred Hospital, Monash University, Melbourne, Australia
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Elbert Trulock
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Antoine Roux
- Service de Pneumologie, Hôpital Foch, Suresnes, France
| | - Stephen Juvet
- Department of Medicine University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Department of Medicine University Health Network, Toronto, Ontario, Canada
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Alberta Transplant Applied Genomics Center, Edmonton, Alberta, Canada.
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Roux A, Levine DJ, Zeevi A, Hachem R, Halloran K, Halloran PF, Gibault L, Taupin JL, Neil DAH, Loupy A, Adam BA, Mengel M, Hwang DM, Calabrese F, Berry G, Pavlisko EN. Banff Lung Report: Current knowledge and future research perspectives for diagnosis and treatment of pulmonary antibody-mediated rejection (AMR). Am J Transplant 2019; 19:21-31. [PMID: 29956477 DOI: 10.1111/ajt.14990] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 01/25/2023]
Abstract
The Lung session of the 2017 14th Banff Foundation for Allograft Pathology Conference, Barcelona focused on the multiple aspects of antibody-mediated rejection (AMR) in lung transplantation. Multidimensional approaches for AMR diagnosis, including classification, histological and immunohistochemical analysis, and donor- specific antibody (DSA) characterization with their current strengths and limitations were reviewed in view of recent research. The group also discussed the role of tissue gene expression analysis in the context of unmet needs in lung transplantation. The current best practice for monitoring of AMR and the therapeutic approach are summarized and highlighted in this report. The working group reached consensus of the major gaps in current knowledge and focused on the unanswered questions regarding pulmonary AMR. An important outcome of the meeting was agreement on the need for future collaborative research projects to address these gaps in the field of lung transplantation.
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Affiliation(s)
- A Roux
- Pneumology, Adult CF Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Paris Translational Research Center for Organ Transplantation, French National institute of Health and Medical Research (INSERM). Unit UMR S970, Paris, France.,Versailles Saint-Quentin-en-Yvelines University, UPRES EA 220, Suresnes, France
| | - D J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - R Hachem
- Washington University, School of Medicine Division of Pulmonary & Critical Care, St. Louis, MO, USA
| | - K Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P F Halloran
- Alberta Transplant Applied Genomics Center, University of Alberta, Edmonton, Alberta, Canada
| | - L Gibault
- Department of Pathology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J L Taupin
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - D A H Neil
- Department of Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation, French National institute of Health and Medical Research (INSERM). Unit UMR S970, Paris, France
| | - B A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - M Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - D M Hwang
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - F Calabrese
- Department of Cardio-Thoracic and Vascular Sciences, Pathology Section, University of Padova, Italy
| | - G Berry
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - E N Pavlisko
- Department of Pathology, Duke University Hospital, Durham, NC, USA
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Hayes D, Parekh H, Baker PB. C3d deposition and antibody-mediated rejection after lung transplantation. J Heart Lung Transplant 2018; 37:1388-1389. [PMID: 30241888 DOI: 10.1016/j.healun.2018.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/17/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Don Hayes
- Nationwide Children's Hospital, Columbus, Ohio, USA; Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Hemant Parekh
- Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Agbor-Enoh S, Jackson AM, Tunc I, Berry GJ, Cochrane A, Grimm D, Davis A, Shah P, Brown AW, Wang Y, Timofte I, Shah P, Gorham S, Wylie J, Goodwin N, Jang MK, Marishta A, Bhatti K, Fideli U, Yang Y, Luikart H, Cao Z, Pirooznia M, Zhu J, Marboe C, Iacono A, Nathan SD, Orens J, Valantine HA, Khush K. Late manifestation of alloantibody-associated injury and clinical pulmonary antibody-mediated rejection: Evidence from cell-free DNA analysis. J Heart Lung Transplant 2018; 37:925-932. [DOI: 10.1016/j.healun.2018.01.1305] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 10/24/2022] Open
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Current challenges and opportunities in the management of antibody-mediated rejection in lung transplantation. Curr Opin Organ Transplant 2018; 23:308-315. [DOI: 10.1097/mot.0000000000000537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Aguilar PR, Carpenter D, Ritter J, Yusen RD, Witt CA, Byers DE, Mohanakumar T, Kreisel D, Trulock EP, Hachem RR. The role of C4d deposition in the diagnosis of antibody-mediated rejection after lung transplantation. Am J Transplant 2018; 18:936-944. [PMID: 28992372 PMCID: PMC5878693 DOI: 10.1111/ajt.14534] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/10/2017] [Accepted: 09/29/2017] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, P = .035), there was no significant difference in the presence of other histologic findings. Despite aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but that the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may respond initially to therapy, there is a high incidence of CLAD and poor survival after AMR.
