De novo Donor-Specific HLA Antibody (DSA)

Actualités Néphrologiques

Jean Hamburger

Hôpital Necker

Paris, April 2014

Peter Nickerson, MD, FRCPC, FCAHS

Flynn Family Chair in Renal Transplantation

Professor of Internal Medicine and Immunology

2008 Routine screen de novo Class II DSA (DQ4)

Tacrolimus, MMF, Prednisone

Creatinine 108 umol/L

2006 Deceased Donor Kidney Transplant

cPRA 0%

Flow crossmatch negative

HLA mismatch 0A 2B 1DR 2DQ

Tacrolimus, MMF, Prednisone

Creatinine 100-120 umol/L

What do we tell him? What should we do next?

Could we have prevented it from occuring?

35 yr male

Overview

De novo DSA leading to acute and chronic ABMR

1. Prevalence of de novo DSA

2. Risk factors associated with de novo DSA

3. Clinical impact associated with de novo DSA

4. Therapeutic options to treat late ABMR

315 patients without pre-transplant DSA (1999-2008)

De Novo DSA Prevalence over Time

Wiebe et al AJT 2012; 12: 1157-1167

De novo DSA leading to acute and chronic ABMR

1. Prevalence of de novo DSA

2. Risk factors associated with de novo DSA

3. Clinical impact associated with de novo DSA

4. Therapeutic options to treat late ABMR

Variation in time of de novo DSA onset

Definition or Depletion related?

Wiebe et al, Current Opinion Organ Transplant (2013) 18:470

0

50

100

150

200

250

300

350

400

450

500

0 1 2 3

Preferential repopulation T-effector memory subsets following Alemtuzumab/Thymoglobulin induction

TN

TEM

Tcm

Treg Tram

Pearl, et al. Am J Transplant 2005; 5:465-474

Induction to Prevent T-cell Mediated Rejection Alemtuzumab induction associated with early memory and

switched memory B-cell repopulation

Todeschini et al, JI (2013)

191:2818

Non-Adherence major risk factor

Adherent

20% at 10 years

Non-Adherent

60% at 10 years

Wiebe et al AJT 2012; 12: 1157-1167

Am J Transplant 2012; 12:1192-1198

Patients switched from CsA to Everolimus at 3.0 to 4.5 months post-

transplant have an increased incidence of de novo DSA and AMR.

Everolimus

CsA

Everolimus

CsA

Non-Adherence

Clinical Rejection

(0-6 months)

Subclinical Rejection

(0-6 months)

No dnDSA

(n=268)

8%

13%

15%

dnDSA

Total

(n=47)

49%

28% (p<0.05)

29% (p=0.09)

Early TCMR precedes the development of de novo

DSA

Wiebe et al AJT 2012; 12: 1157-1167

dnDSA

Adherent

(n=24)

0%

29%

30%

dnDSA

Non-Adherent

(n=23)

100%

26%

22%

Surveillance

biopsy

6 Mt 2 Y 4 Y 6 Y 8 Y 10 Y 12 Y

Indication

biopsy

Moreso et al, Transplantation (2012) 93: 41-46

Subclinical

tubulointerstitial

inflammation

Chronic Antibody-Mediated Rejection (TG, PTC BM multi-layering; C4d+; DSA)

associated

with

Linking early clinical TCMR and development of de novo DSA / ABMR

Hourmant et al. JASN (2005) 16: 2804-2812

Wiebe et al. AJT (2012) 12: 1157-1167

Liefeldt et al. AJT (2012) 12: 1192-1198

El Ters et al. AJT (2013) 13:2334-2341

Gibson et al, Am J Transplant 8:819,

2008

PTC 2

Patients with de novo DSA have early (0-6 month)

TCMR with more intense PTC inflammation

TCMR PTC score

de novo DSA

No DSA

2.0

1.0 p <0.05

Shed MHC II

B

IgG

Lymph Node

TFH

Plasma Cell

Wiebe et al AJT 2012; 12: 1157-1167

MHC II

IFN g

Muczynski et al, J Am Soc Nephro 14:1336,

2003

DR induction by IFN g

Th

Univariate Predictors of de novo DSA

Wiebe et al, Current Opinion Organ Transplant (2013) 18:470

Jean Dausset Nobel Prize (1980) for

Physiology of Medicine

“Genetically determined

structures on the cell

surface that regulate

immunological

reactions”

HLA

Jean Hamburger

Predicted tissue

compatibility proteins,

prior to HLA discovery,

play key role in organ

graft survival

Polymorphic Epitopes

on donor HLA-B51

Epitopes “seen” by

A2, A68

B27, B44

Epitopes “seen”

by

A2, A24

B7, B8

What can the recipient immune system “see”?

