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Auner S, Hillebrand C, Boehm PM, Boecker J, Koren D, Schwarz S, Kovacs Z, Murakoezy G, Fischer G, Aigner C, Hoetzenecker K, Jaksch P, Benazzo A. Impact of Transient and Persistent Donor-Specific Antibodies in Lung Transplantation. Transpl Int 2024; 37:12774. [PMID: 38779355 PMCID: PMC11110840 DOI: 10.3389/ti.2024.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
Lung transplantation (LuTx) is an established treatment for patients with end-stage lung diseases, however, outcomes are limited by acute and chronic rejection. One aspect that has received increasing attention is the role of the host's humoral alloresponse, particularly the formation of de novo donor-specific antibodies (dnDSAs). The aim of this study was to investigate the clinical significance of transient and persistent dnDSAs and to understand their impact on outcomes after LuTx. A retrospective analysis was conducted using DSA screening data from LuTx recipients obtained at the Medical University of Vienna between February 2016 and March 2021. Of the 405 LuTx recipients analyzed, 205 patients developed dnDSA during the follow-up period. Among these, 167 (81%) had transient dnDSA and 38 (19%) persistent dnDSA. Persistent but not transient dnDSAs were associated with chronic lung allograft dysfunction (CLAD) and antibody-mediated rejection (AMR) (p < 0.001 and p = 0.006, respectively). CLAD-free survival rates for persistent dnDSAs at 1-, 3-, and 5-year post-transplantation were significantly lower than for transient dnDSAs (89%, 59%, 56% vs. 91%, 79%, 77%; p = 0.004). Temporal dynamics of dnDSAs after LuTx have a substantial effect on patient outcomes. This study underlines that the persistence of dnDSAs poses a significant risk to graft and patient survival.
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Affiliation(s)
- S. Auner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - C. Hillebrand
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. M. Boehm
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - J. Boecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - D. Koren
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - S. Schwarz
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Z. Kovacs
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Murakoezy
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - C. Aigner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - K. Hoetzenecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. Jaksch
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Benazzo
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Xu Q, Elrefaei M, Taupin JL, Hitchman KMK, Hiho S, Gareau AJ, Iasella CJ, Marrari M, Belousova N, Bettinotti M, Narula T, Alvarez F, Sanchez PG, Levvey B, Westall G, Snell G, Levine DJ, Zeevi A, Roux A. Chronic lung allograft dysfunction is associated with an increased number of non-HLA antibodies. J Heart Lung Transplant 2024; 43:663-672. [PMID: 38141896 DOI: 10.1016/j.healun.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/21/2023] [Accepted: 12/14/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the major cause of adverse outcomes in lung transplant recipients. Multiple factors, such as infection, alloimmunity, and autoimmunity, may lead to CLAD. Here, we aim to examine the role of non-human leukocytes antigen (HLA) antibodies in CLAD in a large retrospective cohort. METHODS We analyzed non-HLA antibodies in the pre- and post-transplant sera of 226 (100 CLAD, 126 stable) lung transplant recipients from 5 centers, and we used a separate cohort to confirm our findings. RESULTS A panel of 18 non-HLA antibodies was selected for analysis based on their significantly higher positive rates in CLAD vs stable groups. The panel-18 non-HLA antibodies (n > 3) may be positive pre- or post-transplant; the risk for CLAD is higher in the latter. The presence of both non-HLA antibody and HLA donor-specific antibody (DSA) was associated with an augmented risk of CLAD (HR=25.09 [5.52-14.04], p < 0.001), which was higher than that for single-positive patients. In the independent confirmatory cohort of 61 (20 CLAD, 41 stable) lung transplant recipients, the risk for CLAD remained elevated in double-positive patients (HR=10.67 [0.98-115.68], p = 0.052). After adjusting for nonstandard immunosuppression, patients with double-positive DSA/Non-HLA antibodies had an elevated risk for graft loss (HR=2.53 [1.29-4.96], p = 0.007). CONCLUSIONS Circulating non-HLA antibodies (n > 3) were independently associated with a higher risk for CLAD. Furthermore, when non-HLA antibodies and DSA were detected concomitantly, the risk for CLAD and graft loss was significantly increased. These results show that humoral immunity to HLA and non-HLA antigens may contribute to CLAD development.
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Affiliation(s)
- Qingyong Xu
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Kelley M K Hitchman
- Department of Pathology and Lab Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Steven Hiho
- Australian Red Cross Life Blood, Victorian and Immunogenetics, Melbourne, Victoria, Australia
| | - Alison J Gareau
- Immunogenetics Laboratory, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Carlo J Iasella
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marilyn Marrari
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Maria Bettinotti
- Immunogenetics Laboratory, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Tathagat Narula
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, Florida
| | - Francisco Alvarez
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, Florida
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bronwyn Levvey
- Lung Transplant Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Glen Westall
- Lung Transplant Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Gregory Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Deborah J Levine
- Department of Medicine, Stanford University, Palo Alto, California
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Antoine Roux
- Department of Pneumology, Hôpital Foch, Suresnes, France
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Hirama T, Akiba M, Watanabe T, Watanabe Y, Oishi H, Okada Y. A Single-Center Analysis of How HLA Mismatch and Donor-Specific Antibodies Affect Short-Term Outcome After Lung Transplantation: A Pilot Study Before a Country-Wide Histocompatibility Study in Japan. Transplant Proc 2024; 56:363-368. [PMID: 38320866 DOI: 10.1016/j.transproceed.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/29/2023] [Accepted: 12/28/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Analyzing HLA polymorphism in lung transplantation (LTx) is important, given its impact on LTx recipient survival and graft function. Accordingly, we conducted a retrospective study to examine the influence of HLA mismatch and donor-specific antibodies (DSA) on short-term outcomes and early-phase post-LTx complications. METHOD HLA antigen or eplet mismatch in LTx patients at Tohoku University Hospital from 2018 to 2023 was determined, and DSA was measured on admission for surgery to identify preformed DSA and at weeks 4 to 12 post-LTx for de novo DSA, respectively. RESULTS The participants were 45 LTx recipients, HLA-A/B/DR antigen mismatch (5-6 of 6) being identified in 57%, HLA-A/B/Cw/DR/DQ mismatch (8-10 of 10) in 57%, and HLA eplet mismatch (>61) in 46%. The prevalence of preformed DSA was 24%, and persistence (uncleared) was 16%. The incidence of de novo DSA was 16% after LTx. During the study,16 recipients experienced grade 3 primary graft dysfunction (PGD), 8 developed acute rejection, and 5 died. No HLA-related variables were significantly associated with post-LTx mortality and were not risk factors for high-grade PGD or acute rejection. CONCLUSION Despite limitations in sample size, resulting in tentative findings, the study serves as a crucial pilot study for an ongoing multicenter prospective trial in Japan.
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Affiliation(s)
- Takashi Hirama
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan; Division of Organ Transplantation, Tohoku University Hospital, Sendai, Miyagi, Japan.
| | - Miki Akiba
- Division of Organ Transplantation, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Toshikazu Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Yui Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Hisashi Oishi
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan; Division of Organ Transplantation, Tohoku University Hospital, Sendai, Miyagi, Japan
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Klein K, Keck M, Langewisch E, Merani S, Hitchman K, Leick M. Evaluation of serial monitoring of donor-specific antibodies in pediatric and adult intestinal/multivisceral transplant recipients. Pediatr Transplant 2024; 28:e14638. [PMID: 37942670 DOI: 10.1111/petr.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The study purpose was to add to limited literature assessing anti-HLA donor-specific antibody (DSA) appearance, clearance, specificity, and impact in intestinal/multivisceral (MV) transplant as well as the value of serial monitoring following an institutional protocol shift implementing serial monitoring. METHODS This single-center retrospective review included intestinal/MV recipients transplanted 1/1/15-9/31/17 with completed DSA testing. Patients were divided into groups based on DSA presence post-transplant. The primary outcome was biopsy-proven acute rejection (BPAR). Secondary outcomes included graft loss and death. Descriptive analysis of DSA was completed. RESULTS Of the 35 intestinal/MV recipients (60% pediatric) with DSA testing, 24 patients had post-transplant DSA. Fifteen patients in the DSA(+) group had T-cell-mediated BPAR versus five in the DSA(-) group (63% vs 45%, p = .47). Days to BPAR were 25 [IQR 19-165] (DSA(+) group) versus 232 [IQR 25.5-632.5] (DSA(-) group) (p = .066). There were no differences between groups for graft loss or death. One hundred and five DSA were identified in the DSA(+) group with 63% being class II, and 54% cleared during follow-up. DSA were directed against 50 different HLA alleles, with the most common being directed against HLA- DQ (35%). Time to first DSA and to clearance did not differ between class I and II. CONCLUSION Findings confirm previous data that suggest post-transplant DSA in this population may lead to increased BPAR or shorter time to BPAR, although not statistically significant. Most DSA were identified within the first month after transplant, and ahead of rejection identification on biopsy. DSA therefore may have utility as an early rejection biomarker and use may be considered in place of early protocol biopsies, particularly in pediatric patients. We identified novel findings of DSA directed against a large breadth of HLA in intestinal/MV patients.
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Affiliation(s)
- Kelsey Klein
- University Health Transplant Institute, San Antonio, Texas, USA
- The University of Texas at Austin, College of Pharmacy, Pharmacotherapy Division, Austin TX, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Megan Keck
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric Langewisch
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shaheed Merani
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kelley Hitchman
- University Health Transplant Institute, San Antonio, Texas, USA
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Mary Leick
- Nebraska Medicine, Omaha, NE, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Dukat-Mazurek A, Stachowicz-Chojnacka K, Karolak W, Zielińska H, Moszkowska G, Kałęka P, Wojarski J, Żegleń S. Antibody-mediated rejection with detection of de novo donor-specific anti-human leukocyte antigen Class II antibodies after lung transplantation: Problems in diagnosis, treatment and monitoring on a case report basis. Transpl Immunol 2023; 81:101918. [PMID: 37598914 DOI: 10.1016/j.trim.2023.101918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/30/2023] [Accepted: 08/17/2023] [Indexed: 08/22/2023]
Abstract
Lung transplantation, like other transplants, carries a risk of graft rejection due to genetic differences between the donor and the recipient. In this paper, we focus on antibody-mediated rejection, which can cause acute and more importantly chronic graft dysfunction and subsequently shortened allograft survival. We present the case of a 46-year-old patient who, two months after lung transplantation (LTx), developed AMR manifested by the deterioration of graft function and de novo production of donor-specific antibodies (DSA): DQ3 (DQ7, DQ8, DQ9). As the patient was after left single LTx and heavily oxygen dependent a transbronchial biopsy was deemed to be high risk and it was decided to determine the clinical significance of the detected antibodies by their ability to bind complement. The test confirmed that the detected DSAs have the ability cause cytotoxicity of the transplanted organ. After treatment with methotrexate, intravenous immunoglobulin G (IVIg) and alemtuzumab, the patient's condition improved and a complete decrease in DSA was obtained. However, after a year, the production of antibodies increased sharply. Treatment with IVIg, cyclophosphamide and plasmapheresis slightly improved the patient's condition, reducing the MFI DSA values by half, but leaving them at high levels. Based on this clinical case, we discuss problems with making a diagnosis, choosing the right AMR treatment and monitoring the patient's condition during treatment. We also indicate a poor prognosis in the case of the production of DSA antibodies at the DQ locus.
