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Maddur H, Wilson N, Patil P, Asrani S. Rejection in Liver Transplantation Recipients. J Clin Exp Hepatol 2024; 14:101363. [PMID: 38495462 PMCID: PMC10943490 DOI: 10.1016/j.jceh.2024.101363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/09/2024] [Indexed: 03/19/2024] Open
Abstract
Rejection following liver transplantation continues to impact transplant recipients although rates have decreased over time with advances in immunosuppression management. The diagnosis of rejection remains challenging with liver biopsy remaining the reference standard for diagnosis. Proper classification of rejection type and severity is imperative as this guides management and ultimately graft preservation. Future areas of promise include non-invasive testing for detection of rejection to reduce the morbidity associated with invasive testing and further advances in immunosuppression management to reduce toxicities associated with immunosuppression while minimizing rejection related morbidity.
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Bellamy COC, O'Leary JG, Adeyi O, Baddour N, Batal I, Bucuvalas J, Del Bello A, El Hag M, El-Monayeri M, Farris AB, Feng S, Fiel MI, Fischer SE, Fung J, Grzyb K, Guimei M, Haga H, Hart J, Jackson AM, Jaeckel E, Khurram NA, Knechtle SJ, Lesniak D, Levitsky J, McCaughan G, McKenzie C, Mescoli C, Miquel R, Minervini MI, Nasser IA, Neil D, O'Neil MF, Pappo O, Randhawa P, Ruiz P, Fueyo AS, Schady D, Schiano T, Sebagh M, Smith M, Stevenson HL, Taner T, Taubert R, Thung S, Trunecka P, Wang HL, Wood-Trageser M, Yilmaz F, Zen Y, Zeevi A, Demetris AJ. Banff 2022 Liver Group Meeting report: Monitoring long-term allograft health. Am J Transplant 2024:S1600-6135(24)00204-1. [PMID: 38461883 DOI: 10.1016/j.ajt.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
The Banff Working Group on Liver Allograft Pathology met in September 2022. Participants included hepatologists, surgeons, pathologists, immunologists, and histocompatibility specialists. Presentations and discussions focused on the evaluation of long-term allograft health, including noninvasive and tissue monitoring, immunosuppression optimization, and long-term structural changes. Potential revision of the rejection classification scheme to better accommodate and communicate late T cell-mediated rejection patterns and related structural changes, such as nodular regenerative hyperplasia, were discussed. Improved stratification of long-term maintenance immunosuppression to match the heterogeneity of patient settings will be central to improving long-term patient survival. Such personalized therapeutics are in turn contingent on a better understanding and monitoring of allograft status within a rational decision-making approach, likely to be facilitated in implementation with emerging decision-support tools. Proposed revisions to rejection classification emerging from the meeting include the incorporation of interface hepatitis and fibrosis staging. These will be opened to online testing, modified accordingly, and subject to consensus discussion leading up to the next Banff conference.
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Affiliation(s)
- Christopher O C Bellamy
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland and Department of Pathology, Edinburgh Royal Infirmary, Edinburgh, Scotland.
| | - Jacqueline G O'Leary
- Dallas VA Medical Center & University of Texas, Southwestern, Department of Medicine, Dallas Texas, USA
| | - Oyedele Adeyi
- University of Minnesota Medical School, Department of Pathology, Minneapolis, Minnesota, USA
| | - Nahed Baddour
- Faculty of Medicine, University of Alexandria, Egypt
| | - Ibrahim Batal
- Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | | | | | | | | | - Alton B Farris
- Pathology, Emory University Hospital, Atlanta, Georgia, USA
| | - Sandy Feng
- UCSF Health, Department of Surgery, San Francisco, California, USA
| | - Maria Isabel Fiel
- Pathology, Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | | | - John Fung
- Uchicago Medicine, Department of Surgery, Chicago, Illinois, USA
| | | | - Maha Guimei
- Armed Forces College of Medicine, Cairo, Egypt
| | | | - John Hart
- Uchicago Medicine, Department of Pathology, Chicago, Illinois, USA
| | | | | | - Nigar A Khurram
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, Pennsylvania, USA
| | | | - Drew Lesniak
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Rosa Miquel
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Marta I Minervini
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, Pennsylvania, USA
| | - Imad Ahmad Nasser
- Beth Israel Deaconess Medical Center, Harvard, Boston, Massachusetts, USA
| | - Desley Neil
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Maura F O'Neil
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Orit Pappo
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Parmjeet Randhawa
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, Pennsylvania, USA
| | - Phillip Ruiz
- University of Miami Hospital, Miami, Florida, USA
| | | | | | - Thomas Schiano
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | | | - Maxwell Smith
- Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Timucin Taner
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard Taubert
- Dept. of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Swan Thung
- Pathology, Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Pavel Trunecka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
| | - Hanlin L Wang
- Pathology, UCLA Health, Los Angeles, California, USA
| | - Michelle Wood-Trageser
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, Pennsylvania, USA
| | - Funda Yilmaz
- Pathology, University of Ege, Imir, Bornova, Turkey
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Adriana Zeevi
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kanamori H, Yamada Y, Ito Y, Shirosaki K, Yamagishi S, Maeda Y, Kudo Y, Umeyama T, Takahashi N, Kato M, Hasegawa Y, Matsubara K, Shinoda M, Obara H, Irie R, Tsujikawa H, Okita H, Nguyen PT, Saigo K, Mitsunaga S, Inoue I, Kitagawa Y, Kuroda T. Noninvasive graft monitoring using donor-derived cell-free DNA in Japanese liver transplantation. Hepatol Res 2024; 54:300-314. [PMID: 37850337 DOI: 10.1111/hepr.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/06/2023] [Accepted: 10/13/2023] [Indexed: 10/19/2023]
Abstract
AIM To evaluate the use of donor-derived cell-free DNA (dd-cfDNA) in diagnosing graft injuries in Japanese liver transplantation (LTx), including family-related living donors. METHODS A total of 321 samples from 10 newly operated LTx recipients were collected to monitor the early dynamics of dd-cfDNA levels after LTx. Fifty-five samples from 55 recipients were collected during protocol biopsies (PB), whereas 36 samples from 27 recipients were collected during event biopsies, consisting of 11 biopsy-proven acute rejection (AR), 20 acute dysfunctions without rejection (ADWR), and 5 chronic rejections. The levels of dd-cfDNA were quantified using a next-generation sequencer based on single nucleotide polymorphisms. RESULTS The dd-cfDNA levels were elevated significantly after LTx, followed by a rapid decline to the baseline in patients without graft injury within 30 days post-LTx. The dd-cfDNA levels were significantly higher in the 11 samples obtained during AR than those obtained during PB (p < 0.0001), which decreased promptly after treatment. The receiver operator characteristic curve analysis of diagnostic ability yielded areas under the curve of 0.975 and 0.897 for AR (rejection activity index [RAI] ≥3) versus PB and versus non-AR (ADWR + PB). The dd-cfDNA levels during AR were elevated earlier and correlated more strongly with the RAI (r = 0.740) than aspartate aminotransferase/alanine aminotransferase. The dd-cfDNA levels were neither associated with graft fibrosis based on histology nor the status of donor-specific antibodies in PB samples. CONCLUSIONS Donor-derived cell-free DNA serves as a sensitive biomarker for detecting graft injuries in LTx. Further large-scale cohort studies are warranted to optimize its use in differentiating various post-LTx etiologies.
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Affiliation(s)
- Hiroki Kanamori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ito
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Shirosaki
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoko Yamagishi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yutaro Maeda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yumi Kudo
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoshige Umeyama
- Department of Pediatric Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Nobuhiro Takahashi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Digestive Diseases Center, International University of Health and Welfare School of Medicine, Mita Hospital, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rie Irie
- Department of Diagnostic Pathology, Nippon Koukan Hospital, Kawasaki, Japan
| | - Hanako Tsujikawa
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Okita
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | | | - Kenichi Saigo
- Department of Transplantation Surgery, Japan Community Health Care Organization, Chiba Hospital, Chiba, Japan
| | - Shigeki Mitsunaga
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Ituro Inoue
- Human Genetics Laboratory, National Institute of Genetics, Mishima, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Children's Medical Center, Kanagawa, Japan
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Demir Z, Raynaud M, Aubert O, Debray D, Sebagh M, Duong Van Huyen JP, Del Bello A, Jolivet NC, Paradis V, Durand F, Muratot S, Lozach C, Chardot C, Francoz C, Kamar N, Sarnacki S, Coilly A, Samuel D, Vibert E, Féray C, Lefaucheur C, Loupy A. Identification of liver transplant biopsy phenotypes associated with distinct liver biological markers and allograft survival. Am J Transplant 2023:S1600-6135(23)00907-3. [PMID: 38097016 DOI: 10.1016/j.ajt.2023.12.007] [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: 06/26/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 01/01/2024]
Abstract
The intricate association between histologic lesions and circulating antihuman leucocyte antigen donor-specific antibodies (DSA) in liver transplantation (LT) requires further clarification. We conducted a probabilistic, unsupervised approach in a comprehensively well-annotated LT cohort to identify clinically relevant archetypes. We evaluated 490 pairs of LT biopsies with DSA testing from 325 recipients transplanted between 2010 and 2020 across 3 French centers and an external cohort of 202 biopsies from 128 recipients. Unsupervised archetypal analysis integrated all clinico-immuno-histologic parameters of each biopsy to identify biopsy archetypes. The median time after LT was 1.17 (interquartile range, 0.38-2.38) years. We identified 7 archetypes distinguished by clinico-immuno-histologic parameters: archetype #1: severe T cell-mediated rejection (15.9%); #2: chronic rejection with ductopenia (1.8%); #3: architectural and microvascular damages (3.5%); #4: (sub)normal (55.9%); #5: mild T cell-mediated rejection (4.9%); #6: acute antibody-mediated rejection (6.5%); and #7: chronic rejection with DSA (11.4%). Cell infiltrates vary in the archetype. These archetypes were associated with distinct liver biological markers and allograft outcomes. These findings remained consistent when stratified using the patient's age or indications for LT, with good performance in the external cohort (mean highest probability assignment = 0.58, standard deviation ± 0.17). In conclusion, we have identified clinically meaningful archetypes, providing valuable insights into the intricate DSA-histology association, which may help standardize liver allograft pathology classification.
