The Lewis system and kidney transplantation

The potential role of antibodies against minor blood group antigens in renal transplantation

Blood group antigens are red blood cell (RBC) surface markers comprising specific carbohydrate moieties attached to the glycolipids and glycoproteins within the membrane. In addition to the major ABO blood group antigens, at least 35 minor blood group antigens have been defined to date. These antigens have immunogenic potential and may cause a transfusion reaction. There is evidence for renal expression of antigens from the Kidd, MNS, Duffy and Lewis groups and therefore the potential for antibodies directed against these antigens to cross-react in a transplanted kidney. In individuals lacking a specific RBC antigen, antibodies may develop after de novo exposure to that antigen, in addition to the potential presence of pre-existing innate antibodies. Relatively little attention has been paid to non-ABO system antibodies, with most reports in the literature focusing on transfusion reactions rather than on any putative role in allograft rejection. Here, we review each of these antigens in the context of renal transplantation and what limited evidence there is on how such immunological risk may be assessed and managed.

Major carbohydrate epitopes in tissues of domestic and African wild animals of potential interest for xenotransplantation research

We investigated the main glycotopes expressed on the tissues of 44 animal species, including primates, nonprimate mammals, marsupials, birds, and a reptile. Paraffin-embedded tissue sections of kidney, heart, liver, pancreas, lung, brain and intestine of 24 domestic animal species were stained with seven fluorescent-labeled lectins. Testis sections of 20 African wild animal species were tested with the same lectins. Overall, three main immunofluorescence patterns were found in the vascular compartment. First, humans and Old World monkeys express genetically polymorphic ABH antigens and do not express alphaGal. Second, New World monkeys, other mammals, and marsupials do not express ABH antigens, but have large amounts of a genetically monomorphic alphaGal. Third, birds and reptiles do not express either ABH or alphaGal, but have monomorphic betaGal, probably different from the lactosamine precursor of ABH and alphaGal. Epithelial cells producing exocrine secretions also expressed carbohydrate epitopes. The fluorescence patterns of the cells of the exocrine compartment are similar, but not identical, to those expressed in the vascular compartment. All the animals tested have some ABH and betaGal in exocrine tissues, but New World monkeys and lower mammals are the only ones expressing alphaGal in exocrine tissues.

Accelerated acute rejection of an apparent A2 renal allograft in an O recipient: report of a case with flow cytometric analysis

We report a case of accelerated acute rejection of a renal allograft from a presumed ABO histo-blood group A2 donor in an O recipient, in which all of the published criteria for compatibility had been met. Flow cytometric analysis of the A and H antigen expression on the kidney donor's erythrocytes suggested that this donor did not have an A2 phenotype, but rather another subgroup of A. Some of the reported cases of accelerated acute rejection of A2 renal allografts in O recipients may have resulted from misapplication of the results of standard lectin agglutination to the transplant setting. The current case suggests that a more sophisticated method of ABO phenotyping, such as erythrocyte flow cytometric analysis, may be necessary in the transplant setting.

Serological and chemical specificities of twelve monoclonal anti-Lea and anti-Leb antibodies

The serological specificities of twelve hybridomas were compared as to their chemical reactivity as determined using direct binding to synthetic carbohydrate structures. All anti-Lea cross-react with type-1-precursor structures and three different variants of anti-Lea could be defined by their binding to type-3-precursor chains, sialylated compounds and the monosaccharide D-galactose. Three major reactivity patterns were also identified among anti-Leb reagents. Anti-LebL cross-react with Lea and do not significantly bind to H-related structures. Anti-LebH,L had both anti-LebL-like activity (cross-reaction with Lea) and anti-LebH-like activity (cross-reaction with H). Finally, anti-LebH cross-reacts strongly with H compounds and do not bind to Lea. The binding pattern of anti-LebL suggests that these antibodies have lower affinity for ALeb and BLeb pentasaccharides than anti-LebH. All these specificities are not absolute, but rather are expressed as members of a quantitative progressive varying series, suggesting the existence of a whole range of antibody specificities gradually changing from Lea----Lea,b----LebL----LebH,L----LebH. The results suggest that anti-LebL will always cross-react with Lea and that anti-LebH will always cross-react with H related structures. However, under certain well-defined conditions these cross-reactions may not be apparent and antibodies might behave as specific anti-Lea or anti-Leb in certain tests.

