Transcript Document

Complement in Heart
Allograft Biopsies
E. Rene Rodriguez
W. M. Baldwin, III
Revision of the 1990
Working Formulation for the
Standardization of Nomenclature in
the Diagnosis of Heart Rejection
Susan Stewart, et al 2005 JHLT (in press)
Acute humoral rejection is recognized as a
clinical entity in th e grafted heart.
It remains controversial, however, with a
highly va ried incidence between different
centers and no consensus has yet been
reached on its recognition and diagnosis
either histopathologically o r
immunologically .
The 2004 ISHLT meeting reviewed evidence from the
immunopathology and clinical task forces and felt able to
suggest di agnostic criteria in s pecific circumstances so that
further assessment of this entity could be encouraged.
Variables in Heart Studies
Patient Population
Percent Sensitized
•LVAD
•Blood Transfusions
•Pregnancy
•Previous transplant
Immunosuppression
Prospective Study of
Cardiac Transplants
• All biopsies from Jan ‘01 to Dec ‘03
• 665 biopsies from 165 patients
• 107 males: 58 females
• 34 patients followed from time of
transplantation
• almost all patients had 0%PRA
Rodriguez et al AJT 2005 (in press)
ROUTINE DIAGNOSTIC
PROTOCOL BIOPSIES FROM
CARDIAC TRANSPLANTS
1 mo
2 mo
3 mo
6 mo
H&E, IP (CD68)
FITC (IgG, IgM, IgA, C1q, C4d, C3d)
1 yr
Number of Patients with
Positive Biopsies
165
150
135
120
105
90
75
60
45
30
15
0
16
(9.6%)
IgG
IgM
IgA
C1q
C4d
17
(10.3%)
C3d
C4d and/or C3d Deposits
(665 consecutive biopsies from 165 patients)
C3d+
C3d -
C4d+
13 (8%)*
3 (2%)
C4d-
4 (2%)
145 (88%)
* One patient 10% PRA
Time of Positiv e Biopsies for C4d and/or C3d
6
5
Number of Patients
4
3
C4d
C3d
C4d & C3d
2
1
0
1
2
3
4
5
6
7
8
9
10
11
Years after Transplantation
12
13
14
15
16
17
18
Incidence of C4d and C3d deposits
Dysfunction
n=5
n=3
C4d
n=4
n = 13
C4d + C3d
C3d
Patients with AMR
ISHLT C4d + CD
Dys#
grade C3d 68 function graft
Donor
Sp. Ab.
HLA
(I or II)
1B
+
+
+
2nd
+
I + II
1A
+
+
+
2nd
-
-
0
+
+
+
2nd
+
I
1B
+
+
+
1st
-
-
1A
+
+
+
1st
+
II
ANTIBODY ASSOCIATED REJECTION
7 years after transplantation
anti-DR7 and DRw53
Macrophages
Response to Therapy
Plasmapheresis and IVIg
• Graft function improved
• DSA decreased or eliminated
• (C consumption not measured)
• C3d deposits cleared first
• Low levels of antibodies (as
detected Flow beads) can persist
beyond C4d
Association of Cardiac Allograft Vasculopathy
with C4d C3d and AMR
10
8
Vasculopathy
total
6
4
2
0
C4d only
C3d only
C4d + C3d
C4d + C3d
AM R
Incidence of C4d and C3d deposits
Dysfunction
n=5
n=3
C4d
n=4
n = 13
C4d + C3d
C3d
Second Heart Transplant with Repeat HLA Mismatch
Strong C4d, Little C3d, No HLA antibodies, Good Function
Fluorescence (1 to 4+)
4
1st heart HLA-A1
2nd heart HLA-A1
C4d
C3d
ISHLT
3
2
1B
1A
1
0
0
12
0
Months after Transplantation
Baldwin et al 2004 AJT 4:311
No antibodies
Class I or II
Regulation of
Complement Cascade
C1
C4
C4bp
DAF
MCP*
CR1*
Factor I
C2
C3
Factor H
DAF
MCP*
CR1*
Factor I
C5 C6
C7
CD59 C8
C9
C4d and C3d are Products
Complement Regulation
C1
C4
C4bp
DAF
MCP*
CR1*
Factor I
C2
C3
Factor H
DAF
MCP*
CR1*
Factor I
C4d
C5 C6
C7
CD59 C8
C9
C3d
Sensitization vs Regulation
C1
C4
C2
C3
Sensitization vs Regulation
C1
C1
C4
C4
C2
C2
C3
C3
Sensitization vs Regulation
C1
C1
C1
C1
C1
C2
C4
C2
C4
C4
C4
C4
C2
C2
C2
C3
C3
C3
C3
C3
C5 C6
C7
C8
C9
Epilogue
“Acute humoral rejection is recognized …
with a highly va ried incidence between
different centers…”
Epilogue
“Acute humoral rejection is recognized …
with a highly va ried incidence between
different centers…”
…and between different eras in the same center
eg, JHU
Increased patients with >0% PRA
2 patients with episodes of antibody-mediated
rejection in the first weeks after transplantation
Required longer treatment with PP & IVIg
Summary
C4d and C3d in Heart Transplants
• Incidence depends on sensitization
• Can occur years after transplantation
• Needs to be correlated with graft function
and Donor Specific Antibody (DSA) for a
diagnosis of antibody-mediated rejection
• May be correlated with increased graft
vasculopathy
Clinical studies
E. Rene Rodriguez
Experimental studies
Kenji Minami
Kazunuri Murata