The multidisciplinary approach to AMR in lung transplantation: Reaching a consensus. Deborah Jo Levine Professor of Medicine University of Texas
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1 The multidisciplinary approach to AMR in lung transplantation: Reaching a consensus Deborah Jo Levine Professor of Medicine University of Texas
2 Disclosures I have no financial relations with any relevant commercial interests I will discuss the off-label use of multiple treatments for pulmonary AMR
3 2 Lung Transplant Recipients Ms. 1 Age: 62 years History: COPD 4 years post bilateral lung transplant CMV mismatch No PGD PRA: 10%/No DSA Ms. 2 Age: 62 years History: COPD 2 years post bilateral lung transplant CMV mismatch No PGD PRA: 0%/No DSA
4 Question Do either or both of these patients have AMR? 1. Neither 2. Ms Ms Both
5 In your experience, what is the definition of pulmonary AMR? Other (responses below) 11 Not sure 15 Positive C4d staining of biopsy 9 DSA + pathologic changes + decreased PFTs 81 Decreased PFT + pathologic changes 50 DSA + pathologic changes 37 DSA + decreased PFTs + pathologic changes DSA + path changes Positive C4d + path changes + DSA + decreased PFT 99 Positive C4d + pathologic changes + DSA 38 Positive C4d staining + DSA Positive C4d + pathologic changes Pathologic changes alone Positive DSA
6 Why are these two patients with DSA experiencing such a dramatically different clinical course? Donor factors Recipient factors Co-exisiting factors Antibody type and characteristics
7 Multifactorial? Recipient Donor Antibody type and characteristics Co-exisiting factors
8 Lung Transplantation (LT) continues to be the best therapy for end-stage lung disease for which other medical or surgical therapy is not available.
9 Survival (%) Adult Lung Transplants Survival by Era (Transplants: January 1990 June 2013) (N=9,783) (N=21,593) /2013 (N=16,006) Median survival (years): : 4.2; Conditional= : 6.0; Conditional= /2013: NA; Conditional=NA 60 N at risk = 2,065 All pair-wise comparisons were significant at p <0.001 except vs /2013 (p=0.1211) N at risk = 252 N at risk = Years 2015 JHLT Oct; 34(10): 33(10):
10 % of Deaths Adult Lung Transplants Relative Incidence of Leading Causes of Death (Deaths: January 1990 June 2014) Bronchiolitis Malignancy (non-lymph/ptld) Infection (non-cmv) Graft Failure Cardiovascular CLAD Days (N=253) 31 Days - 1 Yr (N=334) >1 Yr - 3 Yrs (N=242) >3 Yrs - 5 Yrs (N=94) >5 Yrs (N=131) 2015 JHLT Oct; 34(10): 33(10):
11 Risk Factors of Chronic Lung Allograft Dysfunction (CLAD) Non immune PGD,GERD,Infection CMV, Viruses DSA Lymphocytic Bronchiolitis ACR CLAD AMR
12 Risk Factors of Chronic Lung Allograft Dysfunction (CLAD) Non immune PGD,GERD,Infection CMV, Viruses DSA Lymphocytic Bronchiolitis ACR CLAD AMR
13 Incidence of DSA HALT Study 43/119 (36%) DSA+
14 Impact of DSA on short and long-term outcomes Hachem JHLT 2010; 29: 973 Safavi JHLT 2014;33: Morrel JHLT 33, No 12, December 2014 Lobo 2013 JHLT 32: 70 Tinkanen AJRCCM L 5 Barhat Ann Thorac Surg 2010
15 Impact of AMR on short and long-term outcomes? Issues in understanding outcomes: Until 2016, there was no standard criteria that all centers could use to compare their experience with AMR. No specific clinical or pathological characteristics have been identified Centers treating AMR without criteria/guidelines
16
17 Banff established and re-established criteria for AMR
18 National Conference to Assess AMR in SOT: Devoted little to AMR in the lung allograft it has been difficult to identify features distinguishing the clinical syndrome of primary graft failure from AMR/hyperacute rejection versus endotoxemia and severe ischemia/reperfusion injury. Am J Transplant 2004;4:
19 Stewart, JHLT 2007
20 The challenges of defining pulmonary AMR: Challenge to the immunologists: Antibody assessment varies significantly between centers. Standardization of quantifying measures (ie: MFI vs. titer, etc) Serum specific issues: inhibition, saturation Challenge to clinicians: No specific features in clinical presentation unique to AMR Mimics of AMR: ACR, CLAD, infection, GERD Monitoring (surveillance) schedule Prevention and intervention Challenge to pathologists: Histology: Non-specific findings: infection, ACR, PGD, ALI, CLAD C4D with poor reproducibility, difficult to interpret.
