42
Interplay of subclinical fibrosis and inflammation D. Serón Nephrology Department Hospital Vall d’Hebro Barcelona
Interplay of subclinical fibrosisand
inflammation
D. SerónNephrology Department Hospital Vall d’HebronBarcelona
Inflammation with and without fibrosis
Inflammation and CHR
Innate immunity and inflammation
Surveillance biopsies
Inflammation with and without fibrosis
Inflammation and CHR
Innate immunity and inflammation
Surveillance biopsies
Inflammation
Inflammation and fibrosis in
surveillance Bx
Dimény E, Clin Transplantation 1995; 58(11): 1195Serón D, Kidney Int 1997; 51: 310Nankivell BJ et al, Transplantation 2004; 78:242Choi BS et al, Am J Transplant 2005; 5: 1354
Fibrosis
Graft survival
Graft survival
SCR and CAN in paired biopsiesn=598 Bx, (no SCR 462, SCRB 102, SCRA 34)
Nankivell BJ et al, Transplantation 2004; 78:242Ibernon et al et al, Kidney Int 2006; 76: 557
* p<0.05***p<0.001
Proper classification of inflammation and fibrosis
Normal (no inflammation no fibrosis)
Inflammation and fibrosis
Inflammation (no fibrosis)
Fibrosis (no inflammation)
SCR & IF/TA
Shishido et al, JASN 2003; 14: 1046Cosio FG et al, Am J Transplant 2005; 5: 2464, Moreso F et al Am J Transplant 2006; 6:747
IF/TA without SCR
IF/TA with SCR
Normal1 year protocol BxSCR + IF/TA
SCR + IF/TA
SCR + IF/TA
1 year protocol Bx
.25
.5
.75
1
0 50 100 150 200 months
Normal=186
SCR=74
IF/TA=110
IF/TA+SCR=65
< 6 month protocol Bx
IF/TA without SCR
IF/TA with SCR
Hig
h in
flam
matio
n
Low
infla
mm
atio
n
CD45 CD3 CD20 CD68 CD15
High (upper tertile) and low (two lower tertiles) inflammation
Inflammation with or whitout IF/TA
Moreso F et al. AJT 2007; 7: 2739
0
500
1000
1500
2000
2500
NORMAL SCRa IF/TA SCR+IF/TAa,c0
300
600
900
1200
1500
NORMAL SCRa IF/TA SCR+IF/TAa,c
0
200
400
600
800
NORMAL SCR IF/TAa SCR+IF/TAa,b,c 0
500
1000
1500
2000
2500
3000
3500
NORMAL SCRa IF/TA SCR+IF/TAa,c
CD
45 p
osit
ive c
ells /
mm
2 in
ters
titi
um
CD
20 p
osit
ive c
ells /
mm
2 in
ters
titi
um
CD
68 p
osit
ive c
ells /
mm
2 in
ters
titi
um
CD
3 p
osit
ive c
ells /
mm
2 in
ters
titi
um
Interstitial infiltrating cells
Moreso F et al. AJT 2007; 7: 2739
Renal allograft survival(univariate)
0
,2
,4
,6
,8
1
Survival (%)
0 20 40 60 80 100 120 140
months
T1T2
T3
Moreso F et al Am J Transplant 2006; 6: 747
P=0.001
Renal allograft survival(multivariate)
Variable Univariate MultivariateRR (95% CI) p RR (95% CI) p
Retransplant (yes) 2.5 (0.9-6.9) 0.06 1.2 (0.3-5.3) ns
PRA > 50% 4.6 (1.7-12.6) <0.01 4.5 (1.0-20.4) 0.05
CD20 (upper tertile) 3.3 (1.4-8.3) <0.01 3.0 (1.2-7.3) 0.01
Moreso F et al Am J Transplant 2006; 6: 747
B cells, acute rejection and outcome inindication biopsies
Sarwal et al. et al. NEJM 2003; 349: 125.Hippen BE et al. Am J Transplant 2005; 5: 2248Alausa M et al. Clin Transplant 2005; 10: 137Eileen WT et al. Transplantation 2006; 82: 1769Lehnhardt et al. Am J transplant 2006; 6: 847Zarkhin V et al. Kidney Int 2008; 74: 664Mourah MR et al. Pediatr Transplant 2009; 13
B cells associated with poor outcome in AR
B cells not associated with poor outcome in ARScheepstra C et al. Transplantation 2008; 86:772Bagnasco SM et al. Am J Transplant 2007; 7: 1968-1973
Immunophenotype in protocol biopsies from TAC vs CsA treated patients
n= 44TAC vs 22 CsA
P<0.01
P<0.01 P<0.05ns
Serón D et al, Transplantation 2007; 83:649
B cell survival in CHR after rituximabn=38 explanted grafts with CHR 2 after treatment with rituximab
Intragraft B cells
BAFF positivity
Thaunat et al. Transplantation 2008; 85:1648
SCR vs SCR+IF/TA and FoxP3
Bestard et al. JASN 2008; 19: 2010
SCR SCR +No IF/TA IF/TA p
N 19 18___________________________________________________%FoxP3 + cells 14.2 +/-16.3 8.2+/-8.1 0.035___________________________________________________
T regs in pts ACR and BL (indication (12 ACR, 12 BL) and surveillance (8ACR, 8 BL)
Taflin et al. Transplantation 2010; 89: 194
Surveillance Bx cytokine transcripts
Hueso M et al. Am J Pathol 2010; 176: 1696
P< 0.01
IL10
Inflammation+IFTA
B cellsTregs
Th2 responseAg presentation
Persistent inflammation?CHR?