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Affiliation(s)
- Zeynep Demir
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France
| | - Marc Raynaud
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France; Kidney Transplantation Department, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Dominique Debray
- Pediatric Hepatology and Liver Transplantation Unit, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mylène Sebagh
- Pathology Department Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Villejuif, France
| | - Jean-Paul Duong Van Huyen
- Pathology Department, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Nicolas Congy Jolivet
- Department of Immunology, Hôpital de Rangueil, CHU de Toulouse, Molecular Immunogenetics Laboratory, EA 3034, IFR150 (INSERM), Toulouse, France
| | - Valérie Paradis
- Pathology Department, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - François Durand
- Hepatology Department, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - Sophie Muratot
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France
| | - Cécile Lozach
- Department of Pediatric Radiology, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Claire Francoz
- Hepatology Department, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Audrey Coilly
- Hepatobiliary Center, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Inserm Paris-Saclay Research Unit 1193, Paris-Saclay University, Villejuif, France
| | - Didier Samuel
- Hepatobiliary Center, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Inserm Paris-Saclay Research Unit 1193, Paris-Saclay University, Villejuif, France
| | - Eric Vibert
- Hepatobiliary Center, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Inserm Paris-Saclay Research Unit 1193, Paris-Saclay University, Villejuif, France
| | - Cyrille Féray
- Hepatobiliary Center, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Inserm Paris-Saclay Research Unit 1193, Paris-Saclay University, Villejuif, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France; Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Université de Paris Cité, INSERM, PARCC, Paris, France; Kidney Transplantation Department, Necker enfants malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Ravichandran R, Itabashi Y, Zhou F, Lin Y, Mohanakumar T, Chapman WC. Circulating exosomes from brain death and cardiac death donors have distinct molecular and immunologic properties: A pilot study. Clin Transplant 2023; 37:e15067. [PMID: 37428019 PMCID: PMC11019898 DOI: 10.1111/ctr.15067] [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: 08/29/2022] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND AIMS Comparison of donation after brain death (DBD) and donation after cardiac death (DCD) lung tissue before transplantation have demonstrated activation of pro-inflammatory cytokine pathway in DBD donors. The molecular and immunological properties of circulating exosomes from DBD and DCD donors were not previously described. METHODS We collected plasma from 18 deceased donors (12 DBD and six DCD). Cytokines were analyzed by 30-Plex luminex Panels. Exosomes were analyzed for liver self-antigen (SAg), Transcription Factors and HLA class II (HLA-DR/DQ) using western blot. C57BL/6 animals were immunized with isolated exosomes to determine strength and magnitude of immune responses. Interferon (IFN)-γ and tumor necrosis factor-α producing cells were quantified by ELISPOT, specific antibodies to HLA class II antigens were measured by ELISA RESULTS: We demonstrate increased plasma levels of IFNγ, EGF, EOTAXIN, IP-10, MCP-1, RANTES, MIP-β, VEGF, and interleukins - 6/8 in DBD plasma versus DCD. MiRNA isolated from exosome of DBD donors demonstrated significant increase in miR-421, which has been reported to correlate with higher level of Interleukin-6. Higher levels of liver SAg Collagen III (p = .008), pro-inflammatory transcription factors (NF-κB, p < .05; HIF1α, p = .021), CIITA (p = .011), and HLA class II (HLA-DR, p = .0003 and HLA-DQ, p = .013) were detected in exosomes from DBD versus DCD plasma. The circulating exosomes isolated from DBD donors were immunogenic in mice and led to the development of Abs to HLA-DR/DQ. CONCLUSIONS This study provides potential new mechanisms by which DBD organs release exosomes that can activate immune pathways leading to cytokine release and allo-immune response.
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Affiliation(s)
| | - Yoshihiro Itabashi
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ
| | - Fangyu Zhou
- Division of General Surgery, Washington University School of Medicine, St. Louis, MO 63110
| | - Yiing Lin
- Division of General Surgery, Washington University School of Medicine, St. Louis, MO 63110
| | | | - William C. Chapman
- Division of General Surgery, Washington University School of Medicine, St. Louis, MO 63110
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O’Leary JG, Farris AB, Gebel HM, Asrani SK, Askar M, Garcia V, Snipes GJ, Lo DJ, Knechtle SJ, Klintmalm GB, Demetris AJ. Detailed Analysis of Simultaneous Renal and Liver Allografts in the Presence of DSA. Transplant Direct 2023; 9:e1500. [PMID: 37456590 PMCID: PMC10348731 DOI: 10.1097/txd.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 07/18/2023] Open
Abstract
Liver allografts protect renal allografts from the same donor from some, but not all, preformed donor specific alloantibodies (DSA). However, the precise mechanisms of protection and the potential for more subtle alterations/injuries within the grafts resulting from DSA interactions require further study. Methods We reevaluated allograft biopsies from simultaneous liver-kidney transplant recipients who had both allografts biopsied within 60 d of one another and within 30 d of DSA being positive in serum (positive: mean florescence intensity ≥5000). Routine histology, C4d staining, and specialized immunohistochemistry for Kupffer cells (KCs; CD163) and a C4d receptor immunoglobulin-like transcript-4 were carried out in 4 patients with 6 paired biopsies. Results Overt antibody-mediated rejection was found in 3 of 4 renal and liver allografts. One patient had biopsy-confirmed renal and liver allograft antibody-mediated rejection despite serum clearance of DSA. All biopsies showed KC hypertrophy (minimal: 1; mild: 2; moderate: 1; severe: 2) and cytoplasmic C4d KC staining was easily detected in 2 biopsies from 2 patients; minimal and negative in 2 biopsies each. Implications of which are discussed. Control 1-y protocol liver allograft biopsies from DSA- recipients showed neither KC hypertrophy nor KC C4d staining (n = 6). Conclusions Partial renal allograft protection by a liver allograft from the same donor may be partially mediated by phagocytosis/elimination of antibody and complement split products by KCs, as shown decades ago in controlled sensitized experimental animal experiments.
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Affiliation(s)
| | - Alton B. Farris
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Howard M. Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Sumeet K. Asrani
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Medhat Askar
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - Vanessa Garcia
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
| | - George J. Snipes
- Department of Pathology, Baylor University Medical Center, Dallas TX
| | - Denise J. Lo
- Department of Surgery, Duke University, Durham, NC
| | | | - Goran B. Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas TX
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7
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El Hag MI, Kaneku H, Jorgensen D, Zeevi A, Stevenson HL, Yadak N, Hassan M, Du X, Demetris AJ. Morphologic and immunophenotypic evaluation of liver allograft biopsies with contemporaneous serum DSA measurements. Clin Transplant 2023; 37:e14997. [PMID: 37096730 DOI: 10.1111/ctr.14997] [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: 02/02/2022] [Revised: 02/27/2023] [Accepted: 04/09/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Acute antibody mediated rejection is increasingly identified in liver allografts as a unique form of alloimmune injury associated with donor specific antibodies (DSA). This manifests pathologically as microvascular injury and C4d uptake. Despite the liver allograft's relative resistance to alloimmune injury, liver allografts are not impervious to cellular and antibody-mediated rejection. METHODS In this blinded control study, we evaluated CD163 immunohistochemistry and applied the Banff 2016 criteria for diagnosis of acute AMR on a group of indication allograft liver biopsies from DSA positive patients and compared them to indication biopsies from DSA negative controls. RESULTS Most DSA positive patients were females (75%, p = .027), and underwent transplantation for HCV infection. Significant histopathological predictors of serum DSA positivity were Banff H-score (p = .01), moderate to severe cholestasis (p = .03), and CD163 score > 2 (p = .029). Other morphologic features that showed a trend with DSA positivity include Banff portal C4d-score (p = .06), bile ductular reaction (p = .07), and central perivenulitis (p = .07). The odds of DSA sMFI ≥5000 was 12.5 times higher in those with a C4d score >1 than those with a C4d score ≤ 1 (p = .04). Incidence of definite for aAMR in the DSA positive cohort was 25% (n = 5), and 0% in the DSA negative cohort. A group of 5 DSA positive cases were not classifiable by the current scheme. CONCLUSION Sinusoidal CD163, Banff H-score, and diffuse C4d are predictors of serum DSA, and facilitate recognition of histopathological features associated with serum DSA and tissue-antibody interaction.
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Affiliation(s)
- Mohamed I El Hag
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hugo Kaneku
- Department of Surgery - Immunology and Histocompatibility Laboratory, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dana Jorgensen
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adriana Zeevi
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Hepatic and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nour Yadak
- Department of Pathology, Methodist University Hospital, University of Tennessee, Memphis, Tennessee, USA
| | - Mohamed Hassan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaotang Du
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Anthony J Demetris
- Thomas E Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Hepatic and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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8
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Sebagh M, Yilmaz F, Kounis I, Saliba F, Feray C, Taupin JL, Cherqui D, Azoulay D, Samuel D, Coilly A, Demetris AJ, Neil D. Evidence for Alloimmune Sinusoidal Injury in De Novo Nodular Regenerative Hyperplasia After Liver Transplantation. Transpl Int 2023; 36:11306. [PMID: 37565050 PMCID: PMC10409867 DOI: 10.3389/ti.2023.11306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023]
Abstract
Posttransplant nodular regenerative hyperplasia (NRH) mostly remains unexplained. Microvascular injury due to antibody-mediated rejection (AMR) is suspected, but lack of donor specific antibody (DSA) testing makes it difficult to prove. Centered around a 1-year period of routine DSA testing, concomitant protocol, and indicated posttransplant liver biopsies (LB), recipients with NRH (n = 18) were compared with a matched control group (n = 36). All index, previous, and subsequent LB were reviewed. Both groups were similar in terms of demographics, timing of index LB, and DSA. In the index LB, the NRH group had higher sinusoidal C4d positivity (p = 0.029) and perisinusoidal fibrosis (p = 0.034), both independently associated with NRH (p = 0.038 and 0.050, respectively). Features of "possible" chronic AMR were detected in 28.5% of the NRH group without a known cause and 0% of the control group (p = 0.009). The NRH group had more preceding indicated LB with increased incidence of rejection and biliary obstruction pattern. In the follow-up histology, overall, sinusoidal and portal C4d positivity, sinusoidal microvasculitis, and perisinusoidal fibrosis were also higher (all p < 0.050). In conclusion, we provide evidence towards the hypothesis that some cases of posttransplant NRH are related to preceding active and persistent AMR. Large multicenter studies with protocol DSA testing are required to confirm.
