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Ludwig EK, Abraham N, Schaaf CR, McKinney CA, Freund J, Stewart AS, Veerasammy BA, Thomas M, Cardona DM, Garman K, Barbas AS, Sudan DL, Gonzalez LM. Comparison of the effects of normothermic machine perfusion and cold storage preservation on porcine intestinal allograft regenerative potential and viability. Am J Transplant 2024; 24:564-576. [PMID: 37918482 PMCID: PMC11082874 DOI: 10.1016/j.ajt.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Abstract
Intestinal transplantation (IT) is the final treatment option for intestinal failure. Static cold storage (CS) is the standard preservation method used for intestinal allografts. However, CS and subsequent transplantation induce ischemia-reperfusion injury (IRI). Severe IRI impairs epithelial barrier function, including loss of intestinal stem cells (ISC), critical to epithelial regeneration. Normothermic machine perfusion (NMP) preservation of kidney and liver allografts minimizes CS-associated IRI; however, it has not been used clinically for IT. We hypothesized that intestine NMP would induce less epithelial injury and better protect the intestine's regenerative ability when compared with CS. Full-length porcine jejunum and ileum were procured, stored at 4 °C, or perfused at 34 °C for 6 hours (T6), and transplanted. Histology was assessed following procurement (T0), T6, and 1 hour after reperfusion. Real-time quantitative reverse transcription polymerase chain reaction, immunofluorescence, and crypt culture measured ISC viability and proliferative potential. A greater number of NMP-preserved intestine recipients survived posttransplant, which correlated with significantly decreased tissue injury following 1-hour reperfusion in NMP compared with CS samples. Additionally, ISC gene expression, spheroid area, and cellular proliferation were significantly increased in NMP-T6 compared with CS-T6 intestine. NMP appears to reduce IRI and improve graft regeneration with improved ISC viability and proliferation.
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Affiliation(s)
- Elsa K Ludwig
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Nader Abraham
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cecilia R Schaaf
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Caroline A McKinney
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - John Freund
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Amy S Stewart
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Brittany A Veerasammy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Mallory Thomas
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Diana M Cardona
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine Garman
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Debra L Sudan
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Liara M Gonzalez
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA.
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2
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Vianna R, Gaynor JJ, Selvaggi G, Farag A, Garcia J, Tekin A, Tabbara MM, Ciancio G. Liver Inclusion Appears to Be Protective Against Graft Loss-Due-to Chronic But Not Acute Rejection Following Intestinal Transplantation. Transpl Int 2023; 36:11568. [PMID: 37779512 PMCID: PMC10538304 DOI: 10.3389/ti.2023.11568] [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: 05/11/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
In intestinal transplantation, while other centers have shown that liver-including allografts have significantly more favorable graft survival and graft loss-due-to chronic rejection (CHR) rates, our center has consistently shown that modified multivisceral (MMV) and full multivisceral (MV) allografts have significantly more favorable acute cellular rejection (ACR) and severe ACR rates compared with isolated intestine (I) and liver-intestine (LI) allografts. In the attempt to resolve this apparent discrepancy, we performed stepwise Cox multivariable analyses of the hazard rates of developing graft loss-due-to acute rejection (AR) vs. CHR among 350 consecutive intestinal transplants at our center with long-term follow-up (median: 13.5 years post-transplant). Observed percentages developing graft loss-due-to AR and CHR were 14.3% (50/350) and 6.6% (23/350), respectively. Only one baseline variable was selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to AR: Transplant Type MMV or MV (p < 0.000001). Conversely, two baseline variables were selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to CHR: Received Donor Liver (LI or MV) (p = 0.002) and Received Induction (p = 0.007). In summary, while MMV/MV transplants (who receive extensive native lymphoid tissue removal) offered protection against graft loss-due-to AR, liver-containing grafts appeared to offer protection against graft loss-due-to CHR, supporting the results of other studies.
