1
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von Samson-Himmelstjerna FA, Kakavand N, Gleske C, Schraml F, Basta AA, Braunisch MC, Bräsen JH, Schmitz J, Kraus D, Weinmann-Menke J, Zacharias HU, Vaulet T, Naesens M, Krautter M, Schwenger V, Esser G, Kolbrink B, Amann K, Holzmann-Littig C, Echterdiek F, Kunzendorf U, Renders L, Schulte K, Heemann U. Potential and Uncertainties of RejectClass in Acute Kidney Graft Dysfunction: An Independent Validation Study. Transplantation 2024; 108:1228-1238. [PMID: 38196094 DOI: 10.1097/tp.0000000000004906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Kidney graft rejections are classified based on the Banff classification. The RejectClass algorithm, initially derived from a cohort comprising mostly protocol biopsies, identifies data-driven phenotypes of acute rejection and chronic pathology using Banff lesion scores. It also provides composite scores for inflammation activity and chronicity. This study independently evaluates the performance of RejectClass in a cohort consisting entirely of indication biopsies. METHODS We retrospectively applied RejectClass to 441 patients from the German TRABIO (TRAnsplant BIOpsies) cohort who had received indication biopsies. The primary endpoint was death-censored graft failure during 2 y of follow-up. RESULTS The application of RejectClass to our cohort demonstrated moderately comparable phenotypic features with the derivation cohort, and most clusters indicated an elevated risk of graft loss. However, the reproduction of all phenotypes and the associated risks of graft failure, as depicted in the original studies, was not fully accomplished. In contrast, adjusted Cox proportional hazards analyses substantiated that both the inflammation score and the chronicity score are independently associated with graft loss, exhibiting hazard ratios of 1.7 (95% confidence interval, 1.2-2.3; P = 0.002) and 2.2 (95% confidence interval, 1.8-2.6; P < 0.001), respectively, per 0.25-point increment (scale: 0.0-1.0). CONCLUSIONS The composite inflammation and chronicity scores may already have direct utility in quantitatively assessing the disease stage. Further refinement and validation of RejectClass clusters are necessary to achieve more reliable and accurate phenotyping of rejection.
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Affiliation(s)
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Charlotte Gleske
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Florian Schraml
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Agathe A Basta
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jan H Bräsen
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Daniel Kraus
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Helena U Zacharias
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Thibaut Vaulet
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Markus Krautter
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Fabian Echterdiek
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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2
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MacMillan S, Hosgood SA, Walker-Panse L, Rahfeld P, Macdonald SS, Kizhakkedathu JN, Withers SG, Nicholson ML. Enzymatic conversion of human blood group A kidneys to universal blood group O. Nat Commun 2024; 15:2795. [PMID: 38555382 PMCID: PMC10981661 DOI: 10.1038/s41467-024-47131-9] [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: 01/04/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024] Open
Abstract
ABO blood group compatibility restrictions present the first barrier to donor-recipient matching in kidney transplantation. Here, we present the use of two enzymes, FpGalNAc deacetylase and FpGalactosaminidase, from the bacterium Flavonifractor plautii to enzymatically convert blood group A antigens from the renal vasculature of human kidneys to 'universal' O-type. Using normothermic machine perfusion (NMP) and hypothermic machine perfusion (HMP) strategies, we demonstrate blood group A antigen loss of approximately 80% in as little as 2 h NMP and HMP. Furthermore, we show that treated kidneys do not bind circulating anti-A antibodies in an ex vivo model of ABO-incompatible transplantation and do not activate the classical complement pathway. This strategy presents a solution to the donor organ shortage crisis with the potential for direct clinical translation to reduce waiting times for patients with end stage renal disease.
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Affiliation(s)
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Peter Rahfeld
- Avivo Biomedical Inc., Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Spence S Macdonald
- Avivo Biomedical Inc., Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Stephen G Withers
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
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3
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Golshayan D, Schwotzer N, Fakhouri F, Zuber J. Targeting the Complement Pathway in Kidney Transplantation. J Am Soc Nephrol 2023; 34:1776-1792. [PMID: 37439664 PMCID: PMC10631604 DOI: 10.1681/asn.0000000000000192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
The complement system is paramount in the clearance of pathogens and cell debris, yet is increasingly recognized as a key component in several pathways leading to allograft injury. There is thus a growing interest in new biomarkers to assess complement activation and guide tailored therapies after kidney transplantation (KTx). C5 blockade has revolutionized post-transplant management of atypical hemolytic uremic syndrome, a paradigm of complement-driven disease. Similarly, new drugs targeting the complement amplification loop hold much promise in the treatment and prevention of recurrence of C3 glomerulopathy. Although unduly activation of the complement pathway has been described after brain death and ischemia reperfusion, any clinical attempts to mitigate the ensuing renal insults have so far provided mixed results. However, the intervention timing, strategy, and type of complement blocker need to be optimized in these settings. Furthermore, the fast-moving field of ex vivo organ perfusion technology opens new avenues to deliver complement-targeted drugs to kidney allografts with limited iatrogenic risks. Complement plays also a key role in the pathogenesis of donor-specific ABO- and HLA-targeted alloantibodies. However, C5 blockade failed overall to improve outcomes in highly sensitized patients and prevent the progression to chronic antibody-mediated rejection (ABMR). Similarly, well-conducted studies with C1 inhibitors in sensitized recipients yielded disappointing results so far, in part, because of subtherapeutic dosage used in clinical studies. The emergence of new complement blockers raises hope to significantly reduce the negative effect of ischemia reperfusion, ABMR, and nephropathy recurrence on outcomes after KTx.
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Affiliation(s)
- Dela Golshayan
- Transplantation Center, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Julien Zuber
- Service de Transplantation rénale adulte, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
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4
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Böhmig GA, Halloran PF, Feucht HE. On a Long and Winding Road: Alloantibodies in Organ Transplantation. Transplantation 2023; 107:1027-1041. [PMID: 36944603 DOI: 10.1097/tp.0000000000004550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Today we know that both the humoral and the cellular arm of the immune system are engaged in severe immunological challenges. A close interaction between B and T cells can be observed in most "natural" challenges, including infections, malignancies, and autoimmune diseases. The importance and power of humoral immunity are impressively demonstrated by the current coronavirus disease 2019 pandemic. Organ transplant rejection is a normal immune response to a completely "artificial" challenge. It took a long time before the multifaceted action of different immunological forces was recognized and a unified, generally accepted opinion could be formed. Here, we address prominent paradigms and paradigm shifts in the field of transplantation immunology. We identify several instances in which the transplant community missed a timely paradigm shift because essential, available knowledge was ignored. Moreover, we discuss key findings that critically contributed to our understanding of transplant immunology but sometimes developed with delay and in a roundabout way, as was the case with antibody-mediated rejection-a main focus of this article. These include the discovery of the molecular principles of histocompatibility, the recognition of the microcirculation as a key interface of immune damage, the refinement of alloantibody detection, the description of C4d as a footmark of endothelium-bound antibody, and last but not least, the developments in biopsy-based diagnostics beyond conventional morphology, which only now give us a glimpse of the enormous complexity and pathogenetic diversity of rejection.
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Affiliation(s)
- Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre, ATAGC, University of Alberta, Edmonton, AB, Canada
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5
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Abstract
By 2014, strategies to prevent antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) were established in Japan and expanded primarily to Asia, where LDLT is now the predominant form of LT owing to the scarcity of brain-dead donors. A desensitization protocol consisting of rituximab (375 mg/m 2 ), plasma pheresis, tacrolimus, and mycophenolate mofetil before LDLT, followed by standard immunosuppression, is currently the best option in terms of safety and efficacy. Rituximab administration is now known not to increase the risk of hepatocellular carcinoma recurrence, and the feasibility of rituximab for LDLT for acute liver failure and the need for desensitization before LDLT in children older than 1 y have been documented. Strategies are needed to distinguish patients at high risk of AMR from those at low risk and to adjust immunosuppression to prevent both AMR and infection. Specific single-nucleotide polymorphisms in genes encoding Fcγ receptors affecting the cytotoxicity of rituximab on B cells could be useful for adjusting immunosuppression levels to decrease infectious complications. Immunological accommodation after ABO-I transplantation could be provided by immune factors in both the grafts and recipients.
