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How to measure human leukocyte antigen-specific B cells. 如何测量人类白细胞抗原特异性B细胞。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-08-18 DOI: 10.1097/MOT.0000000000001097
Delphine Kervella, Alba Torija, Jose M Zúñiga, Oriol Bestard

Purpose of review: The implementation of highly sensitive immune assays measuring anti-human leukocyte antigen (HLA) antibodies has modified alloimmune risk stratification and diagnosis of rejection. Nonetheless, anti-HLA antibodies represent the downstream effector mechanism of the B-cell response. Better characterizing the cellular components of the humoral immune response (including memory B cells (mBCs) and long-lived plasma cells) could help to further stratify the alloimmune risk stratification and enable discovery of new therapeutic targets. Several tests that characterize HLA-specific mBCs, either functionally or phenotypically, have been developed in the last years, showing promising applications as well as some limitations.

Recent findings: Functional assays involving ex vivo polyclonal activation of mBC have been refined to allow the detection of HLA-specific mBC capable of producing anti-HLA Abs, using different and complementary detection platforms such as multiplex Fluorospot and single antigen bead assay on culture supernatants. Detection of circulating HLA-specific B cells by flow cytometry remains hindered by the very low frequency of HLA-specific mBC.

Summary: Technological refinements have allowed the development of tests detecting HLA-specific mBC. Further evaluation of these assays in clinical trials, both for immune risk stratification and to assess treatment efficacy (desensitization strategies, rescue therapies for ABMR) are now urgently needed.

综述目的:测量抗人类白细胞抗原(HLA)抗体的高灵敏度免疫测定的实施改变了同种免疫风险分层和排斥反应的诊断。尽管如此,抗HLA抗体代表了B细胞反应的下游效应机制。更好地表征体液免疫反应的细胞成分(包括记忆B细胞(mBCs)和长寿命浆细胞)有助于进一步对同种免疫风险分层进行分层,并能够发现新的治疗靶点。在过去的几年里,已经开发了几种表征HLA特异性mBCs的测试,无论是功能性的还是表型的,显示出有前景的应用以及一些局限性。最近的发现:涉及mBC的离体多克隆激活的功能测定已经被完善,以允许使用不同和互补的检测平台检测能够产生抗HLA Abs的HLA特异性mBC,如培养上清液上的多重荧光点和单抗原珠测定。流式细胞术检测循环HLA特异性B细胞仍然受到HLA特异性mBC频率非常低的阻碍。总结:技术的改进使得检测HLA特异性m BC的测试得以发展。现在迫切需要在临床试验中对这些测定进行进一步评估,包括免疫风险分层和评估治疗效果(脱敏策略、ABMR的抢救疗法)。
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引用次数: 0
Editorial introductions. 编辑介绍。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 DOI: 10.1097/MOT.0000000000001089
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引用次数: 0
Challenges with the current United Network for Organ Sharing heart allocation system. 当前器官共享心脏分配系统联合网络面临的挑战。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-08-13 DOI: 10.1097/MOT.0000000000001092
Timothy A Gong, Shelley A Hall

Purpose of review: The revised United States heart organ allocation system was launched in October 2018. In this review, we summarize this United Network for Organ Sharing (UNOS) policy and describe intended and unintended consequences.

Recent findings: Although early studies published after the change suggested postheart transplant survival declined at 6 months and 1 year, recent publications with longer follow-up time have confirmed comparable posttransplant survival in adjusted models and several patient cohorts. Moreover, the new allocation decreased overall waitlist time from 112 to 39 days ( P  < 0.001). Mean ischemic time increased because of greater distances traveled to acquire donor hearts under broader sharing. Despite the intention to decrease exception requests by expanding the number of priority tiers to provide more granular risk stratification, ∼30% of patients remain waitlisted under exception status. Left-ventricular assist device (LVAD) implants are declining and the number of LVAD patients on the transplant list has decreased dramatically after the allocation system change.

