Fibrin thrombi in deceased donor kidneys: Prevalence and influence on graft function and graft survival in transplanted patients

Fibrin thrombi (FT) are occasionally found in the pre‐implantation biopsy of kidneys from deceased donors. The aim of this study was to monitor the prevalence and answer the question whether FT has any impact on future graft function in a Danish patient cohort. We looked for FT in all donor kidney biopsies taken at the time of renal transplantation in a Danish transplantation unit during a 10‐year period. Every recipient transplanted with a FT donor kidney (n = 15) were matched with up to five control recipients (n = 69), and graft function and graft survival were assessed. FT was present in 3% of the transplanted donor kidneys. Graft function was reduced in the FT group 6 months after transplantation (median estimated glomerular filtration rate (eGFR): 29 mL/min vs 46 mL/min; p = 0.017), but at 12 months, an apparent difference did not reach statistical significance. More patients were on dialysis in the FT group after 12 months compared with the control group (27% vs 6%; p = 0.049). In conclusion, FT in donor kidney biopsies at time of transplantation is a risk factor for the development of reduced renal function during the first year of transplantation.     

Kidney graft recipients with pretransplantation HLA CLASS I antibodies and high soluble CD30 are at high risk for graft loss

In the present study, we investigated whether pretransplantation HLA class I and class II antibodies and pretransplantation levels of soluble CD30 (sCD30) and IgA anti-Fab autoantibodies are predictive of kidney allograft survival. Pretransplantation sera of 504 deceased-donor kidney recipients were tested for IgG HLA class I and class II antibodies, sCD30, and IgA anti-Fab levels using the CTS 4 ELISA kit. Kidney graft survival was estimated by Kaplan-Meier method and multivariate Cox regression. Regardless of the presence of HLA class II antibodies, recipients with high HLA class I reactivity had lower 1-year graft survival than recipients with low reactivity (p < 0.01). Recipients with high sCD30 had lower 5-year graft survival rate than those with low sCD30 (p < 0.01). The sCD30 effect was observed in presensitized and nonsensitized recipients, demonstrated a synergistic effect with HLA class I antibodies (p < 0.001), and appeared to be neutralized in recipients with no HLA class II mismatches. IgA anti-Fab did not influence kidney graft survival. Our results indicate that high pretransplantation sCD30 levels and HLA class I positivity increase the risk of kidney graft loss regardless of other factors. Consequently, such determinations should be routinely performed to estimate recipients' risks of graft rejection before transplantation.     

The significance of pretransplant donor‐specific antibodies reactive with intact or denatured human leucocyte antigen in kidney transplantation

Antibodies recognizing denatured human leucocyte antigen (HLA) can co‐react with epitopes on intact HLA or recognize cryptic epitopes which are normally unaccessible to HLA antibodies. Their specificity cannot be distinguished by single antigen beads (SAB) alone, as they carry a mixture of intact and denatured HLA. In this study, we selected pretransplant sera containing donor‐specific HLA class I antibodies (DSA) according to regular SAB analysis from 156 kidney transplant recipients. These sera were analysed using a SAB preparation (iBeads) which is largely devoid of denatured HLA class I, and SAB coated with denatured HLA class I antigens. A total of 241 class I DSA were found by regular SAB analysis, of which 152 (63%) were also found by iBeads, whereas 28 (11%) were caused by reactivity with denatured DNA. Patients with DSA defined either by regular SAB or iBeads showed a significantly lower graft survival rate (P = 0·007) compared to those without HLA class I DSA, whereas reactivity to exclusively denatured HLA was not associated with decreased graft survival. In addition, DSA defined by reactivity to class I SAB or class I iBeads occurred more frequently in female patients and in patients with historic HLA sensitization, whereas reactivity to denatured HLA class I was not associated with any of these parameters. Our data suggest that pretransplant donor‐specific antibodies against denatured HLA are clinically irrelevant in patients already sensitized against intact HLA.     

