Daniel SerónNephrology DepartmentHospital Vall d’HebronBarcelona

Early detection and prevention ofacute and chronic allograft damage

Acute and chronic lesions and outcome

Immunosuprresion and damage

New markers of early damage

Acute and chronic lesions and outcome

Immunosuprresion and damage

New markers of early damage

IF/TASCRCHR

Recurrence De novo GN

Polyoma

Protocol biopsies

Cortesy: M Carrera

Subclinical rejection

=

Tubulointerstitial inflammation

Subclinical rejection (CsA, Aza, PN)n= 25 patients and 125 biopsies

0 1 2 3 6 12 m

Rush DN et al Transplantation 1995; 59: 511

SCR and progression of IF/TAn=598 BX, (no SCR 462, borderline 102, SCR34)

Nankivell BJ et al, Transplantation 2004; 78:242

* p<0.05***p<0.001

SCR at 14 d (living donor) n=304 patients

Choi BS et al, Am J Transplant 2005; 5: 1354

SCR + IF/TA and graft survival

Shishido et al, JASN 2003; 14: 1046

IF/TA without SCR

IF/TA with SCR

Normal

1 year protocol Bx

.25

.5

.75

1

0 50 100 150 200 months

Normal=186SCR=74IF/TA=110

IF/TA+SCR=65

Cosio FG et al, AJT 2005; 5: 2464Moreso F et al AJT 2006; 6: 747

IF/TA with SCR

Inflammation in areas of tubular atrophyn=337 indication Bx for cause

Mannon RB, et al. AJT 20010; 10: 2066

Glomerular enlargement after renal Tx

Serón D and Moreso F. Transplant Rev 2007; 21: 110

Glomerular enlargement and SCR(n=61)

1st B 2nd BδVg

4m 1y

Ibernon et al et al, Kidney Int 2006; 76: 557

Glomerular enlargement

yes no

4-month 1-year

No glom enlargementδ Vg < 1 (n=29)

*

*

*4-month 1-year

Glom enlargement δ Vg ≥ 1 (n=32)

*

*

Ibernon et al et al, Kidney Int 2006; 76: 557*p<0.05

0

2

4

6

4-month 1-year

Glomerulosclerosis (%)

Glomerular enlargementδ Vg ≥ 1 (n=32)

0

2

4

6

4-month 1-year

*

Glomerulosclerosis (%)

No glomerular enlargementδ Vg < 1 (n=29)

Ibernon et al et al, Kidney Int 2006; 76: 557

*p<0.05

Tx SCR CAN Survival

SCR and CAN

Tx SCR IF/TA Survival

SCR and CHR

CHR

Protocol Bx:Is SCR associated with CHR?

SCR and Chronic humoral rejection1988-2006

Protocol Bx n = 517CHR 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 (μmol/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 (μmol/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_________________________________________________________

0

0,5

1

1,5

2

2,5

CHR IF/TA

v

t

i

g

Acute score in protocol biopsies

(p=0.003)

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__________________________________

SCR

IF/TA CHR

?

Decreased allograft survival

Acute and chronic lesions and outcome

Immunosuprresion and damage

New markers of early damage

Treatment of SCR with steroid boluses(n=72; 36 pts in each group)

CsA+AZA+PN

1 2 3 6 12

Biopsy

Control

Randomización

Biopsy Control_________________________________________________________chronic score at 6m 0.50 ± 0.13 1.02 ± 0.31 nsci + ct score at 6m 0.21 ± 0.09 0.62 ± 0.18 0.05_________________________________________________________

Rush D et al, J Am Soc Nephrol 1998; 9: 2129

Treatment of SCR

Rush D et al, J Am Soc Nephrol 1998; 9: 2129

0

50

100

150

200

1 2 3 6 12 24

Control

Biopsy

SCrμmol/l

SCR

Poor outcome Improved outcome

Treatment of SCR

SCR in TAC+MMF+P treated patients(56% induction therapy)

Protocol biopsies at 3m (n=114)

Gloor JM et al, Transplantation 2002; 73: 1965

Dg N %_________________________________SCR 3 2.6%Borderline changes 12 10.6%Normal 99 86.8%__________________________________

114 100__________________________________

TAC vs CsA, case control studyall treated with MMF and P

n=98

Moreso F et al Transplantation 2004; 78: 1064

borderline

AR I

AR II

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

0

10

20

30

40

50

CsAn=363

TACn=49

CNI-freen=23

NormalSCRIF/TAIF/TA+SCR

Moreso F et al Am J Transplant 2006; 6: 747

IS treatment and SCRn=435

IS treatment and SCR

Nankivell BJ et al, Transplantation 2004; 78:242

Treatment Acute rejection, SCR and IFTAn=200, surveillance x at 1,6,12, 24,36,48,60