Summary: As the next allocation system is developed, it is imperative to curtail the use of temporary mechanical support as a strategy solely for listing purposes, identify attributes that more clearly stratify the severity of illness, provide greater oversight of exception requests, and address concerns regarding patients with durable LVADs.

审查目的:修订后的美国心脏器官分配系统于2018年10月启动。在这篇综述中,我们总结了器官共享联合网络(UNOS)的政策,并描述了有意和无意的后果。最近的发现:尽管改变后发表的早期研究表明,移植后的存活率在6岁时下降 月和1 今年,最近发表的随访时间较长的出版物已经证实,在调整后的模型和几个患者队列中,移植后的存活率相当。此外,新的分配将等待名单的总时间从112时间减少到39时间 天(P 摘要:随着下一个分配系统的制定,必须减少将临时机械支持作为仅用于列出目的的策略的使用,确定更明确地划分疾病严重程度的属性,对例外请求进行更大的监督,并解决对患有持久LVAD的患者的担忧。
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引用次数: 0
HLA-DQ antibodies in alloimmunity, what makes them different? 同种免疫中的HLA-DQ抗体,是什么使它们不同?
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-05-23 DOI: 10.1097/MOT.0000000000001079
Maria Meneghini, Anat R Tambur

Purpose of review: De novo HLA-DQ antibodies are the most frequently observed after solid-organ allotransplantation; and are associated with the worse adverse graft outcomes compared with all other HLA antibodies. However, the biological explanation for this observation is not yet known. Herein, we examine unique characteristics of alloimmunity directed specifically against HLA-DQ molecules.

Recent findings: While investigators attempted to decipher functional properties of HLA class II antigens that may explain their immunogenicity and pathogenicity, most early studies focused on the more expressed molecule - HLA-DR. We here summarize up-to-date literature documenting specific features of HLA-DQ, as compared to other class II HLA antigens. Structural and cell-surface expression differences have been noted on various cell types. Some evidence suggests variations in antigen-presenting function and intracellular activation pathways after antigen/antibody interaction.

Summary: The clinical effects of donor-recipient incompatibility at HLA-DQ, the risk of generating de novo antibodies leading to rejection, and the inferior graft outcomes indicate increased immunogenicity and pathogenicity that is unique to this HLA antigen. Clearly, knowledge generated for HLA-DR cannot be applied interchangeably. Deeper understanding of features unique to HLA-DQ may support the generation of targeted preventive-therapeutic strategies and ultimately improve solid-organ transplant outcomes.

综述的目的:实体器官移植后最常见的是HLA-DQ抗体;并且与所有其他HLA抗体相比,与更差的移植物不良结果相关。然而,对这一观察结果的生物学解释尚不清楚。在此,我们研究了特异性针对HLA-DQ分子的同种免疫的独特特征。最近的发现:虽然研究人员试图破译HLA II类抗原的功能特性,以解释其免疫原性和致病性,但大多数早期研究都集中在表达更高的分子HLA-DR上。我们在这里总结了最新文献,记录了HLA-DQ与其他II类HLA抗原相比的特定特征。在各种细胞类型上已经注意到结构和细胞表面表达的差异。一些证据表明,抗原/抗体相互作用后,抗原呈递功能和细胞内激活途径发生了变化。摘要:HLA-DQ供受体不相容性的临床影响、产生导致排斥反应的从头抗体的风险以及较差的移植物结果表明,这种HLA抗原特有的免疫原性和致病性增加。显然,针对HLA-DR产生的知识不能互换应用。对HLA-DQ特有特征的深入了解可能有助于制定有针对性的预防性治疗策略,并最终改善实体器官移植的结果。
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引用次数: 0
Histologic and molecular features of antibody-mediated rejection. 抗体介导的排斥反应的组织学和分子特征。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-07-28 DOI: 10.1097/MOT.0000000000001088
Ivy A Rosales, Rex Neal Smith, Robert B Colvin

Purpose of review: This review aims to summarize the highlights from recent research that involved pathological and molecular analysis of kidney allografts.