Serum antibodies to human leucocyte antigen (HLA)‐E,HLA‐F and HLA‐G in patients with systemic lupus erythematosus (SLE) during disease flares: Clinical relevance of HLA‐F autoantibodies

T lymphocyte hyperactivity and progressive inflammation in systemic lupus erythematosus (SLE) patients results in over‐expression of human leucocyte antigen (HLA)‐Ib on the surface of lymphocytes. These are shed into the circulation upon inflammation, and may augment production of antibodies promoting pathogenicity of the disease. The objective was to evaluate the association of HLA‐Ib (HLA‐E, HLA‐F and HLA‐G) antibodies to the disease activity of SLE. The immunoglobulin (Ig)G/IgM reactivity to HLA‐Ib and β2m in the sera of 69 German, 29 Mexican female SLE patients and 17 German female controls was measured by multiplex Luminex^®‐based flow cytometry. The values were expressed as mean florescence intensity (MFI). Only the German SLE cohort was analysed in relation to the clinical disease activity. In the controls, anti‐HLA‐G IgG predominated over other HLA‐Ib antibodies, whereas SLE patients had a preponderance of anti‐HLA‐F IgG over the other HLA‐Ib antibodies. The disease activity index, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)‐2000, was reflected only in the levels of anti‐HLA‐F IgG. Anti‐HLA‐F IgG with MFI level of 500–1999 was associated with active SLE, whereas inactive SLE revealed higher MFI (>2000). When anti‐HLA‐F IgG were cross‐reactive with other HLA‐Ib alleles, their reactivity was reflected in the levels of anti‐HLA‐E and ‐G IgG. The prevalence of HLA‐F‐monospecific antibodies in SLE patients was also associated with the clinical disease activity. Anti‐HLA‐F IgG is possibly involved in the clearance of HLA‐F shed from lymphocytes and inflamed tissues to lessen the disease's severity, and thus emerges as a beneficial immune biomarker. Therefore, anti‐HLA‐Ib IgG should be considered as a biomarker in standard SLE diagnostics.     

Immunoglobulin A anti‐phospholipid antibodies in Swedish cases of systemic lupus erythematosus: associations with disease phenotypes,vascular events and damage accrual

Immunoglobulin (Ig) G‐ and IgM‐class anti‐cardiolipin antibodies (aCL) and lupus anti‐coagulant (LA) are included in the 1997 update of the American College of Rheumatology (ACR‐97) systemic lupus erythematosus (SLE) criteria. Despite limited evidence, IgA‐aCL and IgA anti‐β₂‐glycoprotein‐I (anti‐β₂GPI) were included in the 2012 Systemic Lupus International Collaborating Clinics criteria. The present study aimed to evaluate IgG‐/IgA‐/IgM‐aCL and anti‐β₂GPI occurrence in relation to disease phenotype, smoking habits, pharmacotherapy, anti‐phospholipid syndrome (APS) and organ damage among 526 Swedish SLE patients meeting ACR‐97. Patients with rheumatoid arthritis (n = 100), primary Sjögren’s syndrome (n = 50) and blood donors (n = 507) served as controls. Anti‐phospholipid antibodies (aPL) were analysed by fluoroenzyme‐immunoassays detecting aCL/anti‐β₂GPI. Seventy‐six (14%) SLE cases fulfilled the Sydney APS‐criteria, and ≥ 1 aCL/anti‐β₂GPI isotype (IgG/IgA/IgM) occurred in 138 SLE patients (26%). Forty‐five (9%) of the SLE cases had IgA‐aCL, 20 of whom (4%) lacked IgG‐/IgM‐aCL. Seventy‐four (14%) tested positive for IgA anti‐β₂GPI, 34 (6%) being seronegative regarding IgG/IgM anti‐β₂GPI. Six (1%) had APS manifestations but were seropositive regarding IgA‐aCL and/or IgA anti‐β₂GPI in the absence of IgG/IgM‐aPL and LA. Positive LA and IgG‐aPL tests were associated with most APS‐related events and organ damage. Exclusive IgA anti‐β₂GPI occurrence associated inversely with Caucasian ethnicity [odds ratio (OR) = 0·21, 95% confidence interval (CI) = 0·06–0·72) and photosensitivity (OR = 0·19, 95% CI = 0·05–0·72). Nephritis, smoking, LA‐positivity and statin/corticosteroid‐medication associated strongly with organ damage, whereas hydroxychloroquine‐medication was protective. In conclusion, IgA‐aPL is not rare in SLE (16%) and IgA‐aPL analysis may have additional value among SLE cases with suspected APS testing negative for other isotypes of aPL and LA.     