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Affiliation(s)
- Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jeffrey J. Gaynor
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ahmed Farag
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
- Department of Surgery, Zagazig University School of Medicine, Zagazig, Egypt
| | - Jennifer Garcia
- Department of Pediatrics, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
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3
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Yue C, Wu X, Mo Z, Yang Q, Wang W, Zhou H, Gao R, Liang J, Yu P, Zhang Y, Ji G, Li X. Multidrug-resistant Klebsiella Pneumoniae Infection Led to Resection of the Graft in a Small Bowel Transplant Recipient: A Case Report and Review of the Literature. Transplant Proc 2023:S0041-1345(23)00254-3. [PMID: 37225551 DOI: 10.1016/j.transproceed.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Infection due to multidrug-resistant Klebsiella pneumoniae is a common cause of graft resection after small bowel transplantation. We report a failed case in which the intestinal graft was resected 18 days after the operation due to postoperative infection with multidrug-resistant K pneumoniae and a literature review of other common causes of small bowel transplantation failure have been reported. METHODS A female, 29 years of age, underwent partial living small bowel transplantation for short bowel syndrome. After the operation, the patient was infected with multidrug-resistant K pneumoniae, even though various anti-infective regimens were employed. It further developed into sepsis and disseminated into intravascular coagulation, leading to exfoliation and necrosis of the intestinal mucosa. Finally, the intestinal graft had to be resected to save the patient's life. RESULTS Multidrug-resistant K pneumoniae infection often affects the biological function of intestinal grafts and can even lead to necrosis. Other common causes of failure, including postoperative infection, rejection, post-transplantation lymphoproliferative disorder, graft-vs-host disease, surgical complications, and other related diseases, were also discussed throughout the literature review. CONCLUSIONS Pathogenesis due to diverse and interrelated factors makes the survival of intestinal allografts a great challenge. Therefore, only by fully understanding and mastering the common causes of surgical failure can the success rate of small bowel transplantation be effectively improved.
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Affiliation(s)
- Chao Yue
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Xiao Wu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Zhenchang Mo
- Department of Oncology, Affiliated Hospital, Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Qinchuan Yang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Weidong Wang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Haikun Zhou
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ruiqi Gao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Jiayi Liang
- Department of Pathology, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Pengfei Yu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ying Zhang
- Department of Radiotherapy, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Xiaohua Li
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
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4
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Abstract
PURPOSE OF REVIEW The role of intestinal transplant has expanded in recent years and is no longer only considered for patients with no other options remaining. 5 year survival in high-volume centres is over 80% for certain graft types. The aim of this review is to update the audience on the current state of intestinal transplant, with a focus on recent medical and surgical advances. RECENT FINDINGS There has been a greater understanding of the interplay and balance of host and graft immune responses, which may facilitate individualized immunosuppression. Some centres are now performing 'no-stoma' transplants, with preliminary data showing no adverse effects from this strategy and other surgical advances have lessened the physiological insult of the transplant operation. Earlier referrals are encouraged by transplant centres, such that vascular access or liver disease has not progressed too much to increase the technical and physiological challenge of the procedure. SUMMARY Clinicians should consider intestinal transplant as a viable option for patients with intestinal failure, benign unresectable abdominal tumours or acute abdominal catastrophes.
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Affiliation(s)
| | - Neil K Russell
- Department of Transplant Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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5
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Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [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: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.
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Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
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6
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Moris D, Cendales LC. Sensitization and Desensitization in Vascularized Composite Allotransplantation. Front Immunol 2021; 12:682180. [PMID: 34456906 PMCID: PMC8385557 DOI: 10.3389/fimmu.2021.682180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/27/2021] [Indexed: 01/02/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is a field under research and has emerged as an alternative option for the repair of severe disfiguring defects that result from severe tissue loss in a selected group of patients. Lifelong immunosuppressive therapy, immunosuppression associated complications, and the effects of the host immune response in the graft are major concerns in this type of quality-of-life transplant. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury-related factors, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibody (DSA) formation and graft rejection in the context of VCA still remain poorly understood. The most common antigenic target of preexisting alloantibodies are MHC mismatches, though recognition of ABO incompatible antigens, minor histocompatibility complexes and endothelial cells has also been shown to contribute to rejection. Mechanistically, alloantibody-mediated tissue damage occurs primarily through complement fixation as well as through antibody-dependent cellular toxicity. If DSA exist, activation of complement and coagulation cascades can result in vascular thrombosis and infarction and thus rejection and graft loss. Both preexisting DSA but especially de-novo DSA are currently considered as main contributors to late allograft injury and graft failure. Desensitization protocols are currently being developed for VCA, mainly including removal of alloantibodies whereas treatment of established antibody-mediated rejection is achieved through high dose intravenous immunoglobulins. The long-term efficacy of such therapies in sensitized VCA recipients is currently unknown. The current evidence base for sensitizing events and outcomes in reconstructive transplantation is limited. However, current data show that VCA transplantation has been performed in the setting of HLA-sensitization.