CsA CsA TAC TACMMF SRL MMF SRL p

N 50 50 50 50_______________________________________________________________AR at 1y (%) 18 8 14 6 <0.05

SCR at 1y (%) 22 8 16 6 <0.05

IFTA at 5y (%) 54 16 38 14 <0.05_______________________________________________________________

Anil Kumar MS et al Transpl Immunol 2008; 20: 32

Treatment of SCR with steroids in TAC+MMF+Ptreated patients

12 centers

Biopsy Control(n=121) (n=119)

_______________________________________________6m ci+ct>2 (%) 35 2024m ci+ct>2 (%) 48 3924 m CrCl (ml/min) 76±27 72 ±18_______________________________________________

Rush D et al. AJT 2007; 7(11): 2538

1 2 3 6 24Biopsy

ControlRandomization

5 7 0 9 0

6 2

Acute and chronic lesions and outcome

Immunosuprresion and damage

New markers of early damage

Risk factors associated with SCR

Previous AR

Degree of sensitation

Donor age

Innate immunity and SCR

(PRP)Pattern recognition

receptors

(PAMPs) Pathogen associated molecular patterns

Infection(Alarmins) Tissue associated molecular patterns

Tissue damage

DAMPsDamage associated molecular patterns

Innate immunityReceptors

Secreted (MBL, amyloid)

Endocytic (NOD)

Signalling (TLR, CD14)

Medzhinov R & Janeway C. NEJM 2008; 343: 338

Defense collagens

Bohlson SS et al. Mol Immunol 2007; 44:33

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

MBL associated serine proteases MASPs

MBL polymorphism and serum MBL

Bouwman LH et al. 2006; 67:247

High MBL

Low MBL

MBL y enfermedad en la población general

Fernandez Real JM et al. Diabetologia 2006; 49: 2402

Low MBL

Infection Chronic inflammation

Diabetes Cardiovascular disease

MBL and susceptebility to disease: a double sword edge protein

MBL and DM

Hansen TK et al Diabetes 2004; 53: 1570Hovind et al. Diabetes 2005; 54: 1527Berger SP et al. AJT 2005; 5: 1361

cv disease in DM1microalbuminuria in DM1mortality in DM2

High MBL is associated with

Low MBL is associated with

incidence DM2

MBL amd disease in general population

Fernandez Real JM et al. Diabetologia 2006; 49: 2402

Low MBL

Infection

Chronic inflammation

Diabetes

Cardiovascular & renaldisease

Trasplante renal

TR

Diabetes Infection

Inflammation CV disease

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-T3

Interaction Bar Plot for CualquierMBLEffect: MBL-terciles

T 1Low MBL

T 2,3High MBL

Log MBL(ng/ml)

MBL before and after TxMarch 2005-Oct 2006, 125 pts,

111 with a functioning graft at 3 m

Ibernon M et al. Transplantation 2009: 88: 272

Variable low MBL high MBL p

(n=42) (n=83)_________________________________________________Induction

ATG 9 17Anti-IL2R 28 54none 5 12 ns

Maintenance

CNI + MMF + P 20 31mTOR + MMF + P 11 30CNI + mTOR + P 6 11Belatacept + MMF + P 5 11 ns

__________________________________________________

Variable low MBL high MBL p(n=42) (n=83)

__________________________________________________

DGF (no / yes) 24 / 18 (43%) 57 / 26 (31%) nsAR (no / yes) 35 / 7 (17%) 65 / 18 (22%) nsSCr 3 m (μmol/L) 135 ± 49 150 ± 92 ns

Graft loss (no / yes) 35 / 7 74 / 9 nsPatient surv (no / yes) 40 / 2 78 / 5 ns

Follow up (months) 19 ± 10 22 ± 10 ns__________________________________________________

sTNFR2 before Txsoluble TNFR

p=0.05

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

Low MBL and NODAT 3m(logistic regression)

Variable RR 95% CIp______________________________________________________Low MBL 3.04 1.18-7.81 0.021

Recipient age (años) 1.05 1.07-1.09 0.002

Impared fasting glucose 6.53 1.15-36.9 0.034before Tx______________________________________________________

P=0,0054

Low MBL and SCR

Resumen

Low MBL

Inflammation before TxsTNFR2

SCRNODAT

Infection after Tx

MBL and clearing of apoptotic and necrotic cells

Leakage“secondary necrosis”

Alo antibodies?

Chronic Inflammation Autoantibodies

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 enhancedin C1q-/- mice

More intense anti-donor Ab response

Innate immunity

SCR

CHR

?

Summary

a.) SCR is associated with IF/TA and CHR

b.) IS decreases the prevalence of SCR and probably of IF/TA

c.) innate immunity alterations as a risk factor for SCR

Low and High MBL are associated with autoimmune

disease

Bouwman LH et al. Hum Immunol2006; 67:247