1
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Gramkow AM, Baatrup JH, Gramkow ET, Thiesson HC, Koefoed-Nielsen P. Association of HLA B- and T-cell molecular mismatches with HLA antibodies, rejection, and graft survival in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14773. [PMID: 38808702 DOI: 10.1111/petr.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/01/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Optimizing graft survival and diminishing human leukocyte antigen (HLA) sensitization are essential for pediatric kidney transplant recipients. More precise HLA matching predicting epitope mismatches could reduce alloreactivity. We investigated the association of predicted HLA B- and T-cell molecular mismatches with the formation of de novo donor-specific antibodies, HLA antibodies, rejection, and graft survival. METHODS Forty-nine pediatric kidney transplant recipients transplanted from 2009 to 2020 were retrospectively studied. Donors and recipients were high-resolution HLA typed, and recipients were screened for HLA antibodies posttransplant. HLA-EMMA (HLA Epitope MisMatch Algorithm) and PIRCHE-II (Predicted Indirectly ReCognizable HLA Epitopes) predicted the molecular mismatches. The association of molecular mismatches and the end-points was explored with logistic regression. RESULTS Five recipients (11%) developed de novo donor-specific antibodies. All five had de novo donor-specific antibodies against HLA class II, with four having HLA-DQ antibodies. We found no associations between PIRCHE-II or HLA-EMMA with de novo donor-specific antibodies, HLA sensitization, graft loss, or rejection. However, we did see a tendency towards an increased odds ratio in PIRCHE-II predicting de novo donor-specific antibodies formation, with an odds ratio of 1.12 (95% CI: 0.99; 1.28) on HLA class II. CONCLUSION While the study revealed no significant associations between the number of molecular mismatches and outcomes, a notable trend was observed - indicating a reduced risk of dnDSA formation with improved molecular match. It is important to acknowledge, however, that the modest population size and limited observed outcomes preclude us from making definitive conclusions.
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Affiliation(s)
- Ann-Maria Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne H Baatrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Emilie T Gramkow
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine - Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Helle C Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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2
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Ladowski JM, Tector M, Martens G, Wang ZY, Burlak C, Reyes L, Estrada J, Adams A, Tector AJ. Late graft failure of pig-to-rhesus renal xenografts has features of glomerulopathy and recipients have anti-swine leukocyte antigen class I and class II antibodies. Xenotransplantation 2024; 31:e12862. [PMID: 38761019 PMCID: PMC11104517 DOI: 10.1111/xen.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/12/2024] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
Prolonged survival in preclinical renal xenotransplantation demonstrates that early antibody mediated rejection (AMR) can be overcome. It is now critical to evaluate and understand the pathobiology of late graft failure and devise new means to improve post xenograft outcomes. In renal allotransplantation the most common cause of late renal graft failure is transplant glomerulopathy-largely due to anti-donor MHC antibodies, particularly anti-HLA DQ antibodies. We evaluated the pig renal xenograft pathology of four long-surviving (>300 days) rhesus monkeys. We also evaluated the terminal serum for the presence of anti-SLA class I and specifically anti-SLA DQ antibodies. All four recipients had transplant glomerulopathy and expressed anti-SLA DQ antibodies. In one recipient tested for anti-SLA I antibodies, the recipient had antibodies specifically reacting with two of three SLA I alleles tested. These results suggest that similar to allotransplantation, anti-MHC antibodies, particularly anti-SLA DQ, may be a barrier to improved long-term xenograft outcomes.
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Affiliation(s)
| | | | - Gregory Martens
- Department of Surgery, Washington University School of Medicine, St. Louis MO
| | - Zheng Yu Wang
- Department of Surgery, University of Miami School of Medicine, Miami, FL
| | - Chris Burlak
- Department of Surgery, University of Miami School of Medicine, Miami, FL
| | - Luz Reyes
- Department of Surgery, University of Miami School of Medicine, Miami, FL
| | - Jose Estrada
- Department of Surgery, University of Miami School of Medicine, Miami, FL
| | - Andrew Adams
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN
| | - A. Joseph Tector
- Department of Surgery, University of Miami School of Medicine, Miami, FL
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3
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Syed FJ, Bekbolsynov D, Stepkowski S, Kaur D, Green RC. Maximizing matching, equity and survival in kidney transplantation using molecular HLA immunogenicity quantitation. Comput Biol Med 2024; 174:108452. [PMID: 38640635 DOI: 10.1016/j.compbiomed.2024.108452] [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: 12/06/2023] [Revised: 03/11/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024]
Abstract
HLA matching improves long-term outcomes of kidney transplantation, yet implementation challenges persist, particularly within the African American (Black) patient demographic due to donor scarcity. Consequently, kidney survival rates among Black patients significantly lag behind those of other racial groups. A refined matching scheme holds promise for improving kidney survival, with prioritized matching for Black patients potentially bolstering rates of HLA-matched transplants. To facilitate quantity, quality and equity in kidney transplants, we propose two matching algorithms based on quantification of HLA immunogenicity using the hydrophobic mismatch score (HMS) for prospective transplants. We mined the national transplant patient database (SRTR) for a diverse group of donors and recipients with known racial backgrounds. Additionally, we use novel methods to infer survival assessment in the simulated transplants generated by our matching algorithms, in the absence of actual target outcomes, utilizing modified unsupervised clustering techniques. Our allocation algorithms demonstrated the ability to match 87.7% of Black and 86.1% of White recipients under the HLA immunogenicity threshold of 10. Notably, at the lowest HMS threshold of 0, 4.4% of Black and 12.1% of White recipients were matched, a marked increase from the 1.8% and 6.6% matched under the prevailing allocation scheme. Furthermore, our allocation algorithms yielded similar or improved survival rates, as illustrated by Kaplan-Meier (KM) curves, and enhanced survival prediction accuracy, evidenced by C-indices and Integrated Brier Scores.
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Affiliation(s)
- Fayeq Jeelani Syed
- Electrical Engineering and Computer Science Department, University of Toledo, 2801 W Bancroft St., Toledo, 43606, OH, USA
| | - Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, 43614, OH, USA
| | - Stanislaw Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, 43614, OH, USA
| | - Devinder Kaur
- Electrical Engineering and Computer Science Department, University of Toledo, 2801 W Bancroft St., Toledo, 43606, OH, USA
| | - Robert C Green
- Department of Computer Science, Bowling Green State University, 1001 E Wooster St., Bowling Green, 43403, OH, USA.
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4
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Kumar V, Bharadwaj R, Sachan D, Munirathnam D. A Single Centre Experience of Effective Desensitization Strategy for Children with High Anti-HLA Donor-Specific Antibodies Undergoing Haploidentical Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2024; 40:335-339. [PMID: 38708152 PMCID: PMC11065789 DOI: 10.1007/s12288-023-01661-2] [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: 10/30/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2024] Open
Abstract
To assess the incidence of anti-HLA donor-specific antibodies and the effectiveness of desensitization strategy in children who underwent haploidentical HSCT at our hospital. A retrospective review, management and outcomes of children with positive anti-HLA DSA who underwent haploidentical HSCT at our hospital from 2020 to 2022. Three patients with Thalassemia major were treated with 2 cycles of pretransplant immune suppression (PTIS) comprising Fludarabine and Dexamethasone in addition to desensitization. Five out of the 26 children who underwent haploidentical HSCT had positive anti-HLA DSA. Post desensitization, three out of the 5 children engrafted with sustained full donor chimerism, 1 patient developed primary graft rejection, while 1 patient died. It is feasible to desensitize children with high anti-HLA donor specific antibodies undergoing haploidentical HSCT to improve outcomes.
