Serena M Bagnasco Department of Pathology Johns Hopkins ... · Learning from kidney allograft...

Learning from kidney allograft biopsies in highly sensitized patients Serena M Bagnasco

Department of Pathology Johns Hopkins School of Medicine

Johns Hopkins Incompatible Kidney Transplant Program

ABOi/HLAi (+XM) Desensitization Protocol

-6 -5 -4 -3 -2 -1 0 1 2 3

Transplantation Steroids

anti-IL2R Ab or Antithymocyte globulin

Continue Tac Continue MMF

Continue Tac (Target 10-12) Continue MMF (2 gm/d)

Prednisone Wean Continue antibody induction

Tac (0.1 mg/kg/d) or Sirolimus

MMF (2 gm/d)

Preoperative PP/CMVIg Target ABOi isoaggl < 1:16 Target HLAi DSA < + Flow XM

Postoperative PP/CMVIg until isoagglutinines/DSA plateau to low level

-7 4 5 6 7 8 9 10 11 12 -8 -9 -10

C5 inhibitor now being used for selected cases – not for this cohort

E Kraus, unpublished

Demographics ABOi +XM SRTR-2009

After 2005 51% 61%

18-34 17.4% 22.1% 20% 35-49 26.1% 42.2% 31% 50-64 46.4% 26.5% 36% 65+ 10.1% 9.2% 12%

Female 36% 65% 39% White 74% 81% 67%

African American 25% 14% 13% Hispanic/Latino 0% 3% 14%

Asian 1% 2% 5%


Previous Transplant 21.7% 52.6% 11% First 78.3% 47.4%

Second 17.4% 37.3% Third 4.3% 13.3%

Mean cPRA 83% PRA> 80% - 3.4% < Flow 20% Flow + 45%

Pos Cytotoxocity XM 34%

ABOi +XM SRTR-2009 Immunologic status

318 patients ABOi 69 HLAi (+XM) 249 ABOi&HLAi 26

Transplanted between 2/10/98-10/11/10 *Transplanted after 2005

* HLAi, +XM

HLAi, +XM

Graft Losses within 1 year : ~5% Cause ABOi HLAi/+XM

AKI 0 3 (1.2%)

Thrombosis 0 1 (0.4%)

Acute Rejection

Cellular 0 1 (0.4%)

AMR 0 1 (0.4%)

Cellular+AMR 0 2 (0.8%)

Chronic Injury

IFTA 0 1 (0.4%)

TG 0 2 (0.8%)

GN-FSGS 0 3 (1.2%)

Graft survival in highly sensitized HLAi/+XM (%) AVG 1 Year 89.9 90.6 98.4 92.9 3 Years 85.7 94.8 90.2 5 Years 69.4 71.2 80.6 70.7 79.9 74.4 8 Years 60.8 78 51 63.3 Haririan et al. AJT 2009, 41 desensitized, +XM HLAi pts LD Lefaucheur et al. JASN 2010, 30 patients with anti-HLA DSA at Tx DD Montgomery et al. NEJM 2011, 211 desensitized, +XM HLAi pts LD Bentall et al. AJT 2013, 102 desensitized, +XM HLAi pts LD Bagnasco et al. Transplantation 2014, 129 desensitized, +XM HLAi LD

One Year Allograft Function eGFR

(2010 USRDS Annual Report)

eGFR >60 51%

ABOi +XM

53% 41%

eGFR CKD-EPI

eGFR MDRD

59 pts 204 pts

eGFR >45 80%


Allograft function and eGFR after the First Year

ABOi HLAi/+XM

Years post Transplant

≥ 90

60-89

45-59

30-44 15-29 <15

eGFR 204 186 158 95 72 Patients 59 58 47 29 20


Time course of histologic injury in total of 745 kidney graft biopsies from 129 patients transplanted with a positive cross-match HLA-incompatible kidney between 2000 and 2010 (follow up: 1-9 years). (Bagnasco et al Transplantation 2014) Protocol biopsies at 1, 3, 6 and 12 months and indication biopsies Inclusion requirement of having at least two protocol biopsies, one at 1 or 3 months and one at 6 or 12 months post transplant Repeated graft biopsies and eGFR measurements in the same patient over time Capture “early” and “late” changes in graph histology and graft function in individual patients