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Affiliation(s)
| | | | - Wojtek Karolak
- Department of Cardiac Surgery, Medical University of Gdansk, Poland
| | - Hanna Zielińska
- Department of Medical Immunology, Medical University of Gdansk, Poland
| | | | - Patrycja Kałęka
- Department of Medical Immunology, Medical University of Gdansk, Poland
| | - Jacek Wojarski
- Department of Cardiac Surgery, Medical University of Gdansk, Poland
| | - Sławomir Żegleń
- Department of Pneumonology and Allergology, Medical University of Gdansk, Poland
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Son BS, Lee HJ, Cho WH, So MW, Park JM, Yeo HJ. Association of positive pre-transplant angiotensin II type 1 receptor antibodies with clinical outcomes in lung transplant recipients. Transpl Immunol 2023; 80:101901. [PMID: 37442212 DOI: 10.1016/j.trim.2023.101901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Autoantibodies against the angiotensin II type 1 receptor (AT1R-Ab) have been previously associated with de novo donor-specific antibody (DSA) formation in lung transplantation. However, data regarding the clinical significance of AT1R-Ab in long-term graft function after lung transplantation are lacking. METHODS Seventy-one patients who underwent lung transplantation between July 2016 and January 2020 were enrolled in this study. We examined the relationship between pre-transplant AT1R-Ab levels and graft function, clinical outcomes, and human leukocyte antigen (HLA) DSA levels during the first 3 years post-transplantation. RESULTS Seventeen (23.9%) patients were AT1R-Ab-positive, and 54 (76.1%) were AT1R-Ab-negative. The median antibody value of the AT1R-Ab-positive group was 18 [18-22.5] U/mL, while that of the AT1R-Ab-negative group was 5.1 [3.5-8.0] U/mL (p < 0.001). There was no significant difference in the median acute cellular rejection (ACR) scores between the two groups (median [interquartile range] 1 [0.8-3] vs. 0.7 [0-1]; p = 0.145). However, there was a significant difference in the distribution of the ACR scores between the two groups (p = 0.015). Most (41.2%) patients in the pre-transplant AT1R-positive group scored above 1. The incidence of de novo DSA was also higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (52.9% vs. 20.4%, p = 0.009). The incidence of chronic lung allograft dysfunction (CLAD) within 3 years was significantly higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (58.3% vs. 11.8%; p < 0.001). In the multivariate Cox regression analysis, AT1R-Ab positivity (hazard ratio, 9.46; 95% confidence interval, 2.89-30.94; p < 0.001) was significantly associated with early CLAD. Furthermore, Kaplan-Meier analysis showed that AT1R-Ab-positive patients had a shorter survival time (χ2 = 39.62, p < 0.001). CONCLUSION High AT1R-Ab levels in the pre-transplant serum of lung recipients were associated with the development of de novo HLA-DSA, ACR, early CLAD, and short survival.
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Affiliation(s)
- Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea; Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun Ji Lee
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Laboratory Medicine, Pusan National University, School of Medicine, Busan, Republic of Korea
| | - Woo Hyun Cho
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Min Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Busan Medical Center, Busan, Republic of Korea
| | - Hye Ju Yeo
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea; Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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Zhang D, Wang X, Du W, Qin W, Chen W, Zuo X, Li P. Impact of statin treatment and exposure on the risk of chronic allograft dysfunction in Chinese lung transplant recipients. Pulm Pharmacol Ther 2023; 82:102243. [PMID: 37454870 DOI: 10.1016/j.pupt.2023.102243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/24/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Chronic lung allograft dysfunction (CLAD) was a common complication following lung transplantation that contributed to long-term morbidity and mortality. Statin therapy had been suggested to attenuate recipient inflammation and immune response, potentially reducing the risk and severity of CLAD. This study aimed to evaluate the impact of statin use and in vivo exposure on the incidence of CLAD in lung transplant recipients (LTRs), as well as their effects on immune cells and inflammatory factors. METHODS A retrospective cohort study was conducted on patients who underwent lung transplantation between January 2017 and December 2020. The incidence of CLAD, as per the 2019 ISHLT criteria, was assessed as the clinical outcome. The plasma concentrations of statin were measured using a validated UPLC-MS/MS method, while inflammation marker levels were determined using ELISA kits. RESULTS The statin group exhibited a significantly lower rate of CLAD (P = 0.002). Patients receiving statin therapy showed lower CD4+ T-cell counts, total T-lymphocyte counts, and IL-6 levels (P = 0.017, P = 0.048, and P = 0.038, respectively). Among the CLAD groups, the atorvastatin level (2.51 ± 1.31 ng/ml) was significantly lower than that in the non-CLAD group (OR = 1.438, 95%CI (1.007-2.053), P = 0.046). CONCLUSION Statin therapy significantly reduced the incidence of CLAD, as well as immune cell counts and inflammatory cytokine levels in LTRs. Although the statin exposure was significantly lower in CLAD patients, it was not associated with the incidence of CLAD.
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Affiliation(s)
- Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wei Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xianbo Zuo
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China; Department of Dermatology, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China.
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Kayawake H, Tanaka S, Yutaka Y, Yamada Y, Ohsumi A, Hamaji M, Nakajima D, Yurugi K, Hishida R, Date H. Impact of Spousal Donation on Postoperative Outcomes of Living-donor Lobar Lung Transplantation. Transplantation 2023; 107:1786-1794. [PMID: 36895091 DOI: 10.1097/tp.0000000000004579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The effect of human leukocyte antigen mismatches between donors and recipients on postoperative outcomes of lung transplantation remains controversial. We retrospectively reviewed adult recipients receiving living-donor lobar lung transplantation (LDLLT) to examine the difference in de novo donor-specific antibody (dnDSA) development and clinically diagnosed unilateral chronic lung allograft dysfunction per graft (unilateral CLAD) between lung grafts donated by spouses (nonblood relatives) and nonspouses (relatives within the third degree). We also investigated the difference in prognoses between recipients undergoing LDLLTs including spouse donors (spousal LDLLTs) and not including spouse donors (nonspousal LDLLTs). METHODS In this study, 63 adult recipients undergoing LDLLTs (61 bilateral and 2 unilateral LDLLTs from 124 living donors) between 2008 and 2020 were enrolled. The cumulative incidence of dnDSAs per lung graft was calculated, and prognoses were compared between recipients undergoing spousal and nonspousal LDLLTs. RESULTS The cumulative incidence of both dnDSAs and unilateral CLAD in grafts donated by spouses was significantly higher than that in grafts donated by nonspouses (5-y incidence of dnDSAs: 18.7% versus 6.4%, P = 0.038; 5-y incidence of unilateral CLAD: 45.6% versus 19.4%, P = 0.011). However, there were no significant differences in the overall survival or chronic lung allograft dysfunction-free survival between recipients undergoing spousal and nonspousal LDLLTs ( P > 0.99 and P = 0.434, respectively). CONCLUSIONS Although there were no significant differences in prognoses between spousal and nonspousal LDLLTs, more attention should be paid to spousal LDLLTs because of the higher development rate of dnDSAs and unilateral CLAD.
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Affiliation(s)
- Hidenao Kayawake
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
- Department of Thoracic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | | | | | - Kimiko Yurugi
- Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Rie Hishida
- Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
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Subburayalu J. Immune surveillance and humoral immune responses in kidney transplantation - A look back at T follicular helper cells. Front Immunol 2023; 14:1114842. [PMID: 37503334 PMCID: PMC10368994 DOI: 10.3389/fimmu.2023.1114842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/22/2023] [Indexed: 07/29/2023] Open
Abstract
T follicular helper cells comprise a specialized, heterogeneous subset of immune-competent T helper cells capable of influencing B cell responses in lymphoid tissues. In physiology, for example in response to microbial challenges or vaccination, this interaction chiefly results in the production of protecting antibodies and humoral memory. In the context of kidney transplantation, however, immune surveillance provided by T follicular helper cells can take a life of its own despite matching of human leukocyte antigens and employing the latest immunosuppressive regiments. This puts kidney transplant recipients at risk of subclinical and clinical rejection episodes with a potential risk for allograft loss. In this review, the current understanding of immune surveillance provided by T follicular helper cells is briefly described in physiological responses to contrast those pathological responses observed after kidney transplantation. Sensitization of T follicular helper cells with the subsequent emergence of detectable donor-specific human leukocyte antigen antibodies, non-human leukocyte antigen antibodies their implication for kidney transplantation and lessons learnt from other transplantation "settings" with special attention to antibody-mediated rejection will be addressed.
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Affiliation(s)
- Julien Subburayalu
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies (CRTD), Technische Universität Dresden, Dresden, Germany
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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10
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González-López E, Mora-Cuesta VM, Roa-Bautista A, Comins-Boo A, Renaldo A, Irure-Ventura J, Iturbe-Fernández D, Tello-Mena S, San Segundo D, Cifrián-Martínez J, López-Hoyos M. DQA1 Eplet Mismatch Load As an Independent Risk Factor of CLAD After Lung Transplantation. Transplant Direct 2023; 9:e1513. [PMID: 37389015 PMCID: PMC10306436 DOI: 10.1097/txd.0000000000001513] [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: 03/08/2023] [Revised: 05/17/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023] Open
Abstract
Lung transplantation remains the treatment of choice for end-stage lung diseases, and recipient selection is currently based on clinical urgency, ABO compatibility, and donor size. The risk of allosensitization is classically based on HLA mismatch, but eplet mismatch load is increasingly seen to be important in long-term outcomes in solid organ transplantation. Chronic lung allograft dysfunction (CLAD) is relatively common and relevant, affecting almost 50% of patients 5 y after transplantation and being the first cause of death from the first year after transplantation. The overall class-II eplet mismatch load has been associated with CLAD development. Methods Based on clinical data, 240 lung transplant recipients were eligible for CLAD, and HLA and eplet mismatch was analyzed using the HLAMatchmaker 3.1 software. Results A total of 92 (38.3%) lung transplant recipients developed CLAD. The time free-of-CLAD was significantly decreased in patients with presence of DQA1 eplet mismatches (P = 0.015). Furthermore, when other previously described CLAD risk factors were studied in a multivariate analysis, the presence of DQA1 eplet mismatches was found to be independently associated with the early onset of CLAD. Conclusions The concept of epitope load has arisen as a new tool to better define donor-recipient immunologic compatibility. The presence of DQA1 eplet mismatches potentially would increase the likelihood of developing CLAD.
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Affiliation(s)
- Elena González-López
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Víctor M. Mora-Cuesta
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Adriel Roa-Bautista
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Alejandra Comins-Boo
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - André Renaldo
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | - Juan Irure-Ventura
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | | | - Sandra Tello-Mena
- Pneumology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - David San Segundo
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
| | | | - Marcos López-Hoyos
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, Santander, Spain
- Molecular Biology Department, Cantabrian University, Santander, Spain
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11
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Liao M, Wang C, Zhang M, Qiao K. Insight on immune cells in rejection and infection postlung transplant. Immun Inflamm Dis 2023; 11:e868. [PMID: 37506156 PMCID: PMC10336664 DOI: 10.1002/iid3.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE The aim of this study is to provide a concise overview of the role of immune cells in rejection and infection after lung transplantation. METHODS Based on previous clinical and basic studies, the role of various types of immune cells in the development of rejection and infection after lung transplantation is summarized. RESULTS Immune cell functional status is strongly associated with common complications after lung transplantation, such as primary graft dysfunction, infection and occlusive bronchitis syndrome. Targeted balancing of immune cell tolerance and rejection is an important tool for successful lung transplantation. CONCLUSION A comprehensive understanding of immune cell function and the mechanisms that balance immune tolerance and immune rejection may be a crucial factor in improving survival after lung transplantation.