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Affiliation(s)
- PR Aguilar
- Baylor University Medical Center Division of Pulmonary & Critical Care, Dallas, TX
| | - D Carpenter
- St. Louis University School of Medicine Department of Pathology, St. Louis, MO
| | - J Ritter
- Washington University School of Medicine Department of Pathology & Immunology, St. Louis, MO
| | - RD Yusen
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - CA Witt
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - DE Byers
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | | | - D Kreisel
- Washington University School of Medicine Division of Cardiothoracic Surgery, St. Louis, MO
| | - EP Trulock
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - RR Hachem
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
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Pathology of Lung Rejection: Cellular and Humoral Mediated. LUNG TRANSPLANTATION 2018. [PMCID: PMC7122533 DOI: 10.1007/978-3-319-91184-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute rejection is an important risk factor for bronchiolitis obliterans syndrome, the clinical manifestation of chronic airway rejection in lung allograft recipients. Patients with acute rejection might be asymptomatic or present with symptoms that are not specific and can be also seen in other conditions. Clinical tests such as pulmonary function tests and imaging studies among others usually are abnormal; however, their results are also not specific for acute rejection. Histopathologic features of acute rejection in adequate samples of transbronchial lung biopsy of the lung allograft are currently the gold standard to assess for acute rejection in lung transplant recipients. Acute alloreactive injury can affect both the vasculature and the airways. Currently, the guidelines of the 2007 International Society of Heart and Lung Transplantation consensus conference are recommended for the histopathologic assessment of rejection. There are no specific morphologic features recognized to diagnose antibody-mediated rejection (AMR) in lung allografts. Therefore, the diagnosis of AMR currently requires a “triple test” including clinical features, serologic evidence of donor-specific antibodies, and pathologic findings supportive of AMR. Complement 4d deposition is used to support a diagnosis of AMR in many solid organ transplants; however, its significance for the diagnosis of AMR in lung allografts is not entirely clear. This chapter discusses the currently recommended guidelines for the assessment of cellular rejection of lung allografts and summarizes our knowledge about morphologic features and immunophenotypic tests that might help in the diagnosis of AMR.
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Abstract
Despite induction immunosuppression and the use of aggressive maintenance immunosuppressive regimens, acute allograft rejection following lung transplantation is still a problem with important diagnostic and therapeutic challenges. As well as causing early graft loss and mortality, acute rejection also initiates the chronic alloimmune responses and airway-centred inflammation that predispose to bronchiolitis obliterans syndrome (BOS), also known as chronic lung allograft dysfunction (CLAD), which is a major source of morbidity and mortality after lung transplantation. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, but the influence of humoral immunity is increasingly recognised. As with other several other solid organ transplants, antibody-mediated rejection (AMR) is now a well-accepted and distinct clinical entity in lung transplantation. While acute cellular rejection (ACR) has defined histopathological criteria, transbronchial biopsy is less useful in AMR and its diagnosis is complicated by challenges in the measurement of antibodies directed against donor HLA, and a determination of their significance. Increasing awareness of the importance of non-HLA antigens further clouds this issue. Here, we review the pathophysiology, diagnosis, clinical presentation and treatment of ACR and AMR in lung transplantation, and discuss future potential biomarkers of both processes that may forward our understanding of these conditions.