Clinical and immunological relevance of antibodies in solid organ transplantation

The two important issues affecting recipients of solid organ transplants and of importance to immunologists are (i) sensitization of the recipient to HLA antigens and the resultant humoral immune response leading to the development of anti‐HLA antibodies; and ii) development of robust assays for early detection of humoral rejection post‐transplant. Evidence from several studies clearly indicates that presence of circulating anti‐HLA antibodies especially donor specific leads to early graft loss and high titres of DSA may even lead to hyperacute or accelerated acute rejection. Long‐term graft survival too is adversely affected by the presence of either pre‐ or post‐transplant DSA. HLA matching status of the recipient – donor pair – is an important factor in the modulation of humoral response following transplantation and in a way affects de novo development of DSA. Data collected over the past decade clearly indicate significantly lower level of DSAs in optimally matched donor‐recipient pairs. HLA mismatches especially those on HLA‐DR and HLA‐C loci have wider implications on post‐transplant graft survival. The presence of circulating anti‐HLA antibodies leads to endothelial damage in the newly grafted organ through complement dependent or independent pathways. Although detection of C4d deposition in renal biopsies serves as an important indicator of humoral rejection, its absence does not preclude the presence of DSAs and humoral rejection, and hence, it cannot be relied upon in every case. The emergence of epitope‐based screening for anti‐HLA antibodies on Luminex platform with high degree of sensitivity has revolutionized the screening for anti‐HLA antibodies and DSAs. Studies indicate that humoral response to non‐HLA antigens might also have a detrimental effect on allograft survival. High titres of such circulating antibodies may even lead to hyperacute rejection. Pre‐emptive testing of solid organ recipients, especially kidney transplant recipients for anti‐HLA and non‐HLA antibodies and aggressive post‐transplant monitoring of allograft function to detect DSAs using Luminex‐based tests, is highly recommended.     

IgA Response to ESAT‐6/CFP‐10 and Rv2031 Antigens Varies in Patients With Culture‐Confirmed Pulmonary Tuberculosis,Healthy Mycobacterium tuberculosis–Infected and Non‐Infected Individuals in a Tuberculosis Endemic Setting,Ethiopia

Little attention has been given to the role of antibodies against Mycobacterium tuberculosis (Mtb) infection. We have compared the levels of IgA and IgG against ESAT‐6/CFP‐10 and Rv2031c antigens in sera of patients with culture‐confirmed pulmonary tuberculosis (PTB), healthy Mtb‐infected and non‐infected individuals in endemic TB settings. Venous blood samples were collected from 166 study participants; sera were separated and assayed by an enzyme‐linked immunosorbent assay (ELISA). QuantiFERON‐TB Gold In‐Tube (QFTGIT) assay was used for the screening of latent TB infection. The mean optical density (OD) values of IgA against ESAT‐6/CFP‐10 and Rv2031 were significantly higher in sera of patients with culture‐confirmed PTB compared with healthy Mtb‐infected and non‐infected individuals (P < 0.001). The mean OD values of IgG against ESAT‐6/CFP‐10 and Rv2031 were also significantly higher in sera of patients with culture‐confirmed PTB compared with healthy Mtb‐infected and non‐infected individuals (P < 0.05). The mean OD values of IgA against both antigens were also higher in sera of healthy Mtb‐infected cases compared with non‐infected individuals. There were positive correlations (P < 0.05) between the level of IFN‐γ induced in QFTGIT assay and the OD values of serum IgA against both antigens in healthy Mtb‐infected subjects. This study shows the potential of IgA response against ESAT‐6/CFP‐10 and Rv2031 antigens in discriminating clinical TB from healthy Mtb‐infected and non‐infected cases. Nevertheless, further well‐designed cohort study is needed to fully realize the full potential of this diagnostic marker.     