Delineation between T- and B-suppressive molecules from human seminal plasma: I. Partial characterization of a 180-kD protein inhibiting the B response to T-independent antigens

The immunosuppressive activity of fractionated human seminal plasma (SP) was investigated both in vitro (on human lymphocytes) and in vivo with Balb/c mice. SP fractionation by dialysis allowed delineation of the major suppressor factors according to their respective sizes--small (less than 12 kD) or large (greater than 12 kD). In vitro, large molecules were found to suppress the B-cell proliferative response induced by the Nocardia mitogen, while small molecules suppressed the T-cell proliferation induced by phytohemagglutinin. In vivo, immunosuppression was obtained almost exclusively on T-independent responses after preliminary treatments either with unfractionated SP or with large SP molecules. Both type 1 and type 2 T-independent responses were suppressed, as evidenced by plaque-forming cells and antibody assays. In contrast, no immunosuppression was found in vivo after treatment by small SP molecules. Purification of the B-cell suppressor by gel filtration and high-performance liquid chromatography, as well as by preparative isofocusing, indicated that its molecular weight was 180 kD and its isoelectric charge was between pH 5 and 6. This factor is a protein, as evidenced by pronase digestion. A possible role for this molecule in the protection of sperm against the female immune system is discussed.

Immunoaffinity isolation of the Lewis blood group antigens

Extraction, followed by immunoaffinity chromatography on a column of immobilized antibodies is described for the isolation of the Lewis blood group antigens. These affinity-isolated antigens are suitable in organ transplant immunology laboratories for screening potential donors and recipients for mismatch at the Lewis antigen loci.

A bone marrow transplant with an acquired anti-Le(a): a case study

A patient with aplastic anemia received an ABO incompatible bone marrow transplant (BMT) from an HLA identical sibling. Weekly HLA antibody screens were performed as part of the BMT protocol. At the time of transplant, a hemolytic anti-Le(a) was detected in the Le (a-b-) donor. The Le (a-b+) recipient had no red cell or LCT antibody. A hemolytic anti-Le(a) was detected in the recipient on day 8, but no LCT reactivity was noted at this time. On day 15, the LCT panel demonstrated reactivity with 9 of 50 panel cells without apparent HLA specificity. Graft vs. host disease (GVHD) was present on the skin at this time. The dose of cyclosporin A was increased, but by day 20 the GVHD worsened and the LCT titers increased to 8. This strong reactivity was noted only in the Le (a+) panel members (12/50) and was neutralized with commercial Lewis substance. On day 34 there was no evidence of GVHD, but the lymphocytotoxic anti-Lea continued to be present. The patient began experiencing renal and gastrointestinal difficulties by day 48, and expired on day 60. In renal transplants the kidneys retain their Lewis type and secrete Lewis substance in the urine. In our experience BMT patients retain their Lewis type regardless of the type of the donor. The Lewis system has been linked to renal allograft rejection, and Lewis antigens may function as transplantation antigens in BMT patients as well. In addition, lymphocytotoxic Lewis antibodies can mask other significant HLA antibodies and must be identified when screening patients in need of plateletpheresis products.

Heterogeneity of Lewis antibodies. A comparison of the reaction of human and animal reagents with synthetic oligosaccharides

Human as well as animal anti-Lewis reagents were shown to have different binding patterns to synthetic structures chemically related to the Lewis epitopes. Two main types of cross-reactions were found: (1) Cross-reactions among type 1 Lewis epitopes (Lea, Leb and Lewis disaccharide). This type of cross-reaction among different type 1 structures was predominant in anti-Lea reagents (16 out of 18), although it was also present in some anti-Leb reagents (4 out of 14). (2) Cross-reactions of Lea and Leb with their type 2 isomers X and Y. The Leb-Y cross-reaction was more frequent (7 out of 14) than the Lea-X cross-reaction (2 out of 18). The serological property of some anti-Lewis reagents reacting with cord cells ('Lex') is also shown to be heterogeneous although probably related to common features of the type 1 Lea and Leb epitopes and independent of the type 2 X and Y epitopes.

HLA, MLR, P and Lewis antigens and living donor renal transplantation in a single centre in the Middle East

One hundred and fifty-one living donor renal transplants performed in a single centre in Kuwait were analysed for graft survival in relation to HLA matching, mixed lymphocyte reaction (MLR), P and Lewis antigens. There was a significant difference in graft survival (P = .05) but only at 3, 4 and 5 years between HLA identical (97%, 94%, 94%) and haploidentical combinations (83%, 81% and 79%), respectively. The zero haplotype matched combinations were not significantly different in graft survival from the identical or haploidentical groups. Compatibility or incompatibility for P or Lewis antigens did not influence graft survival. The MLR was significant (P = .05) with the MLR negative recipients having 100% graft survival at 4 years compared to 84% in the MLR positive group. In conclusion with an overall actuarial graft survival of 84% at 6 years none of the factors examined 'dramatically' influenced graft survival. The 'Centre Effect' is the main factor influencing graft survival in our Centre.

Association of renal failure with Lewis incompatibility after allogeneic bone marrow transplantation

The cause of the renal failure that occurs in approximately 20 percent of patients following allogeneic bone marrow transplantation is poorly understood. A patient is described in whom acute renal failure occurred one week after allogeneic bone marrow transplantation. The onset of the renal failure was associated with the demonstration of anti-Lewis antibodies in the patient's serum, which could only have been derived from donor lymphocytes. Recovery of renal function coincided with the disappearance of the Lewis antibody. It is postulated that Lewis incompatibility between graft and host tissue may have contributed to the renal failure in this patient and that incompatibility associated with determinants present on renal cells may account for other instances of acute renal failure following allogeneic bone marrow transplantation.