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Affiliation(s)
- Mylène Sebagh
- Laboratoire d’Anatomopathologie, AP-HP Hôpital Paul-Brousse, Villejuif, France
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
| | - Funda Yilmaz
- Ege University Organ Transplantation Center, Department of Pathology, School of Medicine, Ege University, Bornova, Izmir, Türkiye
| | - Ilias Kounis
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Faouzi Saliba
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Cyrille Feray
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Jean-Luc Taupin
- Département d’Immunologie and d’Histocompatibilité, AP-HP Hôpital Saint-Louis, Paris, France
| | - Daniel Cherqui
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Daniel Azoulay
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Didier Samuel
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Audrey Coilly
- Inserm, Unité 1193, Université Paris-Saclay, Villejuif, France
- Université Paris-Saclay, Villejuif, France
- Centre Hépato-Biliaire, AP-HP Hôpital Paul-Brousse, Villejuif, France
| | - Antony-Jake Demetris
- Division of Transplantation, Medical Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Desley Neil
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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9
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van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [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: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
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Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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10
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Peters AL, Rogers M, Begum G, Sun Q, Fei L, Leino D, Hildeman D, Woodle ES. T-cell infiltrate intensity is associated with delayed response to treatment in late acute cellular rejection in pediatric liver transplant recipients. Pediatr Transplant 2023; 27:e14475. [PMID: 36691289 PMCID: PMC10121906 DOI: 10.1111/petr.14475] [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: 06/27/2022] [Revised: 11/21/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Late acute cellular rejection (ACR) is associated with donor-specific antibodies (DSA) development, chronic rejection, and allograft loss. However, accurate predictors of late ACR treatment response are lacking. ACR is primarily T-cell mediated, yet B cells and plasma cells (PC) also infiltrate the portal areas during late ACR. To test the hypothesis that the inflammatory milieu is associated with delayed response (DR) to rejection therapy, we performed a single-center retrospective case-control study of pediatric late liver ACR using multiparameter immunofluorescence for CD4, CD8, CD68, CD20, and CD138 to identify immune cell subpopulations. METHODS Pediatric liver transplant recipients transplanted at <17 years of age and treated for biopsy-proven late ACR between January 2014 and 2019 were stratified into rapid response (RR) and DR based on alanine aminotransferase (ALT) normalization within 30 days of diagnosis. All patients received IV methylprednisolone as an initial rejection treatment. Immunofluorescence was performed on archived formalin-fixed paraffin embedded (FFPE) liver biopsy tissue. RESULTS Liver biopsies from 60 episodes of late ACR in 54 patients were included in the analysis, of which 33 were DR (55%). Anti-thymocyte globulin was only required in the DR group. The frequency of liver-infiltrating CD20+ and CD8+ lymphocytes and the prevalence of autoantibodies were higher in the DR group. In univariate logistic regression analysis, serum gamma-glutamyl transpeptidase (GGT) level at diagnosis, but not ALT, Banff score or presence of DSA, predicted DR. CONCLUSIONS Higher serum GGT level, presence of autoantibodies, and increased CD8+ T-cell infiltration portends DR in late ACR treatment in children.
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Affiliation(s)
- Anna L. Peters
- Department of Pediatrics, University of Cincinnati College of Medicine
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Michael Rogers
- Department of Pediatrics, University of Cincinnati College of Medicine
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Gousia Begum
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center
| | - Qin Sun
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
| | - Daniel Leino
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center
- Department of Pathology and Laboratory Medicine, University of Cincinnati
| | - David Hildeman
- Department of Pediatrics, University of Cincinnati College of Medicine
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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11
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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12
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Hübscher SG, Feng S, Gouw ASH, Haga H, Kang HJ, Kelly DA, Komuta M, Lesniak A, Popp BA, Verkade HJ, Yu E, Demetris AJ. Standardizing the histological assessment of late posttransplantation biopsies from pediatric liver allograft recipients. Liver Transpl 2022; 28:1475-1489. [PMID: 35429359 DOI: 10.1002/lt.26482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023]
Abstract
Excellent short-term survival after pediatric liver transplantation (LT) has shifted attention toward the optimization of long-term outcomes. Despite considerable progress in imaging and other noninvasive modalities, liver biopsies continue to be required to monitor allograft health and to titrate immunosuppression. However, a standardized approach to the detailed assessment of long-term graft histology is currently lacking. The aim of this study was to formulate a list of histopathological features relevant for the assessment of long-surviving liver allograft health and to develop an approach for assessing the presence and severity of these features in a standardized manner. Whole-slide digital images from 31 biopsies obtained ≥4 years after transplantation to determine eligibility for an immunosuppression withdrawal trial were selected to illustrate a range of typical histopathological findings seen in children with clinically stable grafts, including those associated with alloantibodies. Fifty histological features were independently assessed and, where appropriate, scored semiquantitatively by six pathologists to determine inter- and intraobserver reproducibility of the histopathological features using unweighted and weighted kappa statistics; the latter metric enabled distinction between minor and major disagreements in parameter severity scoring. Weighted interobserver kappa statistics showed a high level of agreement for various parameters of inflammation, interface activity, fibrosis, and microvascular injury. Intraobserver agreement for these features was even more substantial. The results of this study will help to standardize the assessment of biopsies from long-surviving liver allografts, aid the recognition of important histological features, and facilitate international comparisons and clinical trials aiming to improve outcomes for children undergoing LT.
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Affiliation(s)
- Stefan G Hübscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandy Feng
- Division of Transplantation, Department of Surgery, University of California, San Francisco, California, USA
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Hironori Haga
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hyo Jeong Kang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's & Children's NHS Trust and University of Birmingham, Birmingham, UK
| | - Mina Komuta
- Department of Pathology, Keio University, Tokyo, Japan
| | - Andrew Lesniak
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin A Popp
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Henkjan J Verkade
- Pediatric Gastroenterology/Hepatology, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Eunsil Yu
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Anthony J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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13
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Vij M, Rammohan A, Rela M. Long-term liver allograft fibrosis: A review with emphasis on idiopathic post-transplant hepatitis and chronic antibody mediated rejection. World J Hepatol 2022; 14:1541-1549. [PMID: 36157865 PMCID: PMC9453462 DOI: 10.4254/wjh.v14.i8.1541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is a life-saving surgical procedure and the current standard of care for most patients with end stage liver disease. With improvements in organ preservation techniques, perioperative care, and immunosuppression, there is better patient and graft survival following LT, and assessment of the liver allograft in long-term survivors is becoming increasingly important. Recurrent or de novo viral or autoimmune injury remains the most common causes of chronic hepatitis and fibrosis following liver transplantation in adults. However, no obvious cause can be identified in many adults with controlled recurrent disease and the majority of pediatric LT recipients, as they have been transplanted for non-recurrent liver diseases. Serial surveillance liver biopsies post LT have been evaluated in several adult and pediatric centers to identify long-term pathological changes. Pathological findings are frequently present in liver biopsies obtained after a year post LT. The significance of these findings is uncertain as many of these are seen in protocol liver biopsies from patients with clinically good allograft function and normal liver chemistry parameters. This narrative review summaries the factors predisposing to long-term liver allograft fibrosis, highlighting the putative role of idiopathic post-LT hepatitis and chronic antibody mediated rejection in its pathogenesis.
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Affiliation(s)
- Mukul Vij
- Department of Pathology, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr. Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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14
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The New Challenge in Pediatric Liver Transplantation: Chronic Antibody-Mediated Rejection. J Clin Med 2022; 11:jcm11164834. [PMID: 36013073 PMCID: PMC9409831 DOI: 10.3390/jcm11164834] [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: 05/08/2022] [Revised: 08/07/2022] [Accepted: 08/16/2022] [Indexed: 12/21/2022] Open
Abstract
Antibody-mediated rejection (AMR) of liver allograft transplantation was considered as anecdotal for many decades. However recently, AMR has gained clinical awareness as a potential cause of chronic liver injury, leading to liver allograft fibrosis and eventual graft failure. (1) Methods: Literature on chronic AMR (cAMR) in pediatric post-liver transplant patients was reviewed for epidemiologic data, physiopathology, diagnosis, and treatment approaches. (2) Results: Accurate incidence of cAMR in pediatric liver transplantation remains unknown. Diagnostic criteria of cAMR were suggested by the Banff Working Group in 2016 and are based on standardized histopathological findings, C4d staining pattern, associated with the presence of donor-specific antibodies (DSA). Physio-pathological mechanisms are not clear for the technically difficult-to-obtain animal models reproducing cAMR. Treatment protocols are not established, being limited to case reports and case series, based on experience in ABO incompatible transplantation and kidney transplantation. Immunosuppression compliance with adequate dose adjustment may prevent cAMR. Conversion of Cyclosporine to Tacrolimus may improve pathological findings if treated in early phase. The association of steroids, Mycophenolate Mofetil (MMF) and mTOR inhibitors have shown some synergistic effects. Second-line treatments such as intravenous immunoglobulin (IVIG) and plasma exchange may decrease antibody titers based on ABO incompatible transplant protocols. The use of anti-CD20 (Rituximab) and proteasome inhibitors (Bortezomib) is controversial due to the lack of qualified studies. Therefore, multicenter randomized trials are needed to establish the best therapeutic strategy. In refractory cases, re-transplantation is the only treatment for allograft failure. (3) Conclusions: This literature review collects recent clinical, histopathological, and therapeutical advances of cAMR in liver allograft transplantation of pediatric patients. There are many physio-pathological aspects of cAMR to be clarified. Further efforts with multicenter prospective protocols to manage patients with cAMR are needed to improve its outcome.
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15
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Belatacept Treatment of Recurrent Late-onset T Cell-mediated Rejection/Antibody-mediated Rejection With De Novo Donor-specific Antibodies in a Liver Transplant Patient. Transplant Direct 2022; 8:e1076. [PMID: 35774420 PMCID: PMC9236599 DOI: 10.1097/txd.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/26/2022] Open
Abstract
T cell-mediated rejection that appears and persists late after transplantation is often associated with development of de novo donor-specific antibodies. Treatment of this condition often presents a conundrum because of the uncertainty regarding the trade-off between immunosuppression-related toxicities/complications and restoration of allograft function and structure. Methods Herein, we report an illustrative case of a young 20-y-old otherwise healthy woman who underwent liver replacement for Alagille's syndrome from an ABO-compatible, 6 antigen-mismatched crossmatch-negative 24-y-old man. Although triple baseline immunosuppression was used (tacrolimus, mycophenolate mofetil, and prednisone), she developed rejection 3 d after liver replacement. Despite verified continual immunosuppression compliance, 1.5 y after liver replacement she experienced 6 more rejection episodes over the following 18 mo and development of de novo donor-specific antibody. Results Treatment with belatacept began 3.5 y after transplantation, normalizing her liver tests with no further rejections. A biopsy obtained 6 y after transplantation (postoperative day 2221) was normal, appearing without inflammation or residual fibrosis. Conclusions Belatacept may be a useful treatment approach in this setting.
