Refractory Rejection Research Articles

Diagnosis and Treatment of Acute Cellular Rejection (ACR) Following Intestinal Transplant Performed at Addenbrooke’s Hospital, Cambridge, Cambridge University Hospitals

Aim: To review the diagnosis, treatment and management of ACR after intestinal transplantation (ITx) in a single UK adult centre (Addenbrooke’s Hospital, Cambridge). Method: We undertook a retrospective review of patients with intestinal containing grafts at Addenbrooke’s hospital from 2007 to 2016 who developed ACR. Biopsies were reviewed by an experienced GI pathologist and were graded based on the VIII International Small Bowel Transplant Symposium Consensus criteria with minor modifications for evaluation of colon biopsies. Each biopsy was graded either negative or positive for ACR. Resolution of ACR was the first normal biopsy without any features of rejection including any borderline features. Comparison between groups was with Chi-squared test. Results: During the study a total of 71 ITx were performed in 65 patients (42 Multivisceral or Liver/Intestine, 9 Modified multivisceral and 20intestine only). Of these, 30 patients had at least one episode of rejection in 32 grafts. Two patients were re-transplanted for refractory rejection. Of the patients who had rejection, 18/30 had colon-containing grafts and 20/30 were liver-containing grafts. The median time to first rejection was 8.60 months. 19 grafts had a single episode of rejection and 13 grafts had more than one episode of rejection. Of these rejections, 26% were mild, 40% were moderate and 34% were severe. The average time to resolution after the first episode of rejection was 61.07 days. First line treatment for the episode of rejection was pulsed methyl prednisolone in 75% cases, of which 45% required second line treatment. The rates of rejection in liver containing vs non-liver containing grafts were not significantly different (p = 0.81). However, the rates of rejection in patients with a colon as part of their graft is 64%, whereas in those without colon it is 32% (p = 0.008) Conclusion: The overall rate of rejection is 45% in our cohort, which is similar to previous reports in this organ type[1]. However, contrary to those previous reports, we did not find that having a liver containing graft influenced the rate of ACR, but the presence of a colon did increase the risk. However, this needs to be balanced against the known benefits of having a colon. Reference: 1. Grant et al. 2003 Report of the Intestine Transplant Registry. Ann Surg. 2005; 241(4): 607-613.

Rescue alemtuzumab for refractory acute cellular rejection and bronchiolitis obliterans syndrome after lung transplantation.

Refractory acute cellular rejection (rACR) is associated with death and bronchiolitis obliterans syndrome (BOS) post-lung transplantation. We report the largest cohort of lung transplant recipients (LTRs) treated with rescue alemtuzumab for rACR or BOS. RACR outcomes included burden of ACR 30days before and 180days after rescue assessed by a novel composite rejection standardized score (CRSS, range 0-6) and freedom from ≥A2 ACR. BOS outcomes included freedom from BOS progression and FEV1 decline >10%. Univariate parametric and nonparametric statistical approaches were used to assess treatment response. Kaplan-Meier method with log rank conversion was used to assess freedom from events. Fifty-seven alemtuzumab doses (ACR 40 and BOS 17) given to 51 patients were included. Median time to rescue was 722 (IQR 42-1403) days. CRSS declined significantly (3 vs 0.67, P<0.001) after rescue. Freedom from ≥A2 was 62.5% in rACR. Freedom from BOS progression was 52.9% at 180 days in the BOS cohort. Freedom from FEV1 decline >10% was 70% in BOS grade 1 and 14.3% in advanced BOS grades 2-3. Infections developed in 72.5% and 76.5% of rACR and BOS groups. Rescue alemtuzumab appears useful for rACR. Patients with BOS 1 may have transient benefit, and patients with advanced BOS seem not to respond to alemtuzumab.

Donor Genotype and Intragraft Expression of CYP3A5 Reflect the Response to Steroid Treatment During Acute Renal Allograft Rejection.