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Affiliation(s)
- Mark Benzimra
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - Greg L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Allan R Glanville
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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Abstract
Despite advances in immunosuppression over the past 25 years, acute cellular rejection remains a common complication early after lung transplantation. Although acute cellular rejection has often not resulted in clinical signs or symptoms of allograft dysfunction, it has been widely recognized as a strong independent risk factor for the development of chronic rejection, emphasizing its clinical significance. In recent years, the role of humoral immunity in lung rejection has been increasingly appreciated, and antibody-mediated rejection is now recognized as a form of rejection that may result in allograft failure.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110, USA.
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Miyamoto E, Motoyama H, Sato M, Aoyama A, Menju T, Shikuma K, Sowa T, Yoshizawa A, Saito M, Takahagi A, Tanaka S, Takahashi M, Ohata K, Kondo T, Hijiya K, Chen-Yoshikawa TF, Date H. Association of Local Intrapulmonary Production of Antibodies Specific to Donor Major Histocompatibility Complex Class I With the Progression of Chronic Rejection of Lung Allografts. Transplantation 2017; 101:e156-e165. [PMID: 28207638 DOI: 10.1097/tp.0000000000001665] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibody-mediated rejection may lead to chronic lung allograft dysfunction, but antibody-mediated rejection may develop in the absence of detectable donor-specific antibody (DSA) in recipient serum. This study investigated whether humoral immune responses develop not only systemically but locally within rejected lung allografts, resulting in local production of DSA. METHODS Lewis rats received orthotopic left lung transplantation from Lewis (syngeneic control) or Brown-Norway (major histocompatibility complex-mismatched allogeneic) donor rats. Rats that underwent allogeneic lung transplantation were subsequently administered cyclosporine until day 14 (short immunosuppression) or day 35 (long immunosuppression). The lung grafts and spleens of recipient animals were tissue cultured for 4 days, and the titer of antibody against donor major histocompatibility complex molecules was assayed by flow cytometry. Explanted lung grafts were also evaluated pathologically. RESULTS By day 98, DSA titers in supernatants of lung graft (P = 0.0074) and spleen (P = 0.0167) cultures, but not serum, from the short immunosuppression group were significantly higher than titers in syngeneic controls. Cultures and sera from the long immunosuppression group showed no production of DSA. Microscopically, the lung grafts from the short immunosuppression group showed severe bronchiole obliteration and parenchymal fibrosis, along with lymphoid aggregates containing T and B cells, accompanying plasma cells. These findings suggestive of local humoral immune response were not observed by days 28 and 63. CONCLUSIONS DSA can be locally produced in chronically rejected lung allografts, along with intragraft immunocompetent cells. Clinical testing of DSA in serum samples alone may underestimate lung allograft dysfunction.
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Affiliation(s)
- Ei Miyamoto
- 1 Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 2 Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan. 3 Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
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Islam AK, Sinha N, DeVos JM, Kaleekal TS, Jyothula SS, Teeter LD, Nguyen DTM, Eagar TN, Moore LW, Puppala M, Wong STC, Knight RJ, Frost AE, Graviss EA, Osama Gaber A. Early clearance vs persistence of de novo donor-specific antibodies following lung transplantation. Clin Transplant 2017; 31. [PMID: 28658512 DOI: 10.1111/ctr.13028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The natural history of de novo donor-specific antibodies (dnDSA) after lung transplantation is not well-described. We sought to determine the incidence and risk factors associated with dnDSA and compare outcomes between recipients with transient (or isolated) vs persistent dnDSA after transplantation. METHODS A single-center review of all lung transplants from 1/2009-7/2013. DSAs were tested eight times in the first year and every 4 months thereafter. Outcomes examined included acute rejection and graft failure. RESULTS Median follow-up was 18 months (range: 1-61 months), and 24.6% of 333 first-time lung-only transplant recipients developed a dnDSA. Ethnicity, HLA-DQ mismatches, post-transplantation platelet transfusion and Lung Allocation Score >60 were associated with dnDSA (P<.05). Overall graft survival was worse for dnDSA-positive vs negative recipients (P=.025). Of 323 recipients with 1-year follow-up, 72 (22.2%) developed dnDSA, and in 25 (34.7%), the dnDSA was transient and cleared. Recipients with transient dnDSA were less likely to develop acute rejection than those with persistent dnDSA (P=.007). CONCLUSIONS Early post-lung transplantation, dnDSA occurred in 1/4 of recipients, was associated with peri-transplant risk factors and resulted in decreased survival. Spontaneous clearance of dnDSA, seen in one-third of recipients, was associated with a lower risk of acute rejection.