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Affiliation(s)
- Mingfeng Liao
- Guangdong Key Lab for Diagnosis & Treatment of Emerging Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Chaoxi Wang
- Department of Thoracic Surgery, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Mingxia Zhang
- Guangdong Key Lab for Diagnosis & Treatment of Emerging Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
| | - Kun Qiao
- Department of Thoracic Surgery, Shenzhen Third People's Hospital, Shenzhen, Guangdong Province, People's Republic of China
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12
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Stoker A, Hicks A, Wright MC, Ali A, Klapper J, Poisson J, Zaffiri L, Chen D, Hartwig M, Ghadimi K, Welsby I, Bottiger B. Development of New Donor-Specific and Human Leukocyte Antigen Antibodies After Transfusion in Adult Lung Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00274-4. [PMID: 37263806 DOI: 10.1053/j.jvca.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The development of new human leukocyte antigens (HLAs) and donor-specific antibodies (DSAs) in patients are associated with worse outcomes following lung transplantation. The authors aimed to examine the relationship between blood product transfusion in the first 72 hours after lung transplantation and the development of HLA antibodies, including DSAs. DESIGN A retrospective observational study. SETTING At a single academic tertiary center. PARTICIPANTS Adult lung transplant recipients who underwent transplantation between September 2014 and June 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 380 patients were included in this study, and 87 (23%) developed de novo donor-specific antibodies in the first year after transplantation. Eighty-five patients (22%) developed new HLA antibodies that were not donor-specific, and 208 patients (55%) did not develop new HLA antibodies in the first year after transplantation. Factors associated with increased HLA and DSA development included donor pulmonary infection, non-infectious indication for transplant, increased recipient body mass index, and a preoperative calculated panel reactive antibody value above 0. Multivariate analysis identified platelet transfusion associated with an increased risk of de novo HLA antibody development compared to the negative group (odds ratio [OR; 95% CI] 1.18 [1.02-1.36]; p = 0.025). Cryoprecipitate transfusion was associated with de novo DSA development compared to the negative group (OR [95% CI] 2.21 [1.32-3.69] for 1 v 0 units; p = 0.002). CONCLUSIONS Increased perioperative transfusion of platelets and cryoprecipitate are associated with de novo HLA and DSA development, respectively, in lung transplant recipients during the first year after transplantation.
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Affiliation(s)
- Alexander Stoker
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC
| | - Anne Hicks
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC
| | - Mary Cooter Wright
- Department of Anesthesiology, Biostatistics, Duke University Medical Center, Durham, NC
| | - Azfar Ali
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Jacob Klapper
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Jessica Poisson
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Lorenzo Zaffiri
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Dongfeng Chen
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Matthew Hartwig
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC; Department of Anesthesiology, Critical Care Medicine Division, Duke University Medical Center, Durham, NC
| | - Ian Welsby
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC; Department of Anesthesiology, Critical Care Medicine Division, Duke University Medical Center, Durham, NC
| | - Brandi Bottiger
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, NC.
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13
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Kleid L, Walter J, Vorstandlechner M, Schneider CP, Michel S, Kneidinger N, Irlbeck M, Wichmann C, Möhnle P, Humpe A, Kauke T, Dick A. Predictive value of molecular matching tools for the development of donor specific HLA-antibodies in patients undergoing lung transplantation. HLA 2023. [PMID: 37068792 DOI: 10.1111/tan.15068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/21/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
Molecular matching is a new approach for virtual histocompatibility testing in organ transplantation. The aim of our study was to analyze whether the risk for de novo donor-specific HLA antibodies (dnDSA) after lung transplantation (LTX) can be predicted by molecular matching algorithms (MMA) and their combination. In this retrospective study we included 183 patients undergoing LTX at our center from 2012-2020. We monitored dnDSA development for 1 year. Eplet mismatches (epMM) using HLAMatchmaker were calculated and highly immunogenic eplets based on their ElliPro scores were identified. PIRCHE-II scores were calculated using PIRCHE-II algorithm (5- and 11-loci). We compared epMM and PIRCHE-II scores between patients with and without dnDSA using t-test and used ROC-curves to determine optimal cut-off values to categorize patients into four groups. We used logistic regression with AIC to compare the predictive value of PIRCHE-II, epMM, and their combination. In total 28.4% of patients developed dnDSA (n = 52), 12.5% class I dnDSA (n = 23), 24.6% class II dnDSA (n = 45), and 8.7% both class II and II dnDSA (n = 16). Mean epMMs (p-value = 0.005), mean highly immunogenic epMMs (p-value = 0.003), and PIRCHE-II (11-loci) (p = 0.01) were higher in patients with compared to without class II dnDSA. Patients with highly immunogenic epMMs above 30.5 and PIRCHE-II 11-loci above 560.0 were more likely to develop dnDSA (31.1% vs. 14.8%, p-value = 0.03). The logistic regression model including the grouping variable showed the best predictive value. MMA can support clinicians to identify patients at higher or lower risk for developing class II dnDSA and might be helpful tools for immunological risk assessment in LTX patients.
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Affiliation(s)
- Lisa Kleid
- Laboratory for Immunogenetics, Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Julia Walter
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany
| | | | - Christian P Schneider
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Sebastian Michel
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Kneidinger
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Wichmann
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Patrick Möhnle
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Humpe
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Teresa Kauke
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Transplantation Center, University Hospital, LMU Munich, Munich, Germany
| | - Andrea Dick
- Laboratory for Immunogenetics, Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
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14
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Ennis SL, Olsen N, Tong WWY, Goddard L, Watson N, Weston L, Iqbal A, Patel P, Malouf MA, Plit ML, Darley DR. Specific HLA-DQ risk epitope mismatches are associated with chronic lung allograft dysfunction after lung transplantation. Am J Transplant 2023:S1600-6135(23)00401-X. [PMID: 37054889 DOI: 10.1016/j.ajt.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Abstract
A high-risk epitope mismatch (REM) (found in DQA1*05 + DQB1*02/DQB1*03:01) is associated with de novo donor-specific antibodies (dn-DSA) after lung transplant (LTx). Chronic lung allograft dysfunction (CLAD) remains a barrier to LTx survival. The aims of this study were to measure the association between DQ REM and risk of CLAD and death after LTx. A retrospective analysis of LTx recipients at a single centre was conducted between Jan-2014 and Apr-2019. Molecular typing at HLA-DQA/DBQ identified DQ REM. Multivariable competing risk and Cox regression models were used to measure the association between DQ REM and time-to-CLAD and time-to-death. DQ REM was detected in 96/268(35.8%) and DQ REM dn-DSA detected in 34/96(35.4%). CLAD occurred in 78(29.1%) and 98(36.6%) recipients died during follow-up. When analysed as a baseline predictor, DQ REM status was associated with CLAD (SHR 2.19 95%CI 1.40-3.43; p=0.001). After adjustment for time dependent variables, dn-DQ-REM DSA (SHR 2.43 95%CI 1.10-5.38; p=0.029) and A-grade rejection score (SHR 1.22 95%CI 1.11-1.35; p=<0.001), but not DQ REM status was associated with CLAD. DQ REM was not associated with death (HR 1.18 95%CI 0.72-1.93; p=0.51). Classification of DQ REM may identify patients at risk of poor outcomes and should be incorporated into clinical decision-making.
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Affiliation(s)
- Samantha Louse Ennis
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Nicholas Olsen
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Winnie W Y Tong
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Louise Goddard
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Narelle Watson
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Lyanne Weston
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Ayesha Iqbal
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Purvesh Patel
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Monique Anne Malouf
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Marshall L Plit
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - David Ross Darley
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
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15
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Keller M, Yang S, Ponor L, Bon A, Cochrane A, Philogene M, Bush E, Shah P, Mathew J, Brown AW, Kong H, Charya A, Luikart H, Nathan SD, Khush KK, Jang M, Agbor-Enoh S. Preemptive treatment of de novo donor-specific antibodies in lung transplant patients reduces subsequent risk of chronic lung allograft dysfunction or death. Am J Transplant 2023; 23:559-564. [PMID: 36732088 PMCID: PMC10079558 DOI: 10.1016/j.ajt.2022.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023]
Abstract
The development of donor-specific antibodies after lung transplantation is associated with downstream acute cellular rejection, antibody-mediated rejection (AMR), chronic lung allograft dysfunction (CLAD), or death. It is unknown whether preemptive (early) treatment of de novo donor-specific antibodies (dnDSAs), in the absence of clinical signs and symptoms of allograft dysfunction, reduces the risk of subsequent CLAD or death. We performed a multicenter, retrospective cohort study to determine if early treatment of dnDSAs in lung transplant patients reduces the risk of the composite endpoint of CLAD or death. In the cohort of 445 patients, 145 patients developed dnDSAs posttransplant. Thirty patients received early targeted treatment for dnDSAs in the absence of clinical signs and symptoms of AMR. Early treatment of dnDSAs was associated with a decreased risk of CLAD or death (hazard ratio, 0.36; 95% confidence interval, 0.17-0.76; P < .01). Deferring treatment until the development of clinical AMR was associated with an increased risk of CLAD or death (hazard ratio, 3.00; 95% confidence interval, 1.46-6.18; P < .01). This study suggests that early, preemptive treatment of donor-specific antibodies in lung transplant patients may reduce the subsequent risk of CLAD or death.
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Affiliation(s)
- Michael Keller
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Song Yang
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Lucia Ponor
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Ann Bon
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Mary Philogene
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Johns Hopkins Immunogenetics Laboratory, Baltimore, Maryland, USA
| | - Errol Bush
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Pali Shah
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joby Mathew
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne W Brown
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Hyesik Kong
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Ananth Charya
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Helen Luikart
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA; Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Kiran K Khush
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Moon Jang
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Sean Agbor-Enoh
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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16
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Vajter J, Vachtenheim J, Prikrylova Z, Berousek J, Vymazal T, Lischke R, Martin AK, Durila M. Effect of targeted coagulopathy management and 5% albumin as volume replacement therapy during lung transplantation on allograft function: a secondary analysis of a randomized clinical trial. BMC Pulm Med 2023; 23:80. [PMID: 36894877 PMCID: PMC9996868 DOI: 10.1186/s12890-023-02372-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) after lung transplantation (LuTx) contributes substantially to early postoperative morbidity. Both intraoperative transfusion of a large amount of blood products during the surgery and ischemia-reperfusion injury after allograft implantation play an important role in subsequent PGD development. METHODS We have previously reported a randomized clinical trial of 67 patients where point of care (POC) targeted coagulopathy management and intraoperative administration of 5% albumin led to significant reduction of blood loss and blood product consumption during the lung transplantation surgery. A secondary analysis of the randomized clinical trial evaluating the effect of targeted coagulopathy management and intraoperative administration of 5% albumin on early lung allograft function after LuTx and 1-year survival was performed. RESULTS Compared to the patients in the control (non-POC) group, those in study (POC) group showed significantly superior graft function, represented by the Horowitz index (at 72 h after transplantation 402.87 vs 308.03 with p < 0.001, difference between means: 94.84, 95% CI: 60.18-129.51). Furthermore, the maximum doses of norepinephrine administered during first 24 h were significantly lower in the POC group (0.193 vs 0.379 with p < 0.001, difference between the means: 0.186, 95% CI: 0.105-0.267). After dichotomization of PGD (0-1 vs 2-3), significant difference between the non-POC and POC group occurred only at time point 72, when PGD grade 2-3 developed in 25% (n = 9) and 3.2% (n = 1), respectively (p = 0.003). The difference in 1-year survival was not statistically significant (10 patients died in non-POC group vs. 4 patients died in POC group; p = 0.17). CONCLUSIONS Utilization of a POC targeted coagulopathy management combined with Albumin 5% as primary resuscitative fluid may improve early lung allograft function, provide better circulatory stability during the early post-operative period, and have potential to decrease the incidence of PGD without negative effect on 1-year survival. TRIAL REGISTRATION This clinical trial was registered at ClinicalTrials.gov (NCT03598907).