Glucocorticoid (GC)-refractory acute rejection (AR) is a risk factor for inferior renal allograft outcome. We investigated genetic predisposition to the response to steroid treatment of acute allograft rejection. Single nucleotide polymorphisms of genes involved in GC signaling (GR, GLCCI1) and drug metabolism and transport (CYP3A5, ABCB1, and PXR) were analyzed in kidney transplant recipients (1995-2005, Leiden cohort, n = 153) treated with methylprednisolone. Significant associations were verified in a second cohort (Berlin cohort, n = 66). Patients who received a CYP3A5*1 allele expressing allograft had a lower risk of resistance to methylprednisolone during AR (odds ratio, 0.29; 95% confidence interval, 0.11-0.79; P = 0.016 in combined cohorts analysis). No differences were observed for GC signaling or other drug metabolism/transport-related genes. Both before transplantation (n = 69) and at time of AR (n = 88), tissue CYP3A5 mRNA expression was significantly higher in CYP3A5*1 allele expressing donor kidneys than in CYP3A5*3/*3 allografts (P < 0.00001). Moreover, steroid-responsive patients (n = 64) expressed significantly higher intragraft CYP3A5 mRNA levels compared to steroid-refractory patients (n = 42) in AR (P = 0.006). CYP3A5 protein expression was detected in tubular epithelial cells and inflammatory cells within the grafts. Our findings show that steroid resistance during AR is associated with donor genotype and intragraft expression levels of CYP3A5.

Alemtuzumab (Campath-1H) therapy for refractory rejections in pediatric heart transplant recipients.

Despite substantial improvements in survival after pediatric heart transplantation, refractory rejection remains a major cause of morbidity and mortality. We have utilized ALE (Campath-1H) in six consecutive patients with refractory rejection. These rejection episodes persisted despite conventional treatment, which included intravenous methylprednisolone, rituximab, immunoglobulin G, and antithymocyte globulin. In our series, after ALE therapy, LV SF increased from 22%±5% to 33%±5% (P=.01). However, in our series, ALE therapy neither led to persistent LV function recovery nor could it prevent subsequent antibody-mediated rejection.

Refractory Antibody-Mediated Rejection in Kidney-Pancreas Transplant

Refractory Antibody-Mediated Rejection in Kidney-Pancreas Transplant

Effectiveness of Bortezomib in a Patient With Acute Rejection Associated With an Elevation of Donor-Specific HLA Antibodies After Small-Bowel Transplantation: Case Report

BackgroundA significant association between donor-specific antibody (DSA) and graft rejection has recently been documented. However, confirmed strategy has not been established for DSA-associated rejection after intestinal transplantation (ITx). Case ReportA 20-year-old male patient with chronic intestinal obstruction caused by hypoganglionosis of the entire intestine underwent cadaveric donor ITx with grafting performed on 232 cm of the small intestine, cecum, and a part of the ascending colon. On post-operative day (POD) 14, a histological evaluation showed an acute rejection of indeterminate grade. The patient had severe acute rejection on POD 16, which prompted us to administer bolus steroids and polyclonal anti-thymocyte antibody, along with baseline maintenance immunosuppression. The histopathological findings of the graft indicated typical acute cellular rejection, although C4d was positive. We then detected donor-specific HLA antibody. The patient initially responded well to the therapy and showed decreased histological rejection signs. However, the refractory low-grade rejection persisted in the graft. During this period, the patient showed increased levels of DSA, and we speculated that the persistent rejection was associated with DSA; thus, bortezomib was administered at this stage as a salvage therapy. This rejection was thereafter successfully controlled without severe adverse effect. Twenty-three months after ITx, the patient is currently alive with complete enteral autonomy. ConclusionsA case of acute graft rejection followed by a marked elevation of DSA is presented. In this particular case, a modified treatment protocol using bortezomib in addition to the typical immunosuppressive agents was effective.

Use of preoperative embolization prior to Transplant nephrectomy

ABSTRACTIntroduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Acute antibody-mediated rejection after intestinal transplantation.

