DE-MYSTIFYING THE BLACK BOX OF TRANSPLANT IMMUNOLOGY
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1 2016 DE-MYSTIFYING THE BLACK BOX OF TRANSPLANT IMMUNOLOGY James H Lan, MD, FRCP(C), D(ABHI) Clinical Assistant Professor, University of British Columbia Nephrology & Kidney Transplantation, Vancouver General Hospital October 6, 2016
2 Objectives 1. Basic terminology 2. Mechanisms of sensitization 3. Assays and technologies 4. Updates on antibody- mediated rejection 5. New initiatives
3 Part I. HLA 101
4 Human Leukocyte Antigen (HLA) HLA-C HLA-DR HLA-B HLA-DQ HLA-A HLA-DP Nucleated Cell HLA-A HLA-DP HLA-B HLA-DQ HLA-C HLA-DR HLA Class I HLA Class II 4
5 HLA Nomenclature Resolution Example Cost Low- Resolution B35 $150/locus Intermediate B*35:XTNJ XTNJ= 01/09/11/27/28 $150/locus High- Resolution B*35:01 $300/locus 5
6 HLA Nomenclature Resolution Example Cost Low- Resolution B35 $150/locus Intermediate B*35:XTNJ XTNJ= 01/09/11/27/28 $150/locus High- Resolution B*35:01 $300/locus Homer Simpson Marge Simpson Lisa Simpson Bart Simpson Maggie Simpson 6
7 HLA Nomenclature Resolution Example Cost Low- Resolution B35 $150/locus Intermediate B*35:XTNJ XTNJ= 01/09/11/27/28 $150/locus High- Resolution B*35:01 $300/locus Homer Simpson B*35:01 Marge Simpson B*35:09 Lisa Simpson B*35:11 Bart Simpson B*35:27 Maggie Simpson B*35:28 7
8 HLA Nomenclature Resolution Example Cost Low- Resolution B35 $150/locus Intermediate B*35:XTNJ XTNJ= 01/09/11/27/28 $150/locus High- Resolution B*35:01 $300/locus Homer Simpson B*35:01 Marge Simpson B*35:09 Lisa Simpson B*35:11 Bart Simpson B*35:27 Maggie Simpson B*35:28 8
9
10 Part II. HLA Incompatibility and Mechanisms of Allo-sensitization
11 HLA Incompatibility 11
12 Pathogenicity of anti-hla antibodies Wiebe et al, AJT,
13 How does one become sensitized to produce anti- HLA antibodies? 13
14 Effect of Blood Transfusion Leffell et al, Transplantation
15 Effect of Blood Transfusion Leffell et al, Transplantation
16 Effect of Blood Transfusion Leffell et al, Transplantation
17 Effect of Blood Transfusion Leffell et al, Transplantation
18 Effect of Blood Transfusion Leffell et al, Transplantation
19 Effect of Pregnancy Triulzi et al, Transfusion
20 Effect of Transplantation 45% 81% 19% 55% Scornik et al, Human Immunology,
21 Part II. Methods of Antibody Detection 1. Complement- dependent cytotoxicity (CDC) 2. Flow cytometric crossmatch 3. Single- antigen bead (SAB) assay
22 Famous Twins
23
24 First successful kidney transplant December 23, 1954, Brigham and Women s Hospital
25 Dismal early outcomes Murray, Annals of Surgery, 1976
26 How to Overcome Hyperacute Rejection?
27 Antibody detection: CDC crossmatch
28 Antibody detection: CDC crossmatch CDC Positive CDC Negative No rejection Rejection 24 (80%) * 8 (4%) * p < 0.001
29 Antibody detection: flow crossmatch Patient Serum Anti-IgG-FITC A2 B8 A1 A2 A1 Donor Cell B27 B27 B8 A2 29
30 Antibody detection: flow crossmatch Patient Serum Anti-IgG-FITC A2 B8 A1 A2 A1 Donor Cell B27 B27 B8 A2 30
31 Antibody detection: flow crossmatch Patient Serum Anti-IgG-FITC A2 B8 A1 A2 A1 B8 Donor Cell B27 B27 HLA Antibody A2 31
32 Antibody detection: single antigen bead A1 A1 A1 SAB A1 A1 A1 A1 32
33 Antibody detection: single antigen bead 33
34 Question: What does it mean when a patient is highly sensitized? What is cpra? 34
35 35
36 Level of sensitization determined by cpra 36
37 Antigen frequency matters B71 Patient 1: Antibody: B71 cpra = 1/100 = 1% 37
38 Antigen frequency matters A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 Patient 2: Antibody: A2 cpra = 50/100 = 50% 38
39 Highly sensitized patients (HSP) Patient 3: cpra = 99/100 = 99% 39
40 How can someone make so many antibodies MR. C
41 Antibodies recognize epitopes DRB1*0301 (DR17) 81HV 85VV 96HK 98KS 104SK 120S DRB1*0801 (DR8) 81HV 85VG 96HK 98KS 104SK 120S DRB1*1101 (DR11) 81HV 85VG 96HK 98KS 104SK 120S DRB1*0302 (DR18) 81HV 85VG 96HK 98KS 104SK 120S DRB1*1401 (DR14) 81HV 85VV 96HK 98KS 104SK 120S
42 Antibodies recognize epitopes Patient 3: cpra = 99/100 = 99% 42
43 Antibodies recognize epitopes Patient 3: cpra = 99/100 = 99% 43
44 A solution for the HSP patients 44
45 Virtual crossmatch Compatible? Donor: Vancouver Recipient: Toronto Donor Typing A 2 26 B C 7 1 DR 17 1 DQ
46 Dangerous business: it takes team work Day 0 Sensitizing event Flow XM Day 700 Antibody Testing (SAB) Ab Testing Organ Offer No Abs 46
47 Part IV. Building provincial consensus in the diagnosis & treatment of AMR
48 AMR is a heterogeneous disease Wiebe, AJT,