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Affiliation(s)
- Ana K Islam
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Neeraj Sinha
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Jennifer M DeVos
- Department of Solid Organ Transplant Clinical Pharmacy, University of Kansas Medical Hospital, Kansas City, KS, USA
| | - Thomas S Kaleekal
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Soma S Jyothula
- Department of Pulmonary and Critical Care, Memorial Hermann Hospital, Houston, TX, USA
| | | | - Duc T M Nguyen
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Todd N Eagar
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Mamta Puppala
- Department of Systems Medicine and Bioengineering, Houston Methodist Hospital, Houston, TX, USA
| | - Stephen T C Wong
- Department of Systems Medicine and Bioengineering, Houston Methodist Hospital, Houston, TX, USA
| | - Richard J Knight
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Edward A Graviss
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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IgM-Enriched Human Intravenous Immunoglobulin-Based Treatment of Patients With Early Donor Specific Anti-HLA Antibodies After Lung Transplantation. Transplantation 2017; 100:2682-2692. [PMID: 26714123 PMCID: PMC5120772 DOI: 10.1097/tp.0000000000001027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND At our institution, until April 2013, patients who showed early donor specific anti-HLA antibodies (DSA) after lung transplantation were preemptively treated with therapeutic plasma exchange (tPE) and a single dose of Rituximab. In April 2013, we moved to a therapy based on IgM-enriched human immunoglobulins (IVIG), repeated every 4 weeks, and a single dose of Rituximab. METHODS This observational study was designed to evaluate the short-term patient and graft survival in patients who underwent IVIG-based DSA treatment (group A, n = 57) versus contemporary patients transplanted between April 2013 and January 2015 without DSA (group C, n = 180), as well as to evaluate DSA clearance in IVIG-treated patients versus historic patients who had undergone tPE-based treatment (group B, n = 56). Patient records were retrospectively reviewed. Follow-up ended on April 1, 2015. RESULTS At 6 months and 1 year of follow-up, group A had a survival similar to group C (P = 0.81) but better than group B (P = 0.008). Group A showed statistically nonsignificant trends toward improved freedom from pulsed-steroid therapy and biopsy-confirmed rejection over groups B and C. The DSA clearance was better in group A than group B at treatment end (92% vs 64%; P = 0.002) and last DSA control (90% vs 75%; P = 0.04). CONCLUSIONS Patients with new early DSA but without graft dysfunction that are treated with IVIG and Rituximab have similarly good early survival as contemporary lung transplant recipients without early DSA. The IVIG yielded increased DSA clearance compared with historic tPE-based treatment, yet spontaneous clearance of new DSA also remains common.
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Lama VN, Belperio JA, Christie JD, El-Chemaly S, Fishbein MC, Gelman AE, Hancock WW, Keshavjee S, Kreisel D, Laubach VE, Looney MR, McDyer JF, Mohanakumar T, Shilling RA, Panoskaltsis-Mortari A, Wilkes DS, Eu JP, Nicolls MR. Models of Lung Transplant Research: a consensus statement from the National Heart, Lung, and Blood Institute workshop. JCI Insight 2017; 2:93121. [PMID: 28469087 DOI: 10.1172/jci.insight.93121] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Lung transplantation, a cure for a number of end-stage lung diseases, continues to have the worst long-term outcomes when compared with other solid organ transplants. Preclinical modeling of the most common and serious lung transplantation complications are essential to better understand and mitigate the pathophysiological processes that lead to these complications. Various animal and in vitro models of lung transplant complications now exist and each of these models has unique strengths. However, significant issues, such as the required technical expertise as well as the robustness and clinical usefulness of these models, remain to be overcome or clarified. The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop in March 2016 to review the state of preclinical science addressing the three most important complications of lung transplantation: primary graft dysfunction (PGD), acute rejection (AR), and chronic lung allograft dysfunction (CLAD). In addition, the participants of the workshop were tasked to make consensus recommendations on the best use of these complimentary models to close our knowledge gaps in PGD, AR, and CLAD. Their reviews and recommendations are summarized in this report. Furthermore, the participants outlined opportunities to collaborate and directions to accelerate research using these preclinical models.