AIMTo investigate the incidence, risk factors and clinical outcomes of acute antibody-mediated rejection (ABMR) after intestinal transplantation (ITx).METHODSA retrospective single-center analysis was performed to identify cases of acute ABMR after ITx, based on the presence of donor-specific antibody (DSA), acute tissue damage, C4d deposition, and allograft dysfunction.RESULTSAcute ABMR was identified in 18 (10.3%) out of 175 intestinal allografts with an average occurrence of 10 d (range, 4-162) after ITx. All acute ABMR cases were presensitized to donor human leukocyte antigens class I and/or II antigens with a detectable DSA. A positive cross-match was seen in 14 (77.8%) cases and twelve of 18 patients (66.7%) produced newly-formed DSA following ITx. Histological characteristics of acute ABMR include endothelial C4d deposits, interstitial hemorrhage, and severe congestion with focal fibrin thrombin in the lamina propria capillaries. Multivariate analysis identified a liver-free graft and high level of panel reactive antibody as a significant independent risk factor. Despite initial improvement after therapy, eleven recipients (61.1%) lost transplant secondary to rejection. Of those, 9 (50%) underwent graft removal and 4 (22.2%) received second transplantation following acute ABMR. At an average follow-up of 32.3 mo (range, 13.3-76.4), 8 (44.4%) recipients died.CONCLUSIONOur results indicate that acute ABMR is an important cause of intestine graft dysfunction, particularly in a liver-exclusive graft and survivors are at an increased risk of developing refractory acute rejection and chronic rejection. More effective strategies to prevent and manage acute ABMR are needed to improve outcomes.

Role of Photopheresis in the Treatment of Refractory Cellular Rejection in Kidney Transplantation

Role of Photopheresis in the Treatment of Refractory Cellular Rejection in Kidney Transplantation

Rituximab in the treatment of refractory late acute antibody-mediated rejection: Our initial experience.

Antibody-mediated rejection (AMR) is not uncommon after renal transplantation and is harder to handle compared to cell-mediated rejection. When refractory to conventional therapies, rituximab is an attractive option. This study aims to examine the effectiveness of rituximab in refractory late acute AMR. This is a retrospective study involving nine renal transplant recipients. Four doses of rituximab were administered at weekly interval for 4 weeks, at a dose of 375 mg/m2. The mean age of patients was 35.3 ± 7.38 years. The median period between transplantation and graft dysfunction was 30 ± 20 months. Mean serum creatinine at the time of discharge after transplantation and at the time of acute AMR diagnosis was 1.14 ± 0.19 mg/dl and 2.26 ± 0.57 mg/dl, respectively. After standard therapy, it was 2.68 ± 0.62 mg/dl. One patient died of Pseudomonas sepsis and three patients progressed to end-stage renal disease (ESRD). Four biopsies showed significant plasma cell infiltrations. Mean serum creatinine among non-ESRD patients at the end of 1 year progressed from 2.3 ± 0.4 to 3.8 ± 1.2 mg/dl (P value 0.04). eGFR prior to therapy and at the end of 1 year were 34.4 ± 6.18 and 20.8 ± 7.69 ml/min (P value 0.04), respectively. Only one patient showed improvement in graft function in whom donor-specific antibody (DSA) titers showed significant improvement. Rituximab may not be effective in late acute AMR unlike in early acute AMR. Monitoring of DSA has a prognostic role in these patients and plasma cell rich rejection is associated with poor prognosis.