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6
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Haas M, Mirocha J, Huang E, Najjar R, Peng A, Sethi S, Vo A, Anglicheau D, Jordan SC, Rabant M. A Banff-based histologic chronicity index is associated with graft loss in patients with a kidney transplant and antibody-mediated rejection. Kidney Int 2023; 103:187-195. [PMID: 36332728 DOI: 10.1016/j.kint.2022.09.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/19/2022] [Accepted: 09/16/2022] [Indexed: 11/15/2022]
Abstract
Antibody-mediated rejection (AMR) is the major cause of graft loss in kidney transplant recipients. The Banff classification defines two classes of AMR, active and chronic active but over time this classification has become increasingly complex. To simplify the approach to AMR, we developed activity and chronicity indices based on kidney transplant biopsy findings and examined their association with graft survival in 147 patients with active or chronic active AMR, all of whom had donor-specific antibodies and were treated for AMR. The activity index was determined as the sum of Banff glomerulitis (g), peritubular capillaritis (ptc), arteritis (v) and C4d scores, with a maximum score of 12. The chronicity index was the sum of interstitial fibrosis (ci), tubular atrophy (ct), chronic vasculopathy (cv), and chronic glomerulopathy (cg) scores, the latter doubled, with a maximum score of 15. While the activity index was generally not associated with graft loss, the chronicity index was significantly associated with graft loss with an optimal threshold value of 4 or greater for predicting graft loss. The association of the chronicity index of 4 or greater with graft loss was independent of other parameters associated with graft loss, including the estimated glomerular filtration rate at the time of biopsy, chronic active (versus active) AMR, AMR with de novo (versus persistent/rebound) donor-specific antibodies, Banff (g+ptc) scores, concurrent T cell-mediated rejection and donor-specific antibody reduction post-biopsy. The association of the chronicity index of 4 or greater with graft loss was confirmed in an independent cohort of 61 patients from Necker Hospital, Paris. Thus, our findings suggest that the chronicity index may be valuable as a simplified approach to decision-making in patients with AMR.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - James Mirocha
- General Clinical Research Center, Clinical & Translational Science Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Reiad Najjar
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Supreet Sethi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dany Anglicheau
- Deparment of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, AP-HP, INSERM U1151, Université Paris Cite, Paris, France
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, AP-HP, Université Paris Cite, Paris, France
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7
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Kervella D, Le Bas-Bernardet S, Bruneau S, Blancho G. Protection of transplants against antibody-mediated injuries: from xenotransplantation to allogeneic transplantation, mechanisms and therapeutic insights. Front Immunol 2022; 13:932242. [PMID: 35990687 PMCID: PMC9389360 DOI: 10.3389/fimmu.2022.932242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term allograft survival in allotransplantation, especially in kidney and heart transplantation, is mainly limited by the occurrence of antibody-mediated rejection due to anti-Human Leukocyte Antigen antibodies. These types of rejection are difficult to handle and chronic endothelial damages are often irreversible. In the settings of ABO-incompatible transplantation and xenotransplantation, the presence of antibodies targeting graft antigens is not always associated with rejection. This resistance to antibodies toxicity seems to associate changes in endothelial cells phenotype and modification of the immune response. We describe here these mechanisms with a special focus on endothelial cells resistance to antibodies. Endothelial protection against anti-HLA antibodies has been described in vitro and in animal models, but do not seem to be a common feature in immunized allograft recipients. Complement regulation and anti-apoptotic molecules expression appear to be common features in all these settings. Lastly, pharmacological interventions that may promote endothelial cell protection against donor specific antibodies will be described.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Sarah Bruneau
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
- *Correspondence: Gilles Blancho,
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8
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Fakhouri F, Schwotzer N, Golshayan D, Frémeaux-Bacchi V. The Rational Use of Complement Inhibitors in Kidney Diseases. Kidney Int Rep 2022; 7:1165-1178. [PMID: 35685323 PMCID: PMC9171628 DOI: 10.1016/j.ekir.2022.02.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/14/2022] Open
Abstract
The development of complement inhibitors represented one of the major breakthroughs in clinical nephrology in the last decade. Complement inhibition has dramatically transformed the outcome of one of the most severe kidney diseases, the atypical hemolytic uremic syndrome (aHUS), a prototypic complement-mediated disorder. The availability of complement inhibitors has also opened new promising perspectives for the management of several other kidney diseases in which complement activation is involved to a variable extent. With the rapidly growing number of complement inhibitors tested in a rapidly increasing number of indications, a rational use of this innovative and expensive new therapeutic class has become crucial. The present review aims to summarize what we know, and what we still ignore, regarding complement activation and therapeutic inhibition in kidney diseases. It also provides some clues and elements of thoughts for a rational approach of complement modulation in kidney diseases.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Service de Néphrologie et d'hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Déla Golshayan
- Centre de Transplantation d'organes, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie, Paris University, Paris, France
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9
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Siegl J, Nikolin C, Phung NL, Thoms S, Blume C, Mayer G. Split-Combine Click-SELEX Reveals Ligands Recognizing the Transplant Rejection Biomarker CXCL9. ACS Chem Biol 2022; 17:129-137. [PMID: 35018777 DOI: 10.1021/acschembio.1c00789] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Renal rejection is a major incidence in patients after kidney transplantation and associated with allograft scarring and function loss, especially in antibody-mediated rejection. Regular clinical monitoring of kidney-transplanted patients is thus necessary, but measuring donor-specific antibodies is not always predictive, and graft biopsies are time-consuming and costly and may come up with a histological result unsuspicious for rejection. Therefore, a noninvasive diagnostic approach to estimate an increased probability of kidney graft rejection by measuring specific biomarkers is highly desired. The chemokine CXCL9 is described as an early indicator of rejection. In this work, we identified clickmers and an aptamer by split-combine click-SELEX (systematic evolution of ligands by exponential enrichment) that bind CXLC9 with high affinity. The aptamers recognize native CXCL9 and maintain binding properties under urine conditions. These features render the molecules as potential binding and detector probes for developing point-of-care devices, e.g., lateral flow assays, enabling the noninvasive monitoring of CXCL9 in renal allograft patients.
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Affiliation(s)
- Julia Siegl
- Chemical Biology & Chemical Genetics, Life and Medical Sciences (LIMES) Institute, University of Bonn, Gerhard-Domagk-Str. 1, Bonn 53121, Germany
| | - Christoph Nikolin
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Ngoc Linh Phung
- Institute for Technical Chemistry, Leibniz University Hannover, Callinstr. 5, Hannover 30167, Germany
| | - Stefanie Thoms
- Institute for Technical Chemistry, Leibniz University Hannover, Callinstr. 5, Hannover 30167, Germany
| | - Cornelia Blume
- Institute for Technical Chemistry, Leibniz University Hannover, Callinstr. 5, Hannover 30167, Germany
| | - Günter Mayer
- Chemical Biology & Chemical Genetics, Life and Medical Sciences (LIMES) Institute, University of Bonn, Gerhard-Domagk-Str. 1, Bonn 53121, Germany
- Center of Aptamer Research & Development (CARD), University of Bonn, Gerhard-Domagk-Str. 1, Bonn 53121, Germany
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10
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Callemeyn J, Lamarthée B, Koenig A, Koshy P, Thaunat O, Naesens M. Allorecognition and the spectrum of kidney transplant rejection. Kidney Int 2021; 101:692-710. [PMID: 34915041 DOI: 10.1016/j.kint.2021.11.029] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022]
Abstract
Detection of mismatched human leukocyte antigens by adaptive immune cells is considered as the main cause of transplant rejection, leading to either T-cell mediated rejection or antibody-mediated rejection. This canonical view guided the successful development of immunosuppressive therapies and shaped the diagnostic Banff classification for kidney transplant rejection that is used in clinics worldwide. However, several observations have recently emerged that question this dichotomization between T-cell mediated rejection and antibody-mediated rejection, related to heterogeneity in the serology, histology, and prognosis of the rejection phenotypes. In parallel, novel insights were obtained concerning the dynamics of donor-specific anti-human leukocyte antigen antibodies, the immunogenicity of donor-recipient non-human leukocyte antigen mismatches, and the autoreactivity against self-antigens. Moreover, the potential of innate allorecognition was uncovered, as exemplified by natural killer cell-mediated microvascular inflammation through missing self, and by the emerging evidence on monocyte-driven allorecognition. In this review, we highlight the gaps in the current classification of rejection, provide an overview of the expanding insights into the mechanisms of allorecognition, and critically appraise how these could improve our understanding and clinical approach to kidney transplant rejection. We argue that consideration of the complex interplay of various allorecognition mechanisms can foster a more integrated view of kidney transplant rejection and can lead to improved risk stratification, targeted therapies, and better outcome after kidney transplantation.
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Affiliation(s)
- Jasper Callemeyn
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Baptiste Lamarthée
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Necker-Enfants Malades Institute, French National Institute of Health and Medical Research (INSERM) Unit 1151, Paris, France
| | - Alice Koenig
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Priyanka Koshy
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Thaunat
- CIRI, INSERM U1111, Université Claude Bernard Lyon I, CNRS UMR5308, Ecole Normale Supérieure de Lyon, University Lyon, Lyon, France; Department of Transplantation, Nephrology and Clinical Immunology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France; Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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11
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Cornell LD. Histopathologic Features of Antibody Mediated Rejection: The Banff Classification and Beyond. Front Immunol 2021; 12:718122. [PMID: 34646262 PMCID: PMC8503253 DOI: 10.3389/fimmu.2021.718122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/07/2021] [Indexed: 01/27/2023] Open
Abstract
Antibody mediated rejection (ABMR) in the kidney can show a wide range of clinical presentations and histopathologic patterns. The Banff 2019 classification currently recognizes four diagnostic categories: 1. Active ABMR, 2. Chronic active ABMR, 3. Chronic (inactive) ABMR, and 4. C4d staining without evidence of rejection. This categorization is limited in that it does not adequately represent the spectrum of antibody associated injury in allograft, it is based on biopsy findings without incorporating clinical features (e.g., time post-transplant, de novo versus preformed DSA, protocol versus indication biopsy, complement inhibitor drugs), the scoring is not adequately reproducible, and the terminology is confusing. These limitations are particularly relevant in patients undergoing desensitization or positive crossmatch kidney transplantation. In this article, I discuss Banff criteria for these ABMR categories, with a focus on patients with pre-transplant DSA, and offer a framework for considering the continuum of allograft injury associated with donor specific antibody in these patients.