49 Revised Banff 2013 Criteria Histology: Acute/Active AMR 1. Microvascular capillaries: (g or ptc) 2. Arteritis 3. Thrombotic microangiopathy 4. ATN- unknown cause Chronic/Active AMR 1. Transplant glomerulopathy (cg) 2. Peritubular basement membrane duplication (need EM) 3. Arterial intimal fibrosis Serology: Interaction: Donor- specific antibodies (HLA, AT1R- Ab, MICA) C4d Moderate microvascular inflammation (g+ptc >= 2) Endothelial cell gene transcripts 49
50 Building provincial consensus in the treatment of AMR AMR I Recognition of clinical need to standardize treatment AMR II Review evidence for acute AMR treatment AMR III Finalize acute AMR treatment protocol AMR IV Treatment endpoints and failure 50
51 Acute AMR treatment protocol
52 IVIG side effects Adverse Events: 1. Acute kidney injury 2. Infusion- related: headache, N, V, back pain, fever, tachycardia 3. Aseptic meningitis (1-10%) 4. Thrombosis 5. RBC hemolysis 6. Anaphylaxis (IgA deficiency) 52
53 AKI with IVIG Adverse Effects of IVIg 175 Table 1 Demographic and Clinical Data on Reported Cases of Renal Failure Following IVIg Therapy Published case reports FDA report FRPC report (N = 87) (N = 88) (N = 49) Age median (range) 64.2 (20 90) 62.5 (3 91) 67 (22 92) Male/female ratio 49/38 (56%) 48/40 (55%) 30/19 (61%) Indications for use Hematological 46 (53%) 39 (44%) 29 (59%) Immunological 20 (23%) 20 (23%) 6 (12%) Neurological 14 (16%) 17 (19%) 13 (27%) Infectious diseases 7 ( 8%) 9 (11%) 0 Not reported 3 (3%) 1 (2%) Preexisting renal disease 40/87 (46%) 14/54 (26%) 21/45 (47%) Sucrose-containing products 64/87 (74%) 79/88 (90%) 44 (90%) Maltose/glucose products 14/86 (16%) 7/88 (8%) 1/49 (2%) Undetermined stabilizer 7/86 ( 8%) 2/88 (2%) 4/49 (8%) Acute hemodialysis 28/87 (32%) 35/88 (40%) 17/49 (34%) Deaths 8/87 (9%) 13/88 (15%) 4/49 (8%) FRPC, French Regional Pharmacovigilance Center. Orbach, Clinical Reviews in Allergy and Immunology,
54 How to avoid IVIG-related side effects 1. Slow infusion: 2-3 mg/kg/min 2. Premedicate: benadry (loratidine), acetaminophen 3. Adequate hydration 4. Avoid large doses (< 1 g/kg/day) 5. Avoid high osmolarity products 6. Avoid sucrose- based products 54
55 Different preparations of IVIG 55
56 B cell maturation 56
57 Peripheral B cell depletion with rituximab Cells/microL peripheral blood CD19+ cells CD20+ cells Healthy controls Day 0 Day1 to 3 Week 1 to 2 Week 3 to 6 Week 6 to 10 Month 3 to 5 Month 6 to 7 Month 8 to 10 Month 11 to 13 Month 14 to 16 Month 17 to 20 Month 22 to 26 Month 28 to 31 Month 34 to 43 Time in relation to rituximab treatment Genberg, AJT,
58 Timing of PLEX with rituximab dosing Percentage of rituximab extracted during plasmapheresis (%) 70% 60% 50% 40% 30% 20% 10% y = 0380e x r = % Time interval between rituximab infusion and first plasmapheresis (h) PLEX Timing in AUC 24 hr 48 hr 72 hr 26% 20% 16% Puisset, Br J Clin Pharmacol,
59 Acute AMR treatment protocol
60 Chronic active antibody- mediated rejection 60
61 AMR is a heterogeneous disease Wiebe, AJT,
62 AMR is a heterogeneous disease 62
63 Part V. New study to examine the impact of immunosuppression reduction
64 Immunosuppression Reduction and the Risk of De Novo Donor-Specific Antibody Formation After Kidney Transplantation Primary Investigator: James Lan, MD, Transplant Nephrologist Co-PI: Jagbir Gill, MD, Transplant Nephrologist Paul Keown, MD, HLA Laboratory Director John Gill, MD, Transplant Nephrologist Olwyn Johnston, MD, Transplant Nephrologist Mei Lin Bissonnette, MD, Renal Pathologist Alissa Wright, MD, Infectious Diseases Caren Rose, MD, Biostatistician
65 Physician driven immunosuppression reduction? 65
66 Side effects of immunosuppression Physician prescribed immunosuppression reduction: 1. Gastrointestinal side effects 2. Neutropenia (low white blood cell count) 3. Infection (BK virus, CMV) 4. Malignancy 66
67 Prevalence of immunosuppression reduction Proportion of patients on reduced dose MPA BCT Annual Data Report
68 TRFBC study cohort PROOF (Prevention of Organ Failure) Cohort N = 600 kidney transplant recipients Enrolled Median follow-up of 4 years Clinical data extracted from PROMIS (electronic medical record database) Biopsy data extracted from Pathology Database Patient s serum prospectively collected and stored at: 1, 2, 3, 4, 8, 12 weeks, 6, 9, 12 months, then annually posttransplant 68
69 Establishing a provincial biorepository Histopathology Clinical Data Immunology 69
70 THANK YOU Questions?
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