Eculizumab for Treatment of Refractory Antibody-Mediated Rejection in Kidney Transplant Patients: A Single-Center Experience

Antibody-mediated rejection (AMR) is responsible for up to 20%–30% of acute rejection episodes after kidney transplantation. In several cases, conventional therapies including plasmapheresis, intravenous immunoglobulin, and anti-CD20 therapy can resolve AMR successfully. But in some cases the load of immunoglobulins that can activate complement cascade may submerge the routine desensitization therapy and result in the formation of membrane attack complexes. Eculizumab, a monoclonal antibody against C5, was reported to be an option in cases with severe AMR that are resistant to conventional therapy. Here, we present 8 cases that were resistant to conventional therapy and in which eculizumab was given as a salvage treatment. Given the bad prognosis for renal transplants displaying acute injury progressing rapidly to cortical necrosis on the biopsy, the prompt use of eculizumab could have the advantage of immediate effects by stopping cellular injury. This can provide a therapeutic window to allow conventional treatment modalities to be effective and prevent early graft loss.

SUCCESSFUL APPLICATION OF PERIPHERAL VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION FOR CARDIAC ALLOGRAFT ANTIBODY-MEDIATED REJECTION WITH SEVERE HEMODYNAMIC COMPROMISE

Introduction . Acute antibody-mediated rejection (AMR) is one of the severe complications of early and late period after heart transplantation (HT). Only few case reports and studies presented of mechanical circulatory support (MCS) application for refractory acute rejection causing hemodynamic compromise. Aim . We report the case of a woman with cardiogenic shock caused by severe AMR that was successfully treatment by peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO). Material and methods. In december 2014, a 60-year-old woman with dilated cardiomyopathy was operated for HT. The patient had a good initial cardiac allograft function and no and was discharged from ICU on the 4 th day after HT. 1 st endomyocardial biopsy (EMB) (the 7 th day after HT) showed absence of acute cellular and antibody-mediated rejection. On the 11 th day after HT patient aggravated and presented clinical signs of life-threatening acute cardiac allograft dysfunction: arterial blood pressure 78/49/38 mm Hg, HR 111 in min, CVP 20 mm Hg, PAP 47/34/25 mm Hg, PCWP 25 mm Hg, CI 1.5 l/min/m 2 , adrenalin 110 ng/kg/min, dopamine 15 mcg/kg/min. ECG showed impairment of systolic left (LVEF 25%) and right (RVEF 15%) ventricle function, left and right ventricle diffuse hypokinesis, thickness of IVS, LV and RV wall 1.7, 1.4 and 0.8 cm, tricuspid and mitral valve regurgitation 2–3 degrees. EMB presented AMR. In conscience peripheral VA ECMO was installed. We used peripheral transcutaneous cannulation technique via femoral vessels – arterial cannula 15 F, venous cannula – 23 F, vascular catheter 14 G for anterograde leg’s perfusion. ACT 130–150 sec. AMR therapy included: methylprednisolon pulse-therapy (10 mg/kg for 5 day), IgG, plasmapheresis (No 7), rituximab. Results. Under MCS by VA ECMO we noted quick improvement of hemodynamic, metabolic homeostasis and organ functions. On the 6 th day of VA ECMO (blood flow 1.8 l/min): arterial blood pressure 133/81/54 mm Hg, CVP 5 mm Hg, PAP 31/21/12 mm Hg, PCWP 12 mm Hg, CI 3,4 l/min/м 2 , HR 85 in min, LVEF 53%, IVS 1.3 cm, mitral valve regurgitation <1 degree, inotropic support was discontinued. Control EMB showed resolution of AMR. Duration of VA ECMO was 7 days. Patient was discharged from ICU on the 2 nd and 26 th day after VA ECMO in stable clinical status. Conclusion. VA ECMO should be crucial component of treatment of cardiac allogaft antibody-mediated rejection with severe hemodynamic compromise.

(923) - Total Lymphoid Irradiation to Successfully Treat Refractory Rejection in Pediatric Heart Transplant Recipients

Total lymphoid irradiation (TLI) is used to treat acute recurrent heart transplant (HTx) rejection, especially in those not responding to the usual therapies. We evaluate the role of TLI in the management of refractory rejection in a single center review.