Time course of histologic injury in total of 745 kidney graft biopsies from 129 patients transplanted with a positive cross-match HLA-incompatible kidney between 2000 and 2010 (follow up: 1-9 years). (Bagnasco et al Transplantation 2014)

70% pts experienced rejection during entire FU 52% pts experienced subclinical rejection 39% of all rejections detected in biopsies were subclinical N

of p

atie

nts

1 3 6 120

20406080

100120140

Subclinical RejectionRejection

Months post transplant

All Patients

36% 13%

A

1 2 3 40123456 P<0.0001

Years post transplant

ci +

ct s

core

3 6 120123456 P<0.0001


ci +

ct s

core

Histological parameters of graft injury Tubulointerstitial scarring

The average tubulointerstitial scarring increased significantly from 3 to 6 to 12 months within the first year 41% pts ci + ct ≥ 1 at 3 months 71% pts ci + ct ≥ 1 at 1 year

Bagnasco et al Transplantation 2014

1 2 3 40123456 P<0.0001


ci +

ct s

core

3 6 120123456 P<0.0001


ci +

ct s

core

Histological parameters of graft injury Tubulointerstitial scarring

P< 0.0006

Last eGFR

Last

ci+

ct

0 20 40 60 80 100

120

0

2

4

6

8

The average tubulointerstitial scarring increased significantly from 3 to 6 to 12 months within the first year 41% pts ci + ct ≥ 1 at 3 months 71% pts ci + ct ≥ 1 at 1 year

There was a small but significant inverse correlation between the degree of tubulointerstitial scarring at last follow up and the last known eGFR value in individual recipients (r = -0.2992; P<0.0006). Episodes of CMR in the first year did not result in a higher ci + ct score at 12 month, and were not associated with decreased graft function compared to the whole group.


Histological parameters of graft injury Microvascular inflammation in glomeruli (g ≥1) and peritubular capillaries (ptc ≥1) Glomerulitis (g ≥ 1) was detected in a total of 434 biopsies from 94/129 (72%) patients during total FU Correlation between g and ptc: Pearson r = 0.4866; 95% CI 0.4285 to 0.5408; P < 0.0001 Correlation between ptc and i: Pearson r = 0.2634; 95% CI 0.1936 to 0.3305; P < 0.0001


Margination of leukocytes in glomerular capillaries: Glomerulitis (g>1)

Margination of leukocytes in peritubular capillaries (ptc >1)

Histological parameters of graft injury Microvascular inflammation in glomeruli (g ≥1) and peritubular capillaries (ptc ≥1) Glomerulitis (g ≥ 1) was detected in a total of 434 biopsies from 94 patients during total FU Correlation between g and ptc: Pearson r = 0.4866; 95% CI 0.4285 to 0.5408; P < 0.0001 Correlation between ptc and i: Pearson r = 0.2634; 95% CI 0.1936 to 0.3305; P < 0.0001

1 3 6 120

20406080

100120140 Protocol bx

All bx

Months post transplantAll biopsies 188 139 158 172Protocol 85 92 99 101

N of

pat

ient

s

Glomerulitis in the first year First appearance of glomerulitis Median 1.2 months Average 3.8 ± 5.2 months Glomerulitis associated with lower eGFR 69 patients with glomerulitis in biopsies at 1 month (g ≥ 1) compared with those without glomerulitis (g=0) 6 months eGFR 53 ± 13 vs 60 ± 16 (P=0.007) 12 months eGFR 50 ± 17 vs 59 ± 16 (P=0.005)


Histological parameters of graft injury

Transplant glomerulopathy (cg ≥ 1) developed in 61 pts (47%)

3 6 120

1

2

3P < 0.0001


cg s

core

1 2 3 40

1

2

3P < 0.0001

Years post transplantcg

sco

re

the cg scores in indication biopsies after the first year were on average higher than those measured at 1 year


Histological parameters of graft injury

Transplant glomerulopathy (cg ≥ 1) developed in 61 pts (47%)

3 6 120

1

2

3P < 0.0001


cg s

core

1 2 3 40

1

2

3P < 0.0001

Years post transplantcg

sco

re

the cg scores in indication biopsies after the first year were on average higher than those measured at 1 year