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Affiliation(s)
| | - Linda C. Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
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7
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Chan AP, Guerra MAR, Rossetti M, Hickey MJ, Venick RS, Marcus EA, McDiarmid SV, Farmer DG, Reed EF, Wozniak LJ. Non-HLA AT1R antibodies are highly prevalent after pediatric intestinal transplantation. Pediatr Transplant 2021; 25:e13987. [PMID: 33590644 PMCID: PMC8058288 DOI: 10.1111/petr.13987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 12/16/2022]
Abstract
The role of angiotensin II type-1 receptor (AT1R) antibodies in intestinal transplantation (ITx) is unclear. The aims were 1) to identify the prevalence of AT1R antibodies in pediatric ITx, compared to pediatric intestinal failure (IF), and 2) to determine whether AT1R antibodies were associated with graft dysfunction. 46 serum samples from 25 ITx patients (3 isolated ITx, 22 liver-inclusive ITx) were collected during routine visits >6 months apart and during episodes of graft dysfunction as a result of infectious enteritis or rejection. For comparison, samples were collected from 7 IF control patients. AT1R antibodies were considered positive for levels >17 U/mL. The median (range) AT1R antibody level for ITx patients was 40.0 U/mL (7.2-40.0), compared to 7.0 U/mL (5.7-40.0) for IF patients (p = .02). There was a trend toward higher prevalence of AT1R antibodies in ITx compared with IF patients (68% versus 29%, p = .09). Among ITx patients, the prevalence of AT1R antibodies was not different between periods of active graft dysfunction and normal health (83% versus 67%, p = .31). For 16 patients with >2 samples, AT1R antibodies remained positive in 67% cases, developed in 14% cases, disappeared in 10% cases, and remained negative in 10% cases. The changes in AT1R antibodies did not correlate with de/sensitizing events. This is the first study of AT1R antibodies in pediatric ITx. AT1R antibodies are highly prevalent after ITx and may be triggered by immune activation associated with the transplant. However, their pathogenicity and clinical utility remain in question.
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Affiliation(s)
- Alvin P Chan
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Marjorie-Anne R Guerra
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Michelle J Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Robert S Venick
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Elizabeth A Marcus
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA,VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Suzanne V McDiarmid
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Douglas G Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Laura J Wozniak
- Pediatric Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital and David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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8
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Smith J, Godfrey E, Bowden D, Hickman K, Sharkey L, Butler A, Upponi S. Imaging of intestinal transplantation. Clin Radiol 2019; 74:613-622. [DOI: 10.1016/j.crad.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
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9
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Stobutzki N, Schlickeiser S, Streitz M, Stanko K, Truong KL, Akyuez L, Vogt K, Appelt C, Pascher A, Blau O, Gerlach UA, Sawitzki B. Long-Term Signs of T Cell and Myeloid Cell Activation After Intestinal Transplantation With Cellular Rejections Contributing to Further Increase of CD16 + Cell Subsets. Front Immunol 2019; 10:866. [PMID: 31134051 PMCID: PMC6514047 DOI: 10.3389/fimmu.2019.00866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 04/04/2019] [Indexed: 02/06/2023] Open
Abstract
The intestine mediates a delicate balance between tolerogenic and inflammatory immune responses. The continuous pathogen encounter might also augment immune cell responses contributing to complications observed upon intestinal transplantation (ITx). We thus hypothesized that ITx patients show persistent signs of immune cell activation affecting both the adaptive and innate immune cell compartment. Information on the impact of intestinal grafts on immune cell composition, however, especially in the long-term is sparse. We here assessed activated and differentiated adaptive and innate immune subsets according to time, previous experience of cellular or antibody-mediated rejections or type of transplant after ITx applying multi-parametric flow cytometry, gene expression, serum cytokine and chemokine profiling. ITx patients showed an increase in CD16 expressing monocytes and myeloid dendritic cells (DCs) compared to healthy controls. This was even detectable in patients who were transplanted more than 10 years ago. Also, conventional CD4+ and CD8+ T cells showed persistent signs of activation counterbalanced by increased activated CCR4+ regulatory T cells. Patients with previous cellular rejections had even higher proportions of CD16+ monocytes and DCs, whereas transplanting higher donor mass with multi-visceral grafts was associated with increased T cell activation. The persistent inflammation and innate immune cell activation might contribute to unsatisfactory results after ITx.