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Affiliation(s)
- Vimal Kumar
- Department of Pediatric Hematology, Oncology and Blood & Marrow Transplantation, Dr Rela Institute and Medical Centre, 7, CLC Works Road, Chromepet, Chennai, India
| | - Rishab Bharadwaj
- Department of Pediatric Hematology, Oncology and Blood & Marrow Transplantation, Dr Rela Institute and Medical Centre, 7, CLC Works Road, Chromepet, Chennai, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute and Medical Centre, Chennai, India
| | - Deenadayalan Munirathnam
- Department of Pediatric Hematology, Oncology and Blood & Marrow Transplantation, Dr Rela Institute and Medical Centre, 7, CLC Works Road, Chromepet, Chennai, India
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5
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Meneghini M, Tambur AR. HLA (emphasis on DQ) compatibility for longer allograft survival in pediatric transplantation: Modern evidence and challenges. Pediatr Transplant 2024; 28:e14606. [PMID: 37716000 DOI: 10.1111/petr.14606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
Kidney transplantation is the treatment of choice for children with end-stage kidney failure, yet suboptimal outcomes, the need for long-term immunosuppression, and the dependency on consecutive transplants pose significant barriers to success. Providing better HLA-matched organs to pediatric patients seems to be the most logical approach to improve graft and patient outcomes and to reduce risk of anti-HLA sensitization after graft failure. We here review recent literature on HLA matching in pediatric kidney transplantation. We further review newer approaches attempting to improve matching by using molecular mismatch load analysis. Our main focus is on the role of HLA-DQ compatibility between recipient and donor. We further emphasize the need to develop creative approaches that will support HLA (and DQ) matching utilization in organ allocation schemes, at least in those geared specifically for pediatric patients.
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Affiliation(s)
- Maria Meneghini
- Transplant Immunology Laboratory, Feinberg School of Medicine, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
- Nephrology and Kidney Transplantation Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Anat Roitberg Tambur
- Transplant Immunology Laboratory, Feinberg School of Medicine, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
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6
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Shih NR, Nong T, Murphey C, Lopez-Cepero M, Nickerson PW, Taupin JL, Devriese M, Nilsson J, Matignon MB, Bray RA, Lee JH. HLA class I peptide polymorphisms contribute to class II DQβ0603:DQα0103 antibody specificity. Nat Commun 2024; 15:609. [PMID: 38242876 PMCID: PMC10798988 DOI: 10.1038/s41467-024-44912-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
Antibodies reactive to human leukocyte antigens (HLA) represent a barrier for patients awaiting transplantation. Based on reactivity patterns in single-antigen bead (SAB) assays, various epitope matching algorithms have been proposed to improve transplant outcomes. However, some antibody reactivities cannot be explained by amino acid motifs, leading to uncertainty about their clinical relevance. Antibodies against the HLA class II molecule, DQβ0603:DQα0103, present in some candidates, represent one such example. Here, we show that peptides derived from amino acids 119-148 of the HLA class I heavy chain are bound to DQβ0603:DQα0103 proteins and contribute to antibody reactivity through an HLA-DM-dependent process. Moreover, antibody reactivity is impacted by the specific amino acid sequence presented. In summary, we demonstrate that polymorphic HLA class I peptides, bound to HLA class II proteins, can directly or indirectly be part of the antibody binding epitope. Our findings have potential important implications for the field of transplant immunology and for our understanding of adaptive immunity.
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Affiliation(s)
- N Remi Shih
- Terasaki Innovation Center, Los Angeles, CA, USA
| | - Thoa Nong
- Terasaki Innovation Center, Los Angeles, CA, USA
| | - Cathi Murphey
- Southwest Immunodiagnostics, Inc., San Antonio, TX, USA
| | | | - Peter W Nickerson
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité and INSERM U976 IRSL, Hôpital Saint-Louis APHP, Paris, France
| | - Magali Devriese
- Laboratoire d'Immunologie et Histocompatibilité and INSERM U976 IRSL, Hôpital Saint-Louis APHP, Paris, France
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | | | - Robert A Bray
- Department of Pathology, Emory University, Atlanta, GA, USA
| | - Jar-How Lee
- Terasaki Innovation Center, Los Angeles, CA, USA.
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7
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Islam S, Zhang D, Ho K, Divers J. Racial Disparities in Hospitalization Rates During Long-Term Follow-Up After Deceased-Donor Kidney Transplantation. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01847-4. [PMID: 37930581 DOI: 10.1007/s40615-023-01847-4] [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: 05/17/2023] [Revised: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To compare hospitalization rates between African American (AA) and European American (EA) deceased-donor (DD) kidney transplant (KT) recipients during over a10-year period. METHOD Data from the Scientific Registry of Transplant Recipients and social determinants of health (SDoH), measured by the Social Deprivation Index, were used. Hospitalization rates were estimated for kidney recipients from AA and EA DDs who had one kidney transplanted into an AA and one into an EA, leading to four donor/recipient pairs (DRPs): AA/AA, AA/EA, EA/AA, and EA/EA. Poisson-Gamma models were fitted to assess post-transplant hospitalizations. RESULT Unadjusted hospitalization rates (95% confidence interval) were higher among all DRP involving AA, 131.1 (122.5, 140.3), 134.8 (126.3, 143.8), and 102.4 (98.9, 106.0) for AA/AA, AA/EA, and EA/AA, respectively, compared to 97.1 (93.7, 100.6) per 1000 post-transplant person-years for EA/EA pairs. Multivariable analysis showed u-shaped relationships across SDoH levels within each DRP, but findings varied depending on recipients' race, i.e., AA recipients in areas with the worst SDoH had higher hospitalization rates. However, EA recipients in areas with the best SDoH had higher hospitalization rates than their counterparts. CONCLUSIONS Relationship between healthcare utilization and SDoH depends on DRP, with higher hospitalization rates among AA recipients living in areas with the worst SDoH and among EA recipients in areas with the best SDoH profiles. SDoH plays an important role in driving disparities in hospitalizations after kidney transplantation.
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Affiliation(s)
- Shahidul Islam
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA.
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA.
| | - Donglan Zhang
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
| | - Kimberly Ho
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
| | - Jasmin Divers
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
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8
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Battle R, Pritchard D, Peacock S, Hastie C, Worthington J, Jordan S, McCaughlan JA, Barnardo M, Cope R, Collins C, Diaz-Burlinson N, Rosser C, Foster L, Kallon D, Shaw O, Briggs D, Turner D, Anand A, Akbarzad-Yousefi A, Sage D. BSHI and BTS UK guideline on the detection of alloantibodies in solid organ (and islet) transplantation. Int J Immunogenet 2023; 50 Suppl 2:3-63. [PMID: 37919251 DOI: 10.1111/iji.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
Solid organ transplantation represents the best (and in many cases only) treatment option for patients with end-stage organ failure. The effectiveness and functioning life of these transplants has improved each decade due to surgical and clinical advances, and accurate histocompatibility assessment. Patient exposure to alloantigen from another individual is a common occurrence and takes place through pregnancies, blood transfusions or previous transplantation. Such exposure to alloantigen's can lead to the formation of circulating alloreactive antibodies which can be deleterious to solid organ transplant outcome. The purpose of these guidelines is to update to the previous BSHI/BTS guidelines 2016 on the relevance, assessment, and management of alloantibodies within solid organ transplantation.
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Affiliation(s)
- Richard Battle
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | | | - Sarah Peacock
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Sue Jordan
- National Blood Service Tooting, London, UK
| | | | - Martin Barnardo
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebecca Cope
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Luke Foster
- Birmingham Blood Donor Centre, Birmingham, UK
| | | | - Olivia Shaw
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David Turner
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Arthi Anand
- Imperial College Healthcare NHS Trust, London, UK
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9
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Meneghini M, Tambur AR. HLA-DQ antibodies in alloimmunity, what makes them different? Curr Opin Organ Transplant 2023; 28:333-339. [PMID: 37219535 PMCID: PMC10487393 DOI: 10.1097/mot.0000000000001079] [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] [Indexed: 05/24/2023]
Abstract
PURPOSE OF REVIEW De novo HLA-DQ antibodies are the most frequently observed after solid-organ allotransplantation; and are associated with the worse adverse graft outcomes compared with all other HLA antibodies. However, the biological explanation for this observation is not yet known. Herein, we examine unique characteristics of alloimmunity directed specifically against HLA-DQ molecules. RECENT FINDINGS While investigators attempted to decipher functional properties of HLA class II antigens that may explain their immunogenicity and pathogenicity, most early studies focused on the more expressed molecule - HLA-DR. We here summarize up-to-date literature documenting specific features of HLA-DQ, as compared to other class II HLA antigens. Structural and cell-surface expression differences have been noted on various cell types. Some evidence suggests variations in antigen-presenting function and intracellular activation pathways after antigen/antibody interaction. SUMMARY The clinical effects of donor-recipient incompatibility at HLA-DQ, the risk of generating de novo antibodies leading to rejection, and the inferior graft outcomes indicate increased immunogenicity and pathogenicity that is unique to this HLA antigen. Clearly, knowledge generated for HLA-DR cannot be applied interchangeably. Deeper understanding of features unique to HLA-DQ may support the generation of targeted preventive-therapeutic strategies and ultimately improve solid-organ transplant outcomes.