(654) - Rescue Alemtuzumab for Refractory Acute Cellular Rejection and Bronchiolitis Obliterans Syndrome After Lung Transplantation at a Single High-Volume Center

(654) - Rescue Alemtuzumab for Refractory Acute Cellular Rejection and Bronchiolitis Obliterans Syndrome After Lung Transplantation at a Single High-Volume Center

Quilty effect after extracorporeal photopheresis in a patient with severe refractory cardiac allograft rejection.

Quilty effect after extracorporeal photopheresis in a patient with severe refractory cardiac allograft rejection.

Failure of Splenectomy in The Treatment of Late Period Humoral Rejection.

Humoral mechanisms are increasingly recognized as important mediators of late period graft outcomes. Despite advances in therapy an optimal treatment strategy has not yet been defined. Splenectomy has been previously described in the management of refractory humoral rejection occurring in the early post transplant period. We here describe the case of a patient who presented with mixed cellular and humoral rejection in the late post transplant period. Emergent splenectomy was undertaken in an effort to control humoral rejection without success as indicated by failure of significant improvement in alloantibody levels, progression of antibody mediated graft injury on repeat graft biopsy, and eventual development of graft failure with permanent return to dialysis.Table: No Caption available.Histological comparison of graft and splenic tissue showed significant numbers of functional plasma cells within the allograft but not the spleen, suggesting that the graft itself is a signifcant source of antibody. Our case highlights that late period humoral rejection is a unique entity in which the graft itself functions as a lymphoid organ; as a result, splenectomy, whilst useful in early period humoral rejection, does not appear to be effective.

The Impact of Toll-Like Receptor Signaling On B Cells Responding to Blood Group A Carbohydrates.

[Aim] Bacterial infection following ABO-incompatible organ transplantation has been reported to be associated with refractory antibody-mediated rejection targeting blood type antigens. In this study, we investigated the influence of toll-like receptor(TLR) signaling, through the binding of bacterial-derived ligands, on B cell activation in response to blood group carbohydrate-antigens. [Methods] We have previously demonstrated that B cells responding to blood group A-antigens differentiate into CD11+CD5+B-1a cells, which can be blocked by calcineurin inhibitor(CsA) treatment, in mice, resembling humans. Resting B cells isolated from the splenocytes of Balb/c mice were treated with anti-IgM F(ab), an analog of TI-2 Ags, in the presence or absence of lipopolysaccharide(LPS)(10μg/ml) and CsA in vitro. After 3 days in culture, the phenotypic alteration of proliferating B-cells was analyzed by flow cytometry. Balb/c mice were also immunized with human blood type A-erythrocytes, with or without LPS administration(1 or 10μg/mouse). [Results] CD19+B cells stimulated with anti-IgM F(ab) proliferated vigorously. The proliferating B cells differentiated into CD5+B-1a cells in the absence of LPS, but in the presence of LPS, they differentiated into CD5-B-1b cells. A clinically relevant concentration of CsA(100ng/mL) completely blocked B-1a differentiation, but did not affect B-1b cell differentiation. Consistent with our previous findings, B-cells with anti-A receptors showed an sIgM+CD5+B-1a phenotype in mice immunized with A-erythrocytes. However, those cells showed an sIgM+CD5dim/-B-1b phenotype in mice immunized with A-erythrocytes together with LPS. Anti-A antibody production was augmented by LPS dose-dependently. CsA-treatment significantly inhibited anti-A Ab production in response to immunization with A-erythrocytes, though not in mice treated with LPS. [Conclusions] To our knowledge, these data provide the first evidence that B-cells responding to blood type A carbohydrate, in the presence of TLR signaling, show the sIgM+CD5dim/-B-1b phenotype, and lose susceptibility to inhibition by CsA. Blocking TLR signaling in B-cells with anti-A receptors may be a novel strategy to regulate Ab-mediated rejection associated with bacterial infection, following transplantation.

Extracorporeal Photopheresis (ECP) Improved Allograft Function and Significantly Reduced Inflammatory Cytokines in Patients (Pts) With Refractory Heart Allograft Dysfunction.