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Affiliation(s)
- Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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12
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Caveolin-1 in Kidney Chronic Antibody-Mediated Rejection: An Integrated Immunohistochemical and Transcriptomic Analysis Based on the Banff Human Organ Transplant (B-HOT) Gene Panel. Biomedicines 2021; 9:biomedicines9101318. [PMID: 34680435 PMCID: PMC8533527 DOI: 10.3390/biomedicines9101318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023] Open
Abstract
Caveolin-1 overexpression has previously been reported as a marker of endothelial injury in kidney chronic antibody-mediated rejection (c-ABMR), but conclusive evidence supporting its use for daily diagnostic practice is missing. This study aims to evaluate if Caveolin-1 can be considered an immunohistochemical surrogate marker of c-ABMR. Caveolin-1 expression was analyzed in a selected series of 22 c-ABMR samples and 11 controls. Caveolin-1 immunohistochemistry proved positive in peritubular and glomerular capillaries of c-ABMR specimens, irrespective of C4d status whereas all controls were negative. Multiplex gene expression profiling in c-ABMR cases confirmed Caveolin-1 overexpression and identified additional genes (n = 220) and pathways, including MHC Class II antigen presentation and Type II interferon signaling. No differences in terms of gene expression (including Caveolin-1 gene) were observed according to C4d status. Conversely, immune cell signatures showed a NK-cell prevalence in C4d-negative samples compared with a B-cell predominance in C4d-positive cases, a finding confirmed by immunohistochemical assessment. Finally, differentially expressed genes were observed between c-ABMR and controls in pathways associated with Caveolin-1 functions (angiogenesis, cell metabolism and cell–ECM interaction). Based on our findings, Caveolin-1 resulted as a key player in c-ABMR, supporting its role as a marker of this condition irrespective of C4d status.
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13
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Kim AY, Cho KH, Park JW, Do JY, Han MH, Kim YJ, Kang SH. Acute antibody-mediated rejection limited to medullary lesions in following ABO-incompatible living donor kidney transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:53-58. [PMID: 35769620 PMCID: PMC9235326 DOI: 10.4285/kjt.20.0047] [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: 10/08/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/21/2022] Open
Abstract
Anatomical differences between the renal cortex and medulla may influence inflammatory responses. Owing to the difficulty in diagnosing rejections from the medulla, rejection is usually diagnosed through the cortex. However, previous studies have shown that there are no significant differences in renal cortical and medullary lesions in acute allograft rejection. A 60-year-old man with a history of diabetic nephropathy underwent kidney transplant from a living unrelated donor at our hospital in August 2019. Three days after surgery, his urine output suddenly decreased, whereas the serum creatinine levels increased. A kidney biopsy showed only medullary lesions with positive C4d-staining and a Banff score of PTC grade 3. He was diagnosed with acute antibody-mediated rejection (AMR) and treatment was initiated. He did not respond to conventional treatments, including plasma exchange and intravenous immunoglobulin, but his general condition improved after bortezomib administration. There have been a few cases of acute AMR limited to medullary lesions. We consider that rejection cannot be excluded even if the lesions are confined to the medulla.
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Affiliation(s)
- A Young Kim
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyu Hyang Cho
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jong Won Park
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Jin Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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14
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Choi G, Kim YG, Cho H, Kim N, Lee H, Moon KC, Go H. Automated detection algorithm for C4d immunostaining showed comparable diagnostic performance to pathologists in renal allograft biopsy. Mod Pathol 2020; 33:1626-1634. [PMID: 32218521 DOI: 10.1038/s41379-020-0529-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/09/2022]
Abstract
A deep learning-based image analysis could improve diagnostic accuracy and efficiency in pathology work. Recently, we proposed a deep learning-based detection algorithm for C4d immunostaining in renal allografts. The objective of this study is to assess the diagnostic performance of the algorithm by comparing pathologists' diagnoses and analyzing the associations of the algorithm with clinical data. C4d immunostaining slides of renal allografts were obtained from two different institutions (100 slides from the Asan Medical Center and 86 slides from the Seoul National University Hospital) and scanned using two different slide scanners. Three pathologists and the algorithm independently evaluated each slide according to the Banff 2017 criteria. Subsequently, they jointly reviewed the results for consensus scoring. The result of the algorithm was compared with that of each pathologist and the consensus diagnosis. Clinicopathological associations of the results of the algorithm with allograft survival, histologic evidence of microvascular inflammation, and serologic results for donor-specific antibodies were also analyzed. As a result, the reproducibility between the pathologists was fair to moderate (kappa 0.36-0.54), which is comparable to that between the algorithm and each pathologist (kappa 0.34-0.51). The C4d scores predicted by the algorithm achieved substantial concordance with the consensus diagnosis (kappa = 0.61), and they were significantly associated with remarkable microvascular inflammation (P = 0.001), higher detection rate of donor-specific antibody (P = 0.003), and shorter graft survival (P < 0.001). In conclusion, the deep learning-based C4d detection algorithm showed a diagnostic performance similar to that of the pathologists.
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Affiliation(s)
- Gyuheon Choi
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Young-Gon Kim
- Department of Biomedical Engineering, Asan Institute of Life Science, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Haeyon Cho
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Namkug Kim
- Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Hyunna Lee
- Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehang-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Heounjeong Go
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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15
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Mühlbacher J, Doberer K, Kozakowski N, Regele H, Camovic S, Haindl S, Bond G, Haslacher H, Eskandary F, Reeve J, Böhmig GA, Wahrmann M. Non-invasive Chemokine Detection: Improved Prediction of Antibody-Mediated Rejection in Donor-Specific Antibody-Positive Renal Allograft Recipients. Front Med (Lausanne) 2020; 7:114. [PMID: 32328494 PMCID: PMC7160229 DOI: 10.3389/fmed.2020.00114] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/12/2020] [Indexed: 01/02/2023] Open
Abstract
Background: Screening for donor-specific antibodies (DSA) has limited diagnostic value in patients with late antibody-mediated rejection (ABMR). Here, we evaluated whether biomarkers reflecting microcirculation inflammation or tissue injury-as an adjunct to DSA detection-are able to improve non-invasive ABMR monitoring. Methods: Upon prospective cross-sectional antibody screening of 741 long-term kidney transplant recipients with a silent clinical course, 86 DSA-positive patients were identified and biopsied. Serum and urine levels of E-selectin/CD62E, vascular cell adhesion molecule 1 (VCAM-1), granzyme B, hepatocyte growth factor (HGF), C-C motif chemokine ligand (CCL)3, CCL4, C-X-C motif chemokine ligand (CXCL)9, CXCL10, and CXCL11 in DSA-positive recipients were investigated applying multiplexed bead-based immunoassays. Results: Diagnosis of ABMR (50 patients) was associated with significantly higher levels of CXCL9 and CXCL10 in blood and urine and of HGF in blood. Overall, urinary CXCL9 had the highest diagnostic accuracy for ABMR (area under the receiver operating characteristic curve: 0.77; accuracy: 80%) and its combined evaluation with the mean fluorescence intensity of the immunodominant DSA (DSAmax MFI) revealed a net reclassification improvement of 73% compared to DSAmax MFI alone. Conclusions: Our results suggest urinary CXCL9 testing, combined with DSA analysis, as a valuable non-invasive tool to uncover clinically silent ABMR late after transplantation.
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Affiliation(s)
- Jakob Mühlbacher
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Sümeyra Camovic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Susanne Haindl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, AB, Canada
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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16
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Metter C, Torrealba JR. Pathology of the kidney allograft. Semin Diagn Pathol 2020; 37:148-153. [PMID: 32249077 DOI: 10.1053/j.semdp.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 11/11/2022]
Abstract
The kidney biopsy still represents the best approach to diagnose renal transplant complications. It is considered the gold standard in the diagnosis of rejection and non-rejection complications. Although invasive, it is a safe procedure with a very low complication rate. With adequate sampling, changes related to antibody-mediated rejection (ABMR) and T-cell mediated rejection (TCMR) can be identified. However, the pathologist needs to be aware of the many other complications, not related to rejection, that can affect the allograft function. Examples include viral infections, drug toxicity, systemic diseases such as hypertension and diabetes, and recurrent or de novo glomerulopathy, among others. In this article, we review the recent classification of pathology of the kidney allograft, with reference to recent consensus reached at the most recent Banff renal allograft classification meetings, and also highlight common non-rejection complications of the kidney transplant.
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Affiliation(s)
- Christopher Metter
- Department of Pathology, University of Texas Southwestern Medical Center, Professional Office Building I, 3rd Floor Suite HP3.370, Room HP3.392 ,5959 Harry Hines Blvd, Dallas, TX 75390, TX, United States
| | - Jose R Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Professional Office Building I, 3rd Floor Suite HP3.370, Room HP3.392 ,5959 Harry Hines Blvd, Dallas, TX 75390, TX, United States.