Effect of infusion of monoclonal antibodies to tumour necrosis factor‐receptor super family 25 on graft rejection in allo‐immune mice receiving autologous marrow transplantation

Significant barriers to transplantation exist for individuals who are pre‐sensitized to donor antigen and have high titres of donor‐reactive antibody. We report the effect of autologous bone marrow transplantation (BMTx) after myeloablation in pre‐sensitized mice along with the use of monoclonal antibodies (mAbs) to tumour necrosis factor‐receptor super family 25 (TNFRSF25), expressed on regulatory T (Treg) cells. C57BL/6 mice, which had been sensitized earlier with BALB/c skin allografts, received secondary BALB/c grafts after the primary grafts had been rejected. Subsequently, recipient mice underwent myeloablation with cyclophosphamide and busulphan and were injected with T‐cell‐depleted bone marrow from CD45.1 congenic donors (BMTx). Recipient mice underwent immunosuppressive treatment with rapamycin. A subgroup of mice was also treated with mAbs to TNFRSF25. Control mice were pre‐sensitized mice that received cyclophosphamide and busulphan followed by rapamycin. BMTx‐treated mice had significantly prolonged skin graft survival versus control mice. These mice also showed attenuated donor‐specific mixed lymphocyte co‐culture responses relative to controls, increased splenic Treg cells and markedly diminished serum anti‐donor IgG. Infusion of anti‐TNFRSF25 mAbs further augmented graft survival and increased graft‐infiltrating Treg cells. These mAbs also expanded murine and human Treg cells in vitro with the capacity to attenuate mixed lymphocyte co‐cultures using fresh peripheral blood mononuclear cells. Overall, this study delineates the roles of autologous BMTx and anti‐TNFRSF25 mAbs in expanding Treg cells and attenuating alloimmune responses in pre‐sensitized mice.     

Immunoglobulin (Ig)G purified from human sera mirrors intravenous Ig human leucocyte antigen (HLA) reactivity and recognizes one's own HLA types,but may be masked by Fab complementarity‐determining region peptide in the native sera

Intravenous immunoglobulin (IVIg) reacted with a wide array of human leucocyte antigen (HLA) alleles, in contrast to normal sera, due possibly to the purification of IgG from the pooled plasma. The reactivity of IgG purified from normal sera was compared with that of native sera to determine whether any serum factors mask the HLA reactivity of anti‐HLA IgG and whether IgG purified from sera can recognize the HLA types of the corresponding donors. The purified IgG, unlike native sera, mirrored IVIg reactivity to a wide array of HLA‐I/‐II alleles, indicating that anti‐HLA IgG may be masked in normal sera – either by peptides derived from soluble HLA or by those from antibodies. A < 3 kDa peptide from the complementarity‐determining region (CDR) of the Fab region of IgG (but not the HLA peptides) masked HLA recognition by the purified IgG. Most importantly, some of the anti‐HLA IgG purified from normal sera – and serum IgG from a few donors – indeed recognized the HLA types of the corresponding donors, confirming the presence of auto‐HLA antibodies. Comparison of HLA types with the profile of HLA antibodies showed auto‐HLA IgG to the donors' HLA antigens in this order of frequency: DPA (80%), DQA (71%), DRB345 (67%), DQB (57%), Cw (50%), DBP (43%), DRB1 (21%), A (14%) and B (7%). The auto‐HLA antibodies, when unmasked in vivo, may perform immunoregulatory functions similar to those of therapeutic preparations of IVIg.     