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Affiliation(s)
- Vibha N Lama
- Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - John A Belperio
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Souheil El-Chemaly
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, UCLA Center for the Health Sciences, Los Angeles, California, USA
| | - Andrew E Gelman
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wayne W Hancock
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Victor E Laubach
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Mark R Looney
- Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - John F McDyer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Rebecca A Shilling
- Department of Medicine, University of Illinois College of Medicine at Chicago, Illinois, USA
| | - Angela Panoskaltsis-Mortari
- Departments of Pediatrics, and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David S Wilkes
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jerry P Eu
- National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Mark R Nicolls
- Department of Medicine, Stanford University School of Medicine/VA Palo Alto Health Care System, Stanford, California, USA
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Ensor CR, Yousem SA, Marrari M, Morrell MR, Mangiola M, Pilewski JM, D'Cunha J, Wisniewski SR, Venkataramanan R, Zeevi A, McDyer JF. Proteasome Inhibitor Carfilzomib-Based Therapy for Antibody-Mediated Rejection of the Pulmonary Allograft: Use and Short-Term Findings. Am J Transplant 2017; 17:1380-1388. [PMID: 28173620 DOI: 10.1111/ajt.14222] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/08/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
We present this observational study of lung transplant recipients (LTR) treated with carfilzomib (CFZ)-based therapy for antibody-mediated rejection (AMR) of the lung. Patients were considered responders to CFZ if complement-1q (C1q)-fixing ability of their immunodominant (ID) donor-specific anti-human leukocyte antibody (DSA) was suppressed after treatment. Treatment consisted of CFZ plus plasma exchange and immunoglobulins. Fourteen LTRs underwent CFZ for 20 ID DSA AMR. Ten (71.4%) of LTRs responded to CFZ. DSA IgG mean fluorescence intensity (MFI) fell from 7664 (IQR 3230-11 874) to 1878 (653-7791) after therapy (p = 0.001) and to 1400 (850-8287) 2 weeks later (p = 0.001). DSA C1q MFI fell from 3596 (IQR 714-14 405) to <30 after therapy (p = 0.01) and <30 2 weeks later (p = 0.02). Forced expiratory volume in 1s ( FEV1 ) fell from mean 2.11 L pre-AMR to 1.92 L at AMR (p = 0.04). FEV1 was unchanged after CFZ (1.91 L) and subsequently rose to a maximum of 2.13 L (p = 0.01). Mean forced expiratory flow during mid forced vital capacity (25-75) (FEF25-75 ) fell from mean 2.5 L pre-AMR to 1.95 L at AMR (p = 0.01). FEF25-75 rose after CFZ to 2.54 L and reached a maximum of 2.91 L (p = 0.01). Responders had less chronic lung allograft dysfunction or progression versus nonresponders (25% vs. 83%, p = 0.04). No deaths occurred within 120 days and 7 patients died post CFZ therapy of allograft failure. Larger prospective interventional studies are needed to further describe the benefit of CFZ-based therapy for pulmonary AMR.