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Affiliation(s)
- Nadja Stobutzki
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Stephan Schlickeiser
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mathias Streitz
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Katarina Stanko
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kim-Long Truong
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Levent Akyuez
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Katrin Vogt
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christine Appelt
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Andreas Pascher
- Department of Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Olga Blau
- Department for Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Undine A Gerlach
- Department of Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Birgit Sawitzki
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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10
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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11
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Rabant M, Racapé M, Petit LM, Taupin JL, Aubert O, Bruneau J, Barbet P, Goulet O, Chardot C, Suberbielle C, Lacaille F, Canioni D, Duong Van Huyen JP. Antibody-mediated rejection in pediatric small bowel transplantation: Capillaritis is a major determinant of C4d positivity in intestinal transplant biopsies. Am J Transplant 2018; 18:2250-2260. [PMID: 29397036 DOI: 10.1111/ajt.14685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/21/2017] [Accepted: 01/24/2018] [Indexed: 01/25/2023]
Abstract
The diagnostic criteria for antibody-mediated rejection (ABMR) after small bowel transplantation (SBT) are not clearly defined, although the presence of donor-specific antibodies (DSAs) has been reported to be deleterious for graft survival. We aimed to determine the incidence and prognostic value of DSAs and C4d in pediatric SBT and to identify the histopathologic features associated with C4d positivity. We studied all intestinal biopsies (IBx) obtained in the first year posttransplantation (N = 345) in a prospective cohort of 23 children. DSAs and their capacity to fix C1q were identified by using Luminex technology. Eighteen patients (78%) had DSAs, and 9 had the capacity to fix C1q. Seventy-eight IBx (22.6%) were C4d positive. The independent determinants of C4d positivity were capillaritis grades 2 and 3 (odds ratio [OR] 4.02, P = .047 and OR 5.17, P = .003, respectively), mucosal erosion/ulceration (OR 2.8, P = .019), lamina propria inflammation grades 1 and 2/3 (OR 1.95, P = .043 and OR 3.1, P = .016, respectively), and chorion edema (OR 2.16, P = .028). Complement-fixing DSAs and repeated C4d-positive IBx were associated with poor outcome (P = .021 and P = .001, respectively). Our results support that capillaritis should be considered as a feature of ABMR in SBT and identify C1q-fixing DSAs and repeated C4d positivity as potential markers of poor outcome.
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Affiliation(s)
- Marion Rabant
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U1151, Hôpital Necker, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Maud Racapé
- Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
| | - Laetitia-Marie Petit
- Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean Luc Taupin
- Immunology and histocompatibility laboratory, Saint Louis Hospital, Paris, France
| | - Olivier Aubert
- Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
| | - Julie Bruneau
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Patrick Barbet
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Olivier Goulet
- Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Chardot
- Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Pediatric Surgery Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Suberbielle
- Immunology and histocompatibility laboratory, Saint Louis Hospital, Paris, France
| | - Florence Lacaille
- Pediatric Gastroenterology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Danielle Canioni
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Pathology Department, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris V Descartes University, Sorbonne-Paris-Cité, Paris, France.,Paris Translational Research for Organ Transplant INSERM U 970, PARCC, HEGP, Paris, France
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Small-for-size Syndrome Does Not Occur in Intestinal Transplantation Without Liver Containing Grafts. Transplantation 2018; 102:1300-1306. [PMID: 29485511 DOI: 10.1097/tp.0000000000002145] [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
BACKGROUND The ideal donor in intestinal transplantation (ITX) is generally considered to be 50% to 70% of recipient body weight. This may be due to concerns for "small for size" syndrome as seen in liver transplantation. We report our experience using smaller donors (donor-recipient weight ratio [DRWR], < 50%) in ITX recipients. METHODS We studied a group of ITX recipients with DRWR of 50% or less to unmatched controls who received intestinal allografts with DRWR greater than 50%. We examined patient and graft survival and enteral autonomy from parenteral nutrition as surrogate markers for safety of using smaller donors and ease of abdominal wall closure between groups to determine the value. RESULTS There was no difference in overall patient and graft survival, time to enteral autonomy from parenteral nutrition, and weight gain after ITX over time between groups. The need for complicated abdominal closure techniques was significantly more frequent in the control group than in the study group (34.6% vs 6.9%, P = 0.01). Secondary abdominal closure occurred more frequently in the control group (15.4% vs 0%, P = 0.014). Wound revisions also occurred more frequently in the control group (15.4% vs 0%, P = 0.028). CONCLUSIONS Our data suggest that ITX using smaller donors (DRWR ≤ 50%) seems to be an acceptable practice without adverse impact on surgical complications, nutritional autonomy, and patient and graft survival. Abdominal wall closure seems easier in recipients of smaller donors and "small for size" syndrome as described in liver transplantation does not occur with intestinal allografts.