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17
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High-activity Classical and Alternative Complement Pathway Genotypes-Association With Donor-specific Antibody-triggered Injury and Renal Allograft Survival. Transplant Direct 2020; 6:e534. [PMID: 32195325 PMCID: PMC7056277 DOI: 10.1097/txd.0000000000000978] [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: 12/10/2019] [Accepted: 12/24/2019] [Indexed: 11/26/2022] Open
Abstract
Background Complement may contribute to donor-specific antibody (DSA)-triggered transplant injury. Here, we investigated whether the intrinsic strength of classical pathway and alternative pathway (AP) relates to the pathogenicity of DSA. Methods Classical pathway and AP high-activity genotypes were defined according to C4 gene copy number and the presence of functional polymorphisms in C3 (C3102G), factor B (fB32R), and factor H (fH62V) genes. Associations of these genotypes with blood complement profiles and morphologic/molecular rejection features were evaluated in a cohort of 83 DSA-positive patients (antibody-mediated rejection [AMR], n = 47) identified upon cross-sectional screening of 741 kidney allograft recipients ≥180 days posttransplantation. Associations with long-term graft survival were evaluated in a larger kidney transplant cohort (n = 660) not enriched for a specific type of rejection. Results In the cohort of DSA-positive subjects, the number of C4 gene copies was related to C4 protein levels in serum and capillary C4d staining, but not AMR activity. Patients with a high-activity AP complotype, which was associated with complement consumption in serum, showed enhanced microcirculation inflammation (median glomerulitis plus peritubular capillaritis score, 2 [interquartile range, 0-4 versus 1 0-2]; P = 0.037). In the larger transplant cohort, this complotype was associated with a slightly increased risk of graft loss (hazard ratio, 1.52; 95% confidence interval, 1.02-2.25; P = 0.038 and multivariable Cox model, 1.55; 1.04-2.32; P = 0.031). Conclusions Our study suggests a contribution of complement genetics to the phenotypic presentation of AMR. Future studies will have to clarify whether a possible association of AP strength with graft survival relates to enhanced antibody-triggered injury.
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18
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A curious case of de novo anti-HLA-C antibody-mediated humoral rejection and Fabry-like zebra bodies in a renal transplant recipient. Clin Nephrol Case Stud 2020; 8:12-16. [PMID: 32038904 PMCID: PMC7003131 DOI: 10.5414/cncs109998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/06/2019] [Indexed: 11/18/2022] Open
Abstract
Detection of donor-specific antibodies (DSA) is an essential part of diagnosing antibody-mediated renal allograft rejection (ABMR). The role of solitary preformed, or post-transplant HLA-C antigens in solid organ transplantation is unclear, due to the less sensitive nature of the historical assays, lack of data, low expression level on the cell surface, and their co-existence with other anti-HLA DSA. Herein, we present the case of a 39-year-old African American man, without prior history of pre-transplant sensitization that was diagnosed with biopsy-proven ABMR due to de novo donor-specific anti-HLA-C antibodies. This case report illustrates the role of HLA-C antibodies in causing ABMR if generated toward immunogenic-shared epitopes and demonstrates the need for their recognition in the pre- and post-transplant period. Another interesting aspect of this case is the incidental finding of Fabry-like zebra bodies, which we eventually determined to be of unclear etiology.
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19
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Holscher CM, Jackson KR, Segev DL. Transplanting the Untransplantable. Am J Kidney Dis 2020; 75:114-123. [DOI: 10.1053/j.ajkd.2019.04.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
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20
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Complement fragments are biomarkers of antibody-mediated endothelial injury. Mol Immunol 2019; 118:142-152. [PMID: 31884386 DOI: 10.1016/j.molimm.2019.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
Abstract
Antibody-mediated rejection (AbMR) adversely affects long-term graft survival in kidney transplantation. Currently, the diagnosis of AbMR requires a kidney biopsy, and detection of complement C4d deposition in the allograft is one of the diagnostic criteria. Complement activation also generates several soluble fragments which could potentially provide non-invasive biomarkers of the process. Furthermore, microvesicles released into the plasma from injured cells can serve as biomarkers of vascular injury. To explore whether soluble complement fragments or complement fragments bound to endothelial microvesicles can be used to non-invasively detect AbMR, we developed an in vitro model in which human endothelial cells were exposed to anti-HLA antibodies and complement sufficient serum. We found that complement fragments C4a and sC5b-9 were increased in the supernatants of cells exposed to complement-sufficient serum compared to cells treated complement-deficient serum. Furthermore, complement activation on the cell surface was associated with the release of microvesicles bearing C4 and C3 fragments. We next measured these analytes in plasma from kidney transplant recipients with biopsy-proven acute AbMR (n = 9) and compared the results with those from transplant recipients who also had impaired allograft function but who did not have AbMR (n = 30). Consistent with the in vitro results, complement fragments C4a and Ba were increased in plasma from patients with AbMR compared to control subjects (P < 0.001 and P < 0.01, respectively). Endothelial microvesicle counts were not increased in patients with AbMR, however, and the number of microvesicles with C4 and C3 bound to the surface was actually lower compared to control subjects (both P < 0.05). Our results suggest that plasma complement activation fragments may be useful as non-invasive biomarkers of antibody-mediated complement activation within the allograft. Complement-opsonized endothelial microvesicles are decreased in patients with AbMR, possibly due to enhanced clearance of microvesicles opsonized with C3 and C4 fragments.
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21
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Grafals M, Thurman JM. The Role of Complement in Organ Transplantation. Front Immunol 2019; 10:2380. [PMID: 31636644 PMCID: PMC6788431 DOI: 10.3389/fimmu.2019.02380] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022] Open
Abstract
The current immunosuppressive protocols used in transplant recipients have improved short-term outcomes, but long-term allograft failure remains an important clinical problem. Greater understanding of the immunologic mechanisms that cause allograft failure are needed, as well as new treatment strategies for protecting transplanted organs. The complement cascade is an important part of the innate immune system. Studies have shown that complement activation contributes to allograft injury in several clinical settings, including ischemia/reperfusion injury and antibody mediated rejection. Furthermore, the complement system plays critical roles in modulating the responses of T cells and B cells to antigens. Therapeutic complement inhibitors, therefore, may be effective for protecting transplanted organs from several causes of inflammatory injury. Although several anti-complement drugs have shown promise in selected patients, the role of these drugs in transplantation medicine requires further study.
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Affiliation(s)
- Monica Grafals
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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22
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Volkmann J, Schmitz J, Nordlohne J, Dong L, Helmke A, Sen P, Immenschuh S, Bernhardt WM, Gwinner W, Bräsen JH, Schmitt R, Haller H, von Vietinghoff S. Kidney injury enhances renal G-CSF expression and modulates granulopoiesis and human neutrophil CD177 in vivo. Clin Exp Immunol 2019; 199:97-108. [PMID: 31509227 PMCID: PMC6904607 DOI: 10.1111/cei.13372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/25/2022] Open
Abstract
Kidney injury significantly increases overall mortality. Neutrophilic granulocytes (neutrophils) are the most abundant human blood leukocytes. They are characterized by a high turnover rate, chiefly controlled by granulocyte colony stimulating factor (G‐CSF). The role of kidney injury and uremia in regulation of granulopoiesis has not been reported. Kidney transplantation, which inherently causes ischemia–reperfusion injury of the graft, elevated human neutrophil expression of the surface glycoprotein CD177. CD177 is among the most G‐CSF‐responsive neutrophil genes and reversibly increased on neutrophils of healthy donors who received recombinant G‐CSF. In kidney graft recipients, a transient rise in neutrophil CD177 correlated with renal tubular epithelial G‐CSF expression. In contrast, CD177 was unaltered in patients with chronic renal impairment and independent of renal replacement therapy. Under controlled conditions of experimental ischemia–reperfusion and unilateral ureteral obstruction injuries in mice, renal G‐CSF mRNA and protein expression significantly increased and systemic neutrophilia developed. Human renal tubular epithelial cell G‐CSF expression was promoted by hypoxia and proinflammatory cytokine interleukin 17A in vitro. Clinically, recipients of ABO blood group‐incompatible kidney grafts developed a larger rise in neutrophil CD177. Their grafts are characterized by complement C4d deposition on the renal endothelium, even in the absence of rejection. Indeed, complement activation, but not hypoxia, induced primary human endothelial cell G‐CSF expression. Our data demonstrate that kidney injury induces renal G‐CSF expression and modulates granulopoiesis. They delineate differential G‐CSF regulation in renal epithelium and endothelium. Altered granulopoiesis may contribute to the systemic impact of kidney injury.
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Affiliation(s)
- J Volkmann
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - J Schmitz
- Department of Pathology, Hannover Medical School, Hannover, Germany
| | - J Nordlohne
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - L Dong
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - A Helmke
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - P Sen
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - S Immenschuh
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - W M Bernhardt
- Clinic for Hypertension, Kidney- and Metabolic Diseases Hannover, Hannover, Germany
| | - W Gwinner
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - J H Bräsen
- Department of Pathology, Hannover Medical School, Hannover, Germany
| | - R Schmitt
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - H Haller
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - S von Vietinghoff
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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23
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Panzer SE, Joachim E, Parajuli S, Zhong W, Astor BC, Djamali A. Glomerular C3 Deposition Is an Independent Risk Factor for Allograft Failure in Kidney Transplant Recipients With Transplant Glomerulopathy. Kidney Int Rep 2019; 4:582-593. [PMID: 30993233 PMCID: PMC6451156 DOI: 10.1016/j.ekir.2019.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction Transplant glomerulopathy (TG) becomes increasingly prevalent in kidney transplant recipients over time, and it is strongly associated with allograft failure. To date, our prognostic biomarkers and understanding of the processes of immunologic injury in TG are limited. Methods This is a retrospective cohort analysis of kidney transplant recipients with TG (double contours of the glomerular basement membrane as defined by the chronic glomerulopathy score). Glomerular deposition of the complement protein C3 was determined, and its association with allograft survival was analyzed by Cox regression analysis. Results Of the 111 patients with TG, 72 (65%) had allograft failure, with a median follow-up time of 3 years from biopsy diagnosis of TG. C3-positive compared to C3-negative patients did not differ with respect to cause of end-stage renal disease, induction or maintenance immunosuppression, or sensitization. A greater proportion of patients with glomerular C3 deposition developed allograft failure compared to those with no C3 deposition (78% vs. 55%, P = 0.01). C3 deposition was independently associated with allograft failure in multivariate analyses (adjusted hazard ratio [HR] = 1.38, 95% confidence interval [CI] = 1.13−1.69, P = 0.002). There was no association between C4d or C1q deposition and allograft failure. Chronicity score was also associated with allograft failure in multivariate analysis (adjusted HR 1.26, 95% CI 1.12-1.41, P = 0.0001). Conclusion In this cohort of patients with TG, glomerular C3 deposition was independently associated with a higher risk of allograft failure. These findings identify glomerular C3 as a novel prognostic indicator in patients with TG.