Assessing the potential of angiotensin II type 1 receptor and donor specific anti-endothelial cell antibodies to predict long-term kidney graft outcome

Endothelial cell antigens have been reported as potential targets for antibodies in the context of organ transplantation, leading to increased risk for graft failure. Serum samples from 142 consecutive living donor kidney recipients were tested for the presence of antibodies to angiotensin II – type 1 receptor (AT1R), donor endothelial cells, and donor HLA. Graft survival was monitored for five years post-transplant, and secondary outcomes, including biopsy-proven rejection, proteinuria, biopsy-proven vasculopathy, and renal function based on serum creatinine were also assessed for the first two to three years. AT1R antibody levels were positive (>17 U/mL) in 11.3%, 18.8% and 8.1% of patients pre-transplant, post-transplant and at time of indication biopsy, respectively. XM-ONE assay was positive in 17.6% of patients pre-transplant (7 IgG+; 15 IgM+; 3 IgG+/IgM+). Overall, 4 patients experienced antibody-mediated rejection (AMR), 31 borderline cellular rejection (BCR), 19 cellular rejection (CR) and 3 mixed AMR and CR within the first 24 months. While pre-existing and de novo donor-specific HLA antibodies were associated with graft failure and many secondary outcomes, no statistical association was found for either anti-endothelial or anti-AT1R antibodies, indicating that these tests may not be the best predictors of graft outcome in living donor renal transplantation.     

The outcome of the endothelial precursor cell crossmatch test in lymphocyte crossmatch positive and negative patients evaluated for living donor kidney transplantation

The presence of human leukocyte antigen (HLA) and non-HLA antibodies (Abs) in kidney transplant recipients is associated with graft rejections. This study reports the results of an endothelial precursor cell crossmatch (EPCXM) test for detection of non-HLA Abs and its correlation to lymphocyte crossmatch (LXM) test results, the degree and type of sensitization, and transplantation (Tx) outcome in patients evaluated for living donor (LD) kidney transplantation (KTx). Patients were tested before any pre-transplantation (pre-Tx) treatment and at Tx. Pre-Tx treatments included B cell depletion and Ab removal. Patient records were reviewed for assessment of renal graft function, results of biopsies, and identification of complications affecting the graft. Pre-Tx sera from 32% of the LD patients had IgG and/or IgM-binding donor EPCs. Twenty-five percent of the patients were EPCXM IgM+. Of the patients with negative LXM tests, 25% had EPC Abs mainly of IgM class not reactive with HLA. There was no difference in rejection frequency or serum creatinine levels between the EPCXM+ and EPCXM− groups. The pre-Tx EPCXM+ group had significantly more patients with delayed graft function. Prospective studies with appropriate control groups are needed to establish whether pre-treatments aiming at removing anti-endothelial cell antibodies, as detected by the EPCXM pre-Tx, have a beneficial effect on short-term and long-term graft survival.     

Suppression of allo‐human leucocyte antigen (HLA) antibodies secreted by B memory cells in vitro: intravenous immunoglobulin (IVIg) versus a monoclonal anti‐HLA‐E IgG that mimics HLA‐I reactivities of IVIg

B memory cells remain in circulation and secrete alloantibodies without antigen exposure > 20 years after alloimmunization postpartum or by transplantation. These long‐lived B cells are resistant to cytostatic drugs. Therapeutically, intravenous immunoglobulin (IVIg) is administered to reduce allo‐human leucocyte antigen (HLA) antibodies pre‐ and post‐transplantation, but the mechanism of reduction remains unclear. Recently, we reported that IVIg reacts with several HLA‐I alleles and the HLA reactivity of IVIg is lost after its HLA‐E reactivity is adsorbed out. Therefore, we have generated an anti‐HLA‐E monoclonal antibody that mimics the HLA‐reactivity of IVIg to investigate whether this antibody suppresses IgG secretion, as does IVIg. B cells were purified from the blood of a woman in whose blood the B memory cells remained without antigen exposure > 20 years after postpartum alloimmunization. The B cells were stimulated with cytokines using a well‐defined culture system. The anti‐HLA‐E monoclonal antibody (mAb) significantly suppressed the allo‐HLA class‐II IgG produced by the B cells, and that this suppression was far superior to that by IVIg. These findings were confirmed with HLA‐I antibody secreted by the immortalized B cell line, developed from the blood of another alloimmunized woman. The binding affinity of the anti‐HLA‐E mAb for peptide sequences shared (i.e. shared epitopes) between HLA‐E and other β2‐microglobulin‐free HLA heavy chains (open conformers) on the cell surface of B cells may act as a ligand and signal suppression of IgG production of activated B memory cells. We propose that anti‐HLA‐E monoclonal antibody may also be useful to suppress allo‐HLA IgG production in vivo.     