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Affiliation(s)
- Jaromir Vajter
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jiri Vachtenheim
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic.
| | - Zuzana Prikrylova
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Berousek
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Tomas Vymazal
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Robert Lischke
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Miroslav Durila
- Department of Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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17
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Miyamae J, Okano M, Katakura F, Kulski JK, Moritomo T, Shiina T. Large-Scale Polymorphism Analysis of Dog Leukocyte Antigen Class I and Class II Genes ( DLA-88, DLA-12/88L and DLA-DRB1) and Comparison of the Haplotype Diversity between Breeds in Japan. Cells 2023; 12:cells12050809. [PMID: 36899945 PMCID: PMC10001263 DOI: 10.3390/cells12050809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/21/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Polymorphisms of canine leukocyte antigen (DLA) class I (DLA-88 and DLA-12/88L) and class II (DLA-DRB1) genes are important for disease susceptibility studies, but information on the genetic diversity among dog breeds is still lacking. To better elucidate the polymorphism and genetic diversity between breeds, we genotyped DLA-88, DLA-12/88L, and DLA-DRB1 loci using 829 dogs of 59 breeds in Japan. Genotyping by Sanger sequencing identified 89, 43, and 61 alleles in DLA-88, DLA-12/88L, and DLA-DRB1 loci, respectively, and a total of 131 DLA-88-DLA-12/88L-DLA-DRB1 haplotypes (88-12/88L-DRB1) were detected more than once. Of the 829 dogs, 198 were homozygotes for one of the 52 different 88-12/88L-DRB1 haplotypes (homozygosity rate: 23.8%). Statistical modeling suggests that 90% of the DLA homozygotes or heterozygotes with one or other of the 52 different 88-12/88L-DRB1 haplotypes within somatic stem cell lines would benefit graft outcome after 88-12/88L-DRB1-matched transplantation. As previously reported for DLA class II haplotypes, the diversity of 88-12/88L-DRB1 haplotypes varied remarkably between breeds but was relatively conserved within most breeds. Therefore, the genetic characteristics of high DLA homozygosity rate and poor DLA diversity within a breed are useful for transplantation therapy, but they may affect biological fitness as homozygosity progresses.
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Affiliation(s)
- Jiro Miyamae
- Faculty of Veterinary Medicine, Okayama University of Science, 1-3 Ikoino-oka, Imabari 794-8555, Japan
- Correspondence: ; Tel.: +81-898-52-9126
| | - Masaharu Okano
- Department of Legal Medicine, Nihon University School of Dentistry, 1-8-13 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan
| | - Fumihiko Katakura
- Department of Veterinary Medicine, College of Bioresource Science, Nihon University, 1866 Kameino, Fujisawa 252-0880, Japan
| | - Jerzy K. Kulski
- Department of Molecular Life Science, Division of Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1143, Japan
| | - Tadaaki Moritomo
- Department of Veterinary Medicine, College of Bioresource Science, Nihon University, 1866 Kameino, Fujisawa 252-0880, Japan
| | - Takashi Shiina
- Department of Molecular Life Science, Division of Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1143, Japan
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18
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Halverson LP, Hachem RR. Antibody-Mediated Rejection: Diagnosis and Treatment. Clin Chest Med 2023; 44:95-103. [PMID: 36774172 PMCID: PMC10148231 DOI: 10.1016/j.ccm.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Antibody-mediated rejection (AMR) is a form of lung allograft rejection that is emerging as an important risk factor for chronic lung allograft dysfunction and decreased long-term survival. In this review, we provide a brief overview of our current understanding of its pathophysiology with an emphasis on donor-specific antibodies before moving on to focus on the current diagnostic criteria and treatment strategies. Our goal is to discuss the limitations of our current knowledge and explore how novel diagnostic and therapeutic options aim to improve outcomes through earlier definitive diagnosis and preemptive targeted treatment.
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Affiliation(s)
- Laura P Halverson
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA.
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, Saint Louis, MO 63108, USA
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19
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Biomarkers for Chronic Lung Allograft Dysfunction: Ready for Prime Time? Transplantation 2023; 107:341-350. [PMID: 35980878 PMCID: PMC9875844 DOI: 10.1097/tp.0000000000004270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) remains a major hurdle impairing lung transplant outcome. Parallel to the better clinical identification and characterization of CLAD and CLAD phenotypes, there is an increasing urge to find adequate biomarkers that could assist in the earlier detection and differential diagnosis of CLAD phenotypes, as well as disease prognostication. The current status and state-of-the-art of biomarker research in CLAD will be discussed with a particular focus on radiological biomarkers or biomarkers found in peripheral tissue, bronchoalveolar lavage' and circulating blood' in which significant progress has been made over the last years. Ultimately, although a growing number of biomarkers are currently being embedded in the follow-up of lung transplant patients, it is clear that one size does not fit all. The future of biomarker research probably lies in the rigorous combination of clinical information with findings in tissue, bronchoalveolar lavage' or blood. Only by doing so, the ultimate goal of biomarker research can be achieved, which is the earlier identification of CLAD before its clinical manifestation. This is desperately needed to improve the prognosis of patients with CLAD after lung transplantation.
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20
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Clinical recommendations for posttransplant assessment of anti-HLA (Human Leukocyte Antigen) donor-specific antibodies: A Sensitization in Transplantation: Assessment of Risk consensus document. Am J Transplant 2023; 23:115-132. [PMID: 36695614 DOI: 10.1016/j.ajt.2022.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
Although anti-HLA (Human Leukocyte Antigen) donor-specific antibodies (DSAs) are commonly measured in clinical practice and their relationship with transplant outcome is well established, clinical recommendations for anti-HLA antibody assessment are sparse. Supported by a careful and critical review of the current literature performed by the Sensitization in Transplantation: Assessment of Risk 2022 working group, this consensus report provides clinical practice recommendations in kidney, heart, lung, and liver transplantation based on expert assessment of quality and strength of evidence. The recommendations address 3 major clinical problems in transplantation and include guidance regarding posttransplant DSA assessment and application to diagnostics, prognostics, and therapeutics: (1) the clinical implications of positive posttransplant DSA detection according to DSA status (ie, preformed or de novo), (2) the relevance of posttransplant DSA assessment for precision diagnosis of antibody-mediated rejection and for treatment management, and (3) the relevance of posttransplant DSA for allograft prognosis and risk stratification. This consensus report also highlights gaps in current knowledge and provides directions for clinical investigations and trials in the future that will further refine the clinical utility of posttransplant DSA assessment, leading to improved transplant management and patient care.
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21
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Abstract
BACKGROUND Donor-specific antibodies (DSAs) have been associated with antibody-mediated rejection, chronic lung allograft dysfunction (CLAD), and increased mortality in lung transplant recipients. Our center performs transplants in the presence of DSA, and we sought to evaluate the safety of this practice with respect to graft loss, CLAD onset, and primary graft dysfunction (PGD). METHODS We reviewed recipients transplanted from 2010 to 2017, classifying them as DSA positive (DSA+) or negative. We used Kaplan-Meier estimation to test the association between DSA status and time to death or retransplant and time to CLAD onset. We further tested associations with severe PGD and rejection in the first year using logistic regression and Fisher exact testing. RESULTS Three hundred thirteen patients met inclusion criteria, 30 (10%) of whom were DSA+. DSA+ patients were more likely to be female, bridged to transplant, and receive induction therapy. There was no association between DSA status and time to death or retransplant (log rank P = 0.581) nor death-censored time to CLAD onset (log rank P = 0.278), but DSA+ patients were at increased risk of severe PGD (odds ratio 2.88; 95% confidence interval, 1.10-7.29; P = 0.031) and more frequent antibody-mediated rejection in the first posttransplant year. CONCLUSIONS Crossing DSA at time of lung transplant was not associated with an increased risk of death or CLAD in our cohort, but patients developed severe PGD and antibody-mediated rejection more frequently. However, these risks are likely manageable when balanced against the benefits of expanded access for sensitized candidates.
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22
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Assessment of Anti-Human Leukocyte Antigen (HLA)-Antibody-Dependent Humoral Response in Patients before and after Lung Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121771. [PMID: 36556973 PMCID: PMC9781897 DOI: 10.3390/medicina58121771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Testing for anti-human leukocyte antigen (HLA) antibodies both before and after transplantation is of fundamental significance for the success of lung transplantation. The aim of this study was the evaluation of anti-HLA immunization of patients before and after lung transplant who were subjected to qualification and transplantation. Materials and Methods: Prior to the transplantation, patients were examined for the presence of IgG class anti-HLA antibodies (anti-human leukocyte antigen), the so-called panel-reactive antibodies (PRA), using the flow cytometry method. After the transplantation, the class and specificity of anti-HLA antibodies (also IgG) were determined using Luminex. Results: In the group examined, the PRA results ranged from 0.1% to 66.4%. Low (30%) and average (30-80%) immunization was found in only 9.7% of the group examined. Presence of class I anti-HLA antibodies with MFI (mean fluorescence intensity) greater than 1000 was found in 42.7% of the patients examined, while class II anti-HLA antibodies were found in 38.4%. Immunization levels before and after the transplantation were compared. In 10.87% of patients, DSA antibodies (donor-specific antibodies) with MFI of over 1000 were found. Conclusions: It seems that it is possible to confirm the correlation between pre- and post-transplantation immunization with the use of the two presented methods of determining IgG class anti-HLA antibodies by increasing the size of the group studied and conducting a long-term observation thereof.
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23
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Bos S, Milross L, Filby AJ, Vos R, Fisher AJ. Immune processes in the pathogenesis of chronic lung allograft dysfunction: identifying the missing pieces of the puzzle. Eur Respir Rev 2022; 31:31/165/220060. [PMID: 35896274 DOI: 10.1183/16000617.0060-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Lung transplantation is the optimal treatment for selected patients with end-stage chronic lung diseases. However, chronic lung allograft dysfunction remains the leading obstacle to improved long-term outcomes. Traditionally, lung allograft rejection has been considered primarily as a manifestation of cellular immune responses. However, in reality, an array of complex, interacting and multifactorial mechanisms contribute to its emergence. Alloimmune-dependent mechanisms, including T-cell-mediated rejection and antibody-mediated rejection, as well as non-alloimmune injuries, have been implicated. Moreover, a role has emerged for autoimmune responses to lung self-antigens in the development of chronic graft injury. The aim of this review is to summarise the immune processes involved in the pathogenesis of chronic lung allograft dysfunction, with advanced insights into the role of innate immune pathways and crosstalk between innate and adaptive immunity, and to identify gaps in current knowledge.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Luke Milross
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Andrew J Filby
- Flow Cytometry Core and Innovation, Methodology and Application Research Theme, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Vos
- Dept of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium.,University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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24
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Determining Clinical Thresholds for Donor HLA Eplet Compatibility to Predict Best Outcomes Following Lung Transplantation. Transplant Direct 2022; 8:e1364. [PMID: 36204183 PMCID: PMC9529050 DOI: 10.1097/txd.0000000000001364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022] Open
Abstract
Currently, the assessment of immunological risk in lung transplantation (LTx) does not completely consider HLA compatibility at the molecular level. We have previously demonstrated the association of HLA eplets in predicting chronic lung allograft dysfunction following LTx; however, the associations between HLA eplet mismatch (epMM) loads and overall survival are unknown.