Recent findings: As the research on antibody-mediated rejection (AMR) continues to evolve, studies are focused on identification through transcript studies of pathogenetic pathways involved in the development of AMR as well as refinement of diagnostic methods either by correlating Banff pathologic lesions with clinical and molecular data or by machine learning. Of note, the past year has generated high impact research that underscore the importance of pathologic and molecular correlations and detection of transcripts or gene sets that would aid prognostication. The studies involving refinement of pathologic criteria also highlight the continuous efforts to achieve diagnostic accuracy and standardization.

Summary: Research involving histologic and molecular characteristics that define AMR are central to identification and understanding of pathogenetic pathways and remain critical in the development of diagnostic criteria.

综述目的:本综述旨在总结近年来同种异体肾移植的病理学和分子分析研究的亮点。最近的发现:随着抗体介导的排斥反应(AMR)研究的不断发展,研究的重点是通过转录本研究识别参与AMR发展的致病途径,以及通过将Banff病理病变与临床和分子数据相关联或通过机器学习来改进诊断方法。值得注意的是,过去一年的研究产生了高影响力,强调了病理和分子相关性的重要性,以及有助于预测的转录物或基因集的检测。涉及完善病理标准的研究也强调了为实现诊断准确性和标准化所做的持续努力。综述:涉及定义AMR的组织学和分子特征的研究是识别和理解发病途径的核心,在制定诊断标准方面仍然至关重要。
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引用次数: 1
Management of the sensitized heart transplant candidate. 致敏心脏移植候选者的管理。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-08-09 DOI: 10.1097/MOT.0000000000001096
Michelle M Kittleson

Purpose of review: For sensitized heart transplant candidates who have antibodies to human leukocyte antigens (HLA), finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting heart transplantation has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease.

Recent findings: Advances in the assessment of HLA antibodies allow for identification of heart transplant candidates who may benefit from desensitization strategies to widen the donor pool and mitigate the risk of adverse posttransplant outcomes.

Summary: Antibody sensitization is a barrier to successful heart transplantation and strategies to identify sensitized patients, stratify their risk, and mitigate this risk through desensitization is crucial to optimize the quality of life and survival of HT recipients.

综述目的:对于具有人类白细胞抗原(HLA)抗体的致敏心脏移植候选者来说,寻找合适的供体可能具有挑战性,并可能导致不良的等待名单结果。近年来,等待心脏移植的致敏患者数量增加,这可能是由于使用了持久的机械循环支持,以及患有潜在先天性心脏病的候选患者数量增加。最近的发现:HLA抗体评估的进展允许识别心脏移植候选者,这些候选者可能受益于脱敏策略,以扩大供体库并降低移植后不良结果的风险。总结:抗体致敏是心脏移植成功的障碍,识别致敏患者、对其风险进行分层并通过脱敏减轻这种风险的策略对于优化HT受体的生活质量和生存至关重要。
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引用次数: 0
Dual organ transplantation: when heart alone is not enough. 双器官移植:当心脏是不够的。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-10-01 Epub Date: 2023-08-13 DOI: 10.1097/MOT.0000000000001093
Abdulelah Nuqali, Lavanya Bellumkonda

Purpose of review: The number of dual organ transplantations (DOT) are steadily increasing over the past few years. This is both a reflection of increasing complexity and advanced disease process in the patients and greater transplant center experience with performing dual organ transplants. Due to lack of standardization of the process, there remains significant center-based variability in patient selection, perioperative and long-term management of these patients.

Recent findings: Overall posttransplant outcomes for DOT have been acceptable with some immunological advantages because of partial tolerance offered by the second organ. These achievements should, however, be balanced with the ethical implications of bypassing the patients who are listed for single organ transplantation because of the preferential allocation of organs for DOT.