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Affiliation(s)
- Maria Meneghini
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Nephrology and Kidney Transplantation Department, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute (VHIR), Barcelona, Spain
| | - Anat R. Tambur
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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10
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Hafeez MS, Awais SB, Razvi M, Bangash MH, Hsiou DA, Malik TH, Haq MU, Awan AAY, Rana AA. HLA mismatch is important for 20-year graft survival in kidney transplant patients. Transpl Immunol 2023; 80:101861. [PMID: 37302557 DOI: 10.1016/j.trim.2023.101861] [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: 02/13/2023] [Revised: 05/03/2023] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Human leukocyte antigens (HLA) matching is gradually being omitted from clinical practice in evaluation for renal allograft transplant. While such practices may yield shorter wait times and adequate short-term outcomes, graft longevity in HLA mismatched patients remains unclear. This study aims to demonstrate that HLA matching may still play an important role in long-term graft survival. METHODS We identified patients undergoing an index kidney transplant in the United Network for Organ Sharing (UNOS) data from 1990 to 1999, with one-year graft survival. The primary outcome of the analysis was graft survival beyond 10 years. We explored the long-lasting impact of HLA mismatches by landmarking the analysis at established time points. RESULTS We identified 76,530 patients receiving renal transplants in the time frame, 23,914 from living donors and 52,616 from deceased donors. On multivariate analysis, more HLA mismatches were associated with worse graft survival beyond 10 years for both living and deceased donor allografts. HLA mismatch continued to remain an essential factor in the long term. CONCLUSIONS A greater number of HLA mismatches was associated with progressively worse long-term graft survival for patients. Our analysis reinforces the importance of HLA matching in the preoperative evaluation of renal allografts.
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Affiliation(s)
- Muhammad Saad Hafeez
- The Aga Khan University - Medical College, The Aga Khan University, Karachi, Pakistan.
| | - Shehar Bano Awais
- The Aga Khan University - Medical College, The Aga Khan University, Karachi, Pakistan
| | - Mohammad Razvi
- Baylor College of Medicine, Houston, TX, United States of America
| | | | - David A Hsiou
- Baylor College of Medicine, Houston, TX, United States of America
| | - Tahir Hafeez Malik
- New York University School of Medicine, Department of Internal Medicine, United States of America
| | - Muneeb Ul Haq
- The Aga Khan University - Medical College, The Aga Khan University, Karachi, Pakistan
| | - Ahmed A Y Awan
- Division of Nephrology and Abdominal Transplantation, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Abbas A Rana
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
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11
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Cheng KP, Shen WX, Jiang YY, Chen Y, Chen YZ, Tan Y. Deep learning of 2D-Restructured gene expression representations for improved low-sample therapeutic response prediction. Comput Biol Med 2023; 164:107245. [PMID: 37480677 DOI: 10.1016/j.compbiomed.2023.107245] [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: 04/26/2023] [Revised: 06/27/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Abstract
Clinical outcome prediction is important for stratified therapeutics. Machine learning (ML) and deep learning (DL) methods facilitate therapeutic response prediction from transcriptomic profiles of cells and clinical samples. Clinical transcriptomic DL is challenged by the low-sample sizes (34-286 subjects), high-dimensionality (up to 21,653 genes) and unordered nature of clinical transcriptomic data. The established methods rely on ML algorithms at accuracy levels of 0.6-0.8 AUC/ACC values. Low-sample DL algorithms are needed for enhanced prediction capability. Here, an unsupervised manifold-guided algorithm was employed for restructuring transcriptomic data into ordered image-like 2D-representations, followed by efficient DL of these 2D-representations with deep ConvNets. Our DL models significantly outperformed the state-of-the-art (SOTA) ML models on 82% of 17 low-sample benchmark datasets (53% with >0.05 AUC/ACC improvement). They are more robust than the SOTA models in cross-cohort prediction tasks, and in identifying robust biomarkers and response-dependent variational patterns consistent with experimental indications.
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Affiliation(s)
- Kai Ping Cheng
- The State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Biology, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, 518055, PR China; Institute of Biomedical Health Technology and Engineering, Shenzhen Bay Laboratory, Shenzhen, 518132, PR China
| | - Wan Xiang Shen
- Bioinformatics and Drug Design Group, Department of Pharmacy, Center for Computational Science and Engineering, National University of Singapore, 117543, Singapore
| | - Yu Yang Jiang
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, 100084, PR China
| | - Yan Chen
- The State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Biology, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, 518055, PR China
| | - Yu Zong Chen
- The State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Biology, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, 518055, PR China; Institute of Biomedical Health Technology and Engineering, Shenzhen Bay Laboratory, Shenzhen, 518132, PR China.
| | - Ying Tan
- The State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Biology, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, 518055, PR China; The Institute of Drug Discovery Technology, Ningbo University, Ningbo, 315211, PR China; Shenzhen Kivita Innovative Drug Discovery Institute, Shenzhen, 518110, PR China.
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12
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Grossi AA, Randhawa G, Jansen NE, Paredes-Zapata D. Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action. Transpl Int 2023; 36:11310. [PMID: 37600748 PMCID: PMC10437067 DOI: 10.3389/ti.2023.11310] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023]
Abstract
International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.
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Affiliation(s)
- Alessandra Agnese Grossi
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy
- Department of Human Sciences, Innovation and Territory, University of Insubria, Como, Italy
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Luton, United Kingdom
| | | | - David Paredes-Zapata
- Donation and Transplant Coordination Section, Hospital Clínic, Barcelona, Spain
- Surgical Department, University of Barcelona, Barcelona, Spain
- Donation and Transplantation Institute Foundation, Barcelona, Spain
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13
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Oomen L, de Jong H, Bouts AHM, Keijzer-Veen MG, Cornelissen EAM, de Wall LL, Feitz WFJ, Bootsma-Robroeks CMHHT. A pre-transplantation risk assessment tool for graft survival in Dutch pediatric kidney recipients. Clin Kidney J 2023; 16:1122-1131. [PMID: 37398686 PMCID: PMC10310505 DOI: 10.1093/ckj/sfad057] [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: 10/31/2022] [Indexed: 07/04/2023] Open
Abstract
Background A prediction model for graft survival including donor and recipient characteristics could help clinical decision-making and optimize outcomes. The aim of this study was to develop a risk assessment tool for graft survival based on essential pre-transplantation parameters. Methods The data originated from the national Dutch registry (NOTR; Nederlandse OrgaanTransplantatie Registratie). A multivariable binary logistic model was used to predict graft survival, corrected for the transplantation era and time after transplantation. Subsequently, a prediction score was calculated from the β-coefficients. For internal validation, derivation (80%) and validation (20%) cohorts were defined. Model performance was assessed with the area under the curve (AUC) of the receiver operating characteristics curve, Hosmer-Lemeshow test and calibration plots. Results In total, 1428 transplantations were performed. Ten-year graft survival was 42% for transplantations before 1990, which has improved to the current value of 92%. Over time, significantly more living and pre-emptive transplantations have been performed and overall donor age has increased (P < .05).The prediction model included 71 829 observations of 554 transplantations between 1990 and 2021. Other variables incorporated in the model were recipient age, re-transplantation, number of human leucocyte antigen (HLA) mismatches and cause of kidney failure. The predictive capacity of this model had AUCs of 0.89, 0.79, 0.76 and 0.74 after 1, 5, 10 and 20 years, respectively (P < .01). Calibration plots showed an excellent fit. Conclusions This pediatric pre-transplantation risk assessment tool exhibits good performance for predicting graft survival within the Dutch pediatric population. This model might support decision-making regarding donor selection to optimize graft outcomes. Trial registration ClinicalTrials.gov Identifier: NCT05388955.