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16
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Lee BT, Ganjoo N, Fiel MI, Hechtman JF, Sarkar SA, Kim-Schluger L, Florman SS, Schiano TD. Recurrent Liver Allograft Injury in Patients With Donor-Derived Malignancy Treated With Immunosuppression Cessation and Retransplantation. Am J Clin Pathol 2022; 158:199-205. [PMID: 35285881 DOI: 10.1093/ajcp/aqac026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/28/2022] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Donor-derived malignancy of the liver allograft is a rare but serious condition in the setting of necessary immunosuppression. Retransplantation after abrupt immunosuppression cessation has been performed with durable cancer-free survival. METHODS We present 2 cases of patients with donor-derived malignancy who were treated with complete immunosuppression cessation, which induced rapidly progressive liver allograft rejection and failure, with a need for subsequent retransplantation. We reviewed all serial liver biopsies and explants from both patients and performed C4d immunostaining. RESULTS Initial explants of both patients showed severe allograft rejection, with unusual features of sinusoidal obstruction syndrome and C4d positivity. Malignant tumors in the explants were necrotic, related to rejection of donor-derived cancer cells and tissue. Follow-up of both patients has shown long-term cancer-free survival but issues with recurrent allograft failure requiring a third transplant. The reasons for retransplantation in both cases were related to allograft failure from antibody-mediated rejection. CONCLUSIONS Clinicians should be aware of a potentially increased risk of rejection and recurrent allograft failure when strategizing treatment of donor-derived malignancy with immunosuppression cessation and retransplantation.
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Affiliation(s)
- Brian T Lee
- Division of Gastroenterology and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, New York, NY, USA
| | - Naveen Ganjoo
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, New York, NY, USA
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, New York, NY, USA
| | | | - Suparna A Sarkar
- Department of Pathology, New York University School of Medicine, New York, NY, USA
| | - Leona Kim-Schluger
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, New York, NY, USA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Division of Abdominal Transplantation, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, New York, NY, USA
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17
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Nakamura T, Shirouzu T, Sugimoto R, Harada S, Yoshikawa M, Nobori S, Ushigome H, Kawai S. Intra-Liver Allograft C3d-Binding Donor-Specific Anti-HLA Antibodies Predict Rejection After Liver Transplantation. Transplant Proc 2022; 54:450-453. [PMID: 35039161 DOI: 10.1016/j.transproceed.2021.08.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/26/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is no doubt that antibody-mediated rejection (AMR) due to donor-specific anti-HLA antibodies (DSA) brings a poor outcome for liver transplant recipients. However, the relationship between intragraft DSA (g-DSA), complement-binding abilities, and AMR remains unknown. MATERIALS AND METHODS We enrolled a total of 20 liver transplant recipients who underwent protocol or episode graft biopsies in the mid to long term after liver transplant (median 48.5, range 6-198 months), and their status of g-DSA and complement 3d (C3d)-binding abilities was assessed with the graft immunocomplex capture fluorescence analysis (ICFA) technique. RESULTS The prevalence of g-DSA was 15.0 % in liver transplant recipients (3/20), and serum DSA (s-DSA) also existed in 15.0% of recipients. The number of g-DSA+/s-DSA+, g-DSA+/s-DSA-, g-DSA-/s-DSA+, and g-DSA-/s-DSA- cases are 1, 2, 2, and 15, respectively. The g-DSA+ group demonstrated a significant high rejection activity index: 3.67 ± 1.53, compared with the g-DSA- group: 1.24 ± 1.15 (P = .0045). Moreover, C3d-binding reaction was notably higher in the g-DSA+ group (C3d index: 1.87 ± 0.38 vs 0.76 ± 0.35) (P < .0001). Overall, the g-DSA+ group was more associated with liver allograft rejection-not only AMR, but also T cell-mediated rejection (P = .031). CONCLUSIONS These results suggest that the existence of g-DSA and intragraft C3d-binding reaction had a negative impact on the liver allografts, but in contrast s-DSA did not have any significant impact.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan.
| | - Takayuki Shirouzu
- Wakunaga Pharmaceutical Co, Ltd Molecular Diagnostics Division, 1624 Shimokotachi, Koda-cho, Akitakata, Hiroshima, Japan
| | - Ryusuke Sugimoto
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan
| | - Shumpei Harada
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan
| | - Mikiko Yoshikawa
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan
| | - Shuji Nobori
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan
| | - Hidetaka Ushigome
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto-prefecture, Japan
| | - Shintaro Kawai
- Wakunaga Pharmaceutical Co, Ltd Molecular Diagnostics Division, 1624 Shimokotachi, Koda-cho, Akitakata, Hiroshima, Japan
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18
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Angelico R, Sensi B, Manzia TM, Tisone G, Grassi G, Signorello A, Milana M, Lenci I, Baiocchi L. Chronic rejection after liver transplantation: Opening the Pandora’s box. World J Gastroenterol 2021; 27:7771-7783. [PMID: 34963740 PMCID: PMC8661381 DOI: 10.3748/wjg.v27.i45.7771] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/25/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic rejection (CR) of liver allografts causes damage to intrahepatic vessels and bile ducts and may lead to graft failure after liver transplantation. Although its prevalence has declined steadily with the introduction of potent immunosuppressive therapy, CR still represents an important cause of graft injury, which might be irreversible, leading to graft loss requiring re-transplantation. To date, we still do not fully appreciate the mechanisms underlying this process. In addition to T cell-mediated CR, which was initially the only recognized type of CR, recently a new form of liver allograft CR, antibody-mediated CR, has been identified. This has indeed opened an era of thriving research and renewed interest in the field. Liver biopsy is needed for a definitive diagnosis of CR, but current research is aiming to identify new non-invasive tools for predicting patients at risk for CR after liver transplantation. Moreover, the minimization or withdrawal of immunosuppressive therapy might influence the establishment of subclinical CR-related injury, which should not be disregarded. Therapies for CR may only be effective in the “early” phases, and a tailored management of the immunosuppression regimen is essential for preventing irreversible liver damage. Herein, we provide an overview of the current knowledge and research on CR, focusing on early detection, identification of non-invasive biomarkers, immunosuppressive management, re-transplantation and future perspectives of CR.
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Affiliation(s)
- Roberta Angelico
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Bruno Sensi
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Tommaso M Manzia
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Tisone
- Department of Surgery Sciences, HPB and Transplant Unit, University of Tor Vergata, Rome 00100, Italy
| | - Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
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19
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Lee BT, Fiel MI, Schiano TD. Antibody-mediated rejection of the liver allograft: An update and a clinico-pathological perspective. J Hepatol 2021; 75:1203-1216. [PMID: 34343613 DOI: 10.1016/j.jhep.2021.07.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Antibody-mediated rejection after liver transplantation is an under-recognised cause of allograft injury. While definitions of acute and chronic antibody-mediated rejection have increased clinical awareness, timely identification and management of antibody-mediated rejection remain difficult because of complexities in diagnosis and histopathology, lack of treatment protocols, and unclear long-term outcomes. While recent cohort studies assessing the importance of donor-specific antibodies have aided in its diagnosis, literature on the treatment of antibody-mediated rejection in liver transplantation remain limited to case reports and small series. Further increasing the awareness and timely recognition of antibody-mediated rejection post-liver transplantation is crucial in order to stimulate future research and the development of protocols for its diagnosis and treatment. This review will summarise recent advances in the clinical diagnosis and treatment of antibody-mediated rejection in liver transplantation, as well as some of the histopathologic features (on liver biopsy tissue) of acute and chronic antibody-mediated rejection.
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Affiliation(s)
- Brian T Lee
- Division of Gastroenterology and Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas D Schiano
- Division of Liver Diseases, Department of Medicine, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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20
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Dehghani SM, Shahramian I, Ayatollahi M, Parooie F, Salarzaei M, Bahmanyar M, Sargazi A, Delaramnasab M. The incidence and risk factors of chronic rejection in acutely rejected pediatric liver transplantation. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2021. [DOI: 10.15825/25/1995-1191-2021-4-26-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background. Chronic graft rejection (CR) represents an increasing concern in pediatric liver transplantation (LT). Risk factors of CR in this population are uncertain. In present study, we aimed to ascertain if clinical parameters could predict the occurrence of CR in LT children.Methods. We retrospectively analyzed the results from 47 children who had experienced acute hepatic rejection in Namazee hospital, Shiraz, Iran during 2007–2017.Results. Out of 47 children, 22 (46.8%) and 25 (53.2%) were boys and girls respectively. Ascites, gastrointestinal bleeding, and spontaneous bacterial peritonitis were observed in 20 (44.4%), 14 (31.1%), and 4 (9.1%) respectively. Posttransplant vascular and biliary complications were observed in 3 (7%) and 4 (9.3%) cases respectively. The mean time from LT to normalization of liver enzymes was 14.2 ± 7.5 days. The mean of acute rejection episodes was 1.4 ± 0.6 (median = 1 (22, 46.8%), range of 1–3). Six (12.7%) patients experienced CR. The mean time from LT to CR was 75 ± 28.4 days. A significant association was found between CR and patients’ condition (being inpatient or outpatient) before surgery (P = 0.03). No significant relationship was found between CR and post-transplant parameters except for biliary complications (P = 0.01). Both biliary complication (RR = 33.7, 95% CI: 2.2–511, P = 0.01) and inpatient status (RR = 10.9, 95% CI: 1.1–102.5, P = 0.03) significantly increased the risk of CR.Conclusion. Being hospitalized at the time of LT, and development of biliary complications might predict risk factors for development of CR in LT children.
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Affiliation(s)
- S. M. Dehghani
- Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz University of Medical Sciences
| | - I. Shahramian
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Science
| | - M. Ayatollahi
- Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz University of Medical Sciences
| | - F. Parooie
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Science
| | - M. Salarzaei
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Science
| | | | - A. Sargazi
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Science
| | - M. Delaramnasab
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Science
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21
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Sakamoto S, Akamatsu N, Hasegawa K, Ohdan H, Nakagawa K, Egawa H. The efficacy of rituximab treatment for antibody-mediated rejection in liver transplantation: A retrospective Japanese nationwide study. Hepatol Res 2021; 51:990-999. [PMID: 33818877 DOI: 10.1111/hepr.13643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/17/2021] [Accepted: 03/27/2021] [Indexed: 12/17/2022]
Abstract
AIM Antibody-mediated rejection (AMR) has been consistently elucidated in liver transplantation (LT); however, the treatment for AMR, including rituximab, has not been indicated as a strongly recommended therapeutic protocol. METHODS This study was conducted as the Japanese multicenter retrospective study to accumulate data on the use of rituximab for AMR among patients undergoing LT between August 2001 and December 2016. Thirteen patients (five children and eight adults) were enrolled. RESULTS The types of AMR in the pediatric cases were chronic AMR in four cases and indeterminate AMR in one case. Among the pediatric cases, rituximab treatment only showed therapeutic efficacy in two patients with chronic AMR. Among the adult patients, five patients had chronic AMR, and three had acute AMR. Although two patients with chronic AMR died due to graft failure, liver function tests revealed improvement after rituximab treatment in the other patients. Two of the three patients with acute AMR died due to graft failure; rituximab treatment showed no therapeutic efficacy in these cases. Although bacterial infections occurred within 3 months after rituximab administration in three patients, rituximab treatment could be safely administered without any direct adverse effects. CONCLUSIONS The indication of rituximab therapy as an additional treatment for mild acute AMR and chronic AMR may be feasible; however, a prospective randomized control study is needed to evaluate the therapeutic efficacy of rituximab treatment for AMR.