P< 0.0001

Last eGFR

Last

cg

20 40 60 80 100

120

-1

0

1

2

3

4

There was no significant difference in the 12 month eGFR between patients with or without TxGN. However, there was moderate but significant inverse correlation between the degree of transplant glomerulopathy and the last known eGFR value in individual recipients


Glomerulitis as a precursor of transplant glomerulopathy

First appearance of glomerulitis Median 1.2 months Average 3.8 ± 5.2 months

0 12 24 36 48 60 72

1≥cg

1 ≥g


Firs

t app

eara

nce



First appearance of glomerulitis Median 1.2 months Average 3.8 ± 5.2 months First appearance of transplant glomerulopathy (TxGN) Median 12 months Average 17.6 ± 16.7 months

0 12 24 36 48 60 72

1≥cg

1 ≥g


Firs

t app

eara

nce




Of 61 patients who developed TxGN, 58 (95%) had previous evidence of glomerulitis

0 12 24 36 48 60 72

1≥cg

1 ≥g


Firs

t app

eara

nce




Of 61 patients who developed TxGN, 58 (95%) had previous evidence of glomerulitis

0 12 24 36 48 60 72

Months

g≥

1 to

cg≥

1 between detection glomerulitis and first appearance of TxGN Median 12 months Average 15 ± 15 months

0 12 24 36 48 60 72

1≥cg

1 ≥g


Firs

t app

eara

nce


Post transplant

DSA No DSA0

20

40

60cg ≥ 1 1 yearcg = 0 1 year

Patie

nts

P = 0.0486

Presence of DSA after transplant is associated with increased rates of TxGN by year 1 post transplant

Glomerulitis detected in the first month is associated with increased development of TxGN by year 1 post transplant (P<0.0002) and year 2 post transplant (P<0.0001)

1 month post transplant

g ≥ 1 g = 0 0

20

40


Patie

nts

P = 0.0002


g ≥ 1 g = 0 0

20

40

60cg ≥ 1 by year 2cg = 0 by year 2

Patie

nts

P = 0.0001

33% 77%

40%


No TxGN = 96.7% TxGN = 66.7%

Transplant glomerulopathy (cg ≥1) detected on 1 year graft biopsies in JHU HLA-incompatible transplant recipients is associated with decreased graft survival (P<0.001)

Sharif et al. Transplantation 97: 541-547, 2014 Histologic phenotype on 1-year posttransplantation biopsy and allograft survival in HLA-incompatible kidney transplants.

Long term kidney allograft survival in patients with transplant glomerulitis Nabokov et al Transplantation 99: 2015 112 pts (ABO-compatible) with glomerulits (G) • Isolated G (isG) n=24 • G+TCMR n=22 • ABMR n=24 149 controls • TCMR n=61 • No rejection (NR) n=88

Glomerulitis was independently associated with risk of graft failure.

The diffuse extent of peritubular capillaritis in renal allograft rejection is an independent risk factor for graft loss. Kozakowski et al Kidney Int. 2015 Retrospective study 1322 indication bx from 749 transplant recipients A ptc score of 3 and diffuse peritubular capillaritis were significant impartial risk factors for allograft loss. Diffuse peritubular capillaritis was independently associated with features of chronic antibody-mediated rejection and greater eGFR decline after 3 years.

(Type of leukocyte in peritubular capillaritis did not confer additional prognostic information)

Goal: improve the outcome for highly sensitized kidney transplant recipients Differences among US and international transplant centers : definitions, technologies, criteria for pre-transplant evaluation and desensitization, clinical protocols for post-transplant follow-up, management, treatment of these patients

Systematic analysis of different approaches is needed Identification of best evidence-based approaches to the care of these patients Design of multi-center clinical trials

Objectives of the Banff Highly Sensitized Working Group

• Determine the definitions and practices of clinicians, tissue typing laboratory

directors, and pathologists in evaluating and managing highly sensitized kidney transplant candidates and recipients

• Develop evidence-based recommendations for evaluation and transplantation of

patients with broad sensitization and/or high titer donor-specific antibodies

• 3 questionnaires sent to US and international transplant centers targeting practices

• Tissue typing laboratories • Nephrologists and surgeons • Pathologists

Questionnaire to identify current practice relevant to highly sensitized patients

HLA-typing labs: • Criteria used to define your allo-sensitized patient population? • Reporting strength of anti-HLA antibodies? Definition of Strong/Medium/Weak/Negative?