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Affiliation(s)
- C R Ensor
- School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S A Yousem
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M Marrari
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M R Morrell
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - M Mangiola
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J M Pilewski
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J D'Cunha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S R Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R Venkataramanan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J F McDyer
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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Fernandez R, Chiu S, Raparia K, Garcha P, Farver C, Budev M, Tambur AR, DeCamp MM, Budinger S, Perlman H, Mohanakumar T, Bharat A. Humoral Human Lung Allograft Rejection by Tissue-Restricted Non-HLA Antibodies. Ann Thorac Surg 2017; 102:e339-41. [PMID: 27645977 DOI: 10.1016/j.athoracsur.2016.03.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/11/2016] [Accepted: 03/14/2016] [Indexed: 02/08/2023]
Abstract
A third of lung recipients have preexisting antibodies against nonhuman leukocyte self-antigens (nHAbs) present in the lung tissue. These nHAbs also form de novo in about 70% of patients within 3 years after transplantation. Both preexisting and de novo nHAbs can cause murine lung allograft dysfunction. However, their role in human transplantation remains unclear. We report hyperacute rejection after right lung transplant in a recipient with preexisting nHAbs. The recipient of the left lung from the same donor had an uneventful initial course, but de novo nHAbs developed at 3 weeks, leading to acute humoral rejection. Both patients were successfully treated with antibody-directed therapies.
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Affiliation(s)
- Ramiro Fernandez
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen Chiu
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kirtee Raparia
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Marie Budev
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anat R Tambur
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Malcolm M DeCamp
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Scott Budinger
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Harris Perlman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - T Mohanakumar
- Washington University School of Medicine, Saint Louis, Missouri
| | - Ankit Bharat
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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48
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Vacha M, Chery G, Hulbert A, Byrns J, Benedetti C, Finlen Copeland CA, Gray A, Onwuemene O, Palmer SM, Snyder LD. Antibody depletion strategy for the treatment of suspected antibody-mediated rejection in lung transplant recipients: Does it work? Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12886] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mary Vacha
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Godefroy Chery
- Department of Medicine; Duke University Hospital; Durham NC USA
| | - Amanda Hulbert
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Jennifer Byrns
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Clark Benedetti
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | | | - Alice Gray
- Department of Medicine; Duke University Hospital; Durham NC USA
| | | | - Scott M. Palmer
- Department of Medicine; Duke University Hospital; Durham NC USA
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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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Roden AC, Aisner DL, Allen TC, Aubry MC, Barrios RJ, Beasley MB, Cagle PT, Capelozzi VL, Dacic S, Ge Y, Hariri LP, Lantuejoul S, Miller RA, Mino-Kenudson M, Moreira AL, Raparia K, Rekhtman N, Sholl L, Smith ML, Tsao MS, Vivero M, Yatabe Y, Yi ES. Diagnosis of Acute Cellular Rejection and Antibody-Mediated Rejection on Lung Transplant Biopsies: A Perspective From Members of the Pulmonary Pathology Society. Arch Pathol Lab Med 2016; 141:437-444. [DOI: 10.5858/arpa.2016-0459-sa] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
The diagnosis and grading of acute cellular and antibody-mediated rejection (AMR) in lung allograft biopsies is important because rejection can lead to acute graft dysfunction and/or failure and may contribute to chronic graft failure. While acute cellular rejection is well defined histologically, no reproducible specific features of AMR are currently identified. Therefore, a combination of clinical features, serology, histopathology, and immunologic findings is suggested for the diagnosis of AMR.
Objective.—
To describe the perspective of members of the Pulmonary Pathology Society (PPS) on the workup of lung allograft transbronchial biopsy and the diagnosis of acute cellular rejection and AMR in lung transplant.
Data Sources.—
Reports by the International Society for Heart and Lung Transplantation (ISHLT), experience of members of PPS who routinely review lung allograft biopsies, and search of literature database (PubMed).
Conclusions.—
Acute cellular rejection should be assessed and graded according to the 2007 working formulation of the ISHLT. As currently no specific features are known for AMR in lung allografts, the triple test (clinical allograft dysfunction, donor-specific antibodies, pathologic findings) should be used for its diagnosis. C4d staining might be performed when morphologic, clinical, and/or serologic features suggestive of AMR are identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eunhee S. Yi
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota (Drs Roden, Aubry, and Yi); the Department of Pathology, University of Colorado, Denver (Dr Aisner); the Department of Pathology, University of Texas Medical Branch, Galveston (Dr Allen); the Department of Pathology and Genomic Medicine, Methodist Hospital, Houston, Texas (Drs Barrios, Cagle, Ge,
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