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Affiliation(s)
- Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Tokyo University Graduate School of Medicine, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Tokyo University Graduate School of Medicine, Tokyo, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Nakagawa
- Department of Urology, Ichikawa General Hospital Tokyo Dental College, Chiba, Japan
| | - Hiroto Egawa
- Department of Gastroenterological Surgery, Institute of Gastroenterology, Tokyo Women's Medical University of Medicine, Tokyo, Japan
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22
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Gül-Klein S, Hegermann H, Röhle R, Schmelzle M, Tacke F, Schöning W, Öllinger R, Dziodzio T, Maier P, Plewe JM, Horst D, Sauer IM, Pratschke J, Lachmann N, Eurich D. Donor-Specific Antibodies Against Donor Human Leukocyte Antigen are Associated with Graft Inflammation but Not with Fibrosis Long-Term After Liver Transplantation: An Analysis of Protocol Biopsies. J Inflamm Res 2021; 14:2697-2712. [PMID: 34188517 PMCID: PMC8236257 DOI: 10.2147/jir.s307778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background Donor-specific antibodies (DSA) against donor human leukocyte antigen after liver transplantation, which are associated with histological changes, have been widely studied with respect to their sustained impact on transplant function. However, their long-term impact after liver transplantation remains unclear. Methods We performed a cross-sectional analysis from June 2016 to July 2017 that included all patients who presented themselves for scheduled follow-up after receiving a liver transplantation between September 1989 and December 2016. In addition to a liver protocol biopsy, patients were screened for human leukocyte antigen antibodies (HLAab) and donor-specific antibodies. Subsequently, the association between human leukocyte antigen antibodies, donor-specific antibodies, histologic and clinical features, and immunosuppression was analyzed. Results Analysis for human leukocyte antigen antibodies and donor-specific antibodies against donor human leukocyte antigen was performed for 291 and 271 patients. A significant association between higher inflammation grades and the presence of human leukocyte antigen antibodies and donor-specific antibodies was detected, while fibrosis stages remained unaffected. These results were confirmed by multivariate logistic regression for inflammation showing a significant increase for presence of human leukocyte antigen antibodies and donor-specific antibodies (OR: 4.43; 95% CI: 1.67–12.6; p=0.0035). Furthermore, the use of everolimus in combination with tacrolimus was significantly associated with the status of negative human leukocyte antigen antibodies and donor-specific antibodies. Viral etiology for liver disease, hepatocellular carcinoma (HCC) and higher steatosis grades of the graft were significantly associated with a lower rate of human leukocyte antigen antibodies. The impact of human leukocyte antigen antibodies and donor-specific antibodies against donor human leukocyte antigen was associated with higher levels of laboratory parameters, such as transaminases and bilirubin. Conclusion Donor-specific antibodies against donor human leukocyte antigen are associated with histological and biochemical graft inflammation after liver transplantation, while fibrosis seems to be unaffected. Future studies should validate these findings for longer observation periods and specific subgroups.
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Affiliation(s)
- Safak Gül-Klein
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Henriette Hegermann
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Robert Röhle
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Coordinating Center for Clinical Studies, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Moritz Schmelzle
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Hepatology & Gastroenterology, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Wenzel Schöning
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Robert Öllinger
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Tomasz Dziodzio
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Patrick Maier
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Julius M Plewe
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - David Horst
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Igor Maximilian Sauer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Nils Lachmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, HLA Laboratory, Institute of Transfusion Medicine, Histocompatibility and Immunogenetics, Charité - Universitätsmedizin, Berlin, Germany
| | - Dennis Eurich
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
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23
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Voutilainen SH, Kosola SK, Lohi J, Jahnukainen T, Pakarinen MP, Jalanko H. Expression of fibrosis-related genes in liver allografts: Association with histology and long-term outcome after pediatric liver transplantation. Clin Transplant 2021; 35:e14373. [PMID: 34043847 DOI: 10.1111/ctr.14373] [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: 11/21/2020] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unexplained graft fibrosis and inflammation are common after pediatric liver transplantation (LT). OBJECTIVE We investigated the graft expression of fibrogenic genes and correlated the findings with transplant histopathology and outcome. METHODS Liver biopsies from 29 recipients were obtained at a median of 13.1 (IQR: 5.0-18.4) years after pediatric LT. Control samples were from six liver-healthy subjects. Hepatic expression of 40 fibrosis-related genes was correlated to histological findings: normal histology, fibrosis with no inflammation, and fibrosis with inflammation. Liver function was evaluated after a subsequent follow-up of 9.0 years (IQR: 8.0-9.4). RESULTS Patients with fibrosis and no inflammation had significantly increased gene expression of profibrotic TGF-β3 (1.17 vs. 1.02 p = .005), CTGF (1.64 vs. 0.66 p = .014), PDGF-α (1.79 vs. 0.98 p = .049), PDGF -β (0.99 vs. 0.76 p = .006), integrin-subunit-β1 (1.19 vs. 1.02 p = .045), α-SMA (1.12 vs. 0.58 p = .013), type I collagen (0.82 vs. 0.53 p = .005) and antifibrotic decorin (1.15 vs. 0.99 p = .045) compared to patients with normal histology. mRNA expression of VEGF A (0.84 vs. 1.06 p = .049) was lower. Only a few of the studied genes were upregulated in patients with both fibrosis and inflammation. The gene expression levels showed no association with later graft outcome. CONCLUSIONS Altered hepatic expression of fibrosis-related genes is associated with graft fibrosis without concurrent inflammation.
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Affiliation(s)
- Silja H Voutilainen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University, Hospital and University of Helsinki, Helsinki, Finland
| | - Silja K Kosola
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University, Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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24
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Sultani B, Marget M, Briem-Richter A, Herrmann J, Meisner S, Grabhorn EF, Ozga AK, Weidemann S, Herden U, Fischer L, Sterneck M. Presence of donor specific HLA class 2 antibodies (DSA class 2) is associated with development of graft fibrosis more than 10 years after liver transplantation-a retrospective single center study. Clin Transplant 2021; 35:e14336. [PMID: 33949011 DOI: 10.1111/ctr.14336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023]
Abstract
Here the impact of donor specific human leukocyte antigen (HLA) class 2 antibodies (DSA cl 2) on long term outcome after liver transplantation (LT) was investigated. Altogether 156 (44 pediatric and 112 adult) LT recipients were included in the study. Graft fibrosis was assessed by liver elastography and biopsy. DSA cl 2 were determined by Luminex technology. 46% of LT recipients were positive for DSA cl 2 after a median follow-up of 15 years. In the multivariate analysis DSA cl 2 were significantly associated with immunosuppressive monotherapy (OR 5.42; 95% CI: 1.02-28.90; p = .048). Compared to DSA cl 2 negative patients, positive recipients had significantly more graft fibrosis based on the liver stiffness (mean 9.4 ± 9.0 kPa vs. 6.5 ± 6.3 kPa; p < .002) and fibrosis stages determined by liver elastography (p = .016) and the performed liver biopsies (p = .002). Also, a significantly higher incidence of chronic rejections (11% vs. 2%; p = .045) and graft losses (6% vs. 0%; p = .043) were found. In the multivariate regression analysis DSA cl 2 were significantly associated with graft fibrosis (OR 4.57; 95% CI 1.59-13.10; p = .005). So, these data suggest that development of DSA cl 2 occurs more often with immunosuppressive monotherapy and may ultimately result in chronic rejection and graft fibrosis.
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Affiliation(s)
- Bejan Sultani
- Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Matthias Marget
- Institute of Transfusion Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Andrea Briem-Richter
- Department of Pediatric Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Sebastian Meisner
- Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Enke Freya Grabhorn
- Department of Pediatric Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Ozga
- Insitute of Medical Biometry, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- Department of Pathology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Uta Herden
- Department of Visceral Transplantation, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Visceral Transplantation, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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25
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Commentary: Late Allograft Fibrosis and Inflammation - An Unexpected Finding with Need for More Aggressive Treatment? Transplantation 2021; 106:16-17. [PMID: 33496559 DOI: 10.1097/tp.0000000000003650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Thomson AW, Vionnet J, Sanchez-Fueyo A. Understanding, predicting and achieving liver transplant tolerance: from bench to bedside. Nat Rev Gastroenterol Hepatol 2020; 17:719-739. [PMID: 32759983 DOI: 10.1038/s41575-020-0334-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
Abstract
In the past 40 years, liver transplantation has evolved from a high-risk procedure to one that offers high success rates for reversal of liver dysfunction and excellent patient and graft survival. The liver is the most tolerogenic of transplanted organs; indeed, immunosuppressive therapy can be completely withdrawn without rejection of the graft in carefully selected, stable long-term liver recipients. However, in other recipients, chronic allograft injury, late graft failure and the adverse effects of anti-rejection therapy remain important obstacles to improved success. The liver has a unique composition of parenchymal and immune cells that regulate innate and adaptive immunity and that can promote antigen-specific tolerance. Although the mechanisms underlying liver transplant tolerance are not well understood, important insights have been gained into how the local microenvironment, hepatic immune cells and specific molecular pathways can promote donor-specific tolerance. These insights provide a basis for the identification of potential clinical biomarkers that might correlate with tolerance or rejection and for the development of novel therapeutic targets. Innovative approaches aimed at promoting immunosuppressive drug minimization or withdrawal include the adoptive transfer of donor-derived or recipient-derived regulatory immune cells to promote liver transplant tolerance. In this Review, we summarize and discuss these developments and their implications for liver transplantation.