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Affiliation(s)
| | - Huib de Jong
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Antonia H M Bouts
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Mandy G Keijzer-Veen
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elisabeth A M Cornelissen
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Liesbeth L de Wall
- Department of Urology, Division of Pediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Wout F J Feitz
- Department of Urology, Division of Pediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Charlotte M H H T Bootsma-Robroeks
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Pediatric Nephrology, Beatrix Children's Hospital, Groningen, The Netherlands
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14
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Slomp C, Edwards L, Burgess M, Sapir-Pichhadze R, Keown P, Bryan S. Public values and guiding principles for implementing epitope compatibility in kidney transplantation allocation criteria: results from a Canadian online public deliberation. BMC Public Health 2023; 23:844. [PMID: 37165330 PMCID: PMC10170053 DOI: 10.1186/s12889-023-15790-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 04/30/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Epitope compatibility in deceased donor kidney allocation is an emerging area of precision medicine (PM), seeking to improve compatibility between donor kidneys to transplant candidates in the hope of avoiding kidney rejection. Though the potential benefits of using epitope compatibility are promising, the implied modification of deceased organ allocation criteria requires consideration of significant clinical and ethical trade-offs. As a matter of public policy, these trade-offs should consider public values and preferences. We invited members of the Canadian public to participate in a deliberation about epitope compatibility in deceased donor kidney transplantation; to identify what is important to them and to provide recommendations to policymakers. METHODS An online public deliberation was conducted with members of the Canadian public, in which participants were asked to construct recommendations for policymakers regarding the introduction of epitope compatibility to kidney allocation criteria. In the present paper, a qualitative analysis was conducted to identify the values reflected in participants' recommendations. All virtual sessions were recorded, transcribed, and analyzed using NVivo 12 software. RESULTS Thirty-two participants constructed nine recommendations regarding the adoption of epitope compatibility into deceased donor kidney allocation. Five values were identified that drove participants' recommendations: Health Maximization, Protection/Mitigation of Negative Impacts, Fairness, Science/Evidence-based Healthcare, and Responsibility to Maintain Trust. Conflicts between these values were discussed in terms of operational principles that were required for epitope compatibility to be implemented in an acceptable manner: the needs for Flexibility, Accountability, Transparent Communication and a Transition Plan. All nine recommendations were informed by these four principles. Participant deliberations were often dominated by the conflict between Health Maximization and Fairness or Protection/Mitigation of Negative Impacts, which was discussed as the need for Flexibility. Two additional values (Efficient Use of Resources and Logic/Rationality) were also discussed and were reasons for some participants voting against some recommendations. CONCLUSIONS Public recommendations indicate support for using epitope compatibility in deceased donor kidney allocation. A flexible approach to organ allocation decision-making may allow for the balancing of Health Maximization against maintaining Fairness and Mitigating Negative Impacts. Flexibility is particularly important in the context of epitope compatibility and other PM initiatives where evidence is still emerging.
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Affiliation(s)
- Caitlin Slomp
- BC Children's Hospital Research Institute, 938 W 28th Ave, BC, V5Z 4H4, Vancouver, Canada.
- Department of Psychiatry, University of British Columbia, Vancouver, Canada.
| | - Louisa Edwards
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Michael Burgess
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
- W. Maurice Young Centre for Applied Ethics, University of British Columbia, Vancouver, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Paul Keown
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Immune Centre of BC, Vancouver Coastal Health, Vancouver, Canada
| | - Stirling Bryan
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
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15
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Toews M, Chandler JA, Pope T, Pape R, Weiss M, Sandiumenge A. Legislation and Policy Recommendations on Organ and Tissue Donation and Transplantation From an International Consensus Forum. Transplant Direct 2023; 9:e1395. [PMID: 37138556 PMCID: PMC10150854 DOI: 10.1097/txd.0000000000001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/12/2022] [Accepted: 08/25/2022] [Indexed: 05/05/2023] Open
Abstract
There is a shared global commitment to improving baseline donation and transplantation performance metrics in a manner consistent with ethics and local cultural and social factors. The law is one tool that can help improve these metrics. Although legal systems vary across jurisdictions, our objective was to create expert, consensus guidance for law and policymakers on foundational issues underlying organ and tissue donation and transplantation (OTDT) systems around the world. Methods Using the nominal group technique, a group composed of legal academics, a transplant coordinator/clinician, and a patient partner identified topic areas and recommendations on foundational legal issues. The recommendations were informed by narrative literature reviews conducted by group members based on their areas of expertise, which yielded a range of academic articles, policy documents, and sources of law. Best practices were identified from relevant sources in each subtopic, which formed the basis of the recommendations contained herein. Results We reached consensus on 12 recommendations grouped into 5 subtopics: (i) legal definitions and legislative scope, (ii) consent requirements for donation' (iii) allocation of organs and tissue' (iv) operation of OTDT systems' and (v) travel for transplant and organ trafficking. We have differentiated between those foundational legal principles for which there is a firm basis of support with those requiring further consideration and resolution. Seven such areas of controversy are identified and discussed alongside relevant recommendations. Conclusions Our recommendations encompass some principles staunchly enshrined in the OTDT landscape (eg, the dead donor rule), whereas others reflect more recent developments in practice (eg, mandatory referral). Although some principles are widely accepted, there is not always consensus as to how they ought to be implemented. As the OTDT landscape continues to evolve, recommendations must be reconsidered for the law to keep pace with developments in knowledge, technology, and practice.
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Affiliation(s)
- Maeghan Toews
- University of Adelaide, Law School, Adelaide, SA, Australia
| | - Jennifer A. Chandler
- Faculty of Law and Centre for Health Law, Policy and Ethics, University of Ottawa, Ottawa, ON, Canada
| | - Thaddeus Pope
- Mitchell Hamline School of Law, Saint Paul, MN
- Fulbright Canada Research Chair in Health Law, Policy and Ethics, University of Ottawa, Ottawa, ON, Canada
| | - Roger Pape
- National Institutes for Health Research/NHS Blood and Transplant Research Unit, University of Cambridge and Newcastle University, Cambridge and Newcastle, UK
| | - Matthew Weiss
- Transplant Québec, Montréal, QC, Canada
- Division of Critical Care, Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Québec, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Alberto Sandiumenge
- Transplant Coordination Department, University Hospital Vall d'Hebron, Organ, Tissue and Cell Donation and Transplantation Research Group, Vall d'Hebron Research Instititute (VHIR), Barcelona, Spain
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16
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Dasariraju S, Gragert L, Wager GL, McCullough K, Brown NK, Kamoun M, Urbanowicz RJ. HLA Amino Acid Mismatch-Based Risk Stratification of Kidney Allograft Failure Using a Novel Machine Learning Algorithm. J Biomed Inform 2023; 142:104374. [PMID: 37120046 DOI: 10.1016/j.jbi.2023.104374] [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: 12/12/2022] [Revised: 04/02/2023] [Accepted: 04/23/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE While associations between HLA antigen-level mismatches (Ag-MM) and kidney allograft failure are well established, HLA amino acid-level mismatches (AA-MM) have been less explored. Ag-MM fails to consider the substantial variability in the number of MMs at polymorphic amino acid (AA) sites within any given Ag-MM category, which may conceal variable impact on allorecognition. In this study we aim to develop a novel Feature Inclusion Bin Evolver for Risk Stratification (FIBERS) and apply it to automatically discover bins of HLA amino acid mismatches that stratify donor-recipient pairs into low versus high graft survival risk groups. METHODS Using data from the Scientific Registry of Transplant Recipients, we applied FIBERS on a multiethnic population of 166,574 kidney transplants between 2000-2017. FIBERS was applied (1) across all HLA-A, B, C, DRB1, and DQB1 locus AA-MMs with comparison to 0-ABDR Ag-MM risk stratification, (2) on AA-MMs within each HLA locus individually, and (3) using cross validation to evaluate FIBERS generalizability. The predictive power of graft failure risk stratification was evaluated while adjusting for donor/recipient characteristics and HLA-A, B, C, DRB1, and DQB1 Ag-MMs as covariates. RESULTS FIBERS's best-performing bin (on AA-MMs across all loci) added significant predictive power (hazard ratio = 1.10, Bonferroni adj. p < 0.001) in stratifying graft failure risk (where low-risk is defined as zero AA-MMs and high-risk is one or more AA-MMs) even after adjusting for Ag-MMs and donor/recipient covariates. The best bin also categorized more than twice as many patients to the low-risk category, compared to traditional 0-ABDR Ag mismatching (∼24.4% vs ∼9.1%). When HLA loci were binned individually, the bin for DRB1 exhibited the strongest risk stratification; relative to zero AA-MM, one or more MMs in the bin yielded HR = 1.11, p < 0.005 in a fully adjusted Cox model. AA-MMs at HLA-DRB1 peptide contact sites contributed most to incremental risk of graft failure. Additionally, FIBERS points to possible risk associated with HLA-DQB1 AA-MMs at positions that determine specificity of peptide anchor residues and HLA-DQ heterodimer stability. CONCLUSION FIBERS's performance suggests potential for discovery of HLA immunogenetics-based risk stratification of kidney graft failure that outperforms traditional assessment.