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13
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Wu G, Cruz RJ. Liver-inclusive intestinal transplantation results in decreased alloimmune-mediated rejection but increased infection. Gastroenterol Rep (Oxf) 2017; 6:29-37. [PMID: 29479440 PMCID: PMC5806397 DOI: 10.1093/gastro/gox043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
Background and aims A co-transplanted liver allograft has been thought to protect other organs from rejection-mediated injury; however, detailed analyses of co-transplanted liver on intestinal allograft outcomes have not been conducted to date. The aim of the study was to compare immune-mediated injury, causes of graft failure and clinical outcomes between recipients who underwent either a liver-inclusive intestinal transplant (LITx) or liver-exclusive intestinal transplant (LETx). Methods Between May 2000 and May 2010, 212 adult patients undergoing LITx (n =76) and LETx (n =136) were included. LITx underwent either liver combined intestinal or full multivisceral transplantation. LETx underwent either isolated intestinal or modified multivisceral transplantation. Results During 44.9 ± 31.4 months of follow-up, death-censored intestinal graft survival was significantly higher for LITx than LETx (96.9%, 93.2% and 89.9% vs 91.4%, 69.3% and 60.0% at 1, 3 and 5 years; p =0.0001). Incidence of graft loss due to rejection was higher in LETx than in LITx (30.9% vs 6.6%; p <0.0001), while infection was the leading cause of graft loss due to patient death in LITx (25.0% vs 5.1%; p <0.0001). Despite similar immunosuppression, the average number (0.87 vs 1.42, p =0.02) and severity of acute cellular rejection episode (severe grade: 7.9% vs 21.3%; p =0.01) were lower in LITx than in LETx. Incidence of acute antibody-mediated rejection was also significantly lower in LITx than in LETx (3.6% vs 15.2%; p =0.03). Incidence of chronic rejection was reduced in LITx (3.9% vs 24.3%; p =0.0002). Conclusions Intestinal allografts with a liver component appear to decrease risk of rejection but increase risk of infection. Our findings emphasize that LITx has characteristic immunologic and clinical features. Lower immunosuppression may need to be considered for patients who undergo LITx to attenuate increased risk of infection.
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Affiliation(s)
- Guosheng Wu
- Department of Gastrointestinal Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shannxi, China
| | - Ruy J Cruz
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Valenzuela NM, Reed EF. Antibody-mediated rejection across solid organ transplants: manifestations, mechanisms, and therapies. J Clin Invest 2017; 127:2492-2504. [PMID: 28604384 DOI: 10.1172/jci90597] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Solid organ transplantation is a curative therapy for hundreds of thousands of patients with end-stage organ failure. However, long-term outcomes have not improved, and nearly half of transplant recipients will lose their allografts by 10 years after transplant. One of the major challenges facing clinical transplantation is antibody-mediated rejection (AMR) caused by anti-donor HLA antibodies. AMR is highly associated with graft loss, but unfortunately there are few efficacious therapies to prevent and reverse AMR. This Review describes the clinical and histological manifestations of AMR, and discusses the immunopathological mechanisms contributing to antibody-mediated allograft injury as well as current and emerging therapies.
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