Lewis blood group antigens defined by monoclonal anti-colon carcinoma antibodies

Monoclonal antibodies directed against human cancer cells were prepared by the murine hybridoma technique. These antibodies detect Lewis blood group antigens as determined by indirect solid-phase radioimmunoassay, hapten inhibition studies, and chromatogram binding assay. One monoclonal antibody is specific for the Lea terminal carbohydrate of Gal beta 1----3Glc NAc(4----1 alpha Fuc) beta 1----3LacCer. Five monoclonal antibodies react with the Leb terminal carbohydrate sequence of Fuc alpha 1----2Gal beta 1----3GlcNAc(4----1 alpha Fuc) beta 1----3LacCer, and four of these antibodies are highly specific for this glycolipid and do not react with other similar di- and monofucosylated glycolipids. One of the anti-Leb antibodies cross-reacts with blood group H glycolipid and has binding properties similar to those of the previously described antibody NS-10-17 [M. Brockhaus, J. L. Magnani, M. Blaszczyk, Z. Steplewski, H. Koprowski, K.-A. Karlsson, G. Larson, and V. Ginsburg (1981) J. Biol. Chem. 256, 13223-13225]. Two antibodies react with both the Lea and Leb antigens, though both bind preferentially to Leb.

The role of the Lewis antigen system in renal transplantation and allograft rejection

The recent literature on the technologic and clinical progress being made in renal transplantation has not emphasized applicable advances in blood group serology. Accumulated data on the Lewis blood group system, however, seem to implicate Lewis incompatibilities between kidney donors and recipients as contributing factors in allograft rejection. Lewis antigens may be capable of inciting both cell-mediated and humoral immune responses of a cytotoxic nature, and such antigens are expressed on cell surfaces of the renal parenchyma in Lewis-positive persons. Hence, this serologically defined system could be the source of diminished allograft survival in recipients who are mismatched with their organ donors for Lewis antigens, despite compatibility within other histocompatibility antigen systems. This premise is still open to question, and future, controlled, clinical studies will be necessary to establish a definite role for the Lewis antigen system in renal transplant rejection.

Anti-erythrocyte antibodies, leukocytotoxins and human renal allograft survival

ABO blood group compatibility is generally required for successful human kidney transplants and new data suggest donor-recipient incompatibility for the Lewis or multiple minor blood groups is detrimental. This is of special importance in the setting of liberal transfusions prior to transplant. To assess the impact of immunizing exposure to disparate blood groups of ABO-matched transfusions and kidney transplants, we studied the interrelationships of anti-erythrocyte antibodies, leukocytotoxins and graft survival in 42 kidney transplant recipients. Three hundred forty-four sera were screened for anti-erythrocyte antibodies using standard hemagglutination techniques and leukocytotoxins, using the antiglobulin method. Statistical analysis by computer used a 2 x 2 x 2 contingency table with model fitting. Only 13 of 42 patients had anti-erythrocyte antibodies at some time: anti-I (4); anti-Kell (1); cold panagglutinin (7); unidentifiable agglutinin (1). Of 42 patients, 16 had no detectable leukocytotoxins. By computer analysis, immunizations to blood group and HLA antigens were independent phenomena. Analysis showed that leukocytotoxins, but not anti-erythrocyte antibodies, were associated with poor graft survival. A computer generated probability of graft survival by antibody status is presented. We conclude that immunization to blood group antigens is not common, is largely non-specific, and is not detrimental to kidney graft survival.

Lymphocytotoxic definition of combined ABH and Lewis antigens and their transfer from sera to lymphocytes

Analysis of lymphocytotoxic reactions with peripheral blood lymphocytes from 74 donors, typed for ABO, secretor, and Lewis phenotypes, identified clusters of reactions distinguishing six antigens resulting from the interactions of Lewis, secretor, and ABO systems: Lea, Leb, ALed, BLed, ALeb, and BLeb. In these experiments, Led on O lymphocytes and Lec were not detected as expected from the experience of other authors with A antigen, B and Leb were detected only on the lymphocytes of ABH secretors, demonstrating that all the ABH antigens of lymphocytes are controlled by the secretor system as are the ABH antigens in external secretions. The ABH and Lewis antigens identified on lymphocytes could be transferred in vitro to lymphocytes, cultured for 2 to 7 days at 37 degrees C in the serum of donors of selected ABO, Lewis, and secretor phenotypes, confirming that ABH and Lewis antigens are not synthesized by lymphocytes but are acquired from circulation as are the Lewis antigens on erythrocytes. As expected, the HLA antigens of lymphocytes were not modified after culture.