Immunoglobulin (Ig)G1 and IgG4 anti‐cyclic citrullinated peptide (CCP) associate with shared epitope,whereas IgG2 anti‐CCP associates with smoking in patients with recent‐onset rheumatoid arthritis (the Swedish TIRA project)

Given the possible importance of anti‐citrullinated peptide/protein antibodies (ACPA) for initiation and progression of rheumatoid arthritis (RA), extended knowledge about the different isotypes and subclasses is important. In the present study, we analysed the immunoglobulin (Ig)G subclasses regarding reactivity against cyclic citrullinated peptides (anti‐CCP) among 504 clinically well‐characterized patients with recent‐onset RA in relation to smoking habits, shared epitope (SE) status and IgA and pan‐IgG anti‐CCP antibodies. All patients, regardless of pan‐IgG anti‐CCP status, were analysed for IgG1–4 CCP reactivity. Sixty‐nine per cent were positive in any IgG anti‐CCP subclass, and of these 67% tested positive regarding IgG1, 35% IgG2, 32% IgG3, and 59% IgG4 anti‐CCP. Among ever‐smokers the percentages of IgG2 anti‐CCP (P = 0·01) and IgA anti‐CCP (P = 0·002)‐positive cases were significantly higher compared to never‐smokers. A positive IgG anti‐CCP subclass ‐negative cases. Combining SE and smoking data revealed that IgG1 and IgG4 anti‐CCP were the IgG anti‐CCP isotypes associated with expression of SE, although the lower number of patients positive for IgG2 or IgG3 anti‐CCP could, however, have influenced the results. High levels of IgG2 anti‐CCP were shown to correlate with expression of the ‘non‐SE’ allele human leucocyte antigen (HLA)‐DRB1*15. In conclusion, in this study we describe different risk factor characteristics across the IgG anti‐CCP subclasses, where IgG2 appears similar to IgA anti‐CCP regarding the predominant association with smoking, while IgG1 and IgG4 related more distinctly to the carriage of SE genes.     

Anti-HLA class II antibodies in kidney retransplant patients

The relevance of anti-HLA class II antibodies for kidney graft survival is still controversial. In part, this can be attributed to difficulties to detect and differentiate anti-HLA class II antibodies. Anti-HLA class II IgG antibody screening was performed by enzyme-linked immunosorbent assay. Subsequently, all anti-HLA class II-positive sera were subjected to the determination and specification using color-coded microspheres coated with purified HLA antigens. In a cohort of 934 patients awaiting kidney transplantation, 41 sera (4.4%) were positive for IgG anti-HLA class II antibodies. The presence was confirmed in 90.2% sera by retesting. Subsequently, all anti-HLA class II-positive patients (n = 27) who in the past had undergone a kidney transplantation with an HLA-DR and/or -DQ-mismatched graft were selected. In 25 of 27 sera (92.6%), the alloantibody specificities corresponded to the known previous transplant mismatches on a broad antigen level. In 20 of 27 sera (74.1%), anticlass I antibodies were detected as well. Anti-HLA-DP antibodies were seen in 24 of the 27 sera of this cohort. In the majority of the cases, the reactivities with different DPB1 alleles could be explained by involvement of a single, specific DPB1 epitope. Donor-specific anti-HLA-DR and -DQ antibodies were seen in the majority of cases with graft failure following HLA class II alloantigen exposure in prior kidney transplantations. In addition, HLA-DP may serve as a transplantation antigen in kidney transplantation, leading to a humoral response.     