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Affiliation(s)
- Angus W Thomson
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Julien Vionnet
- Institute of Liver Studies, Medical Research Council (MRC) Centre for Transplantation, School of Immunology and Infectious Diseases, King's College London University, King's College Hospital, London, UK.,Transplantation Center, University Hospital of Lausanne, Lausanne, Switzerland.,Service of Gastroenterology and Hepatology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, Medical Research Council (MRC) Centre for Transplantation, School of Immunology and Infectious Diseases, King's College London University, King's College Hospital, London, UK
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27
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Caballero Marcos A, Díaz Ruiz R, Romero Cristóbal M, Fernández Yunquera A, Díaz-Fontenla F, Pérez Carazo L, Peligros Gómez MI, Vicario Moreno JL, Salcedo Plaza M, Bañares Cañizares R. Long-term outcomes and clinical impact of anti-HLA donor-specific antibodies (DSA) after liver transplantation: a prospective study in a pilot cohort. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:557-562. [PMID: 33244987 DOI: 10.17235/reed.2020.7337/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION the presence of donor-specific antibodies (DSA) is thought to affect survival of the allograft and patient after liver transplantation (LT). However, their significance is not well understood. PATIENTS AND METHODS a prospective study was performed of 32 adult patients who underwent LT in 2011 to analyze the existence of DSA, associated risk factors and medium-term impact. Immunological determinations were performed immediately before LT and at three, six, 12 months and five years after LT. RESULTS eight patients (24.2 %) presented pre-formed DSA. However, titers were negative in all patients five years after LT and there were no associated events. Eight out of 24 patients (33.3 %) developed de novo DSA. After five years, only two remained positive; both were class II with high mean fluorescence intensity (MFI) values at diagnosis (over 15,000). No association was found between the development of DSA and the risk of rejection, graft loss or death. However, an increase in liver stiffness values was observed in patients with persistent DSA, and focal sinusoidal deposition of C4d and moderate liver fibrosis were reported. CONCLUSION the incidence of DSA is high after LT. In addition, the persistence of de novo DSA could be associated with silent liver fibrosis with a potential impact on graft outcomes.
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Affiliation(s)
| | - Raquel Díaz Ruiz
- Digestive Diseases, Hospital General Universitario Gregorio Marañon, España
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28
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Herzer K, Sterneck M, Welker MW, Nadalin S, Kirchner G, Braun F, Malessa C, Herber A, Pratschke J, Weiss KH, Jaeckel E, Tacke F. Current Challenges in the Post-Transplant Care of Liver Transplant Recipients in Germany. J Clin Med 2020; 9:jcm9113570. [PMID: 33167567 PMCID: PMC7694452 DOI: 10.3390/jcm9113570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/25/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023] Open
Abstract
Improving long-term patient and graft survival after liver transplantation (LT) remains a major challenge. Compared to the early phase after LT, long-term morbidity and mortality of the recipients not only depends on complications immediately related to the graft function, infections, or rejection, but also on medical factors such as de novo malignancies, metabolic disorders (e.g., new-onset diabetes, osteoporosis), psychiatric conditions (e.g., anxiety, depression), renal failure, and cardiovascular diseases. While a comprehensive post-transplant care at the LT center and the connected regional networks may improve outcome, there is currently no generally accepted standard to the post-transplant management of LT recipients in Germany. We therefore described the structure and standards of post-LT care by conducting a survey at 12 German LT centers including transplant hepatologists and surgeons. Aftercare structures and form of cost reimbursement considerably varied between LT centers across Germany. Further discussions and studies are required to define optimal structure and content of post-LT care systems, aiming at improving the long-term outcomes of LT recipients.
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Affiliation(s)
- Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Knappschafts-Klinik Bad Neuenahr, 53474 Bad Neuenahr-Ahrweiler, Germany
| | - Martina Sterneck
- Department of Medicine, University Medical Center Hamburg Eppendorf, 20251 Hamburg, Germany;
| | - Martin-Walter Welker
- Department of Internal Medicine I, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Silvio Nadalin
- Department for General, Visceral and Transplant Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany;
| | - Gabriele Kirchner
- Department of Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
- Innere Medizin I, Caritaskrankenhaus St. Josef, 93053 Regensburg, Germany
| | - Felix Braun
- Department for Transplantation Surgery, University Hospital Kiel, 24105 Kiel, Germany;
| | - Christina Malessa
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, 07747 Jena, Germany;
| | - Adam Herber
- Department of Gastroenterology and Rheumatology, University Hospital Leipzig, 04103 Leipzig, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité University Medicine Berlin, 13353 Berlin, Germany;
- Berlin Institute of Health, 13353 Berlin, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine, University of Heidelberg, 69120 Heidelberg, Germany;
- Department of Internal Medicine, Salem Medical Center, 69120 Heidelberg, Germany
| | - Elmar Jaeckel
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, 30625 Hannover, Germany;
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Campus Charité Mitte/Campus Virchow-Klinikum, Charité University Medicine Berlin, 13353 Berlin, Germany
- Correspondence:
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Donor-specific antibodies in liver transplantation: challenges in diagnosis and determining clinical impact. Curr Opin Organ Transplant 2020; 25:549-554. [PMID: 33105198 DOI: 10.1097/mot.0000000000000825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Our understanding of the clinical impact of donor-specific antibodies in liver transplant recipients has evolved in recent years as outcomes for liver allografts have improved and advances in diagnostic testing have made recognition of antibody mediated rejection in transplant patients more sensitive. RECENT FINDINGS Two main types of donor-specific antibodies - preformed and de novo - have been reported in the literature to have a negative impact on graft survival, and researchers have been able to further identify subclasses of class II donor-specific antibodies as being the most clinically impactful. Furthermore, there is evidence that donor-specific antibody formation can augment cellular rejection in liver grafts and lead to worsened clinical outcomes. Recent data have shown a higher prevalence of donor-specific antibody formation than previously reported. SUMMARY This review explores the most recent literature regarding the clinical impact of both preformed and de-novo donor-specific antibodies and potential management guidelines for patients undergoing liver transplantation. The best practice guidelines for undergoing monitoring for donor-specific antibody formation and protocol biopsies in sensitized patients will depend on further multiinstitutional studies.
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Wu Y, Huang M, Sun H, Zhou X, Zhou R, Gu G, Xia Q. Role of Innate Immunity in Pediatric Post-transplant Idiopathic Liver Fibrosis. Front Immunol 2020; 11:2111. [PMID: 33193293 PMCID: PMC7642407 DOI: 10.3389/fimmu.2020.02111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/04/2020] [Indexed: 01/22/2023] Open
Abstract
Pediatric post-transplant idiopathic liver fibrosis is an unexplained graft fibrosis that occurs in symptom-free children without acute rejection and surgical complications. Despite a lack of consensus on the subject, the development of pediatric post-transplant idiopathic liver fibrosis is believed to be the result of multiple potential factors, including ischemia-reperfusion injury, allogeneic acute and chronic rejection, viral hepatitis recurrence, opportunistic infection, and drug-induced liver damage. Among them, there is growing evidence that innate immunity may also have a unique role in this progression. This study reviews the features of pediatric post-transplant idiopathic liver fibrosis and discusses current studies illustrating the potential mechanisms of liver allograft tolerance induced by intrahepatic innate immunity, the role of components including Toll-like receptors (TLRs), interferons (IFN), dendritic cells (DC), natural killer cells (NK cells), NKT cells, neutrophils, and Kupffer cells, as well as their possibly relevant role in the development of pediatric post-transplant idiopathic liver fibrosis.
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Affiliation(s)
- Yue Wu
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingzhu Huang
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haojie Sun
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiying Zhou
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruoqiao Zhou
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guangxiang Gu
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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31
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Höfer A, Jonigk D, Hartleben B, Verboom M, Hallensleben M, Manns MP, Jaeckel E, Taubert R. Non-invasive screening for subclinical liver graft injury in adults via donor-specific anti-HLA antibodies. Sci Rep 2020; 10:14242. [PMID: 32859929 PMCID: PMC7455737 DOI: 10.1038/s41598-020-70938-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023] Open
Abstract
The majority of liver grafts exhibit abnormal histological findings late after transplantation, even when liver enzymes are normal. Such subclinical graft injuries were associated with rejection and fibrosis progression in recent studies. The identification of non-invasive biomarkers for subclinical graft injury might help to individualize immunosuppression. Therefore, graft injury was assessed in 133 liver biopsies with normal/near normal liver enzymes from a prospective liver biopsy program. Cytokeratin-18 cell death marker (M65) and donor specific anti-HLA antibodies (DSA) were measured as non-invasive markers in paired plasma samples in addition to routine parameters. M65 was associated with subclinical graft injury but this association was too weak for reasonable clinical application. DSA positivity was associated with more graft inflammation (OR = 5.4) and more fibrosis (OR = 4.2). Absence of DSA excluded fibrosis in 87–89%, while presence of DSA excluded histological criteria for immunosuppression minimization attempts in 92–97%. While CK18 cell death marker had no diagnostic value for the detection of subclinical liver graft injury, DSA testing can help to preselect patients for immunosuppression reduction in case of DSA negativity, while DSA positivity should prompt elastography or liver biopsy for the assessment of subclinical graft injury.
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Affiliation(s)
- Anne Höfer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Danny Jonigk
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Björn Hartleben
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael Hallensleben
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany. .,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany. .,European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany.
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32
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Baba HA, Theurer S, Canbay A, Schwertheim S, Lainka E, Kälsch J, Wohlschläger J. [Liver transplantation. Current aspects of pretransplantation diagnosis and rejection]. DER PATHOLOGE 2020; 41:505-514. [PMID: 32776226 DOI: 10.1007/s00292-020-00813-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation is an established treatment option for patients with end-stage liver disease. The therapy management of these patients is interdisciplinary and requires pathologists to have both clinical and immunological knowledge. Continuous advances in treatment and increasing clinical experience are accompanied by the further development of pathological transplant diagnostics. This article presents and discusses the latest classification of T‑cell-mediated rejection (TCMR), antibody-mediated rejection (AMR), and aspects of pretransplant diagnostics.