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25
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Huang HJ, Schechtman K, Askar M, Bernadt C, Mittler B, Dore P, Witt C, Byers D, Vazquez-Guillamet R, Halverson L, Nava R, Puri V, Gelman A, Kreisel D, Hachem RR. A pilot randomized controlled trial of de novo belatacept-based immunosuppression following anti-thymocyte globulin induction in lung transplantation. Am J Transplant 2022; 22:1884-1892. [PMID: 35286760 PMCID: PMC9262777 DOI: 10.1111/ajt.17028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/25/2023]
Abstract
The development of donor-specific antibodies (DSA) after lung transplantation is common and results in adverse outcomes. In kidney transplantation, Belatacept has been associated with a lower incidence of DSA, but experience with Belatacept in lung transplantation is limited. We conducted a two-center pilot randomized controlled trial of de novo immunosuppression with Belatacept after lung transplantation to assess the feasibility of conducting a pivotal trial. Twenty-seven participants were randomized to Control (Tacrolimus, Mycophenolate Mofetil, and prednisone, n = 14) or Belatacept-based immunosuppression (Tacrolimus, Belatacept, and prednisone until day 89 followed by Belatacept, Mycophenolate Mofetil, and prednisone, n = 13). All participants were treated with rabbit anti-thymocyte globulin for induction immunosuppression. We permanently stopped randomization and treatment with Belatacept after three participants in the Belatacept arm died compared to none in the Control arm. Subsequently, two additional participants in the Belatacept arm died for a total of five deaths compared to none in the Control arm (log rank p = .016). We did not detect a significant difference in DSA development, acute cellular rejection, or infection between the two groups. We conclude that the investigational regimen used in this study is associated with increased mortality after lung transplantation.
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Affiliation(s)
| | | | - Medhat Askar
- Department of Pathology and Laboratory Medicine, Texas A & M College of Medicine
| | - Cory Bernadt
- Department of Pathology and Immunology, Washington University in St. Louis
| | - Brigitte Mittler
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Peter Dore
- Division of Biostatistics, Washington University in St. Louis
| | - Chad Witt
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Derek Byers
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | | | - Laura Halverson
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care, Washington University in St. Louis
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26
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Sorbini M, Togliatto G, Mioli F, Simonato E, Marro M, Cappuccio M, Arruga F, Caorsi C, Mansouri M, Magistroni P, Gambella A, Delsedime L, Papotti MG, Solidoro P, Albera C, Boffini M, Rinaldi M, Amoroso A, Vaisitti T, Deaglio S. Validation of a Simple, Rapid, and Cost-Effective Method for Acute Rejection Monitoring in Lung Transplant Recipients. Transpl Int 2022; 35:10546. [PMID: 35755857 PMCID: PMC9221674 DOI: 10.3389/ti.2022.10546] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/19/2022] [Indexed: 11/24/2022]
Abstract
Despite advances in immunosuppression therapy, acute rejection remains the leading cause of graft dysfunction in lung transplant recipients. Donor-derived cell-free DNA is increasingly being considered as a valuable biomarker of acute rejection in several solid organ transplants. We present a technically improved molecular method based on digital PCR that targets the mismatch between the recipient and donor at the HLA-DRB1 locus. Blood samples collected sequentially post-transplantation from a cohort of lung recipients were used to obtain proof-of-principle for the validity of the assay, correlating results with transbronchial biopsies and lung capacity tests. The results revealed an increase in dd-cfDNA during the first 2 weeks after transplantation related to ischemia-reperfusion injury (6.36 ± 5.36%, p < 0.0001). In the absence of complications, donor DNA levels stabilized, while increasing again during acute rejection episodes (7.81 ± 12.7%, p < 0.0001). Respiratory tract infections were also involved in the release of dd-cfDNA (9.14 ± 15.59%, p = 0.0004), with a positive correlation with C-reactive protein levels. Overall, the dd-cfDNA percentages were inversely correlated with the lung function values measured by spirometry. These results confirm the value of dd-cfDNA determination during post-transplant follow-up to monitor acute rejection in lung recipients, achieved using a rapid and inexpensive approach based on the HLA mismatch between donor and recipient.
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Affiliation(s)
- Monica Sorbini
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Fiorenza Mioli
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Erika Simonato
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Matteo Marro
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | | | - Francesca Arruga
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Cristiana Caorsi
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Morteza Mansouri
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Paola Magistroni
- Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | | | - Luisa Delsedime
- Pathology Unit, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Mauro Giulio Papotti
- Pathology Unit, Città Della Salute e Della Scienza University Hospital, Turin, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Paolo Solidoro
- Lung Transplantation and Advanced Airways Management, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Carlo Albera
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery Division, Surgical Sciences Department, Heart and Lung Transplant Center, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Antonio Amoroso
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Tiziana Vaisitti
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Silvia Deaglio
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Transplant Biology Service, Città Della Salute e Della Scienza University Hospital, Turin, Italy
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27
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Glanville AR, Benden C, Bergeron A, Cheng GS, Gottlieb J, Lease ED, Perch M, Todd JL, Williams KM, Verleden GM. Bronchiolitis obliterans syndrome after lung or haematopoietic stem cell transplantation: current management and future directions. ERJ Open Res 2022; 8:00185-2022. [PMID: 35898810 PMCID: PMC9309343 DOI: 10.1183/23120541.00185-2022] [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: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host-disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, that are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies, and (in patients with BOS after lung transplantation) B-cell–directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required.
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28
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Ravichandran R, Bansal S, Rahman M, Sureshbabu A, Sankpal N, Fleming T, Bharat A, Mohanakumar T. Extracellular Vesicles Mediate Immune Responses to Tissue-Associated Self-Antigens: Role in Solid Organ Transplantations. Front Immunol 2022; 13:861583. [PMID: 35572510 PMCID: PMC9094427 DOI: 10.3389/fimmu.2022.861583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Transplantation is a treatment option for patients diagnosed with end-stage organ diseases; however, long-term graft survival is affected by rejection of the transplanted organ by immune and nonimmune responses. Several studies have demonstrated that both acute and chronic rejection can occur after transplantation of kidney, heart, and lungs. A strong correlation has been reported between de novo synthesis of donor-specific antibodies (HLA-DSAs) and development of both acute and chronic rejection; however, some transplant recipients with chronic rejection do not have detectable HLA-DSAs. Studies of sera from such patients demonstrate that immune responses to tissue-associated antigens (TaAgs) may also play an important role in the development of chronic rejection, either alone or in combination with HLA-DSAs. The synergistic effect between HLA-DSAs and antibodies to TaAgs is being established, but the underlying mechanism is yet to be defined. We hypothesize that HLA-DSAs damage the transplanted donor organ resulting in stress and leading to the release of extracellular vesicles, which contribute to chronic rejection. These vesicles express both donor human leukocyte antigen (HLA) and non-HLA TaAgs, which can activate antigen-presenting cells and lead to immune responses and development of antibodies to both donor HLA and non-HLA tissue-associated Ags. Extracellular vesicles (EVs) are released by cells under many circumstances due to both physiological and pathological conditions. Primarily employing clinical specimens obtained from human lung transplant recipients undergoing acute or chronic rejection, our group has demonstrated that circulating extracellular vesicles display both mismatched donor HLA molecules and lung-associated Ags (collagen-V and K-alpha 1 tubulin). This review focuses on recent studies demonstrating an important role of antibodies to tissue-associated Ags in the rejection of transplanted organs, particularly chronic rejection. We will also discuss the important role of extracellular vesicles released from transplanted organs in cross-talk between alloimmunity and autoimmunity to tissue-associated Ags after solid organ transplantation.
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Affiliation(s)
| | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mohammad Rahman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Angara Sureshbabu
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Narendra Sankpal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Ankit Bharat
- Department of Surgery-Thoracic, Northwestern University, Chicago, IL, United States
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29
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Venado A, Kukreja J, Greenland JR. Chronic Lung Allograft Dysfunction. Thorac Surg Clin 2022; 32:231-242. [PMID: 35512941 DOI: 10.1016/j.thorsurg.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) is a syndrome of progressive lung function decline, subcategorized into obstructive, restrictive, and mixed phenotypes. The trajectory of CLAD is variable depending on the phenotype, with restrictive and mixed phenotypes having more rapid progression and lower survival. The mechanisms driving CLAD development remain unclear, though allograft injury during primary graft dysfunction, acute cellular rejection, antibody-mediated rejection, and infections trigger immune responses with long-lasting effects that can lead to CLAD months or years later. Currently, retransplantation is the only effective treatment.
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Affiliation(s)
- Aida Venado
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, 505 Parnassus Ave, M1093A, San Francisco, CA 94143-2204, USA.
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Univeristy of California, San Francisco, 500 Parnassus Ave, MU 405W Suite 305, San Francisco, CA 94143, USA
| | - John R Greenland
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, SF VAHCS Building 2, Room 453 (Mail stop 111D), 4150 Clement St, San Francisco CA 94121, USA
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30
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Silva TD, Voisey J, Hopkins P, Apte S, Chambers D, O'Sullivan B. Markers of rejection of a lung allograft: state of the art. Biomark Med 2022; 16:483-498. [PMID: 35315284 DOI: 10.2217/bmm-2021-1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic lung allograft dysfunction (CLAD) affects approximately 50% of all lung transplant recipients by 5 post-operative years and is the leading cause of death in lung transplant recipients. Early CLAD diagnosis or ideally prediction of CLAD is essential to enable early intervention before significant lung injury occurs. New technologies have emerged to facilitate biomarker discovery, including epigenetic modification and single-cell RNA sequencing. This review examines new and existing technologies for biomarker discovery and the current state of research on biomarkers for identifying lung transplant rejection.
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Affiliation(s)
- Tharushi de Silva
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia
| | - Joanne Voisey
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Peter Hopkins
- Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Simon Apte
- Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Daniel Chambers
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
| | - Brendan O'Sullivan
- School of Biomedical Sciences, Centre for Genomics & Personalised Heath, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Queensland Lung Transplant Service, Ground Floor, Clinical Sciences Building, The Prince Charles Hospital, Rode Road, Chermside, 4032, Brisbane, Queensland, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, The University of Queensland, 4032, Brisbane, Queensland, Australia
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31
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Shino MY, Zhang Q, Li N, Derhovanessian A, Ramsey A, Saggar R, Britton IN, Amubieya OO, Lari SM, Hickey M, Reed EF, Noble PW, Stripp BR, Fishbein GA, Lynch JP, Ardehali A, Sayah DM, Weigt SS, Belperio JA. The allograft injury marker CXCL9 determines prognosis of anti-HLA antibodies after lung transplantation. Am J Transplant 2022; 22:565-573. [PMID: 34464505 PMCID: PMC10826889 DOI: 10.1111/ajt.16827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 01/25/2023]
Abstract
Despite the common detection of non-donor specific anti-HLA antibodies (non-DSAs) after lung transplantation, their clinical significance remains unclear. In this retrospective single-center cohort study of 325 lung transplant recipients, we evaluated the association between donor-specific HLA antibodies (DSAs) and non-DSAs with subsequent CLAD development. DSAs were detected in 30% of recipients and were associated with increased CLAD risk, with higher HRs for both de novo and high MFI (>5000) DSAs. Non-DSAs were detected in 56% of recipients, and 85% of DSA positive tests had concurrent non-DSAs. In general, non-DSAs did not increase CLAD risk in multivariable models accounting for DSAs. However, non-DSAs in conjunction with high BAL CXCL9 levels were associated with increased CLAD risk. Multivariable proportional hazards models demonstrate the importance of the HLA antibody-CXCL9 interaction: CLAD risk increases when HLA antibodies (both DSAs and non-DSAs) are detected in conjunction with high CXCL9. Conversely, CLAD risk is not increased when HLA antibodies are detected with low CXCL9. This study supports the potential utility of BAL CXCL9 measurement as a biomarker to risk stratify HLA antibodies for future CLAD. The ability to discriminate between high versus low-risk HLA antibodies may improve management by allowing for guided treatment decisions.