Importance of B cells to development of regulatory T cells and prolongation of tissue allograft survival in recipients receiving autologous bone marrow transplantation

We previously showed that congenic bone marrow transplantation (BMTx) post myeloablation augmented tissue allograft survival in association with increased regulatory T (Treg) cells of both host and bone marrow donor origin. Regulatory B (Breg) cells can also modulate T‐cell immunity and B cells may be implicated in the development of Treg cells. Accordingly, we explored the effect of B‐cell depletion in vivo on augmented graft survival post BMTx. C57BL/6 mice received BALB/c skin allografts followed 7 days later by myeloablation using cyclophosphamide and busulphan. Mice then received T‐cell‐depleted bone marrow from CD45.1 congenic donors, and ongoing immunosuppression with rapamycin (to day 28 after BMTx). Control mice received cyclophosphamide and busulphan followed by rapamycin, but not congenic bone marrow. At different times post BMTx, mice received B‐cell‐depleting antibody treatment, and the effect on both skin graft survival, and induction of Treg cells was assessed. BMTx resulted in significantly prolonged skin graft survival versus control mice, in association with attenuated donor‐specific alloreactivity relative to controls, increased splenic Treg cells and significantly diminished anti‐donor IgG. In mice receiving infusion of B‐depleting antibodies for 12 days from day 15 post BMTx, both graft survival and Treg cell activity were diminished, particularly for functional Treg cells of donor origin. Adoptive transfer of Breg cells from mice harvested at 15 days post BMTx prolonged survival in naive transplanted mice and increased Treg cell levels. Thus, autologous BMTx augmentation of graft survival is dependent in part upon a population of Breg cells that can modulate the function of donor‐derived Treg cells.     

ARHGDIB and AT1R autoantibodies are differentially related to the development and presence of chronic antibody-mediated rejection and fibrosis in kidney allografts

The role of non-HLA autoantibodies in chronic-active antibody-mediated rejection (c-aABMR) of kidney transplants is largely unknown. In this study, the presence and clinical relevance of non-HLA autoantibodies using a recently developed multiplex Luminex-based assay were investigated. Patients with a kidney allograft biopsy at least 6 months after transplantation with a diagnosis of c-aABMR (n = 36) or no rejection (n = 21) were included. Pre-transplantation sera and sera at time of biopsy were tested for the presence of 14 relevant autoantibodies.A significantly higher signal for autoantibodies against Rho GDP‐dissociation inhibitor 2 (ARHGDIB) was detected in recipients with c-aABMR as compared to recipients with no rejection. However, ARHGDIB autoantibodies did not associate with graft survival. Levels of autoantibodies against angiotensin II type 1-receptor (AT1R) and peroxisomal trans‐2‐enoyl‐CoA reductase (PECR) were increased in recipients with interstitial fibrosis in their kidney biopsy. Only the signal for AT1R autoantibody showed a linear relationship with the degree of interstitial fibrosis and was associated with graft survival.In conclusion, anti-ARHGDIB autoantibodies are increased when c-aABMR is diagnosed but are not associated with graft survival, while higher levels of AT1R autoantibody are specifically associated with the presence of interstitial fibrosis and graft survival.     

HLA antibodies are associated with deterioration of kidney allograft function irrespective of donor specificity

BackgroundDonor-specific antibodies are associated with high immunological risk and poor allograft outcome. Risk and clinical relevance of non-donor-specific HLA antibodies is less clear.MethodsA retrospective single-center study was conducted in all patients receiving a first kidney transplant at the University hospital of Zürich between 01/2006 and 02/2015. Patients were stratified into 3 groups having either no HLA antibodies at all (NoAB), HLA antibodies with donor specificity (DSA) and HLA antibodies without donor specificity (NonDSA). Allograft outcome was assessed using the slope of the estimated glomerular filtration rate (eGFR slope) starting at 12 months after transplantation.ResultsDuring a median follow-up of 1808 days HLA antibodies were detected in 106 of 238 eligible patients (44%). Out of these, 73 patients (69%) had DSA and 33 patients (31%) had NonDSA only. Medium-term allograft function, as determined by eGFR slope over three years, improved in patients with NoAB (months 12–48: +0.7 ml/min/1.73 m²) but deteriorated significantly in patients with both DSA (months 12–48: ?1.5 ml/min per1.73 m²/year, p = 0.015) and NonDSA (months 12–48: ?1.8 ml/min per1.73 m²/year, p = 0.03) as compared to the group with NoAB.ConclusionBoth, donor-specific and non-donor-specific HLA antibodies are associated with medium-term kidney allograft dysfunction as compared to patients with no HLA antibodies.     