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Affiliation(s)
- Satvik Dasariraju
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA; The Lawrenceville School, Lawrenceville, NJ
| | - Loren Gragert
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Grace L Wager
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA
| | | | - Nicholas K Brown
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars Sinai Medical Center, Los Angeles, CA.
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17
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Muñoz-Herrera CM, Gutiérrez-Bautista JF, López-Nevot MÁ. Complement Binding Anti-HLA Antibodies and the Survival of Kidney Transplantation. J Clin Med 2023; 12:jcm12062335. [PMID: 36983335 PMCID: PMC10057312 DOI: 10.3390/jcm12062335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Antibody-mediated rejection (AMR) is one of the most important challenges in the context of renal transplantation, because the binding of de novo donor-specific antibodies (dnDSA) to the kidney graft triggers the activation of the complement, which in turn leads to loss of transplant. In this context, the objective of this study was to evaluate the association between complement-fixing dnDSA antibodies and graft loss as well as the possible association between non-complement-fixing antibodies and transplanted organ survival in kidney transplant recipients. Methods: Our study included a cohort of 245 transplant patients over a 5-year period at Virgen de las Nieves University Hospital (HUVN) in Granada, Spain. Results: dnDSA was observed in 26 patients. Of these patients, 17 had non-complement-fixing dnDSA and 9 had complement-fixing dnDSA. Conclusions: Our study demonstrated a significant association between the frequency of rejection and renal graft loss and the presence of C1q-binding dnDSA. Our results show the importance of the individualization of dnDSA, classifying them according to their ability to activate the complement, and suggest that the detection of complement-binding capacity by dnDSA could be used as a prognostic marker to predict AMR outcome and graft survival in kidney transplant patients who develop dnDSA.
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Affiliation(s)
- Claudia M. Muñoz-Herrera
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18010 Granada, Spain
- Programa de Doctorado en Biomedicina, University of Granada, 18010 Granada, Spain
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Clínica Imbanaco Grupo Quirónsalud, Laboratorio Clínico, Patología y Servicio de Transfusión, Laboratorio de Inmunogenética, 760042 Cali, Colombia
- Correspondence: (C.M.M.-H.); (J.F.G.-B.); Tel.: +57-310-4153949 (C.M.M.-H.); +34-629-908-060 (J.F.G.-B.)
| | - Juan Francisco Gutiérrez-Bautista
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18010 Granada, Spain
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
- Correspondence: (C.M.M.-H.); (J.F.G.-B.); Tel.: +57-310-4153949 (C.M.M.-H.); +34-629-908-060 (J.F.G.-B.)
| | - Miguel Ángel López-Nevot
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18010 Granada, Spain
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
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18
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Kim JJ, Fichtner A, Copley HC, Gragert L, Süsal C, Dello Strologo L, Oh J, Pape L, Weber LT, Weitz M, König J, Krupka K, Tönshoff B, Kosmoliaptsis V. Molecular HLA mismatching for prediction of primary humoral alloimmunity and graft function deterioration in paediatric kidney transplantation. Front Immunol 2023; 14:1092335. [PMID: 37033962 PMCID: PMC10080391 DOI: 10.3389/fimmu.2023.1092335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 03/17/2023] Open
Abstract
Introduction Rejection remains the main cause of allograft failure in paediatric kidney transplantation and is driven by donor-recipient HLA mismatching. Modern computational algorithms enable assessment of HLA mismatch immunogenicity at the molecular level (molecular-mismatch, molMM). Whilst molMM has been shown to correlate with alloimmune outcomes, evidence demonstrating improved prediction performance against traditional antigen mismatching (antMM) is lacking. Methods We analysed 177 patients from the CERTAIN registry (median follow-up 4.5 years). molMM scores included Amino-Acid-Mismatch-Score (AAMS), Electrostatic-Mismatch-Score (EMS3D) and netMHCIIpan (netMHC1k: peptide binding affinity ≤1000 nM; netMHC: binding affinity ≤500 nM plus rank <2%). We stratified patients into high/low-risk groups based on risk models of DSA development. Results Donor-specific HLA antibodies (DSA) predominantly targeted the highest scoring molMM donor antigen within each HLA locus. MolMM scores offered superior discrimination versus antMM in predicting de novo DSA for all HLA loci; the EMS3D algorithm had particularly consistent performance (area under the receiver operating characteristic curve (AUC) >0.7 for all HLA loci vs. 0.52-0.70 for antMM). ABMR (but not TCMR) was associated with HLA-DQ molMM scores (AAMS, EMS3D and netMHC). Patients with high-risk HLA-DQ molMM had increased risk of graft function deterioration (50% reduction in baseline eGFR (eGFR50), adjusted HR: 3.5, 95% CI 1.6-8.2 high vs. low EMS3D). Multivariable modelling of the eGFR50 outcome using EMS3D HLA-DQ stratification showed better discrimination (AUC EMS3D vs. antMM at 2 years: 0.81 vs. 0.77, at 4.5 years: 0.72 vs. 0.64) and stratified more patients into the low-risk group, compared to traditional antMM. Conclusion Molecular mismatching was superior to antigen mismatching in predicting humoral alloimmunity. Molecular HLA-DQ mismatching appears to be a significant prognostic factor for graft function deterioration in paediatric kidney transplantation.