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Affiliation(s)
- Sarah E Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Emily Joachim
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, Wisconsin, USA
| | - Brad C Astor
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, USA
| | - Arjang Djamali
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA.,Department of Surgery, Division of Transplant Surgery, University of Wisconsin, Madison, Wisconsin, USA
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24
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Kosoku A, Uchida J, Nishide S, Kabei K, Shimada H, Iwai T, Kuwabara N, Maeda K, Naganuma T, Kumada N, Takemoto Y, Ishihara T, Shintani A, Nakatani T. ABO-incompatible kidney transplantation as a renal replacement therapy-A single low-volume center experience in Japan. PLoS One 2018; 13:e0208638. [PMID: 30596663 PMCID: PMC6312268 DOI: 10.1371/journal.pone.0208638] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Living donor kidney transplantation is preferable to deceased donor transplantation due to its superior long-term patient and graft survivals. However, ABO blood group incompatibility is a major barrier to living donor kidney transplantation. ABO-incompatible kidney transplantation has been performed in Japan since the late 1980's, but it is still globally uncommon. The objective of this study is to compare the clinical outcomes of ABO-incompatible kidney transplantation (ABO-IKT) with that of ABO-compatible kidney transplantation (ABO-CKT) at an institution where only about two kidney transplants are performed a month on average. DESIGN A single center propensity score-matched cohort study. PATIENTS AND METHODS We retrospectively collected and analyzed the data of 240 patients with end-stage kidney disease (ESKD) who underwent living donor kidney transplantation at Osaka City University Hospital from January 1999 to December 2016, of which 66 patients were ABO-IKT. The remaining 174 patients who underwent ABO-CKT were studied as the control group, and the clinical outcomes of ABO-IKT and ABO-CKT recipients were compared based on propensity score matching. RESULTS After propensity score matching, there were no significant differences in both patient survival and death-censored graft survival rates between the ABO-IKT and ABO-CKT groups. Moreover, there were no significant differences in estimated glomerular filtration rate as well as frequency of acute cellular rejection, antibody-mediated rejection, infectious adverse events, malignancies, and post-operative bleeding between the two groups. CONCLUSION Currently, ABO-IKT may be an acceptable treatment for patients with ESKD even at a low-volume transplant center.
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Affiliation(s)
- Akihiro Kosoku
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
- * E-mail:
| | - Shunji Nishide
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazuya Kabei
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hisao Shimada
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Nobuyuki Kuwabara
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Keiko Maeda
- Department of Nursing, Osaka City University Hospital, Osaka, Japan
| | - Toshihide Naganuma
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Norihiko Kumada
- Department of Urology, Suita Municipal Hospital, Suita, Japan
| | - Yoshiaki Takemoto
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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25
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Molecular Assessment of C4d-Positive Renal Transplant Biopsies Without Evidence of Rejection. Kidney Int Rep 2018; 4:148-158. [PMID: 30596178 PMCID: PMC6308373 DOI: 10.1016/j.ekir.2018.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/17/2018] [Accepted: 09/10/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Immunohistochemical staining for C4d in peritubular capillaries has been part of antibody-mediated rejection (AbMR) definition in the Banff Classification for Allograft Pathology since 2003. However, it has limited sensitivity and specificity, therefore the clinical significance of C4d-positive biopsies without evidence of rejection (C4d+ WER) is unknown. We investigated the transcript levels of genes associated with AbMR in C4d+ WER biopsies from both ABO-compatible and incompatible renal transplant patients. Methods RNA was extracted from formalin-fixed paraffin-embedded renal transplant biopsies (n = 125) and gene expression analysis of 35 AbMR-associated transcripts carried out using the NanoString nCounter system. Results AbMR-associated transcripts were significantly increased in samples with AbMR or suspicious AbMR. A subgroup of 17 of 35 transcripts that best distinguished AbMR from C4d-negative biopsies without evidence of rejection was used to study C4d+ WER samples. There was no differential expression between C4d-negative and C4d+ WER from both ABO-incompatible and -compatible transplants. The geometric mean of 17 differentially expressed genes was used to assign the C4d+ WER biopsies a high- or low-AbMR transcript score. Follow-up biopsies showed AbMR within 1 year of initial biopsy in 5 of 7 high-AbMR transcript patients but only 2 of 46 low-AbMR transcript patients. In multivariate logistic regression analysis, elevated transcript levels in a C4d+ WER biopsy were associated with increased odds for biopsy-proven AbMR on follow-up (P = 0.032, odds ratio 16.318), whereas factors including donor-specific antibody (DSA) status and time since transplantation were not. Conclusion Gene expression analysis in C4d+ WER samples has the potential to identify patients at higher risk of developing AbMR.
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Bynum JP, Zachary A, Ness PM, Luo X, Bagnasco S, King KE, Segev DL, Orandi BJ, Warren DS, Fuller A, Ciappi A, Montgomery R, Tobian AAR. Transfusion of leukoreduced blood products and risk of antibody-mediated rejection of renal allografts. Transfusion 2018; 58:1951-1957. [PMID: 30171817 PMCID: PMC6131050 DOI: 10.1111/trf.14800] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major barrier to the long-term function of renal allografts. White blood cells, which may be present in red blood cell (RBC) units, and platelets (PLTs) express HLA antigens that may increase the risk of AMR by inducing or increasing humoral sensitization to HLA. STUDY DESIGN AND METHODS A retrospective cohort study of HLA-incompatible (HLAi) renal transplant recipients between 2004 and 2015 was conducted. Data on apheresis PLT and leukoreduced RBC transfusions within 4 weeks of transplantation, demographic information, and biopsy-proven AMR were collected from medical records and the Scientific Registry of Transplant Recipients. Patients were evaluated until they showed evidence of AMR or until 1 year posttransplant, whichever came first. Multivariable analysis with Cox modeling was performed. RESULTS Of 244 individuals, 182 (74.6%) received RBCs and 20 (8.2%) of those also received PLTs. During the first year posttransplant, 97 (39.8%) had AMR. RBC-alone or RBC and PLT transfusions were not associated with increased risk of AMR after adjustment for panel-reactive antibody, years on dialysis, HLA antibody strength, and number of therapeutic plasma exchange treatments (adjusted hazard ratio [adjHR] 1.00, 95% confidence interval [95% CI] 0.59-1.69; and adjHR 0.68, 95% CI 0.28-1.68, respectively). For each 1-unit increase in RBC transfusions, there was no association with AMR (adjHR 0.94, 95% CI 0.85-1.05). Only HLA antibody strength before transplantation was associated with AMR (adjHR 2.23, 95% CI 1.10-4.52; cytotoxic crossmatch compared to crossmatch negative but detectable donor-specific HLA antibodies). CONCLUSIONS Patients who receive an HLAi transplant who are transfused with leukoreduced RBCs or PLTs in the peritransplant period are at no higher risk of AMR than nontransfused patients.
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Affiliation(s)
| | | | | | - Xun Luo
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | - Dorry L Segev
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Babak J Orandi
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daniel S Warren
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | | | - Robert Montgomery
- Transplant Institute, New York University Langone Medical Center, New York, New York
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27
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Osickova K, Parikova A, Maluskova J, Fronek J, Viklicky O. Similar Microvascular Inflammation and Tubulointerstitial Injury in ABO-Incompatible and Matched ABO-Compatible Kidney Allografts. Transplant Proc 2018; 50:1305-1309. [PMID: 29880350 DOI: 10.1016/j.transproceed.2018.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 11/28/2022]
Abstract
ABO-incompatible (ABOi) kidney transplantation represents a viable tool to increase the donor pool for kidney transplantation, however, increased alloimmune response has been debated. The early outcomes of 25 low-risk ABOi kidney transplant recipients were compared with thoroughly matched 50 ABO-compatible (ABOc) ones. The matching process was based on gender and age of recipients and immunologic parameters, such as panel reactive antibodies, number of human leukocyte antigen mismatches, and transplantation era. Three-month protocol kidney graft biopsy Banff scores and 1-year clinical outcomes were compared. Apart from C4d positivity, no statistically significant differences were found regarding the Banff scores between the two groups. Similarly, microvascular inflammation and tubulointerstitial injury revealed no differences either. The eGFR at 3 months and 1 year was similar in both groups. In conclusion, blood group incompatibility yields no additional microvascular and tubulointerstitial graft injury if desensitization protocol was applied to low-risk kidney transplant recipients.