• Type of tests for - & - Definition of HLA unacceptable antigens? • Use of Virtual Crossmatch for kidney transplant candidates? When? • Confirmation of Virtual Crossmatch results with other test?

• Assay(s) threshold for entering “desensitization” protocols? • Criteria for eligibility for transplant after “desensitization”? • Absolute contraindications to transplant in your Lab/Center?

Darshana M Dadhania (Cornell), Annette Jackson (Hopkins) et al.

Clinical Nephrologists and Surgeons: • Procedures/treatment protocols for “desensitization” pre-transplant? • Treatments/services readily available at your center within 24 hours? (biopsy results, plasmapheresis, IVIG, anti-complement agents) • Protocol biopsies? If yes when? • Monitor DSA antibodies post-transplant? Pre-formed? De novo? When? • How often do you test for creatinine and proteinuria post-transplant?

• Treatment of acute cell mediated rejection? • Treatment for antibody-mediated rejection? • How do you determine the duration of treatment for rejection?

Ed Kraus (Hopkins), Carrie A Schinstock (Mayo) et al.

Pathologists : • Who read the renal transplant biopsies? Renal pathologists – General surgical

pathologist?

• Do you test for C4d (and immunoglobulins complement) on all the transplant biopsies? • C4d test by immunofluorescence on frozen tissue or by immunohistochemistry?

• Electron microscopy on the kidney transplant biopsies? • If yes, on all, selected cases, at certain times post transplant?

• Process and read transplant biopsies on same day and/or during week-end?

• Use of updated Banff classification for renal transplant biopsies? • Inclusion of all the individual Banff scores (i, t, v….) on the final biopsy report?

• Molecular tests on kidney biopsy tissue (RNA transcripts, others)?

Serena M Bagnasco (Hopkins), Lynn Cornell (Mayo), et al.

Thank you

© 2014 by Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 2

TABLE 1 Time Course of Pathologic Changes in Kidney Allografts of Positive Crossmatch HLA-Incompatible Transplant Recipients. Bagnasco, Serena; Zachary, Andrea; Racusen, Lorraine; Arend, Lois; Carter-Monroe, Naima; Alachkar, Nada; Nazarian, Susanna; Lonze, Bonnie; Montgomery, Robert; Kraus, Edward Transplantation. 97(4):440-445, February 27, 2014. DOI: 10.1097/01.TP.0000437177.40551.f4

TABLE 1 Characteristics of the recipients of HLA-incompatible kidney transplant in this study


FIGURE 1 Time Course of Pathologic Changes in Kidney Allografts of Positive Crossmatch HLA-Incompatible Transplant Recipients. Bagnasco, Serena; Zachary, Andrea; Racusen, Lorraine; Arend, Lois; Carter-Monroe, Naima; Alachkar, Nada; Nazarian, Susanna; Lonze, Bonnie; Montgomery, Robert; Kraus, Edward Transplantation. 97(4):440-445, February 27, 2014. DOI: 10.1097/01.TP.0000437177.40551.f4

FIGURE 1 . Patients with biopsy-proven rejection during the first year after transplantation. Indication and protocol biopsies are included and grouped according to the time after transplantation. A, patients who experienced any type of rejection. Patients with rejections detected in protocol biopsies, representing subclinical rejection, are shown in gray. Patients with rejections detected in for cause biopsies are shown in black. All remaining patients are shown in white. B, patients who experienced CMR, including patients with subclinical CMR. C, patients who experienced AMR, including patients with subclinical AMR.

36% 13%



FIGURE 2 . A, patients with glomerulitis (g>=1) all in serial biopsies in the first year and patients in whom glomerulitis was present without diagnostic evidence of rejection in protocol biopsies. B, TxGN (cg score) in graft biopsies of individual patients. Data are mean+/-SD for biopsies taken at the indicated time after transplantation, with difference among groups tested by ANOVA.



FIGURE 4 . Tubulointerstitial scarring (ci+ct score) in graft biopsies of individual patients. Data are mean+/-SD for biopsies taken at the indicated time after transplantation, with difference among groups tested by ANOVA.