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Affiliation(s)
- Jon Jin Kim
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatric Nephrology, Nottingham University Hospital, Nottingham, United Kingdom
| | - Alexander Fichtner
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Hannah C. Copley
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Loren Gragert
- School of Medicine, Tulane University, New Orleans, LA, United States
| | - Caner Süsal
- Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Jun Oh
- University Hospital Hamburg, Pediatric Nephrology, Hamburg, Germany
| | - Lars Pape
- Clinic for Paediatrics III, Essen University Hospital, Essen, Germany
| | - Lutz T. Weber
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, University Hospital Cologne, Cologne, Germany
| | - Marcus Weitz
- University Hospital Tübingen, Pediatric Nephrology, Tübingen, Germany
| | - Jens König
- Department of General Pediatrics, University Children’s Hospital, Münster, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at the University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom
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19
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Ellison M, Mangiola M, Marrari M, Bentlejewski C, Sadowski J, Zern D, Kramer CSM, Heidt S, Niemann M, Xu Q, Dipchand AI, Mahle WT, Rossano JW, Canter CE, Singh TP, Zuckerman WA, Hsu DT, Feingold B, Webber SA, Zeevi A. Immunologic risk stratification of pediatric heart transplant patients by combining HLA-EMMA and PIRCHE-II. Front Immunol 2023; 14:1110292. [PMID: 36999035 PMCID: PMC10043167 DOI: 10.3389/fimmu.2023.1110292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
Human leukocyte antigen (HLA) molecular mismatch is a powerful biomarker of rejection. Few studies have explored its use in assessing rejection risk in heart transplant recipients. We tested the hypothesis that a combination of HLA Epitope Mismatch Algorithm (HLA-EMMA) and Predicted Indirectly Recognizable HLA Epitopes (PIRCHE-II) algorithms can improve risk stratification of pediatric heart transplant recipients. Class I and II HLA genotyping were performed by next-generation sequencing on 274 recipient/donor pairs enrolled in the Clinical Trials in Organ Transplantation in Children (CTOTC). Using high-resolution genotypes, we performed HLA molecular mismatch analysis with HLA-EMMA and PIRCHE-II, and correlated these findings with clinical outcomes. Patients without pre-formed donor specific antibody (DSA) (n=100) were used for correlations with post-transplant DSA and antibody mediated rejection (ABMR). Risk cut-offs were determined for DSA and ABMR using both algorithms. HLA-EMMA cut-offs alone predict the risk of DSA and ABMR; however, if used in combination with PIRCHE-II, the population could be further stratified into low-, intermediate-, and high-risk groups. The combination of HLA-EMMA and PIRCHE-II enables more granular immunological risk stratification. Intermediate-risk cases, like low-risk cases, are at a lower risk of DSA and ABMR. This new way of risk evaluation may facilitate individualized immunosuppression and surveillance.
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Affiliation(s)
- M. Ellison
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
- *Correspondence: M. Ellison,
| | - M. Mangiola
- Transplant Institute, NYU Langone Health, New York University, New York, NY, United States
| | - M. Marrari
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - C. Bentlejewski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - J. Sadowski
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
| | - D. Zern
- University of Pittsburgh Medical Center, Histocompatibility Laboratory, Pittsburgh, PA, United States
| | | | - S. Heidt
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - M. Niemann
- Research and Development, PIRCHE AG, Berlin, Germany
| | - Q. Xu
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - A. I. Dipchand
- Labatt Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - W. T. Mahle
- Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - J. W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - C. E. Canter
- Division of Cardiology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, United States
| | - T. P. Singh
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - W. A. Zuckerman
- Columbia University, Irving Medical Center, New York, NY, United States
| | - D. T. Hsu
- Division of Pediatric Cardiology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, NY, United States
| | - B. Feingold
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - S. A. Webber
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - A. Zeevi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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20
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Tambur AR, Das R. Can We Use Eplets (or Molecular) Mismatch Load Analysis to Improve Organ Allocation? The Hope and the Hype. Transplantation 2023; 107:605-615. [PMID: 36163639 PMCID: PMC9944744 DOI: 10.1097/tp.0000000000004307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/14/2022] [Accepted: 07/03/2022] [Indexed: 11/25/2022]
Abstract
In recent years, there have been calls for implementation of "epitope matching" in deceased-donor organ allocation policies (later changed to "eplet matching"). Emerging data indeed support the use of molecular mismatch load analysis in specific patient groups, with the objective of posttransplant stratification into different treatment arms. For this purpose, the expectation is to statistically categorize patients as low- or high-immune-risk. Importantly, these patients will continue to be monitored' and their risk category, as well as their management, can be adjusted according to on-going findings. However, when discussing deceased donor organ allocation and matching algorithms, where the decision is not modifiable and has lasting impact on outcomes, the situation is fundamentally different. The goal of changing allocation schemes is to achieve the best possible HLA compatibility between donor and recipient. Immunologically speaking, this is a very different objective. For this purpose, the specific interplay of immunogenicity between the donor and any potential recipient must be understood. In seeking compatibility, the aim is not to redefine matching but to identify those mismatches that are "permissible" or' in other words, less immunogenic. In our eagerness to improve transplant outcome, unfortunately, we have conflated the hype with the hope. Terminology is used improperly, and new terms are created in the process with no sufficient support. Here, we call for a cautious evaluation of baseline assumptions and a critical review of the evidence to minimize unintended consequences.
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Affiliation(s)
- Anat R. Tambur
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL
| | - Rajdeep Das
- Comprehensive Transplant Center, Department of Surgery, Northwestern University, Chicago, IL
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21
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Comparative Study of the Impact of Human Leukocyte Antigens on Renal Transplant Survival in Andalusia and the United States. Diagnostics (Basel) 2023; 13:diagnostics13040608. [PMID: 36832096 PMCID: PMC9954912 DOI: 10.3390/diagnostics13040608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023] Open
Abstract
Renal transplantation is the treatment of choice for patients suffering from chronic renal disease, one of the leading causes of death worldwide. Among the biological barriers that may increase the risk of acute renal graft rejection is the presence of human leukocyte antigen (HLA) incompatibilities between donor and recipient. This work presents a comparative study of the influence of HLA incompatibilities on renal transplantation survival in the Andalusian (South of Spain) and United States (US) population. The main objective is to analyse the extent to which results about the influence of different factors on renal graft survival can be generalised to different populations. The Kaplan-Meier estimator and the Cox model have been used to identify and quantify the impact on the survival probability of HLA incompatibilities, both in isolation and in conjunction with other factors associated with the donor and recipient. According to the results obtained, HLA incompatibilities considered in isolation have negligible impact on renal survival in the Andalusian population and a moderate impact in the US population. Grouping by HLA score presents some similarities for both populations, while the sum of all HLA scores (aHLA) only has an impact on the US population. Finally, the graft survival probability of the two populations differs when aHLA is considered in conjunction with blood type. The results suggest that the disparities in the renal graft survival probability between the two populations under study are due not only to biological and transplantation-associated factors, but also to social-health factors and ethnic heterogeneity between populations.
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Tambur AR, Audry B, Glotz D, Jacquelinet C. Improving equity in kidney transplant allocation policies through a novel genetic metric: The Matched Donor Potential. Am J Transplant 2023; 23:45-54. [PMID: 36695620 DOI: 10.1016/j.ajt.2022.08.001] [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: 03/29/2022] [Revised: 07/12/2022] [Accepted: 08/21/2022] [Indexed: 01/13/2023]
Abstract
The demand for donors' kidneys continues to increase amid a shortage of available donors. Managing policies to thoughtfully allocate this scarce resource is a complex process. Although human leukocyte antigen (HLA) matching has been shown to prolong graft survival, its relative contribution to allocation schemes is empirically compromised owing to competing priorities. We explored using a new metric, Matched Donor Potential (MDP), to facilitate improved HLA matching while promoting equity. We interrogated all active kidney waitlist patients (N = 164 427), their corresponding unacceptable antigen files, and all effective donors in the Scientific Registry of Transplant Recipients (January 1, 2016-December 31, 2017). Cause-specific hazard functions were evaluated to assess the potential impact of the MDP metric on deceased donor transplant access rates for all candidates. Access was affected by ethnicity, blood group type, and calculated Panel Reactive Antibody (cPRA). Importantly, we show that access to transplantation is influenced by the patient's own HLA makeup regardless of their ethnicity and by the HLA makeup of effective donors. The MDP metric demonstrates a high association with access to transplantation. Adjusting Cox models to include this new metric resulted in improved access to kidney transplantation for waitlist candidates of minority heritage while significantly promoting HLA matching. Thus, the MDP metric accounts for balanced, equitable organ allocation algorithms.