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Affiliation(s)
- K Osickova
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Parikova
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Maluskova
- Department of Clinical and Transplant Pathology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Fronek
- Department of Transplant Surgery, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - O Viklicky
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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28
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Evolving criteria for the diagnosis of antibody-mediated rejection in renal allografts. Curr Opin Nephrol Hypertens 2018; 27:137-143. [DOI: 10.1097/mnh.0000000000000398] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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29
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de Mattos Barbosa MG, Cascalho M, Platt JL. Accommodation in ABO-incompatible organ transplants. Xenotransplantation 2018; 25:e12418. [PMID: 29913044 PMCID: PMC6047762 DOI: 10.1111/xen.12418] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/09/2018] [Accepted: 05/03/2018] [Indexed: 12/21/2022]
Abstract
Accommodation refers to a condition in which a transplant (or any tissue) appears to resist immune-mediated injury and loss of function. Accommodation was discovered and has been explored most thoroughly in ABO-incompatible kidney transplantation. In this setting, kidney transplants bearing blood group A or B antigens often are found to function normally in recipients who lack and hence produce antibodies directed against the corresponding antigens. Whether accommodation is owed to changes in anti-blood group antibodies, changes in antigen or a change in the response of the transplant to antibody binding are critically reviewed and a new working model that allows for the kinetics of development of accommodation is put forth. Regardless of how accommodation develops, observations on the fate of ABO-incompatible transplants offer lessons applicable more broadly in transplantation and in other fields.
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30
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Vazquez Martul E. [The pathology of renal transplants]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2018; 51:110-123. [PMID: 29602372 DOI: 10.1016/j.patol.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 11/15/2022]
Abstract
In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.
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Affiliation(s)
- Eduardo Vazquez Martul
- Ex Jefe de Servicio de Anatomía Patológica, Hospital Universitario A Coruña (retirado), A Coruña, España; Ex profesor asociado de la Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Miembro del Club de Nefropatología (Sociedad Española de Nefrología), España.
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31
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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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32
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Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, Nankivell BJ, Halloran PF, Colvin RB, Akalin E, Alachkar N, Bagnasco S, Bouatou Y, Becker JU, Cornell LD, van Huyen JPD, Gibson IW, Kraus ES, Mannon RB, Naesens M, Nickeleit V, Nickerson P, Segev DL, Singh HK, Stegall M, Randhawa P, Racusen L, Solez K, Mengel M. The Banff 2017 Kidney Meeting Report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018; 18:293-307. [PMID: 29243394 PMCID: PMC5817248 DOI: 10.1111/ajt.14625] [Citation(s) in RCA: 743] [Impact Index Per Article: 123.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 01/25/2023]
Abstract
The kidney sessions of the 2017 Banff Conference focused on 2 areas: clinical implications of inflammation in areas of interstitial fibrosis and tubular atrophy (i-IFTA) and its relationship to T cell-mediated rejection (TCMR), and the continued evolution of molecular diagnostics, particularly in the diagnosis of antibody-mediated rejection (ABMR). In confirmation of previous studies, it was independently demonstrated by 2 groups that i-IFTA is associated with reduced graft survival. Furthermore, these groups presented that i-IFTA, particularly when involving >25% of sclerotic cortex in association with tubulitis, is often a sequela of acute TCMR in association with underimmunosuppression. The classification was thus revised to include moderate i-IFTA plus moderate or severe tubulitis as diagnostic of chronic active TCMR. Other studies demonstrated that certain molecular classifiers improve diagnosis of ABMR beyond what is possible with histology, C4d, and detection of donor-specific antibodies (DSAs) and that both C4d and validated molecular assays can serve as potential alternatives and/or complements to DSAs in the diagnosis of ABMR. The Banff ABMR criteria are thus updated to include these alternatives. Finally, the present report paves the way for the Banff scheme to be part of an integrative approach for defining surrogate endpoints in next-generation clinical trials.
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Affiliation(s)
- M. Haas
- Department of Pathology and Laboratory MedicineCedars‐Sinai Medical CenterLos AngelesCAUSA
| | - A. Loupy
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance
| | - C. Lefaucheur
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and TransplantationHopital Saint LouisUniversité Paris VII and INSERM U 1160ParisFrance
| | - C. Roufosse
- Department of MedicineImperial College London and North West London PathologyLondonUK
| | - D. Glotz
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and TransplantationHopital Saint LouisUniversité Paris VII and INSERM U 1160ParisFrance
| | - D. Seron
- Nephrology DepartmentHospital Vall d'HebronAutonomous University of BarcelonaBarcelonaSpain
| | - B. J. Nankivell
- Department of Renal MedicineWestmead HospitalSydneyAustralia
| | - P. F. Halloran
- Alberta Transplant Applied Genomics CentreUniversity of AlbertaEdmontonAlbertaCanada
| | - R. B. Colvin
- Department of PathologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Enver Akalin
- Montefiore‐Einstein Center for TransplantationMontefiore Medical CenterBronxNYUSA
| | - N. Alachkar
- Department of MedicineSection of NephrologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - S. Bagnasco
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Y. Bouatou
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance,Division of NephrologyDepartment of Medical SpecialitiesGeneva University HospitalsGenevaSwitzerland
| | - J. U. Becker
- Institute of PathologyUniversity Hospital of CologneCologneGermany
| | - L. D. Cornell
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMNUSA
| | - J. P. Duong van Huyen
- Paris Translational Research Center for Organ TransplantationINSERM U970 and Necker HospitalUniversity Paris DescartesParisFrance
| | - I. W. Gibson
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | - Edward S. Kraus
- Division of NephrologyDepartment of MedicineJohns Hopkins UniversityBaltimoreMDUSA
| | - R. B. Mannon
- Division of NephrologyDepartment of MedicineUniversity of Alabama School of MedicineBirminghamALUSA
| | - M. Naesens
- Department of Microbiology and ImmunologyUniversity of Leuven & Department of NephrologyUniversity Hospitals LeuvenLeuvenBelgium
| | - V. Nickeleit
- Division of NephropathologyDepartment of Pathology and Laboratory MedicineThe University of North Carolina School of MedicineChapel HillNCUSA
| | - P. Nickerson
- Department of Internal Medicine and ImmunologyUniversity of ManitobaWinnipegCanada
| | - D. L. Segev
- Department of SurgeryJohns Hopkins Medical InstitutionsBaltimoreMDUSA
| | - H. K. Singh
- Division of NephropathologyDepartment of Pathology and Laboratory MedicineThe University of North Carolina School of MedicineChapel HillNCUSA
| | - M. Stegall
- Departments of Surgery and ImmunologyMayo ClinicRochesterMNUSA
| | - P. Randhawa
- Division of Transplantation PathologyThomas E. Starzl Transplantation InstituteUniversity of PittsburghPittsburghPAUSA
| | - L. Racusen
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - K. Solez
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
| | - M. Mengel
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonCanada
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33
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Castro MCR, Malafronte P, Silva EF, Cunha MFM, Siqueira R, Baptista-Silva JCC, Luzzi JR, Camargo MFC. Desensitization for ABO incompatible kidney transplantation: Experience of a single center in Brazil. ABO incompatible kidney transplantation. TRANSPLANTATION REPORTS 2017. [DOI: 10.1016/j.tpr.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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34
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Steggerda JA, Kim IK, Haas M, Zhang X, Kang A, Pizzo H, Kamil E, Jordan S, Puliyanda D. Clinical and histopathologic features of antibody-mediated rejection among pediatric renal transplant recipients with preformed vs de novo donor-specific antibodies. Pediatr Transplant 2017; 21. [PMID: 29159992 DOI: 10.1111/petr.13079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 01/18/2023]
Abstract
Preformed and de novo donor specific antibodies (pDSA and dnDSA) are risk factors for ABMR. This study compares the effects of pDSA vs dnDSA in pediatric kidney transplant recipients. Sixteen pediatric patients with biopsy-proven ABMR were evaluated. Strong DSA (MFI >10 000) was recorded at transplant, rejection, and follow-up. DSAs with the highest MFI were termed iDSAs. Allograft biopsies were scored according to Banff 2013 criteria. Seven of 16 (44%) patients had pDSA at transplant; 9 (56%) developed dnDSA. Patients with pDSA developed ABMR earlier (median = 63 vs 1344 days, P = .017), while patients with dnDSA were more likely to have strong Class II iDSA (100% vs 28%, P = .009). Viral infection or non-adherence was more common in patients developing dnDSA (88.8% vs 28.6%, P < .01). Pathology in those with pDSAs demonstrated worse transplant glomerulitis (g score 1.57 ± 0.98 vs 0.56 ± 0.73, P = .031); however, those with dnDSAs exhibited higher C4d+ ABMR (P = .013). Patients developing dnDSAs showed ABMR later post-transplant with predominance of HLA-Class II iDSAs. Inadequate immunosuppression likely contributes to dnDSA formation. Patients with no DSA who have unprotocolized decreases in immunosuppression should be screened for dnDSA as it could lead to early intervention and potentially better outcomes.
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Affiliation(s)
- Justin A Steggerda
- Division of Transplantation, Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Irene K Kim
- Division of Transplantation, Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexis Kang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Helen Pizzo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Elaine Kamil
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dechu Puliyanda
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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35
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Gates KV, Pereira NL, Griffiths LG. Cardiac Non-Human Leukocyte Antigen Identification: Techniques and Troubles. Front Immunol 2017; 8:1332. [PMID: 29093713 PMCID: PMC5651233 DOI: 10.3389/fimmu.2017.01332] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/02/2017] [Indexed: 12/20/2022] Open
Abstract
Historically efforts have focused on the human leukocyte antigen (HLA) as the major cause for acute and chronic rejection following cardiac transplantation. However, rising evidence indicates that non-HLA antibodies can be both primary initiators and modifiers of antibody-mediated rejection (AMR) and cardiac allograft vasculopathy (CAV). The purpose of this review is to assess currently available technologies for non-HLA identification and leveraging such responses toward antibody quantification. Several techniques have been used to identify antigenic determinants of recipient graft-specific non-HLA humoral immune responses, but each comes with its own set of benefits and caveats. Improving our ability to detect non-HLA humoral immune response will aid in our understanding of the underlying antigenic determinants of AMR and CAV, as well as improve patient outcomes.