Time course of histologic injury in total of 745 kidney graft biopsies from 129 patients transplanted with a positive cross-match HLA-incompatible kidney between 2000 and 2010 (follow up: 1-9 years). (Bagnasco et al Transplantation 2014)

70% pts experienced rejection during entire FU 52% pts experienced subclinical rejection 39% of all rejections detected in biopsies were subclinical

In this study CMR was more frequent than AMR

in the first year and afterwards

N of

pat

ient

s

1 3 6 120

20406080

100120140

Subclinical RejectionRejection


All Patients

N of

pat

ient

s w

ith re

ject

ion

1 3 6 120

20

40

60

80

100 CMRAMR


1 2 3 40

5

10

15

20

25

AMRCMR

N bx 188 26 30 37


% o

f gra

ft bi

opsi

es

Histological parameters of graft injury Microvascular inflammation in glomeruli (g ≥1) and peritubular capillaries (ptc ≥1) Glomerulitis (g ≥ 1) was detected in a total of 434 biopsies from 94/129 (72%) patients during total FU Correlation between g and ptc: Pearson r = 0.4866; 95% CI 0.4285 to 0.5408; P < 0.0001 Correlation between ptc and i: Pearson r = 0.2634; 95% CI 0.1936 to 0.3305; P < 0.0001

1 3 6 120

20406080

100120140 Protocol bx

All bx

Months post transplantAll biopsies 188 139 158 172Protocol 85 92 99 101

N of

pat

ient

s

Glomerulitis in the first year First appearance of glomerulitis Median 1.2 months Average 3.8 ± 5.2 months


Allograft function and eGFR after the First Year

ABOi HLAi/+XM

Years post Transplant

≥ 90

60-89

45-59

30-44 15-29 <15

eGFR 204 186 158 95 72 Patients 59 58 47 29 20


2002-2003 kidney only recipients

How can we improve the outcome for highly sensitized kidney transplant recipients?


• Determine the definitions and practices of clinicians, tissue typing laboratory directors, and pathologists in evaluating and managing highly sensitized kidney transplant candidates and recipients




• Assess for differences in antibody-mediated rejection in highly sensitized patients versus other kidney transplant recipients




• Assess for differences in antibody-mediated rejection in highly sensitized patients versus other kidney transplant recipients

• Develop evidence-based recommendations for evaluation and transplantation of patients with broad sensitization and/or high titer donor-specific antibodies

• 3 questionnaires targeting practice of pathologists, clinicians and tissue typing laboratory directors sent to US and international transplant centers, results from these survey responses are being collected to be reviewed, analyzed, and will be presented to the Banff community for further study.

Johns Hopkins Incompatible Kidney Transplant Program

318 Patients 2/10/98-10/11/10

Blood Group Incompatible

ABOi 69

Positive Cross match

+XM 249*

* 26 Recipients with both ABOI and +XM

~ 50% transplanted after 2005

Graft Losses within 1 year : ~5% Cause ABOi HLAi/+XM

AKI 0 3 (1.2%)

Thrombosis 0 1 (0.4%)

Acute Rejection

Cellular 0 1 (0.4%)

AMR 0 1 (0.4%)

Cellular+AMR 0 2 (0.8%)

Chronic Injury

IFTA 0 1 (0.4%)

TG 0 2 (0.8%)

GN-FSGS 0 3 (1.2%)

Cause ABOi HLAi/+XM

AKI 0 1 (0.4%)

Acute Rejection-AMR 1 (1.4%) 0

Chronic Injury

GN 1 (1.4%) 4 (1.6%)

IFTA 2 (2.9%) 5 (2.0%)

TG 1 (1.4%) 9 (3.6%)

Graft Losses after 1 year: ~8%

Graft survival in highly sensitized HLAi/+XM (%) AVG 1 Year 89.9 90.6 98.4 92.9 3 Years 85.7 94.8 90.2 5 Years 69.4 71.2 80.6 70.7 79.9 74.4 8 Years 60.8 78 51 63.3 Haririan et al. AJT 2009, 41 desensitized, +XM HLAi pts LD Lefaucheur et al. JASN 2010, 30 patients with anti-HLA DSA at Tx DD Montgomery et al. NEJM 2011, 211 desensitized, +XM HLAi pts LD Bentall et al. AJT 2013, 102 desensitized, +XM HLAi pts LD Bagnasco et al. Transplantation 2014, 129 desensitized, +XM HLAi LD