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Affiliation(s)
- Hideo A Baba
- Institut für Pathologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Sarah Theurer
- Institut für Pathologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Ali Canbay
- Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Suzan Schwertheim
- Institut für Pathologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Elke Lainka
- Klinik für Kinderheilkunde, Universitätsklinikum Essen, Essen, Deutschland
| | - Julia Kälsch
- Klinik für Gastroenterologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Jeremias Wohlschläger
- Institut für Pathologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
- MVZ für Pathologie, Diakonissenkrankenhaus Flensburg, Flensburg, Deutschland
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33
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Enhancing the Value of Histopathological Assessment of Allograft Biopsy Monitoring. Transplantation 2020; 103:1306-1322. [PMID: 30768568 DOI: 10.1097/tp.0000000000002656] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Traditional histopathological allograft biopsy evaluation provides, within hours, diagnoses, prognostic information, and mechanistic insights into disease processes. However, proponents of an array of alternative monitoring platforms, broadly classified as "invasive" or "noninvasive" depending on whether allograft tissue is needed, question the value proposition of tissue histopathology. The authors explore the pros and cons of current analytical methods relative to the value of traditional and illustrate advancements of next-generation histopathological evaluation of tissue biopsies. We describe the continuing value of traditional histopathological tissue assessment and "next-generation pathology (NGP)," broadly defined as staining/labeling techniques coupled with digital imaging and automated image analysis. Noninvasive imaging and fluid (blood and urine) analyses promote low-risk, global organ assessment, and "molecular" data output, respectively; invasive alternatives promote objective, "mechanistic" insights by creating gene lists with variably increased/decreased expression compared with steady state/baseline. Proponents of alternative approaches contrast their preferred methods with traditional histopathology and: (1) fail to cite the main value of traditional and NGP-retention of spatial and inferred temporal context available for innumerable objective analyses and (2) belie an unfamiliarity with the impact of advances in imaging and software-guided analytics on emerging histopathology practices. Illustrative NGP examples demonstrate the value of multidimensional data that preserve tissue-based spatial and temporal contexts. We outline a path forward for clinical NGP implementation where "software-assisted sign-out" will enable pathologists to conduct objective analyses that can be incorporated into their final reports and improve patient care.
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34
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Tolerance studies in liver transplantation: are we fooling ourselves? Curr Opin Organ Transplant 2020; 25:151-157. [DOI: 10.1097/mot.0000000000000738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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35
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 747] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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36
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37
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Schiano TD, Florman S, Fiel MI. Recurrent Idiopathic Liver Allograft Failure. Am J Clin Pathol 2019; 152:369-376. [PMID: 31139817 DOI: 10.1093/ajcp/aqz044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Many transplant programs have had patients who develop idiopathic recurrent liver allograft failure, necessitating serial transplants, and are deemed to have refractory or recurrent rejection. The frequency and the etiology of this immunologic dysfunction have not been well characterized. METHODS Herein, we illustrate the case of a patient who required three retransplants over a period of 20 years for recurrent liver allograft failure. By extensively compiling the patient's many liver biopsy specimens and explants over time, we demonstrate that antibody-mediated rejection (AMR) was a major contributing factor from the outset. We conducted a review of the Scientific Registry for Transplant Recipients database to estimate the potential frequency of AMR. RESULTS As illustrated by this case, AMR has varied histologic findings in the setting of elevated donor-specific antibody titers. CONCLUSIONS The cause of recurrent allograft failure in this patient was likely a combination of acute cellular rejection and AMR, manifestations of likely underlying immune dysregulation. Pathologists and transplant physicians should recognize the variable histologic presentations of AMR, which is imperative for its timely intervention. This case demonstrates how difficult the diagnosis of AMR can be to make, highlighting the need for strong clinical suspicion in patients having difficult-to-treat rejection and recurrent allograft failure.
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Affiliation(s)
- Thomas D Schiano
- The Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander Florman
- The Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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38
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Wozniak LJ, Venick RS. Donor-specific antibodies following liver and intestinal transplantation: Clinical significance, pathogenesis and recommendations. Int Rev Immunol 2019; 38:106-117. [DOI: 10.1080/08830185.2019.1630404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Laura J. Wozniak
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert S. Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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39
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Han JL, Beal EW, Mumtaz K, Washburn K, Black SM. Combined liver-lung transplantation: Indications, outcomes, current experience and ethical Issues. Transplant Rev (Orlando) 2019; 33:99-106. [DOI: 10.1016/j.trre.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
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40
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Advancing Transplantation: New Questions, New Possibilities in Kidney and Liver Transplantation. Transplantation 2018; 101 Suppl 2S:S1-S41. [PMID: 28125449 DOI: 10.1097/tp.0000000000001563] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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41
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Affiliation(s)
- Alexandre Loupy
- From the Paris Translational Research Center for Organ Transplantation, INSERM, Unité Mixte de Recherche S970 (A.L., C.L.), the Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) (A.L.), and the Kidney Transplant Department, Saint-Louis Hospital, AP-HP (C.L.) - all in Paris
| | - Carmen Lefaucheur
- From the Paris Translational Research Center for Organ Transplantation, INSERM, Unité Mixte de Recherche S970 (A.L., C.L.), the Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) (A.L.), and the Kidney Transplant Department, Saint-Louis Hospital, AP-HP (C.L.) - all in Paris
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42
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Sheikh A, Chau KY, Evans HM. Histological findings in protocol biopsies following pediatric liver transplant: Low incidence of abnormalities at 5 years. Pediatr Transplant 2018; 22:e13212. [PMID: 29749699 DOI: 10.1111/petr.13212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
Abstract
Histological abnormalities, including chronic hepatitis, fibrosis, and steatosis, are increasingly reported in liver biopsies of children after LT. These changes may be progressive and represent a form of rejection. Liver biochemistry is often initially normal. Our LT program began in 2002, utilizing tacrolimus and low-dose steroids for the first year post-LT. Patients undergo a protocol biopsy at 1 year post-LT prior to stopping steroids, then at 5 years and every 5 years thereafter. Target tacrolimus levels are 5-8 μg/L and 3-5 μg/L after 3 and 12 months, respectively. Between 2002 and 2009, 51 LT were performed; 50 (98%) and 49 (96%) patients survived for 1 and 5 years, respectively. A total of 43 patients (median age at LT 2.3 years) underwent a protocol biopsy at 1 year (16 male; median time post-LT 12.5 months), and 44 (20 male; median time post-LT 5.1 years) at 5 years. By 5 years, 3 had transferred to adult services; 1 was re-transplanted for graft failure and 1 moved overseas. Biopsies were reviewed by 2 pathologists. Most patients (31/44) were on tacrolimus monotherapy at 5 years. At 1 and 5 years, 29 of 43 (67.5%) and 31 of 44 (71%) biopsies were normal, respectively. Two of 44 had chronic allograft hepatitis at 5 years. Two of 43 and 1 of 44 had isolated fibrosis, 3 of 43 and 3 of 44 steatosis, and 3 of 43 and 4 of 44 acute rejection at 1 and 5 years, respectively. Other findings included predominantly biliary changes (6/43 & 3/44 at 1 and 5 years, respectively). Tacrolimus levels at 5 years were slightly higher than anticipated (median trough level 5.8 μg/L). With an immunosuppressive regimen of tacrolimus and low-dose steroids for 1 year followed by tacrolimus monotherapy thereafter, the majority of PLB were normal and no progressive changes were observed at 5 years. Compared to other LT programs, we have lower rates of chronic allograft hepatitis, steatosis, and fibrosis at 5 years. However, the tacrolimus levels at 5 years were higher than planned and this may have played a role. Further evaluation is also required to determine the potential long-term adverse effects of corticosteroid use on linear growth and bone mineral density.
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Affiliation(s)
- Amin Sheikh
- Paediatric Gastroenterology & Hepatology, Starship Child Health, Auckland, New Zealand
| | - Kai Y Chau
- Anatomical Pathology, Auckland City Hospital, Auckland, New Zealand
| | - Helen M Evans
- Paediatric Gastroenterology & Hepatology, Starship Child Health, Auckland, New Zealand
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43
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Aday AW, O'Leary JG. Donor-Specific Antibodies' Meaningful Impact on Liver Transplantation. Liver Transpl 2018; 24:999-1000. [PMID: 30028076 DOI: 10.1002/lt.25299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 01/13/2023]
Affiliation(s)
| | - Jacqueline G O'Leary
- University of Texas Southwestern, Dallas, TX.,Dallas VA Medical Center, Dallas, TX
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44
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Dao M, Habès D, Taupin JL, Mussini C, Redon MJ, Suberbielle C, Jacquemin E, Gonzales E, Guettier C. Morphological characterization of chronic antibody-mediated rejection in ABO-identical or ABO-compatible pediatric liver graft recipients. Liver Transpl 2018; 24:897-907. [PMID: 29704327 DOI: 10.1002/lt.25187] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/24/2018] [Accepted: 04/15/2018] [Indexed: 12/17/2022]
Abstract
This study aims to define the morphological profile associated with the presence of donor-specific antibodies (DSAs) and/or C4d immunostaining in ABO-identical or compatible pediatric liver grafts. Ten-year protocol liver graft biopsies performed at 131.3 ± 15.3 months after transplantation in 53 pediatric liver graft recipients were reviewed. Immunostaining for C4d was systematically performed and semiquantitatively analyzed. DSAs were concurrently quantified, and results were available for 44 patients. All biopsies demonstrated fibrotic changes with a mean liver allograft fibrosis score (LAFSc) of 5.1 ± 2.2. A total of 31 (58%) biopsies exhibited C4d positivity. DSAs were detected in 20 (45%) patients, and mean maximal mean fluorescence intensity was 12,977 ± 6731. LAFSc (6.3 ± 1.3 versus 3.9 ± 2.2; P = 0.008), perivenular fibrosis (2.7 ± 0.5 versus 1.3 ± 1.0; P < 0.001), and portal inflammation (1.4 ± 0.8 versus 0.3 ± 0.5; P = 0.009) were significantly higher in the double-DSA and C4d-positive group versus the double-negative group. We defined a histological scoring system from these results, which was integrated with the 2016 Banff definition and allowed reclassifying patients for the diagnosis of chronic active antibody-mediated rejection (cAMR; 11/53 versus 13/53). Diagnoses of probable cAMR according to Banff 2016 (n = 4) were unchanged, but 2 among the 9 patients classified as possible cAMR according to the 2016 Banff definition were excluded for this diagnostic when using our histological score. In conclusion, our results confirmed that perivenular fibrosis and portal inflammation in late pediatric liver graft biopsies are features of cAMR. Our histological score could improve the accuracy of the 2016 Banff definition for the diagnosis of cAMR. Liver Transplantation 24 897-907 2018 AASLD.