Inflammation with and without fibrosis
Inflammation, IF/TA and CHR
Innate immunity and inflammation
Surveillance biopsies
Tx Inflammation CAN±
Inflammation
Survival
SCR and CHR
Tx Inflammation IF/TA±
Inflammation
Survival
SCR and CHR
CHR
SCR and Chronic humoral rejection1988-2006
Protocol Bx n = 517
CHR 44IF/TA nos 42Recurrence 11De novo GN 7Acute rejection 4Polyoma 1
Bx for cause: n = 109
Clinical characteristics at the time of biopsy
Variable CHR (44) IF/TA (42) p
Protocol biopsyTime (m) 4.5 ± 2.4 4.6 ± 3.3 nsSCr (mol/L) 149 ± 37 144 ± 44 nsProteinuria (g/d) 0.3 ± 0.2 0.3 ± 0.2 ns
Biopsy for causeTime (y) 6.4 ± 3.4 8.2 ± 4.4 0.037SCr (mol/L) 240 ± 141 204 ± 80 nsProteinuria (g/d) 2.3 ± 2.4 1.4 ± 1.7 0.061
Clinical characteristics of patientsVariable CHR IF/TA p-value
(n=44) (n=42)__________________________________________________Donor age (years) 40 ± 16 34 ± 15 nsDonor gender (% male) 65.9 78.6 nsPatient age (years) 43 ± 12 40 ± 12 nsPatient gender (male) 59.1 69.0 nsPRA (%) 7 ± 18 3 ± 10 nsVirus hepatitis C 18.2 9.5 nsRe-transplants (%) 15.9 2.3 0.058HLA DR mm 0.7 ± 0.5 0.7 ± 0.6 ns
Cold ischemia time (hours)23 ± 6 21 ± 6 nsImmunosuppression
CNI without MMF 24 27CNI with MMF 18 12CNI with mTOR-i 1 2CNI free 1 1 ns
Delayed graft function (%) 25 19 nsAcute rejection (%) 22.7 26.2 ns_________________________________________________________
(p=0.003)
Acute score
Acute Banff score in surveillance Biopsies
SCR, CHR and IF/TA
CHR IF/TA p__________________________________SCR (%) 52.3 28.6 0.025__________________________________
RR 95% CI p__________________________________SCR 2.52 1.1-6.3 0.047ReTx 6.7 0.8-58.8 ns__________________________________
n=34 n=17 n=17 n=18
% of cases with CHR and IF/TA in the biopsy for cause
Dg categoryin surveillance Bx
Is inflammation in SCR different from SCR + IFTA?
Are early Bx findings different in patients developing IFTA in comparison with patients developing CHR
Innate immune alterations and inflammation
Surveillance biopsies
Risk factors associated with early inflammation in surveillance biopsies
Immunosuppressive treatment
Acute rejection before surveillance Bx
Innate immunity & inflammation in the general population
TLR-2 expression in 6 m surveillance Bx is associated wit lower SCR257 surveillance Bx 6w, 3m, 6m and 108 indication Bx
De Groot K et al. Am J Nephrol 2008; 28: 583
MBL 96KDa protein made of 3 identical 32 KDa structures
Carbohydrate recognition domain
Collagen like domain
N-terminal cross linking region
N-acetylglucosamine D-mannoseN-acetyl mannosamineL-fructose
Bouwman LH et al. 2006; 67:247
Defense collagens
Bohlson SS et al. Mol Immunol 2007; 44:33
MBL in Renal TransplantsMar 2005 –Oct 2006, 125 RT, 111 with a functioning graft at 3 m
0
,5
1
1,5
2
2,5
3
3,5
4
Cel
l Mea
n
MBL-T1 MBL-T2 MBL-T3Cell
Interaction Bar Plot for CualquierMBLEffect: MBL-terciles
T 1
Low MBLN=42
T 2,3
High MBLN=83Log MBL
(ng/ml)
sTNFR2 before Txsoluble TNFR
p=0.05
Ibernon M et al. Transplantation 2009: 88: 272
MBL and infection (bacterial or fungal)March 2005-Oct 2006, 125 pts,
111 with a functioning graft at 3 m
Ibernon M et al. Transplantation 2009: 88: 272
MBL and NODAT March 2005-Oct 2006, 125 pts,
111 with a functioning graft at 3 m
Ibernon M et al. Transplantation 2009: 88: 272
P=0,0054
Low MBL and SCR(n=60)
Ibernon M et al. Kidney Int (in press)
(N=6)
(N=32)
Low MBL, subclinical rejection and Tx CAD
Arnt RF et al. Eur Heart J 2005; 26: 1660
C1q and MBL and rejection
Bohlson SS et al. Mol Immunol 2007; 44:33
C1q deficiency and acute rejectionHeart transplant in C1q deficient mice
Csencsits K et al. AJT 2008; 8: 1622
WT
C1q-/-
C1q deficiency and acute rejectionHeart transplant in C1q deficient mice
Csencsits K et al. AJT 2008; 8: 1622
T cell response is not enhanced in C1q-/- mice
More intense anti-donor Ab response
Tissue injury and repair
TxInjuryApotosisNecrosis
RepairNormalIFTA
Progression of injurySCR + IFTACHR
-
+
Inflammation(SCR)
Innnate Immunity