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Affiliation(s)
- Michael Y. Shino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Qiuheng Zhang
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ning Li
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss Derhovanessian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ian N. Britton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Olawale O. Amubieya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Shahrzad M. Lari
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michelle Hickey
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Elaine F. Reed
- Department of Immunogenetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Paul W. Noble
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Barry R. Stripp
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Gregory A. Fishbein
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P. Lynch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M. Sayah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S. Sam Weigt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A. Belperio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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32
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Anti-HLA immunization of patients qualified for lung transplantation – Single center study. Transpl Immunol 2022; 71:101553. [DOI: 10.1016/j.trim.2022.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022]
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Mangiola M, Marrari M, Xu Q, Sanchez PG, Zeevi A. Approaching the sensitized lung patient: risk assessment for donor acceptance. J Thorac Dis 2022; 13:6725-6736. [PMID: 34992848 PMCID: PMC8662510 DOI: 10.21037/jtd-2021-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/14/2021] [Indexed: 12/16/2022]
Abstract
The presence of HLA antibodies is widely recognized as a barrier to solid organ transplantation, and for lung transplant candidates, it has a significant negative impact on both waiting time and waiting list mortality. Although HLA antibodies have been associated with a broad spectrum of allograft damage, precise characterization of these antibodies in allosensitized candidates may enhance their accessibility to transplant. The introduction of Luminex-based single antigen bead (SAB) assays has significantly improved antibody detection sensitivity and specificity, but SAB alone is not sufficient for risk-stratification. Functional characterization of donor-specific antibodies (DSA) is paramount to increase donor accessibility for allosensitized lung candidates. We describe here our approach to evaluate sensitized lung transplant candidates. By employing state-of-the-art technologies to assess histocompatibility and determine physiological properties of circulating HLA antibodies, we can provide our Clinical Team a better risk assessment for lung transplant candidates and facilitate a "road map" to transplant. The cases presented in this paper illustrate the "individualized steps" taken to determine calculated panel reactive antibodies (cPRA), titer and complement-fixing properties of each HLA antibody present in circulation. When a donor is considered, we can better predict the risk associated with potentially crossing HLA antibodies, thereby allowing the Clinical Team to approach allosensitized lung patients with an individualized medicine approach. To facilitate safe access of sensitized lung transplant candidates to potential donors, a synergy between the histocompatibility laboratory and the Clinical Team is essential. Ultimately, donor acceptance is a decision based on several parameters, leading to a risk-stratification unique for each patient.
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Affiliation(s)
| | - Marilyn Marrari
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bansal S, Arjuna A, Perincheri S, Poulson C, Bremner RM, Smith MA, Tokman S, Mohanakumar T. Restrictive allograft syndrome vs bronchiolitis obliterans syndrome: Immunological and molecular characterization of circulating exosomes. J Heart Lung Transplant 2022; 41:24-33. [PMID: 34602310 PMCID: PMC11019888 DOI: 10.1016/j.healun.2021.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/16/2021] [Accepted: 09/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction in lung transplant recipients (LTxRs) has 2 phenotypes: obstructive bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Our goal was to define distinct immunologic markers of exosomes from LTxRs with BOS or RAS. METHODS Plasma was collected from LTxRs with BOS (n = 18), RAS (n = 13), and from stable LTxRs (n = 5). Antibodies to lung self-antigens (SAgs) were determined by ELISA. Exosomes were isolated by ultracentrifugation. Donor specific antibodies to HLA were quantified using Luminex. Exosomes were characterized for lung SAgs, transcription factors, 20S proteasome, HLA class I and II, and polymeric immunoglobulin receptor protein using western blot. Exosome miRNA was analyzed using NanoString. The exosome-induced immune response was determined in mice. RESULTS LTxRs with RAS, but not BOS, had donor specific antibodies at diagnosis. CIITA, NFkB, polymeric immunoglobulin receptor protein, 20S proteasome, HLA-DQ, and HLA-DR were significantly higher in RAS exosomes than in BOS exosomes. RAS plasma had high levels of proinflammatory cytokines and distinct exosomal miRNA. Immunization of C57BL/6 mice with RAS exosomes showed severe inflammation and peribronchial fibrosis, whereas BOS exosomes induced patchy inflammation and fibrosis. CONCLUSION LTxRs with BOS or RAS had exosomes with distinct molecular and immunologic profiles. RAS samples had a higher concentration of proinflammatory factors, HLA class II, lung SAgs, and antibodies to HLA class II molecules, indicating severe allograft injury. Mice immunized with RAS exosomes developed lesions in airways, pleura, interlobular septum, and alveoli, whereas BOS exosomes induced mild to patchy inflammation with lung fibrosis.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sudhir Perincheri
- Department of Pathology and Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christin Poulson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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35
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Aversa M, Martinu T, Patriquin C, Cypel M, Barth D, Ghany R, Ma J, Keshavjee S, Singer LG, Tinckam K. Long-term outcomes of sensitized lung transplant recipients after peri-operative desensitization. Am J Transplant 2021; 21:3444-3448. [PMID: 34058795 DOI: 10.1111/ajt.16707] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/07/2021] [Accepted: 05/22/2021] [Indexed: 01/25/2023]
Abstract
The Toronto Lung Transplant Program has been using a peri-operative desensitization regimen of plasma exchange, intravenous immune globulin, and antithymocyte globulin in order to accept donor-specific antibody (DSA)-positive lung transplants safely since 2008. There are no long-term data on the impact of this practice on allograft survival or the development of chronic lung allograft dysfunction (CLAD). We extended our prior study to include long-term follow-up of 340 patients who received lung transplants between January 1, 2008 and December 31, 2011. We compared allograft survival and CLAD-free survival among patients in three cohorts: DSA-positive, panel reactive antibody (PRA)-positive/DSA-negative, and unsensitized at the time of transplant. The median follow-up time in this extension study was 6.7 years. Among DSA-positive, PRA-positive/DSA-negative, and unsensitized patients, the median allograft survival was 8.4, 7.9, and 5.8 years, respectively (p = .5908), and the median CLAD-free survival was 6.8, 7.3, and 5.7 years, respectively (p = .5448). This follow-up study confirms that long-term allograft survival and CLAD-free survival of patients who undergo DSA-positive lung transplants with the use of our protocol do not differ from other lung transplant recipients. Use of protocols such as ours, therefore, may improve access to transplant for sensitized candidates.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Christopher Patriquin
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - David Barth
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada.,Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kathryn Tinckam
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
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36
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Epitope-Level Matching—A Review of the Novel Concept of Eplets in Transplant Histocompatibility. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The development of de novo donor-specific antibodies is related to the poor matching of the human leukocyte antigen (HLA) between donor and recipient, which leads to dismal clinical outcomes and graft loss. However, new approaches that stratify the risks of long-term graft failure in solid organ transplantation have emerged, changing the paradigm of HLA compatibility. In addition, advances in software development have given rise to a new structurally based algorithm known as HLA Matchmaker, which determines compatibility at the epitope rather than the antigen level. Although this technique still has limitations, plenty of research maintains that this assessment represents a more complete and detailed definition of HLA compatibility. This review summarizes recent aspects of eplet mismatches, highlighting the most recent advances and future research directions.
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37
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Courtwright AM, Kamoun M, Diamond JM, Kearns J, Ahya VN, Christie JD, Clausen E, Hadjiliadis D, Patel N, Salgado JC, Cevasco M, Cantu EE, Crespo MM, Bermudez CA. Lung Transplantation Outcomes after Crossing Low-Level Donor Specific Antibodies Without Planned Augmented Immunosuppression. Clin Transplant 2021; 35:e14447. [PMID: 34365656 DOI: 10.1111/ctr.14447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
It is unknown whether some donor specific antibodies (DSA) can be crossed at the time of lung transplant without desensitization or augmented induction immunosuppression. This study assessed whether crossing low-level pre-transplant DSA (defined as mean fluorescence intensity (MFI) 1000-6000) without augmented immunosuppression is associated with worse retransplant-free or chronic lung allograft dysfunction (CLAD)-free survival. Of the 458 included recipients, low-level pre-transplant DSA was crossed in 39 (8.6%) patients. The median follow-up time was 2.2 years. There were 15 (38.5%) patients with Class I DSA and 24 (61.5%) with Class II DSA. There was no difference in adjusted overall retransplant-free survival between recipients where pre-transplant DSA was and was not crossed (HR: 0.98 (95% CI = 0.49-1.99), p = 0.96). There was also no difference in CLAD-free survival (HR: 0.71 (95% CI = 0.38-1.33), p = 0.28). There was no difference in Grade 3 PGD at 72 hours (OR: 1.13 (95% CI = 0.52-2.48), p = 0.75) or definite or probable AMR (HR: 2.22 (95% CI = 0.64-7.61), p = 0.21). Lung transplantation in the presence of low-level DSA without planned augmented immunosuppression is not associated with worse overall or CLAD-free survival among recipients with intermediate-term follow-up. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jane Kearns
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Vivek N Ahya
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Emily Clausen
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Denis Hadjiliadis
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Juan C Salgado
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Edward E Cantu
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Maria M Crespo
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
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38
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Narula T, Khouzam S, Alvarez F, Erasmus D, Li Z, Abdelmoneim Y, Elrefaei M. Antithymocyte globulin is associated with a lower incidence of de novo donor-specific antibody detection in lung transplant recipients: A single-center experience. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1418-1427. [PMID: 34310850 PMCID: PMC8589359 DOI: 10.1002/iid3.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022]
Abstract
Purpose Induction immunosuppression has improved the long‐term outcomes after lung transplant. This is the first report exploring the association of induction immunosuppression with the development of de novo donor‐specific human leukocyte antigen (HLA) antibodies (DSA) in lung transplant recipients (LTR). Methods Sixty‐seven consecutive primary LTR were followed for 3 years posttransplant. A total of 41/67 (61%) LTR‐received induction immunosuppression using a single dose of rabbit Antithymocyte Globulin (rATG; 1.5 mg/kg) within 24 h of transplant. All recipients had a negative flow cytometry crossmatch on the day of transplant. Serum samples at 1, 3, 6, and 12 months posttransplant were assessed for the presence of de novo HLA DSA. Results De novo HLA DSA were detected in 22/67 (32.8%) LTR within 1‐year posttransplant. Of these, 9/41 (21.9%) occurred in the induction therapy group and 13/26 (50%) in the noninduction group. Class II DSA were detected in 3/41 (7.3%) LTR who received induction compared to 9/26 (34.6%) LTR without induction immunosuppression (p = .005). Differences in overall survival or freedom from chronic lung allograft dysfunction rates between the two groups were not statistically significant. Conclusion Induction immunosuppression utilizing a modified regimen of single‐dose rATG is associated with a significant reduction in de novo DSA production in LTR.