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Affiliation(s)
- Myriam Dao
- Pathology Department, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Dalila Habès
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
| | - Jean-Luc Taupin
- Immunology and Histocompatibility Department, Saint Louis Hospital, Paris, France
| | - Charlotte Mussini
- Pathology Department, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
| | - Marie-José Redon
- Pathology Department, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
| | - Caroline Suberbielle
- Immunology and Histocompatibility Department, Saint Louis Hospital, Paris, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin-Bicêtre, France
- INSERM, Unité Mixte de Recherche en Santé 1174, Université Paris Sud 11, Orsay, France
- Département Hospitalo-Universitaire Hepatinov, Villejuif, France
| | - Emmanuel Gonzales
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin-Bicêtre, France
- INSERM, Unité Mixte de Recherche en Santé 1174, Université Paris Sud 11, Orsay, France
- Département Hospitalo-Universitaire Hepatinov, Villejuif, France
| | - Catherine Guettier
- Pathology Department, Centre Hospitalier Universitaire Bicêtre, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin-Bicêtre, France
- Département Hospitalo-Universitaire Hepatinov, Villejuif, France
- INSERM, Unité 1193, Villejuif, France
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45
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Koo J, Wang HL. Acute, Chronic, and Humoral Rejection: Pathologic Features Under Current Immunosuppressive Regimes. Surg Pathol Clin 2018; 11:431-452. [PMID: 29751884 DOI: 10.1016/j.path.2018.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Under current immunosuppressive regimes, T-cell-mediated acute and chronic rejection remain common and important posttransplant complications. The definition of humoral (antibody-mediated) rejection has been greatly expanded in recent years. The histopathologic assessment of allograft biopsies continues to serve an important role in the diagnosis of rejection and to facilitate patient management. The diagnosis of both acute and chronic antibody-mediated rejection requires integration of the results of donor-specific antibody testing and C4d immunostaining, as well as exclusion of other potential etiologies of allograft dysfunction. Chronic antibody-mediated rejection should also be included in the differential diagnosis for unexplained allograft fibrosis.
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Affiliation(s)
- Jamie Koo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 8707, Los Angeles, CA 90048, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 27-061-C8 CHS, Los Angeles, CA 90095, USA.
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46
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Stevenson HL, Prats MM, Isse K, Zeevi A, Avitzur Y, Ng VL, Demetris AJ. Isolated vascular "v" lesions in liver allografts: How to approach this unusual finding. Am J Transplant 2018; 18:1534-1543. [PMID: 29464837 DOI: 10.1111/ajt.14708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 01/25/2023]
Abstract
According to the Banff criteria for kidney allografts, isolated vascular or "v" lesions are defined as intimal inflammation, age-inappropriate fibro-intimal hyperplasia, or both, without the presence of associated interstitial T cell-mediated rejection (TCMR). In general, these lesions portend a worse outcome for kidney allografts, particularly in those where the "v" lesions are identified in patients with coexistent donor specific antibodies (DSA) or later after transplantation. Although affected arteries are rarely sampled in liver allograft biopsies, we identified nine patients at a mean of 1805 days posttransplantation and compared these to matched controls. Almost half (4 of 9) of the study patient biopsies showed inflammatory arteritis associated with focal or diffuse C4d positivity, which was not observed in matched controls. One "v" lesion patient progressed to rejection-related graft failure and two developed moderate/severe TCMR in subsequent biopsies, whereas only one rejection episode occurred in follow-up biopsies, and no rejection-related deaths or graft failures were detected in controls. In conclusion, patients with liver allograft isolated "v" lesions should undergo further evaluation and closer follow-up for impending TCMR and/or underlying co-existent chronic antibody-mediated rejection (AMR).
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Affiliation(s)
- H L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - M M Prats
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - K Isse
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A Zeevi
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Y Avitzur
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - V L Ng
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - A J Demetris
- Division of Liver and Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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47
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Kim H, Yi NJ, Song EY, Lee K, Lee KW, Lee HW, Ahn HY, Yoon KC, Hong SK, Suh KS. Preformed donor-specific antibodies do not affect the 1-year allograft survival in living donor liver transplantation. Clin Transplant 2018; 32:e13244. [DOI: 10.1111/ctr.13244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Hyeyoung Kim
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
- Department of Surgery; Seoul Metropolitan Government - Seoul National University Boramae Medical Center; Seoul Korea
| | - Nam-Joon Yi
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Eun Young Song
- Department of Laboratory Medicine; Seoul National University College of Medicine; Seoul Korea
| | - Kyoungbun Lee
- Department of Pathology; Seoul National University College of Medicine; Seoul Korea
| | - Kwang-Woong Lee
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Hae Won Lee
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
- Department of Surgery; Seoul Metropolitan Government - Seoul National University Boramae Medical Center; Seoul Korea
| | - Hye Young Ahn
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Kyung Chul Yoon
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Suk Kyun Hong
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
| | - Kyung-Suk Suh
- Department of Surgery; Seoul National University College of Medicine; Seoul Korea
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48
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Yamada Y, Hoshino K, Oyanagi T, Gatayama R, Maeda J, Katori N, Fuchimoto Y, Hibi T, Shinoda M, Matsubara K, Obara H, Aeba R, Kitagawa Y, Yamagishi H, Kuroda T. Successful management of living donor liver transplantation for biliary atresia with single ventricle physiology-from peri-transplant through total cavopulmonary connection: A case report. Pediatr Transplant 2018; 22:e13118. [PMID: 29457852 DOI: 10.1111/petr.13118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
Children with single ventricle physiology have complete mixing of the pulmonary and systemic circulations, requiring staged procedures to achieve a separation of these circulations, or Fontan circulation. The single ventricle physiology significantly increases the risk of mortality in children undergoing non-cardiac surgery. As liver transplantation for patients with single ventricle physiology is particularly challenging, only a few reports have been published. We herein report a case of successful LDLTx for an 8-month-old pediatric patient with biliary atresia, heterotaxy, and complex heart disease of single ventricle physiology. The cardiac anomalies included total anomalous pulmonary venous return type IIb, intermediate atrioventricular septal defect, tricuspid regurgitation grade III, coarctation of aorta, interrupted inferior vena cava, bilateral superior vena cava, and polysplenia syndrome. Following LDLTx, the patient sequentially underwent total cavopulmonary shunt + Damus-Kaye-Stansel at 3 years of age and extracardiac total cavopulmonary connection (EC-TCPC) completion at 5 years of age; 7 years have now passed since LDLTx (2 years post-EC-TCPC). We describe the details of the management of LTx in the presence of cardiac anomalies and report the long-term cardiac and liver function, from peri-LDLTx through EC-TCPC completion.
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Affiliation(s)
- Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takayuki Oyanagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Ryohei Gatayama
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Jun Maeda
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Fuchimoto
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Aeba
- Department of Cardiac Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
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49
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Del Bello A, Congy-Jolivet N, Danjoux M, Muscari F, Lavayssière L, Esposito L, Hebral AL, Bellière J, Kamar N. High tacrolimus intra-patient variability is associated with graft rejection, and de novo donor-specific antibodies occurrence after liver transplantation. World J Gastroenterol 2018; 24:1795-1802. [PMID: 29713132 PMCID: PMC5922997 DOI: 10.3748/wjg.v24.i16.1795] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/06/2018] [Accepted: 03/30/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the role of tacrolimus intra-patient variability (IPV) in adult liver-transplant recipients.
METHODS We retrospectively assessed tacrolimus variability in a cohort of liver-transplant recipients and analyzed its effect on the occurrence of graft rejection and de novo donor-specific antibodies (dnDSAs), as well as graft survival during the first 2 years posttransplantation. Between 02/08 and 06/2015, 116 patients that received tacrolimus plus mycophenolate mofetil (with or without steroids) were included.
RESULTS Twenty-two patients (18.5%) experienced at least one acute-rejection episode (BPAR). Predictive factors for a BPAR were a tacrolimus IPV of > 35% [OR = 3.07 95%CI (1.14-8.24), P = 0.03] or > 40% [OR = 4.16 (1.38-12.50), P = 0.01), and a tacrolimus trough level of < 5 ng/mL [OR=3.68 (1.3-10.4), P =0.014]. Thirteen patients (11.2%) developed at least one dnDSA during the follow-up. Tacrolimus IPV [coded as a continuous variable: OR = 1.1, 95%CI (1.0-1.12), P = 0.006] of > 35% [OR = 4.83, 95%CI (1.39-16.72), P = 0.01] and > 40% [OR = 9.73, 95%CI (2.65-35.76), P = 0.001] were identified as predictors to detect dnDSAs. IPV did not impact on patient- or graft-survival rates during the follow-up.
CONCLUSION Tacrolimus-IPV could be a useful tool to identify patients with a greater risk of graft rejection and of developing a de novo DSA after liver transplantation
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Affiliation(s)
- Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
- Université Paul Sabatier, Toulouse 31000, France
| | - Nicolas Congy-Jolivet
- Université Paul Sabatier, Toulouse 31000, France
- Department of Immunology, CHU de Toulouse, Hôpital de Rangueil, CHU de Toulouse, Toulouse 31000, France
| | - Marie Danjoux
- Department of Pathology, Institut Universitaire du Cancer, CHU Toulouse 31000, France
| | - Fabrice Muscari
- Université Paul Sabatier, Toulouse 31000, France
- Department of Surgery and Liver Transplantation, Toulouse 31000, France
| | - Laurence Lavayssière
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
| | - Anne-Laure Hebral
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
| | - Julie Bellière
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
- Université Paul Sabatier, Toulouse 31000, France
- Molecular Immunogenetics Laboratory, Faculté de Médecine Purpan, IFR150 (INSERM), Montréal H3G 1Y6, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse 31000, France
- Université Paul Sabatier, Toulouse 31000, France
- INSERM, IFR-BMT, CHU Purpan, Toulouse 31000, France
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50
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Neves Souza L, de Martino RB, Sanchez-Fueyo A, Rela M, Dhawan A, O'Grady J, Heaton N, Quaglia A. Histopathology of 460 liver allografts removed at retransplantation: A shift in disease patterns over 27 years. Clin Transplant 2018; 32:e13227. [DOI: 10.1111/ctr.13227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 12/25/2022]
Affiliation(s)
| | - Rodrigo Bronze de Martino
- Institute of Liver Studies; King's College Hospital; London UK
- Faculdade de Medicina; Departamento de Gastroenterologia; Hospital das Clínicas; Universidade de São Paulo; São Paulo Brazil
| | | | - Mohamed Rela
- Institute of Liver Studies; King's College Hospital; London UK
- Institute of Liver Disease and Transplantation; Global Health City; Chennai India
| | - Anil Dhawan
- Paediatric Liver Centre; King's College Hospital; London UK
| | - John O'Grady
- Institute of Liver Studies; King's College Hospital; London UK
| | - Nigel Heaton
- Institute of Liver Studies; King's College Hospital; London UK
| | - Alberto Quaglia
- Institute of Liver Studies; King's College Hospital; London UK
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