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Affiliation(s)
- Anat R Tambur
- Comprehensive Transplant Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | | | - Denis Glotz
- Department of Nephrology and Transplantation, Hopital Saint-Louis, Paris, France
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Isaacson D, Schold JD, Gmeiner MW, Copley HC, Kosmoliaptsis V, Tambur AR. HLA-DQ Mismatches Lead to More Unacceptable Antigens, Greater Sensitization, and Increased Disparities in Repeat Transplant Candidates. J Am Soc Nephrol 2022; 33:2293-2305. [PMID: 36450598 PMCID: PMC9731640 DOI: 10.1681/asn.2022030296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/25/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In single-center studies, HLA-DQ mismatches stimulate the most pathogenic donor-specific antibodies. However, because of limitations of transplant registries, this cannot be directly confirmed with registry-based analyses. METHODS We evaluated patients in the Scientific Registry of Transplant Recipients who were relisted after renal graft failure with new, unacceptable antigens corresponding to the HLA typing of their previous donor (UA-PD) as a proxy for donor-specific antibodies. Linear regression was applied to estimate the effects of HLA mismatches on UA-PD and the effects of UA-PD on calculated panel reactive antibody (cPRA) values for 4867 kidney recipients from 2010 to 2021. RESULTS Each additional HLA-DQ mismatch increased the probability of UA-PD by 25.2% among deceased donor transplant recipients and by 28.9% among living donor transplant recipients, significantly more than all other HLA loci (P<0.05). HLA-DQ UA-PD increased cPRA by 29.0% in living donor transplant recipients and by 23.5% in deceased donor transplant recipients, significantly more than all loci except for HLA-A in deceased donor transplant recipients (23.1%). African American deceased donor transplant recipients were significantly more likely than Hispanic and White recipients to develop HLA-DQ UA-PD; among living donor transplant recipients, African American or Hispanic recipients were significantly more likely to do so compared with White recipients. Models evaluating interactions between HLA-DR/DQ mismatches revealed largely independent effects of HLA-DQ mismatches on HLA-DQ UA-PD. CONCLUSIONS HLA-DQ mismatches had the strongest associations with UA-PD, an effect that was greatest in African American and Hispanic recipients. cPRA increases with HLA-DQ UA-PD were equivalent or larger than any other HLA locus. This suggests a need to consider the effects of HLA-DQ in kidney allocation.
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Affiliation(s)
- Dylan Isaacson
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael W. Gmeiner
- Department of Economics, London School of Economics, London, United Kingdom
| | - Hannah C. Copley
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge, United Kingdom
| | - Anat R. Tambur
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Fylaktou A, Lioulios G, Tarassi K, Siorenta A, Petasis GC, Gerogiannis D, Theodorou I, Iniotaki AG, Vittoraki AG. An Approach to Identify HLA Class II Immunogenic Epitopes in the Greek Population through Machine Learning Algorithms. J Clin Med 2022; 11:jcm11237046. [PMID: 36498621 PMCID: PMC9738260 DOI: 10.3390/jcm11237046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
Current pre-transplantation routine matching involves serum anti-HLA antibodies quantification but cannot always preclude unfavorable graft outcomes. Epitope-based matching is proposed as a more precise approach, but to date no epitope-matching algorithm provides a satisfactory predictive tool for transplantation outcomes. In this study, anti-HLA-II loci responses from 1748 patients were analyzed with unsupervised machine learning algorithms, namely principal component analysis (PCA) and antigenic distances, projected as dendrograms. PCA for anti-HLA-DR anti-bodies revealed three main clusters of responses: anti-HLA-DR51 combined with anti-HLA-DRB1*01, anti-HLA-DR52 combined with anti-HLA-DRB1*08 and anti-HLA-DR53 combined with anti-HLA-DRB1*10. The dendrogram for anti-HLA-DR confirmed the pattern and showed further bisection of each cluster. Common epitopes present exclusively in all HLA molecules of each cluster were determined following the HLA epitope registry. Thus, we propose that 19 out of 123 HLA-DR epitopes are those that mainly lead anti-HLA-DR responses in the studied population. Likewise, we identified 22 out of 83 epitopes responsible for anti-HLA-DQ and 13 out of 62 responsible for anti-HLA-DP responses. Interpretation of these results may elucidate mechanisms of interlocus cross-reactivity, providing an alternative way of estimating the significance of each epitope in a population and thus suggesting a novel strategy towards optimal donor selection.
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Affiliation(s)
- Asimina Fylaktou
- National Peripheral Histocompatibility Center, Immunology Department, Hippokration General Hospital, 54642 Thessaloniki, Greece
| | - Georgios Lioulios
- National Peripheral Histocompatibility Center, Immunology Department, Hippokration General Hospital, 54642 Thessaloniki, Greece
- Correspondence:
| | - Katerina Tarassi
- Immunology-Histocompatibility Department, “Evangelismos” General Hospital, 10676 Athens, Greece
| | - Alexandra Siorenta
- Immunology Department & National Tissue Typing Center, General Hospital of Athens “G. Gennimatas”, 11527 Athens, Greece
| | - George Ch Petasis
- National Peripheral Histocompatibility Center, Immunology Department, Hippokration General Hospital, 54642 Thessaloniki, Greece
| | - Demetris Gerogiannis
- Department of Computer Science & Engineering, University of Ioannina, 45110 Ioannina, Greece
| | - Ioannis Theodorou
- Laboratoire d’Immunologie, Hôpital Robert Debre, 75010 Paris, France
| | - Aliki G. Iniotaki
- Immunology Department & National Tissue Typing Center, General Hospital of Athens “G. Gennimatas”, 11527 Athens, Greece
| | - Angeliki G. Vittoraki
- Immunology Department & National Tissue Typing Center, General Hospital of Athens “G. Gennimatas”, 11527 Athens, Greece
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Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:jcm11195753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Role of the Immune System in Renal Transplantation, Types of Response, Technical Approaches and Current Challenges. IMMUNO 2022. [DOI: 10.3390/immuno2040035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advances over the last decades have made renal transplantation an important therapy for patients with end-stage renal disease, as the incidences of acute rejection and short-term transplant loss have been significantly reduced. However, long-term transplant survival remains a challenge in the renal transplantation community. The main causes of long-term graft loss are acute and chronic rejection, as well as the complications related to immunosuppression therapy. In spite of the breakthroughs achieved in recent years, histology is the gold standard technique to confirm the activation of the immune system against the graft with all the ensuing problems that taking biopsies brings to immunosuppressed patients. For this reason, several assays have been developed to try to monitor the immune function, but they show serious constraints owing to the fact that they require substantial laboratory work, they are not clinically available and they provide controversial results, so the combination of multiple assays is often needed to obtain a reliable diagnosis. Thus, the aim of this review is to perform a retrospective study of the immune system in renal transplantation, with special emphasis on the cutting-edge technological developments for monitoring, classification and early detection of rejection episodes in order to contribute to a better adjustment of immunosuppressive therapies and, hence, to a more personalized medicine that improves the quality of life of patients.
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López del Moral C, Wu K, Naik M, Osmanodja B, Akifova A, Lachmann N, Stauch D, Hergovits S, Choi M, Bachmann F, Halleck F, Schrezenmeier E, Schmidt D, Budde K. The natural history of de novo donor-specific HLA antibodies after kidney transplantation. Front Med (Lausanne) 2022; 9:943502. [PMID: 36186822 PMCID: PMC9523126 DOI: 10.3389/fmed.2022.943502] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background De novo donor-specific HLA antibodies (dnDSA) are key factors in the diagnosis of antibody-mediated rejection (ABMR) and related to graft loss. Methods This retrospective study was designed to evaluate the natural course of dnDSA in graft function and kidney allograft survival and to assess the impact of mean fluorescence intensity (MFI) evolution as detected by annual Luminex® screening. All 400 kidney transplant recipients with 731 dnDSA against the last graft (01/03/2000-31/05/2021) were included. Results During 8.3 years of follow-up, ABMR occurred in 24.8% and graft loss in 33.3% of the cases, especially in patients with class I and II dnDSA, and those with multiple dnDSA. We observed frequent changes in MFI with 5-year allograft survivals post-dnDSA of 74.0% in patients with MFI reduction ≥ 50%, 62.4% with fluctuating MFI (MFI reduction ≥ 50% and doubling), and 52.7% with doubling MFI (log-rank p < 0.001). Interestingly, dnDSA in 168 (24.3%) cases became negative at some point during follow-up, and 38/400 (9.5%) patients became stable negative, which was associated with better graft survival. Multivariable analysis revealed the importance of MFI evolution and rejection, while class and number of dnDSA were not contributors in this model. Conclusion In summary, we provide an in-depth analysis of the natural course of dnDSA after kidney transplantation, first evidence for the impact of MFI evolution on graft outcomes, and describe a relevant number of patients with a stable disappearance of dnDSA, related to better allograft survival.