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Affiliation(s)
- Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Samir Khouzam
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco Alvarez
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - David Erasmus
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Zhuo Li
- Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
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39
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Cone BD, Zhang JQ, Sosa RA, Calabrese F, Reed EF, Fishbein GA. Phosphorylated S6 ribosomal protein expression by immunohistochemistry correlates with de novo donor-specific HLA antibodies in lung allograft recipients. J Heart Lung Transplant 2021; 40:1164-1171. [PMID: 34330604 DOI: 10.1016/j.healun.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Per the ISHLT 2016 definition, a C4d-positive lung biopsy is required to meet criteria for definite antibody-mediated rejection (AMR). Unfortunately, C4d has poor sensitivity and specificity, and low inter-rater reliability. Phosphorylated S6 ribosomal protein (p-S6RP) expressed via the mTOR pathway has been shown to be a biomarker of AMR and correlates with donor-specific antibodies (DSA) in heart allografts. However, p-S6RP immunohistochemistry (IHC) in the setting of pulmonary AMR has yet to be evaluated. We sought to determine whether p-S6RP IHC performed on lung biopsies correlates with de novo DSA. METHODS IHC for p-S6RP performed on 26 biopsies from lung transplant recipients with de novo HLA DSA (DSA+) and 28 biopsies from patients with no DSA (DSA-) were evaluated by 3 pathologists who independently scored the degree of alveolar macrophage and pneumocyte staining. Staining in ≥50% of the biopsy as determined by at least 2 pathologists was considered positive. RESULTS Twenty-one (81%) DSA+ biopsies stained positive for p-S6RP in pneumocytes and 21 (81%) in macrophages. Six DSA- biopsies (21%) stained positive for p-S6RP in pneumocytes, 6 (21%) were positive in macrophages. Pneumocyte p-S6RP staining was 81% sensitive and 79% specific for DSA. Macrophage staining showed the same sensitivity and specificity but with lower inter-rater agreement (κ = 0.53 vs 0.68). CONCLUSIONS This study demonstrates a positive relationship between de novo DSA and p-S6RP expression in pneumocytes and macrophages using IHC. p-S6RP is relatively sensitive and specific, and has superior inter-rater reliability compared to C4d.
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Affiliation(s)
- Brian D Cone
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Q Zhang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rebecca A Sosa
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Elaine F Reed
- David Geffen School of Medicine at UCLA, Los Angeles, California
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40
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Hirama T, Singer LG, Brode SK, Marras TK, Husain S. Treatment outcomes of nontuberculous mycobacterial pulmonary disease in lung transplant recipients. Transpl Infect Dis 2021; 23:e13679. [PMID: 34184393 DOI: 10.1111/tid.13679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/02/2021] [Accepted: 06/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Lung transplant (LTX) recipients are at risk miscellaneous infections, among whom the clinical significance of nontuberculous mycobacteria (NTM) is increasingly recognized. Despite anti-mycobacterial therapy becoming standardized worldwide, there is a lack of data on treatment outcomes in LTX recipients who develop NTM-pulmonary disease (PD). We aimed to review the treatment outcomes of NTM-PD among LTX recipients in our center. METHODS Patients who underwent LTX from January 2013 to December 2014 were consecutively enrolled in the retrospective cohort, with follow-up of data retrieved to December 2017. Clinical and radiological improvement and culture conversion after anti-mycobacterial therapy were reviewed in those who developed post-transplant NTM-PD. RESULTS Sixteen of 230 LTX recipients developed post-transplant NTM-PD. Ten of 16 patients with post-transplant NTM-PD were treated with macrolide-containing anti-mycobacterial therapy, leading to clinical improvement in 5/10 (50%), radiological improvement in 5/10 (50%) and culture conversion in 6/10 (60%) patients. CONCLUSION Anti-mycobacterial therapy may relieve pulmonary symptoms and reduce microbial load among individuals with post-transplant NTM-PD.
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Affiliation(s)
- Takashi Hirama
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.,Division of Organ Transplantation, Tohoku University Hospital, Sendai, Japan
| | - Lianne G Singer
- Department of Medicine, University of Toronto, Toronto, Canada.,Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Respirology, University Health Network, Toronto, Canada
| | - Sarah K Brode
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, University Health Network, Toronto, Canada.,Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, Canada
| | - Theodore K Marras
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, University Health Network, Toronto, Canada
| | - Shahid Husain
- Department of Medicine, University of Toronto, Toronto, Canada.,Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Canada
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41
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Young KA, Ali HA, Beermann KJ, Reynolds JM, Snyder LD. Lung Transplantation and the Era of the Sensitized Patient. Front Immunol 2021; 12:689420. [PMID: 34122454 PMCID: PMC8187850 DOI: 10.3389/fimmu.2021.689420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Long term outcomes in lung transplant are limited by the development of chronic lung allograft dysfunction (CLAD). Within the past several decades, antibody-mediated rejection (AMR) has been recognized as a risk factor for CLAD. The presence of HLA antibodies in lung transplant candidates, "sensitized patients" may predispose patients to AMR, CLAD, and higher mortality after transplant. This review will discuss issues surrounding the sensitized patient, including mechanisms of sensitization, implications within lung transplant, and management strategies.
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Affiliation(s)
- Katherine A Young
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Hakim A Ali
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Kristi J Beermann
- Department of Pharmacy, Duke University Hospital, Durham, NC, United States
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
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42
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Abstract
PURPOSE OF REVIEW The development of donor-specific antibodies (DSA) after lung transplantation has been recognized as an important risk factor for poor outcomes over the past 20 years. Recently, this has been a focus of intense research, and the purpose of this review is to summarize our current understanding of humoral responses and important recent findings as well as to identify areas of future research. RECENT FINDINGS Recent studies have identified donor-derived cell-free DNA (ddcfDNA) as an important biomarker associated with antibody-mediated rejection (AMR). Importantly, ddcfDNA levels are noted to be elevated approximately 3 months before the onset of clinical allograft dysfunction, making ddcfDNA a particularly appealing biomarker to predict the onset of AMR. Additional notable recent findings include the identification of an independent association between the isolation of Pseudomonas aeruginosa from respiratory specimens and the development of DSA. This finding provides potential insights into crosstalk between innate and alloimmune responses and identifies a potential therapeutic target to prevent the development of DSA. SUMMARY Progress in the field of humoral responses after lung transplantation has been slow, but ongoing and future research in this area are critically necessary to improve patient outcomes in the future.
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Parquin F, Zuber B, Vallée A, Taupin JL, Cuquemelle E, Malard S, Neuville M, Devaquet J, Le Guen M, Fessler J, Beaumont L, Picard C, Hamid A, Colin de Verdière S, Grenet D, De Miranda S, Glorion M, Sage E, Pricopi C, De Wolf J, Brun AL, Longchampt E, Cerf C, Roux A, Brugière O. A virtual crossmatch-based strategy for perioperative desensitisation in lung transplant recipients with preformed donor-specific antibodies: 3-year outcome. Eur Respir J 2021; 58:13993003.04090-2020. [PMID: 34016620 DOI: 10.1183/13993003.04090-2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/08/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Preformed donor-specific antibodies (DSAs) are associated with worse outcome after lung transplantation (LTx) and migvaht limit access to LTx. A virtual crossmatch (CXM)-based strategy for perioperative desensitisation protocol has been used for immunised LTx candidates since 2012 at Foch hospital. We compared the outcome of desensitised LTx candidates with high DSA mean fluorescence intensity (MFI) and those with low or no preformed DSAs, not desensitised. METHODS For all consecutive LTx recipients (January-2012/March-2018), freedom from CLAD and graft survival were assessed by Kaplan-Meier analysis and Cox multivariate analysis. RESULTS We compared outcomes for desensitised patients with high preformed DSAs (n=39) and those with no (n=216) or low pre-formed DSAs (n=66). The desensitisation protocol decreased the level of immunodominant DSA (class I/II) at 1, 3, and 6 month post-LTx (p<0.001, p<0.01, p<0.001, respectively). Freedom from CLAD and graft survival at 3 years was similar in the desensitised group as a whole and other groups. Nevertheless, incidence of CLAD was higher with persistent high- than cleared high-level (p=0.044) or no DSAs (p=0.014). Conversely, graft survival was better with cleared high DSAs than persistent high-, low-level, and no pre-formed DSAs (p=0.019, p=0.025, and p=0.044, respectively). On multivariate analysis, graft survival was associated with cleared high DSAs (HR: 0.12 [95%CI: 0.02-0.85] versus no DSAs, p=0.035) and CLAD with persistent DSAs (HR: 3.04 [1.02-9.17] versus no preformed DSAs, p=0.048). CONCLUSION The desensitisation protocol in LTx recipients with high preformed DSAs was associated with satisfactory outcome, with cleared high pre-formed DSAs after desensitisation identified as an independent predictor of graft survival.
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Affiliation(s)
- Francois Parquin
- Service de Réanimation médicale, Foch Hospital, Suresnes, France
| | - Benjamin Zuber
- Service de Réanimation médicale, Foch Hospital, Suresnes, France
| | - Alexandre Vallée
- Department of Clinical Research and Innovation, Foch Hospital, Suresnes, France
| | - Jean-Luc Taupin
- Laboratoire d'Immunologie et Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | - Elise Cuquemelle
- Service de Réanimation médicale, Foch Hospital, Suresnes, France
| | - Stéphanie Malard
- Laboratoire d'Immunologie et Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | | | - Jérôme Devaquet
- Service de Réanimation médicale, Foch Hospital, Suresnes, France
| | - Morgan Le Guen
- Service d'Anesthésie-Réanimation, Foch Hospital, Suresnes, France
| | - Julien Fessler
- Service d'Anesthésie-Réanimation, Foch Hospital, Suresnes, France
| | - Laurence Beaumont
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Clément Picard
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Abdulmonem Hamid
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Sylvie Colin de Verdière
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Dominique Grenet
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Sandra De Miranda
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Matthieu Glorion
- Service de Chirurgie Thoracique, Foch Hospital, Suresnes, France
| | - Edouard Sage
- Service de Chirurgie Thoracique, Foch Hospital, Suresnes, France
| | - Ciprian Pricopi
- Service de Chirurgie Thoracique, Foch Hospital, Suresnes, France
| | - Julien De Wolf
- Service de Chirurgie Thoracique, Foch Hospital, Suresnes, France
| | | | | | - Charles Cerf
- Service de Réanimation médicale, Foch Hospital, Suresnes, France
| | - Antoine Roux
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
| | - Olivier Brugière
- Service de Transplantation Pulmonaire et centre de compétence de la Mucoviscidose, Foch Hospital, Suresnes, France
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Suzuki Y, Oishi H, Kanehira M, Matsuda Y, Hirama T, Noda M, Okada Y. Effect of CTLA4-Ig on Obliterative Bronchiolitis in a Mouse Intrapulmonary Tracheal Transplantation Model. Ann Thorac Cardiovasc Surg 2021; 27:355-365. [PMID: 33980752 PMCID: PMC8684841 DOI: 10.5761/atcs.oa.20-00398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: One of the serious problems after lung transplantation is chronic lung allograft dysfunction (CLAD). Most CLAD patients pathologically characterized by obliterative bronchiolitis (OB). Cytotoxic T-lymphocyte-associated antigen 4 (CTLA4)-Ig is a combination protein of the Fc fragment of human IgG1 linked to the extracellular domain of CTLA4. The aim of the study was to examine the effect of CTLA4-Ig therapy on OB using a mouse intrapulmonary tracheal transplantation (IPTT) model. Methods: IPTT was performed between BALB/c (donor) and C57BL/6 (recipient) mice. Abatacept, which is a commercially available form of CTLA4-Ig, was intraperitoneally injected in recipient mice immediately after surgery, on days 7, 14, and 21. The mice in the control group received human IgG. Results: We performed semi-quantitative analysis of graft luminal obliteration at post-transplant day 28. We calculated the obliteration ratio of the lumen of the transplanted trachea in each case. The obliteration ratio was significantly lower in the CTLA4-Ig group than that in the control group (91.2 ± 2.1% vs. 47.8 ± 7.9%, p = 0.0008). Immunofluorescent staining revealed significantly decreased lymphoid neogenesis in the lung. Conclusions: CTLA4-Ig therapy attenuated tracheal obliteration with fibrous tissue in the mouse IPTT model. The attenuation of fibrous obliteration was correlated with the inhibition of lymphoid neogenesis.