Extensive Endoscopic Image‐Guided Sinus Surgery Decreases BPI‐ANCA in Patients with Cystic Fibrosis

Antineutrophil cytoplasm autoantibodies (ANCA) directed against bactericidal/permeability‐increasing protein (BPI) are common in patients with cystic fibrosis (CF), and serum levels are correlated with lung colonization by Pseudomonas aeruginosa and the severity of lung damage. The production of BPI‐ANCA may be due to the costimulation of BPI when mounting an immune response against P. aeruginosa. The effect of surgery aiming to eradicate bacteria and infected tissue on BPI‐ANCA levels is sparsely described. A cohort of patients with CF were included: 53 patients having extensive image‐guided sinus surgery (EIGSS) with topical postoperative antibiotic treatment, 131 non‐operated controls and 36 who had double lung transplantation (LTX). In all 219 patients, serum samples before and after surgery or at similar intervals were analysed for IgG and IgA BPI‐ANCA. The EIGSS group showed a highly significant decrease in both IgA and IgG BPI‐ANCA levels compared with their own preoperative values and control group values (P < 0.001–0.02). The LTX patients also showed a highly significant decrease in both IgA and IgG BPI‐ANCA levels (P < 0.001). EIGSS and LTX decrease IgA and IgG BPI‐ANCA levels in patients with CF, indicating that extensive removal of infected tissue influences the pathogenic process of autoantibody production. The results shown herein are in favour of applying EIGSS in selected patients with CF and for using BPI‐ANCA as a surrogate marker for guiding further therapeutic interventions.     

Successful kidney transplant in a patient with IgG anti HLA Class-I auto-antibodies: A case report

Donor specific antibodies (DSA) play a significant role in graft rejection. Many laboratory methods, varied in sensitivity and specificity, are used to detect them. We report a case of a 38-year-old man presented with end stage renal disease considered for kidney transplantation. He had no history of blood transfusions nor transplantation procedures. Dilemma rose when he got multiple positive crossmatches with matching donors and a positive autologous crossmatch due to IgG anti HLA auto-antibodies, which are at the same time against matched donors. Since positive crossmatch is a contraindication for transplant, we couldn’t perform transplant from any matched donor. Therefore, we considered a total mismatched donor then transplantation was performed. Observation after surgery showed normalization of creatinine, blood pressure and a good function of the planted allograft for two years of follow up.     

IgA‐ and SIgA anti‐PR3 antibodies in serum versus organ involvement and disease activity in PR3‐ANCA‐associated vasculitis

Circulating immunoglobulin (Ig)A class anti‐neutrophil cytoplasm antibodies (ANCA) directed against proteinase 3 (PR3) have been reported in ANCA‐associated vasculitis (AAV) with mucosal involvement. However, secretory IgA (SIgA) PR3‐ANCA has not been reported previously. In this study we compared serum levels of SIgA PR3‐ANCA and IgA PR3‐ANCA with IgG PR3‐ANCA in relation to disease characteristics. Among 73 patients with AAV and PR3‐ANCA at diagnosis, 84% tested positive for IgG PR3‐ANCA, 47% for IgA‐ANCA and 36% for SIgA PR3‐ANCA at the time of sampling for the present study. IgA and IgG PR3‐ANCA were represented similarly among patients with different organ manifestations, i.e. upper airway, lung or kidney at time of sampling. However, SIgA PR3‐ANCA was significantly less represented among patients with upper airway involvement. During active disease, the proportions of IgA PR3‐ANCA and SIgA PR3‐ANCA‐positive patients were significantly higher compared to inactive disease. Eight patients were sampled prospectively during 24 months from onset of active disease. In these patients, IgA PR3‐ANCA and SIgA PR3‐ANCA turned negative more often after remission induction compared to IgG PR3‐ANCA. Our findings suggest that serum IgA PR3‐ANCA and SIgA PR3‐ANCA are related more closely to disease activity in AAV compared to IgG PR3‐ANCA. Further studies are required to reveal if this has implications for disease activity monitoring. The mean number of PR3‐ANCA isotypes increased along with disease activity, suggesting a global B cell activation during active disease.