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Affiliation(s)
- Katherine V Gates
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, Davis, CA, United States.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Leigh G Griffiths
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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36
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Jain D, Dorwal P, Pande A, Tyagi N, Mehra S, Raina V. Detection of T and B cells specific complement-fixing alloantibodies using flow cytometry: A diagnostic approach for a resource limited laboratory. Asian J Transfus Sci 2017; 11:171-179. [PMID: 28970687 PMCID: PMC5613426 DOI: 10.4103/0973-6247.214355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Various methods have been reported for the detection of antibodies in recipient sera, which can be human leukocyte antigens (HLAs) or non-HLA specific, complement- or noncomplement fixing, as well as donor T (HLA-Class-I) and/or B cell (HLA-Class-I and II) specific. These alloantibodies play a pivotal role in antibody-mediated renal transplantation rejection. Deposition of C4d in peritubular capillaries of a kidney biopsy is a marker of antibody-mediated rejection. The C4d flow-panel reactive antibodies (PRAs) are a screening method for HLA-specific and complement fixing antibodies. However, the method is limited by the lack of donor specificity. DESIGN AND SETTINGS Here, we present a new and simple flow cytometric method referred to as C4d-flow cytometry crossmatch (C4d-FCXM) for the detection of donor-specific (T and/or B cell) and C4d-fixing alloantibodies. RESULTS The method was applied in a series of clinical cases and judged to be useful. The method may limit unwanted deferral of the donor due to positivity in C4d Flow-PRA and/or FCXM and may be helpful in prediction of antibody mediated rejections. Furthermore, this method can provide information pretransplant in contrast to kidney biopsy and C4d evaluation done posttransplant. CONCLUSIONS We postulate that this method incorporates most of the features of all the available modalities (i.e., National Institute of Health-complement dependent lymphocytotoxicity, FCXM, cytotoxic FCXM and C4d-flowPRA) yet cost-effective and best suited for resource-limited laboratory/ies which is a common scenario in developing countries.
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Affiliation(s)
- Dharmendra Jain
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Pranav Dorwal
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Amit Pande
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Neetu Tyagi
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Simmi Mehra
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Vimarsh Raina
- Department of Pathology and Laboraotry Medicine, Molecular Genetics Laboratory, Medanta-The Medicity, Gurgaon, Haryana, India
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37
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Evaluation of Microvascular Inflammation in ABO-Incompatible Kidney Transplantation. Transplantation 2017; 101:1423-1432. [PMID: 27495756 DOI: 10.1097/tp.0000000000001403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In ABO-incompatible kidney transplantation, the diagnostic criteria for antibody-mediated rejection remain controversial because C4d deposition is commonly observed. Thus, we investigated microvascular inflammation (MVI score ≥ 2) within 1 year as a predictor of graft outcome. METHODS A total of 148 recipients without preformed or de novo donor-specific anti-HLA antibody were stratified based on MVI score less than 2 (n = 117) and MVI score of 2 or greater (n = 31). RESULTS We found that 5-year graft survival was significantly lower (P = 0.0129) in patients with MVI (89.8%) than in patients without MVI (97.0%). Graft function, as characterized by serum estimated glomerular filtration rate, was also significantly worse for patients with MVI than it was for patients without MVI, between 3 months and 10 years after transplantation (P = 0.048). Multivariate analysis indicated that HLA class II mismatch (P = 0.0085) was an independent marker of MVI. CONCLUSIONS Microvascular inflammation score of 2 or greater is significantly associated with poor graft outcome after ABO-incompatible kidney transplantation. We suggest that MVI score of 2 or greater in ABOi transplantation be used as a basis to diagnose antibody-mediated rejection.
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Lonze BE, Bae S, Kraus ES, Holechek MJ, King KE, Alachkar N, Naqvi FF, Dagher NN, Sharif A, Desai NM, Segev DL, Montgomery RA. Outcomes and risk stratification for late antibody-mediated rejection in recipients of ABO-incompatible kidney transplants: a retrospective study. Transpl Int 2017; 30:874-883. [DOI: 10.1111/tri.12969] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/20/2016] [Accepted: 03/27/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Bonnie E. Lonze
- Transplant Institute; NYU Langone Medical Center; New York NY USA
| | - Sunjae Bae
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Edward S. Kraus
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Mary J. Holechek
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Karen E. King
- Department of Pathology; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Nada Alachkar
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Fizza F. Naqvi
- Department of Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Nabil N. Dagher
- Transplant Institute; NYU Langone Medical Center; New York NY USA
| | - Adnan Sharif
- Department of Nephrology and Transplantation; Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - Niraj M. Desai
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Dorry L. Segev
- Department of Surgery; The Johns Hopkins University School of Medicine; Baltimore MD USA
- Department of Epidemiology; The Johns Hopkins University School of Public Health; Baltimore MD USA
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Jager NM, Poppelaars F, Daha MR, Seelen MA. Complement in renal transplantation: The road to translation. Mol Immunol 2017; 89:22-35. [PMID: 28558950 DOI: 10.1016/j.molimm.2017.05.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/17/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023]
Abstract
Renal transplantation is the treatment of choice for patients with end-stage renal disease. The vital role of the complement system in renal transplantation is widely recognized. This review discusses the role of complement in the different phases of renal transplantation: in the donor, during preservation, in reperfusion and at the time of rejection. Here we examine the current literature to determine the importance of both local and systemic complement production and how complement activation contributes to the pathogenesis of renal transplant injury. In addition, we dissect the complement pathways involved in the different phases of renal transplantation. We also review the therapeutic strategies that have been tested to inhibit complement during the kidney transplantation. Several clinical trials are currently underway to evaluate the therapeutic potential of complement inhibition for the treatment of brain death-induced renal injury, renal ischemia-reperfusion injury and acute rejection. We conclude that it is expected that in the near future, complement-targeted therapeutics will be used clinically in renal transplantation. This will hopefully result in improved renal graft function and increased graft survival.
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Affiliation(s)
- Neeltina M Jager
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Felix Poppelaars
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mohamed R Daha
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands
| | - Marc A Seelen
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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40
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Haas M, Mirocha J, Reinsmoen NL, Vo AA, Choi J, Kahwaji JM, Peng A, Villicana R, Jordan SC. Differences in pathologic features and graft outcomes in antibody-mediated rejection of renal allografts due to persistent/recurrent versus de novo donor-specific antibodies. Kidney Int 2017; 91:729-737. [DOI: 10.1016/j.kint.2016.10.040] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/06/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
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41
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Katsuma A, Yamakawa T, Nakada Y, Yamamoto I, Yokoo T. Histopathological findings in transplanted kidneys. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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42
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Abstract
PURPOSE OF REVIEW ABO-incompatible (ABOi) heart transplantation (HTx) in young children has evolved from an experimental approach to a standard allocation option in many countries. Clinical and immunological research in ABOi transplantation has revealed insight into the immature immune system and its role in superior graft acceptance in childhood and antigen-specific tolerance. RECENT FINDINGS Multicenter experience has confirmed equal actuarial survival, freedom from rejection, and graft vasculopathy comparing ABOi with ABO-compatible HTx. Observations of reduced antibody production and B-cell immunity toward the donor blood group have been confirmed in long-term follow-up. Mechanisms contributing to tolerance in this setting involve the interplay between B-cells and the complement system and the development of B-cell memory. Better characterization of the ABH polysaccharide antigens has improved diagnostic methods and clinical assessment of blood group antibodies. Boundaries regarding age, immune maturity, and therapeutic interventions to extend the applicability of ABOi HTx have been explored and resulted in data that may be useful for HTx patients beyond infancy and ABOi transplantation of other organs. Tolerance of ABH antigens possibly extends to HLA response. SUMMARY The review provides insight into the clinical evolution of ABOi HTx and associated immunologic discoveries. Current experiences and boundaries are discussed together with recent and potential future developments for utilization in other patient and age groups.
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43
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Nakada Y, Yamamoto I, Horita S, Kobayashi A, Mafune A, Katsumata H, Yamakawa T, Katsuma A, Kawabe M, Tanno Y, Ohkido I, Tsuboi N, Yamamoto H, Okumi M, Ishida H, Yokoo T, Tanabe K. The prognostic values of caveolin-1 immunoreactivity in peritubular capillaries in patients with kidney transplantation. Clin Transplant 2016; 30:1417-1424. [PMID: 27543925 DOI: 10.1111/ctr.12833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 12/24/2022]
Abstract
The low sensitivity of C4d immunoreactivity in peritubular capillaries (PTCs) hinders its use in the diagnosis of chronic active antibody-mediated rejection (CAAMR). C4d-negative CAAMR was defined in the 2013 Banff classification, which included the expression of endothelial-associated transcripts (ENDATs). We previously showed that the ENDAT caveolin-1 (CAV-1) is a distinct feature of CAAMR. In this study, we investigated the prognostic value of CAV-1 immunoreactivity in PTCs in kidney transplant patients. Ninety-eight kidney transplant recipients were included in this study. The prognostic value of CAV-1 immunoreactivity in PTCs was evaluated by double immunostaining for CAV-1 and pathologische Anatomie Leiden endothelium (PAL-E, a PTC marker) in the PTCs of kidney allograft biopsy samples. The patients were divided into two groups: CAV-1/PAL-E<50% and CAV-1/PAL-E≥50%. Kaplan-Meier curves showed that CAV-1/PAL-E≥50% patients had a significantly worse prognosis than that of CAV-1/PAL-E<50% patients (log-rank; P<.001). C4d staining of PTCs was not associated with the development of graft failure (log-rank; P=.345), whereas in a multivariate Cox regression analysis, CAV-1 immunoreactivity in PTCs was independently associated with graft failure (hazard ratio: 11.1; P=.0324). CAV-1 immunoreactivity in PTCs may serve as a prognostic marker for kidney allograft survival.