21 ISHLT Pulmonary AMR Working Group Consensus Create a working definition of pulmonary AMR Crucial for evaluation, management and research A living document created to be updated A dynamic yardstick against we can start from and measure progress based on data collected going forward
22 Antibody mediated rejection (AMR) ISHLT convened a working group to develop a standardized definition for pulmonary AMR.
23 Consensus report now Practice guidelines later Characteristics Recommendations based on: Clinical Consensus Statement Expert opinion Best available evidence (ie: single center studies) Clinical Practice Guidelines Systematic reviews and controlled trials
24 Diagnostic features of Pulmonary AMR Circulating donor specific antibody (DSA) Allograft dysfunction Histologic features of AMR Positive C4d Staining Exclusion of other causes of allograft dysfunction
25 ISHLT Working Group Definition of Pulmonary AMR AMR Clinical Associated with measurable graft dysfunction Can be asymptomatic Subclinical Normal graft function Can be an isolated DSA Can be isolated characteristic histology
26 Degree of Certainty: Depends on the demonstration of whether multiple criteria are present or absent. Diagnostic confidence is increased in the presence of more positive criteria Levine D, Glanville A, et al JHLT 2016: 35:397
27 Definite Clinical AMR: All criteria are present and other possible causes are excluded Allograft dysfunction Exclusion of other causes Lung Histology Lung Biopsy C4d Definite Probable Probable Probable Probable Possible Possible Possible Possible Possible Possible Levine et al JHLT 2016: 35:397 DSA
28 Probable clinical AMR: Lacks one criterion Allograft dysfunction Exclusion of other causes Lung Histology Lung Biopsy C4d Definite Probable Probable Probable Probable Possible Possible Possible Possible Possible Possible DSA Levine D et al JHLT 2016: 35:397
29 Possible clinical AMR: Lacks two criteria Allograft dysfunction Exclusion of other causes Lung Histology Lung Biopsy C4d Definite Probable Probable Probable Probable Possible Possible Possible Possible Possible Possible DSA Levine D, et al JHLT 2016: 35:397
30 Definite subclinical AMR Lung Histology C4D staining DSA Definite Probable Probable Probable Possible Possible Possible Levine et al JHLT 2016: 35:397
31 Probable subclinical AMR Lung Histology C4D staining DSA Definite Probable Probable Probable Possible Possible Possible - - +
32 Possible subclinical AMR Lung Histology C4D staining DSA Definite Probable Probable Probable Possible Possible Possible - - +
33 Pulmonary AMR consensus criteria: A few key points: Definite AMR is stringent: all 4 criteria +exclusion of other causes. Probable AMR: 4 combinations that are likely not equal in weight. There is a different diagnostic certainty between these probable groups.
34 Probable clinical AMR: Lacks one criterion Allograft dysfunction Exclusion of other causes Lung Histology Lung Biopsy C4d Definite Probable Probable Probable Probable Possible Possible Possible Possible Possible Possible DSA Levine D et al JHLT 2016: 35:397
35 AMR Clinical Subclinical
36 AMR Clinical Subclinical
37 Pulmonary AMR Classification Levine D, Glanville A, et al JHLT 2016: 35:397
38 Pulmonary AMR Classification Levine D, Glanville A, et al JHLT 2016: 35:397
39 AMR Clinical Subclinical
40 AMR Clinical Subclinical
41 Pulmonary AMR Classification
42 Pulmonary AMR Classification
43 When there is an isolated finding of DSA without other manifestations of AMR such as histology, C4d staining or allograft dysfunction, heightened surveillance for allograft dysfunction is warranted. Lung Histology C4D staining DSA Definite Probable Probable Probable Possible Possible Possible - - +
44 Consensus conclusions and limitations Definitions are dynamic and will allow modifications as new insights emerge. Limitations: Criteria based on limited data in literature All centers may not be able to evaluate all criteria HLA techniques are not standardized between labs Concurrence of histopathology and C4d is limited Severity and phenotypes of AMR not yet defined
45 Where to go from here? Validation and modification of consensus criteria based on recent literature and collective experience. Develop unified surveillance strategy for monitoring. Consider molecular techniques in the assessment Characteristics of different phenotypes of AMR. Goals of therapy to determine who and when to treat. Determine appropriate response to therapy.
46 Do we have consensus on this consensus?
47 Thank you!
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