Summary: The field of DOT is expanding rapidly, with good long-term outcomes. There is an urgent need for guidelines to standardize the process of patient selection and listing dual organ transplantation.

综述目的:在过去几年中,双器官移植(DOT)的数量稳步增加。这既反映了患者日益复杂和晚期的疾病过程,也反映了移植中心在进行双器官移植方面的更多经验。由于流程缺乏标准化,在患者选择、围手术期和这些患者的长期管理方面,仍存在显著的基于中心的变异性。最近的发现:由于第二器官提供的部分耐受性,DOT的总体移植后结果是可以接受的,具有一些免疫学优势。然而,这些成就应该与绕过因DOT优先分配器官而被列入单器官移植名单的患者的伦理影响相平衡。总结:DOT领域正在迅速扩张,并取得了良好的长期结果。迫切需要制定指导方针,以规范双器官移植的患者选择和上市过程。
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引用次数: 0
Optimizing liver transplant prioritization for hepatocellular carcinoma through risk stratification. 通过风险分层优化肝细胞癌肝移植的优先顺序。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-08-01 Epub Date: 2023-06-19 DOI: 10.1097/MOT.0000000000001080
Joshua Norman, Neil Mehta, Allison Kwong

Purpose of review: In the United States, candidates with hepatocellular carcinoma (HCC) meeting standardized qualifying criteria receive similar priority on the liver transplant waiting list through Model for End-Stage Liver Disease exception points, without consideration of the dropout risk or relative expected benefit from liver transplantation. A more nuanced allocation scheme for HCC is needed to better represent the individual urgency for liver transplant and optimize organ utility. In this review, we discuss the development of HCC risk prediction models for practical use in liver allocation.

Recent findings: HCC is a heterogenous disease that requires improved risk stratification for patients who fall within current transplant eligibility criteria. Several models have been proposed, though none have been adopted in clinical practice or liver allocation to date, due to various limitations.

Summary: Improved HCC risk stratification for liver transplant candidates is needed to more accurately represent their urgency for transplant, with continued attention to the potential impact on post-liver transplant outcomes. Plans to implement a continuous distribution model for liver allocation in the United States may provide an opportunity to re-consider a more equitable allocation scheme for patients with HCC.

审查目的:在美国,符合标准化合格标准的肝细胞癌(HCC)候选者通过终末期肝病模型例外点在肝移植候选名单上获得类似的优先权,而不考虑退出风险或肝移植的相对预期收益。我们需要一个更细致的HCC分配方案,以更好地体现个体对肝移植的迫切性,并优化器官的效用。在这篇综述中,我们讨论了在肝脏分配中实际使用的HCC风险预测模型的开发情况:HCC是一种异质性疾病,需要对符合当前移植资格标准的患者进行更好的风险分层。摘要:需要改进肝移植候选者的HCC风险分层,以更准确地反映他们的移植迫切性,并持续关注对肝移植后预后的潜在影响。美国计划实施肝脏分配的连续分配模式,这可能为重新考虑更公平的HCC患者分配方案提供了机会。
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引用次数: 0
Immunosuppression in HIV-positive kidney transplant recipients. HIV 阳性肾移植受者的免疫抑制。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-08-01 Epub Date: 2023-05-23 DOI: 10.1097/MOT.0000000000001076
Bogdan Marian Sorohan, Gener Ismail, Nicolae Leca

Purpose of study: The purpose of this review is to provide the current state of immunosuppression therapy in kidney transplant recipients (KTR) with HIV and to discuss practical dilemmas to better understand and manage these patients.