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Affiliation(s)
- Yasuyuki Nakada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Shigeru Horita
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Akimitsu Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Aki Mafune
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruki Katsumata
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Yamakawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Ai Katsuma
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Atsugi City Hospital, Kanagawa, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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44
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Sánchez-Escuredo A, Oppenheimer F, Solé M, Revuelta I, Cid J, Lozano M, Blasco M, Esforzado N, Ricart MJ, Cofán F, Torregrosa JV, Paredes D, Musquera M, Ercilla G, Campistol JM, Diekmann F. Borderline rejection in ABO-incompatible kidney transplantation. Clin Transplant 2016; 30:872-9. [DOI: 10.1111/ctr.12759] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Anna Sánchez-Escuredo
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Federico Oppenheimer
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Manel Solé
- Pathology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Joan Cid
- Apheresis Unit; Hemotherapy and Hemostasis Department; CDB; IDIBAPS Hospital Clinic; University of Barcelona; Barcelona Spain
| | - Miguell Lozano
- Apheresis Unit; Hemotherapy and Hemostasis Department; CDB; IDIBAPS Hospital Clinic; University of Barcelona; Barcelona Spain
| | - Miquel Blasco
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Nuria Esforzado
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Maria Jose Ricart
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Federico Cofán
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Josep Vicens Torregrosa
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - David Paredes
- Transplant Service Foundation; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Mireia Musquera
- Urology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Guadalupe Ercilla
- Immunology Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Josep M. Campistol
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplant Department; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
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45
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Stites E, Le Quintrec M, Thurman JM. The Complement System and Antibody-Mediated Transplant Rejection. THE JOURNAL OF IMMUNOLOGY 2016; 195:5525-31. [PMID: 26637661 DOI: 10.4049/jimmunol.1501686] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Complement activation is an important cause of tissue injury in patients with Ab-mediated rejection (AMR) of transplanted organs. Complement activation triggers a strong inflammatory response, and it also generates tissue-bound and soluble fragments that are clinically useful markers of inflammation. The detection of complement proteins deposited within transplanted tissues has become an indispensible biomarker of AMR, and several assays have recently been developed to measure complement activation by Abs reactive to specific donor HLA expressed within the transplant. Complement inhibitors have entered clinical use and have shown efficacy for the treatment of AMR. New methods of detecting complement activation within transplanted organs will improve our ability to diagnose and monitor AMR, and they will also help guide the use of complement inhibitory drugs.
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Affiliation(s)
- Erik Stites
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
| | - Moglie Le Quintrec
- Department of Nephrology and Renal Transplantation, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
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46
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Antibody-Mediated Rejection in a Blood Group A-Transgenic Mouse Model of ABO-Incompatible Heart Transplantation. Transplantation 2016; 100:1228-37. [DOI: 10.1097/tp.0000000000001172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Haas M. The Revised (2013) Banff Classification for Antibody-Mediated Rejection of Renal Allografts: Update, Difficulties, and Future Considerations. Am J Transplant 2016; 16:1352-7. [PMID: 26696524 DOI: 10.1111/ajt.13661] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 01/25/2023]
Abstract
The Banff 2013 classification (Banff 2013) for antibody-mediated rejection (ABMR) in renal allografts represents the first major revision of the original Banff classification for ABMR that was published in 2003. The main impetus for this revision was the need to include C4d-negative ABMR, although this revised classification contains a number of additional features based on findings reported from 2007 to 2013. Since its publication, several studies have examined the validity of different aspects of Banff 2013 and compared it to earlier (2003, 2007) versions of the Banff ABMR classification. Recent evidence, albeit limited, indicates that Banff 2013 represents an improvement over the previous versions, enhancing our ability to accurately diagnose cases of acute/active and chronic active ABMR on renal allograft biopsy. Molecular studies appear to justify the threshold value of glomerulitis plus peritubular capillaritis score ≥2 required by Banff 2013 for the diagnosis of C4d-negative ABMR; however, other aspects of the classification, including its overall interobserver reproducibility, the clinical significance of the category of C4d staining without evidence of rejection, and whether surrogate markers might potentially substitute for the requirement for the presence of donor-specific antibodies, require additional investigation.
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Affiliation(s)
- M Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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48
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Rostaing L, Karam B, Congy-Jolivet N, Hage V, Sallusto F, Esposito L, Doumerc N, Debiol B, Guilbeau-Frugier C, Game X, Allal A, Kamar N. Successful Transplantation in ABO- and HLA-Incompatible Living Kidney Transplant Patients: A Report on 12 Cases. Ther Apher Dial 2016; 20:507-516. [DOI: 10.1111/1744-9987.12408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 01/25/2023]
Affiliation(s)
- Lionel Rostaing
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
- CHU Purpan, INSERM01043, IFR-BMT; Toulouse France
- Université Toulouse 3 Paul Sabaiter; Toulouse France
| | | | - Nicolas Congy-Jolivet
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- CHU Rangueil, Laboratory of Immunology; Toulouse France
| | - Valérie Hage
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Federico Sallusto
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Laure Esposito
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Nicolas Doumerc
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Bénédicte Debiol
- CHU Purpan, Etablissement Français du Sang de Midi-Pyrénées; Toulouse France
| | | | - Xavier Game
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Asma Allal
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Nassim Kamar
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- IFB-BMT - CHU Purpan, INSERM U563; Toulouse France
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49
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Jha PK, Bansal SB, Sethi SK, Jain M, Sharma R, Nandwani A, Phanish MK, Duggal R, Tiwari AK, Ghosh P, Ahlawat R, Kher V. ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier. Indian J Nephrol 2016; 26:113-8. [PMID: 27051135 PMCID: PMC4795426 DOI: 10.4103/0971-4065.159557] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
ABO incompatibility has been considered as an important immunological barrier for renal transplantation. With the advent of effective preconditioning protocols, it is now possible to do renal transplants across ABO barrier. We hereby present a single center retrospective analysis of all consecutive ABOi renal transplants performed from November 2011 to August 2014. Preconditioning protocol consisted of rituximab, plasmapheresis and intravenous immunoglobulin (IVIG) and maintenance immunosuppression consisted of tacrolimus, mycophenolate sodium, and prednisolone. The outcome of these ABOi transplants was compared with all other consecutive ABO-compatible (ABOc) renal transplants performed during same time. Twenty ABOi renal transplants were performed during the study period. Anti-blood group antibody titer varied from 1:2 to 1:512. Patient and graft survival was comparable between ABOi and ABOc groups. Biopsy proven acute rejection rate was 15% in ABOi group, which was similar to ABOc group (16.29%). There were no antibody-mediated rejections in ABOi group. The infection rate was also comparable. We conclude that the short-term outcome of ABOi and ABOc transplants is comparable. ABOi transplants should be promoted in developing countries to expand the donor pool.
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Affiliation(s)
- P K Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - S B Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - S K Sethi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - M Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Sharma
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - A Nandwani
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - M K Phanish
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Duggal
- Department of Lab Medicine, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - A K Tiwari
- Department of Transfusion Medicine, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - P Ghosh
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - R Ahlawat
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - V Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurgaon, Haryana, India
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50
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Troxell ML, Lanciault C. Practical Applications in Immunohistochemistry: Evaluation of Rejection and Infection in Organ Transplantation. Arch Pathol Lab Med 2016; 140:910-25. [PMID: 26759930 DOI: 10.5858/arpa.2015-0275-cp] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Immunohistochemical analysis of tissue biopsy specimens is a crucial tool in diagnosis of both rejection and infection in patients with solid organ transplants. In the past 15 years, the concept of antibody-mediated rejection has been refined, and diagnostic criteria have been codified in renal, heart, pancreas, and lung allografts (with studies ongoing in liver, small intestine, and composite grafts), all of which include immunoanalysis for the complement split product C4d. OBJECTIVES -To review the general concepts of C4d biology and immunoanalysis, followed by organ-allograft-specific data, and interpretative nuances for kidney, pancreas, and heart, with discussion of early literature for lung and liver biopsies. Additionally, practical applications and limitations of immunostains for infectious organisms (Polyomavirus, Adenoviridae [adenovirus], and the herpes virus family, including Herpes simplex virus, Cytomegalovirus, Human herpes virus 8, and Epstein-Barr virus) are reviewed in the context of transplant recipients. DATA SOURCES -Our experience and published primary and review literature. CONCLUSIONS -Immunohistochemistry continues to have an important role in transplant pathology, most notably C4d staining in assessment of antibody-mediated rejection and assessment of viral pathogens in tissue. In all facets of transplant pathology, correlation of morphology with special studies and clinical data is critical, as is close communication with the transplant team.
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Affiliation(s)
| | - Christian Lanciault
- From the Department of Pathology, Oregon Health & Science University, Portland
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