Demographics ABOi +XM SRTR-2009

After 2005 51% 61%

18-34 17.4% 22.1% 20%

35-49 26.1% 42.2% 31%

50-64 46.4% 26.5% 36%

65+ 10.1% 9.2% 12%

Female 36% 65% 39%

White 74% 81% 67%

African American 25% 14% 13%

Hispanic/Latino 0% 3% 14%

Asian 1% 2% 5%

• +XM slightly younger • ABOi slightly older

compared to US live donor kidney transplant patients

There are more women in the +XM group compared to US live donor

kidney transplant patients •Effect of pregnancy

More African Americans in ABOi compared to US live donor kidney transplant patients Blood Groups B and O

Courtesy of E Kraus

Immunologic Status ABOi +XM SRTR-2009

Previous Transplant 21.7% 52.6% 11%

First 78.3% 47.4%

Second 17.4% 37.3%

Third 4.3% 13.3%

Fourth 0.0% 1.6%

Fifth 0.0% 0.4%

Mean cPRA 83% PRA> 80% - 3.4%

< Flow 20%

Flow + 45%

Pos Cytotoxocity XM 34%

Courtesy of E Kraus

Post transplant

DSA No DSA0

20

40


Patie

nts

P = 0.0486

Data analyzed cg ≥ 1 1 year cg = 0 1 year Total DSA 20 50 70 No DSA 4 31 35 Total 24 81 105

Risk of TxGN increased with post tx DSA Risk of TxGN at 1 and increased with glomerulitis at 1 month


g ≥ 1 g = 0 0

20

40


Patie

nts

P = 0.0002

Data analyzed cg ≥ 1 by year 1 cg = 0 by year 1 Total g ≥ 1 23 46 69 g = 0 3 50 53 Total 26 96 122

Risk of TxGN at 2 years increased with glomerulitis at 1 month


g ≥ 1 g = 0 0

20

40

60cg ≥ 1 by year 2cg = 0 by year 2

Patie

nts

P = 0.0001

Data analyzed cg ≥ 1 by year 2 cg = 0 by year 2 Total g ≥ 1 30 39 69 g = 0 4 49 53 Total 34 88 122

Graft Losses After the First Year Cause ABOi +XM

AKI 0 1 (0.4%)

Acute Rejection-AMR 1 (1.4%) 0

Chronic Injury

GN 1 (1.4%) 4 (1.6%)

IFTA 2 (2.9%) 5 (2.0%)

TG 1 (1.4%) 9 (3.6%)

Graft survival in highly sensitized recipients (%) Mean 1 Year 89.9 90.6 98.4 92.9 3 Years 85.7 94.8 90.2 5 Years 69.4 71.2 80.6 70.7 79.9 92.9 8 Years 60.8 78 51 63.3 Haririan et al. AJT 2009, 41 desensitized, +XM HLAi pts LD Lefaucheur et al. JASN 2010, 30 patients with anti-HLA DSA at Tx DD Montgomery et al. NEJM 2011, 211 desensitized, +XM HLAi pts LD Bentall et al. AJT 2013, 102 desensitized, +XM HLAi pts LD Bagnasco et al. Transplantation 2014, 129 desensitized, +XM HLAi LD

Graft survival in highly sensitized recipients (%) Mean 1 Year 89.9 90.6 98.4 92.9 3 Years 85.7 94.8 90.2 5 Years 69.4 71.2 80.6 70.7 79.9 92.9 8 Years 60.8 78 51 63.3

Haririan et al. AJT 2009, 41 desensitized, +XM HLAi pts LD Lefaucheur et al. JASN 2010, 30 patients with anti-HLA DSA at transplantation DD Montgomery et al. NEJM 2011, 211 desensitized, +XM HLAi pts LD Bentall et al. AJT 2013, 102 desensitized, +XM HLAi pts LD Bagnasco et al. Transplantation 2014, 129 desensitized, +XM HLAi LD

Change of eGFR after the First Year (2010 USRDS)

2002-2003 kidney only recipients Courtesy of E Kraus

Date post:	01-Jan-2019
Category:	Documents
Upload:	vutuong
View:	226 times
Download:	0 times

Serena M Bagnasco Department of Pathology Johns Hopkins ... · Learning from kidney allograft...

Documents