Recent findings: Certain studies find higher rates of rejection, which raises the need to critically assess the approach to immunosuppression management in HIV-positive KTR. Induction immunosuppression is guided by transplant center-level preference rather than by the individual patient characteristics. Earlier recommendations expressed concerns about the use of induction immunosuppression, especially utilizing lymphocyte-depleting agents; however, updated guidelines based on newer data recommend that induction can be used in HIV-positive KTR, and the choice of agent be made according to immunological risk. Likewise, most studies point out success with using first-line maintenance immunosuppression including tacrolimus, mycophenolate, and steroids. In selected patients, belatacept appears to be a promising alternative to calcineurin inhibitors with some well established advantages. Early discontinuation of steroids in this population carries a high risk of rejection and should be avoided.

Summary: Immunosuppression management in HIV-positive KTR is complex and challenging, mainly because of the difficulty of maintaining a proper balance between rejection and infection. Interpretation and understanding of the current data towards a personalized approach of immunosuppression could improve management in HIV-positive KTR.

研究目的:本综述旨在介绍感染艾滋病毒的肾移植受者(KTR)的免疫抑制治疗现状,并讨论实际困境,以便更好地理解和管理这些患者:某些研究发现排斥反应发生率较高,因此有必要对 HIV 阳性 KTR 的免疫抑制管理方法进行严格评估。诱导免疫抑制的指导原则是移植中心的偏好,而不是患者的个体特征。早期的建议对诱导免疫抑制的使用表示担忧,尤其是使用淋巴细胞清除剂;然而,根据最新数据更新的指南建议,HIV 阳性 KTR 可以使用诱导免疫抑制,并根据免疫风险选择药物。同样,大多数研究指出,使用一线维持性免疫抑制剂(包括他克莫司、霉酚酸酯和类固醇)取得了成功。在选定的患者中,贝拉替塞似乎是钙调素酶抑制剂的一个很有前途的替代品,具有一些公认的优势。小结:HIV 阳性 KTR 的免疫抑制管理既复杂又具有挑战性,主要是因为很难在排斥反应和感染之间保持适当的平衡。解释和理解现有数据,采用个性化的免疫抑制方法,可以改善艾滋病病毒阳性 KTR 的管理。
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引用次数: 0
Pediatric intestine and multivisceral transplant. 小儿肠道和多脏器移植。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2023-08-01 Epub Date: 2023-06-12 DOI: 10.1097/MOT.0000000000001082
Mohamed Maklad, George Mazariegos, Armando Ganoza

Purpose of review: Intestinal and multivisceral transplantation (ITx, MVTx) is the cornerstone in treatment of irreversible intestinal failure (IF) and complications related to parenteral nutrition. This review aims to highlight the unique aspects of the subject in pediatrics.

Recent findings: Etiology of intestinal failure (IF) in children shares some similarity with adults but several unique considerations when being evaluated for transplantation will be discussed. Owing to significant advancement in IF management and home parenteral nutrition (PN), indication criteria for pediatric transplantation continues to be updated. Outcomes have continued to improve with current long-term patient and graft survival in multicenter registry reports reported at 66.1% and 48.8% at 5 years, respectively. Pediatric specific surgical challenges such abdominal closure, post transplantation outcomes, and quality of life are discussed in this review.

Summary: ITx and MVTx remain lifesaving treatment for many children with IF. However long-term graft function is still a major challenge.

综述目的:肠道和多脏器移植(ITx,MVTx)是治疗不可逆肠道功能衰竭(IF)和肠外营养相关并发症的基石。本综述旨在强调儿科在这方面的独特之处:最近的研究结果:儿童肠功能衰竭(IF)的病因与成人有一些相似之处,但在接受移植评估时会有一些独特的考虑因素。由于肠功能衰竭治疗和家庭肠外营养(PN)的重大进展,儿科移植的适应症标准也在不断更新。移植结果不断改善,据多中心登记报告,目前患者和移植物5年的长期存活率分别为66.1%和48.8%。本综述讨论了小儿外科手术面临的挑战,如腹腔闭合、移植后疗效和生活质量。然而,长期移植功能仍是一项重大挑战。
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引用次数: 0
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Current Opinion in Organ Transplantation
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