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Affiliation(s)
- Yamato Suzuki
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Hisashi Oishi
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Masahiko Kanehira
- Center for Life Science Research, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Yasushi Matsuda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan.,Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Takashi Hirama
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Masafumi Noda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
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Desensitization and management of allograft rejection. Curr Opin Organ Transplant 2021; 26:314-320. [PMID: 33938468 DOI: 10.1097/mot.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) limits the success of lung transplantation. Among the risk factors associated with CLAD, we recognize pretransplant circulating antibodies against the human leukocyte antigens (HLA), acute cellular rejection (ACR) and antibody-mediated rejection (AMR). This review will summarize current data surrounding management of desensitization, ACR, AMR, and CLAD. RECENT FINDINGS Strategies in managing in highly sensitized patients waiting for lung transplant include avoidance of specific HLA antigens and reduction of circulating anti-HLA antibodies at time of transplant. Several multimodal approaches have been studied in the treatment of AMR with a goal to clear circulating donor-specific antibodies (DSAs) and to halt the production of new antibodies. Different immunosuppressive strategies focus on influence of the host immune system, particularly T-cell responses, in order to prevent ACR and the progression of CLAD. SUMMARY The lack of significant evidence and consensus limits to draw conclusion regarding the impact of specific immunosuppressive regimens in the management of HLA antibodies, ACR, and CLAD. Development of novel therapeutic agents and use of multicenter randomized clinical trials will allow to better define patient-specific treatments and improve the length and quality of life of lung transplant recipients.
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Lung microbiota predict chronic rejection in healthy lung transplant recipients: a prospective cohort study. THE LANCET RESPIRATORY MEDICINE 2021; 9:601-612. [PMID: 33460570 DOI: 10.1016/s2213-2600(20)30405-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alterations in the respiratory microbiome are common in chronic lung diseases, correlate with decreased lung function, and have been associated with disease progression. The clinical significance of changes in the respiratory microbiome after lung transplant, specifically those related to development of chronic lung allograft dysfunction (CLAD), are unknown. The aim of this study was to evaluate the effect of lung microbiome characteristics in healthy lung transplant recipients on subsequent CLAD-free survival. METHODS We prospectively studied a cohort of lung transplant recipients at the University of Michigan (Ann Arbor, MI, USA). We analysed characteristics of the respiratory microbiome in acellular bronchoalveolar lavage fluid (BALF) collected from asymptomatic patients during per-protocol surveillance bronchoscopy 1 year after lung transplantation. For our primary endpoint, we evaluated a composite of development of CLAD or death at 500 days after the 1-year surveillance bronchoscopy. Our primary microbiome predictor variables were bacterial DNA burden (total 16S rRNA gene copies per mL of BALF, quantified via droplet digital PCR) and bacterial community composition (determined by bacterial 16S rRNA gene sequencing). Patients' lung function was followed serially at least every 3 months by spirometry, and CLAD was diagnosed according to International Society of Heart and Lung Transplant 2019 guidelines. FINDINGS We analysed BALF from 134 patients, collected during 1-year post-transplant surveillance bronchoscopy between Oct 21, 2005, and Aug 25, 2017. Within 500 days of follow-up from the time of BALF sampling, 24 (18%) patients developed CLAD, five (4%) died before confirmed development of CLAD, and 105 (78%) patients remained CLAD-free with complete follow-up. Lung bacterial burden was predictive of CLAD development or death within 500 days of the surveillance bronchoscopy, after controlling for demographic and clinical factors, including immunosuppression and bacterial culture results, in a multivariable survival model. This relationship was evident when burden was analysed as a continuous variable (per log10 increase in burden, HR 2·49 [95% CI 1·38-4·48], p=0·0024) or by tertiles (middle vs lowest bacterial burden tertile, HR 4·94 [1·25-19·42], p=0·022; and highest vs lowest, HR 10·56 [2·53-44·08], p=0·0012). In patients who developed CLAD or died, composition of the lung bacterial community significantly differed to that in patients who survived and remained CLAD-free (on permutational multivariate analysis of variance, p=0·047 at the taxonomic level of family), although differences in community composition were associated with bacterial burden. No individual bacterial taxa were definitively associated with CLAD development or death. INTERPRETATION Among asymptomatic lung transplant recipients at 1-year post-transplant, increased lung bacterial burden is predictive of chronic rejection and death. The lung microbiome represents an understudied and potentially modifiable risk factor for lung allograft dysfunction. FUNDING US National Institutes of Health, Cystic Fibrosis Foundation, Brian and Mary Campbell and Elizabeth Campbell Carr research gift fund.
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48
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Kayawake H, Chen-Yoshikawa TF, Gochi F, Tanaka S, Yurugi K, Hishida R, Yutaka Y, Yamada Y, Ohsumi A, Hamaji M, Nakajima D, Date H. Postoperative outcomes of lung transplant recipients with preformed donor-specific antibodies. Interact Cardiovasc Thorac Surg 2020; 32:616-624. [PMID: 33351064 DOI: 10.1093/icvts/ivaa311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/19/2020] [Accepted: 10/27/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Few studies have evaluated the outcomes of lung transplantation (LTx) in recipients with preformed donor-specific antibodies (DSAs). This study investigated the postoperative changes in preformed DSAs based on prospectively collected data of DSAs, and the influences of preformed DSAs on postoperative outcomes among LTx recipients. METHODS Between July 2010 and December 2019, 216 recipients underwent LTx (81 living-donor lobar lung transplants and 135 deceased-donor lung transplants). We reviewed 8 cases with preformed DSAs to determine postoperative changes in DSAs and compared postoperative outcomes between recipients with and without DSAs. RESULTS The preoperative mean fluorescence intensity of preformed DSAs ranged from 1141 to 14 695. Two recipients experienced antibody-mediated rejection within 2 weeks after LTx. DSAs disappeared in 7 recipients; however, 1 recipient experienced the relapse of DSAs and died from chronic lung allograft syndrome (CLAD), whereas 1 recipient had persisting DSAs within the study period and died from CLAD. Neither overall survival (OS) nor CLAD-free survival was significantly different between recipients with and without DSAs (P = 0.26 and P = 0.17, respectively). However, both OS and CLAD-free survival were significantly lower in recipients with DSAs against HLA class II than in those without these antibodies {5-year OS: 25.0% [95% confidence interval (CI): 0.9-66.5%] vs 72.1% (95% CI: 63.8-78.9%), P = 0.030 and 5-year CLAD-free survival: 26.7% (95% CI: 1.0-68.6%) vs 73.7% (95% CI: 66.5-79.5%), P = 0.002}. CONCLUSIONS Prognosis in recipients experiencing the relapse of preformed DSAs and those with persisting DSAs may be poor. The recipients with anti-HLA class II preformed DSAs had a significantly worse prognosis.
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Affiliation(s)
- Hidenao Kayawake
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | | | - Fumiaki Gochi
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Kimiko Yurugi
- Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Rie Hishida
- Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate school of Medicine, Kyoto, Japan
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Werlein C, Seidel A, Warnecke G, Gottlieb J, Laenger F, Jonigk D. Lung Transplant Pathology: An Overview on Current Entities and Procedures. Surg Pathol Clin 2020; 13:119-140. [PMID: 32005428 DOI: 10.1016/j.path.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alloimmune reactions are, besides various infections, the major cause for impaired lung allograft function following transplant. Acute cellular rejection is not only a major trigger of acute allograft failure but also contributes to development of chronic lung allograft dysfunction. Analogous to other solid organ transplants, acute antibody-mediated rejection has become a recognized entity in lung transplant pathology. Adequate sensitivity and specificity in the diagnosis of alloimmune reactions in the lung can only be achieved by synoptic analysis of histopathologic, clinical, and radiological findings together with serologic and microbiologic findings.
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Affiliation(s)
- Christopher Werlein
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
| | - Allison Seidel
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Gregor Warnecke
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Jens Gottlieb
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH); Department of Pneumology, OE6210, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Florian Laenger
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
| | - Danny Jonigk
- Institute for Pathology, OE 5110, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)
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50
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Cleary SJ, Kwaan N, Tian JJ, Calabrese DR, Mallavia B, Magnen M, Greenland JR, Urisman A, Singer JP, Hays SR, Kukreja J, Hay AM, Howie HL, Toy P, Lowell CA, Morrell CN, Zimring JC, Looney MR. Complement activation on endothelium initiates antibody-mediated acute lung injury. J Clin Invest 2020; 130:5909-5923. [PMID: 32730229 PMCID: PMC7598054 DOI: 10.1172/jci138136] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022] Open
Abstract
Antibodies targeting human leukocyte antigen (HLA)/major histocompatibility complex (MHC) proteins limit successful transplantation and transfusion, and their presence in blood products can cause lethal transfusion-related acute lung injury (TRALI). It is unclear which cell types are bound by these anti-leukocyte antibodies to initiate an immunologic cascade resulting in lung injury. We therefore conditionally removed MHC class I (MHC I) from likely cellular targets in antibody-mediated lung injury. Only the removal of endothelial MHC I reduced lung injury and mortality, related mechanistically to absent endothelial complement fixation and lung platelet retention. Restoration of endothelial MHC I rendered MHC I-deficient mice susceptible to lung injury. Neutrophil responses, including neutrophil extracellular trap (NET) release, were intact in endothelial MHC I-deficient mice, whereas complement depletion reduced both lung injury and NETs. Human pulmonary endothelial cells showed high HLA class I expression, and posttransfusion complement activation was increased in clinical TRALI. These results indicate that the critical source of antigen for anti-leukocyte antibodies is in fact the endothelium, which reframes our understanding of TRALI as a rapid-onset vasculitis. Inhibition of complement activation may have multiple beneficial effects of reducing endothelial injury, platelet retention, and NET release in conditions where antibodies trigger these pathogenic responses.
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Affiliation(s)
- Simon J. Cleary
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Nicholas Kwaan
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - Daniel R. Calabrese
- Department of Medicine, UCSF, San Francisco, California, USA
- Veterans Affairs Healthcare System, San Francisco, California, USA
| | - Beñat Mallavia
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Mélia Magnen
- Department of Medicine, UCSF, San Francisco, California, USA
| | - John R. Greenland
- Department of Medicine, UCSF, San Francisco, California, USA
- Veterans Affairs Healthcare System, San Francisco, California, USA
| | | | | | - Steven R. Hays
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | - Ariel M. Hay
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Heather L. Howie
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Pearl Toy
- Department of Laboratory Medicine, UCSF, San Francisco, California, USA
| | | | - Craig N. Morrell
- Aab Cardiovascular Research Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - James C. Zimring
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Mark R. Looney
- Department of Medicine, UCSF, San Francisco, California, USA
- Department of Laboratory Medicine, UCSF, San Francisco, California, USA
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