Background: ECP is an immunomodulatory therapy thought to be mediated by induction of lymphocyte apoptosis. ECP has been used for refractory rejection, chronic left ventricular dysfunction or persistence of donor-specific antibodies in heart transplant recipients (Tx pts). However, the mechanism(s) of action are unknown. We hypothesize that inflammatory processes are involved in allograft dysfunction and injury and ECP effectively reverses this process. Here we examined serum levels of inflammatory cytokine levels in heart Tx pts treated with ECP and correlated with clinical parameters. Methods: Thirteen heart Tx pts with chronic left ventricular dysfunction and/or recurrent antibody-mediated rejection underwent ECP consisting of 13 sessions over 6 month. 84 serum or plasma samples were collected pre- and post-ECP, and submitted for Luminex assays for cytokines, PRA class I and II (PRAI & II). Cytokine levels from the last 3 month of ECP therapy were used as post-ECP results. Cytokines >3.5pg/mL were considered +. Echocardiographic left ventricular dysfunction (EF%) pre- and post-ECP were tested. Results: IL-6, IL-17A, IFNγ and IL-10 levels were significantly decreased post-ECP. All 6 pts with IL-6+ (189±444 to 5±5pg/mL, p=0.03) and all 5 with IFNγ+ pre-ECP (20±18 to 7±6 pg/mL, p=0.06) showed significant reduction post-ECP. Five of 6 with IL-17+ pre-ECP showed reduction post-ECP (20±20 to 9±8pg/mL, p=0.15) and 3 of 4 with IL-10+ pre-ECP reduced the level (33±25 to 27±26pg/mL, p=0.3). Six of seven pts with available EF% pre- & post-ECP showed increase of EF% (35±20 to 45±23%, p=0.004). Of 6 pts with PRAII>20% and available results pre- & post-ECP, 4 showed significant reduction and the remaining 2 showed no change or increase (58±28 to 31±35%, p=0.3), while 2 pts with PRAI>20% did not show any change post-ECP (62±42 to 61±41, p=0.5). All patients showed clinical improvement post-ECP. Conclusion: IL-6 & IFNg levels were significantly reduced post-ECP and this correlated with a reversal of chronic left ventricular dysfunction and reduction of PRA, suggesting that the beneficial effect of ECP might be due, in part, to anti-inflammatory mechanism. A larger number of patients are needed to confirm these observations.

Treatment of Refractory Antibody-mediated Rejection with Bortezomib in a Kidney Transplant Recipient: A Case Report

Antibody-mediated rejection (ABMR) is associated with poor renal allograft survival. It shows poor response to conventional treatment with plasmapheresis, rituximab, and intravenous immunoglobulin. Bortezomib, a proteasome inhibitor used for treatment of multiple myeloma, has recently been reported as a treatment alternative for recipient desensitization and ABMR. A 58-year-old man was diagnosed with mixed-type ABMR with donor specific antibodies and acute T cell-mediated rejection early after kidney transplantation. Conventional therapy was administered, including antithymocyte globulin, plasmapheresis, and rituximab; however, his condition was found to be refractory to these antihumoral therapies. Following administration of bortezomib, his serum creatinine level returned to baseline with stable graft function. His serum creatinine level remains stable at 1.3 mg/dL at 10 months posttransplantation. Bortezomib is effective for treatment of refractory ABMR following kidney transplantation.

MHC class I signaling: new functional perspectives for an old molecule.

Donor-specific antibodies are associated with refractory rejection episodes and poor allograft outcomes in solid organ transplantation. Our understanding of antibody-mediated allograft injury is expanding beyond complement deposition. In fact, unique mechanisms of alloantibodies are advancing our knowledge about transplant vasculopathy and antibody-mediated rejection. These include direct effects on the endothelium, resulting in the recruitment of leukocytes, chemokine and cytokine production, and stimulation of innate and adaptive alloresponses. These effects will be the focus of the following review.