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Affiliation(s)
- Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
- *Correspondence: Covadonga López del Moral,
| | - Kaiyin Wu
- Department of Pathology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Naik
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Aylin Akifova
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Lachmann
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Diana Stauch
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Hergovits
- Institute for Transfusion Medicine, HLA-Laboratory, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Charité – Universitätsmedizin Berlin, BIH Academy, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Olszowska-Zaremba N, Gozdowska J, Zagożdżon R. Clinical significance of low pre-transplant donor specific antibodies (DSA) in living donor kidney recipients with negative complement-dependent cytotoxicity crossmatches (CDCXM), and negative flow cytometry crossmatches (FLXM) - A single-center experience. Transpl Immunol 2022; 74:101672. [PMID: 35868613 DOI: 10.1016/j.trim.2022.101672] [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: 04/26/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is controversial whether all donor-specific antibodies (DSA) detected by the solid-phase single antigen bead (SAB) assay negatively affect kidney transplantation outcomes. The study aimed to evaluate the possible clinical significance of low pre-transplant DSA in living donor kidney recipients. We analyzed a group of patients with HLA-A, B, and -DR DSA reactivities below a virtual crossmatch (VXM) value of 5000 MFI but with all VXM DSA reactivities at HLA-DQ, -DP, and -Cw, which were not typed routinely for donors prior to transplantation. We also investigated the incidence of persistent and de novo DSAs in available posttransplant SAB assays. METHODS From the historical cohort of living donor recipients transplanted between 2014 and 2018 at our center (n = 82), 55 patients met the inclusion criteria, namely: these patients were > 18 years old with non-HLA identical sibling donors, who were not desensitized, who had available pre-transplant SAB results, and who had negative both complement-dependent cytotoxicity crossmatch (CDCXM) and flow cytometry crossmatch (FLXM) results. An additional donor HLA typing, performed for all 55 recipients, identified donor additional HLA-DQ, -DP, and -Cw DSA reactivities. These patients were then divided by SAB reactivity into three groups: 1) those with DSA-positive reactivities; 2) those with non-donor-specific anti-HLA reactivities (NDSA); and, 3) those who were anti-HLA-negative. All these recipients were followed for three years and checked for their de novo or persistent DSA. RESULTS In the studied cohort, DSA-positive, NDSA reactive, and anti-HLA negative recipients constituted 33%, 36%, and 31% of 55 patients, respectively. Non-routinely considered pre-transplant HLA-DQ, -DP, and -Cw DSA-positive reactivities were shown in as many as 78% of DSA-positive cases (group 1) with the lowest MFI value of 319 to DP4 and the highest MFI of 5767 to DQ2. Of the pre-transplant HLA-A, B, and -DR DSA reactivities, only -DR52 DSA reactivity reached the highest MFI value of 2191. These detected DSAs did not reduce the mean estimated glomerular filtration rate (eGFR) values and did not increase the incidence of proteinuria in recipients. While the 3-year graft survival was lower in the DSA-positive group (94.4%) with one recipient who lost kidney transplant, the difference was not significantly different (p = 0.7) from the NDSA (100%) and negative (100%) groups. In terms of the incidence of de novo acute antibody-mediated rejection (AMR) at three years after transplantation, no case has been reported in the cohort. This may suggest that low DSA-positive recipients do not experience higher rejection rate. However, DSA-positive recipients had a tendency for a higher frequency of C4d deposits in peritubular capillaries (PTC) and de novo DSA. CONCLUSION Our 3-year follow-up of patients with low pre-transplant DSA found no association with a deterioration in graft function and worse graft survival. Furthermore, we did not observe an increase in AMR in our patients with low DSA. A larger cohort and a longer follow-up period may be needed to evaluate the tendency of low DSA-positive recipients towards the higher incidence of C4d deposits in PTC and/or de novo DSA.
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Affiliation(s)
- Natasza Olszowska-Zaremba
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland.
| | - Jolanta Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland.
| | - Radosław Zagożdżon
- Department of Clinical Immunology, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland; Department of Immunology, Transplantology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland.
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Combined Analysis of HLA Class II Eplet Mismatch and Tacrolimus Levels for the Prediction of De Novo Donor Specific Antibody Development in Kidney Transplant Recipients. Int J Mol Sci 2022; 23:ijms23137357. [PMID: 35806362 PMCID: PMC9267119 DOI: 10.3390/ijms23137357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 02/05/2023] Open
Abstract
We investigated whether HLA class II eplet mismatch was related to dnDSA development and analyzed its combined impact with tacrolimus levels for kidney transplantation outcomes. A total of 347 kidney transplants were included. HLA Matchmaker was used for the single molecular eplet, total eplet, antibody (Ab)-verified eplet mismatch analyses, and Ab-verified single molecular analysis to identify HLA-DR/DQ molecular thresholds for the risk of dnDSA development. A time-weighted tacrolimus trough level (TAC-C0) of 5 ng/mL and a TAC-C0 time-weighted coefficient variability (TWCV) of 20% were applied to find the combined effects on dnDSA development. A high level of mismatch for single molecular eplet (DQ ≥ 10), total eplet (DQ ≥ 12), Ab-verified eplet (DQ ≥ 4), and Ab-verified single molecular eplet (DQ ≥ 4) significantly correlated with HLA class II dnDSA development. Class II dnDSA developed mostly in patients with low TAC-C0 and high eplet mismatch. In the multivariable analyses, low TAC-C0 and high eplet mismatch showed the highest hazard ratio for the development of dnDSA. No significant combined effect was observed in dnDSA development according to TWCV. In conclusion, the determination of HLA class II eplet mismatch may improve the risk stratification for dnDSA development, especially in conjunction with tacrolimus trough levels.
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Time to Move on: HLA Matching Should Be Reconsidered in Modern Deceased Donor Kidney Allocation. Transplant Direct 2022; 8:e1295. [PMID: 35368986 PMCID: PMC8966965 DOI: 10.1097/txd.0000000000001295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 01/12/2023] Open
Abstract
HLA matching has been the cornerstone of deceased donor kidney allocation policies worldwide but can lead to racial inequity. Although HLA matching has been shown to improve clinical outcomes, the long-term impacts of nonallogenic factors are being increasingly recognized. This has led some transplant programs to include points for nonallogenic factors, for example, age. Our study looks at long-term graft and patient outcomes based on allocation cohorts rather than individual number of HLA mismatches.
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Implementation of molecular matching in transplantation requires further characterization of both immunogenicity and antigenicity of individual HLA epitopes. Hum Immunol 2021; 83:256-263. [PMID: 34963506 DOI: 10.1016/j.humimm.2021.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/08/2023]
Abstract
Over the past decade, high HLA epitope mismatch scores have been associated with inferior transplant outcomes using several tools, of which HLAMatchmaker is most well-known. This software uses theoretically defined polymorphic amino acid configurations, called eplets, for HLA compatibility analysis. Although consideration of eplet mismatch loads has potential for immunological risk stratification of transplant patients, the use of eplet matching in organ allocation algorithms is hindered by lacking knowledge of the immunogenicity of individual eplets, and the possibility that single mismatched amino acids, rather than complete eplets, are responsible for HLA antibody induction. There are several approaches to define eplet immunogenicity, such as antibody verification of individual eplets, and data-driven approaches using large datasets that correlate specific eplet mismatches to donor specific antibody formation or inferior transplant outcomes. Data-driven approaches can also be used to define whether single amino acid mismatches may be more informative than eplet mismatches for predicting HLA antibody induction. When using epitope knowledge for the assignment of unacceptable antigens, it important to realize that alleles sharing an eplet to which antibodies have formed are not automatically all unacceptable since multiple contact sites determine the binding strength and thus biological function and pathogenicity of an antibody, which may differ between reactive alleles. While the future looks bright for using HLA epitopes in clinical decision making, major steps need to be taken to make this a clinical reality.
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