1 DR MM

1 DQ MM

# of Epitope MM

Single HLA Antigen MM Range of Epitope MM

Wiebe et al AJT 2013; 13: 3114-3122

Wiebe et al AJT 2013; 13: 3114-3122

High Epitope MM Load in Patients with de novo DSA

Wiebe et al AJT 2013; 13: 3114-3122

Multivariate Model of de novo DSA Risk Factors

p<0.000

1

0-16

17-69

Follow-up (years)

HLA-DQ Epitope Mismatches

p<0.0001

Follow-up (years)

0-9

10-57

HLA-DR Epitope Mismatches

Wiebe et al AJT 2013; 13: 3114-3122

Epitope MM Load

thresholds associated with

de novo DR or DQ DSA

Wiebe et al AJT 2013; 13: 3114-3122

Recurring DQ epitopes

associated with de novo DSA

Case for Immunodominance?

De novo DSA leading to acute and chronic ABMR

1. Prevalence of de novo DSA

2. Risk factors associated with de novo DSA

3. Clinical impact associated with de novo DSA

4. Therapeutic options to treat late ABMR

10 year

Median Survival

No DSA 96.4%

dnDSA 56.9%

De Novo DSA and Graft Survival Adult and Pediatric Kidney Transplants (1999 to 2008)

Wiebe et al AJT 2012; 12: 1157-1167

Pre-transplant HLA Ab and

de novo HLA Ab

do not predict graft survival

De Novo DSA and Graft Survival Adult and Pediatric Kidney Transplants (1999 to 2008)

Wiebe et al AJT 2012; 12: 1157-1167

de novo DSA

De Novo DSA and Graft Survival Adult and Pediatric Kidney Transplants (1999 to 2008)

Wiebe et al AJT 2012; 12: 1157-1167

Mean time to graft failure from time

de novo DSA first detected is ~ 5 to 6

years

Consecutive

Transplants

Jan. 1999 - Dec. 2008

(n=392)

(n=30)

(n=11)

(n=14)

(n=22)

DSA pre transplant

Primary non-function

Moved

Death with function

Excluded (n=77)

Study Patients

(n=315)

de novo DSA

(n=47)

No DSA

(n=268)

Dysfunction

No DSA

(n=55)

Stable

Function

No DSA

(n=213)

Acute

Dysfunction

de novo DSA

(n=14)

Indolent

Dysfunction

de novo DSA

(n=15)

Stable

Function

de novo DSA

(n=18)

Wiebe et al AJT 2012; 12: 1157-1167

Acute Dysfunction dnDSA (n=14) Indolent Dysfunction dnDSA (n=15) Stable Function dnDSA (n=18)

Class I Class II Class I Class II Class I Class II

A2 DQ2 A31* DR13, DR52, DQ6* B58 DR8, DR12, DQ4,

DQ7

B44 DR8*, DQ5 A2*, A11* DR9*, DQ9 A1 DQ6

A30, B61 DR17, DR52, DQ2 A68, B65 DQ7 DR15*, DR51, DQ6

A34 DR15, DR51, DQ5 B62 DR17, DR53*, DQ2 DR53, DQ8, DQ9

A24 DR9 DQ6 DR13, DR52*

A24 DQ4 DR53 DR11

DR17, DQ5 DQ5 DR16, DR51*

DQ2 DQ5 DQ7

DQ7 DQ5 DQ5

DP13 DR13 DQ5

DQ5 DR53*, DQ2 DQ2

DR53, DQ2 DQ7 DQ8

DR15, DR51* DR13, DR52,

DR53, DQ2 DQ7

DQ6 DR53 DQ7

A1 DQ9

DQ4

A30

A1

Class II are the dominant de novo DSA for all

Clinical Phenotypes

Wiebe et al AJT 2012; 12: 1157-1167

Wiebe et al AJT 2012; 12: 1157-1167

Clinical

Phenotypes

• 10/14 patients biopsied had pathologic features of AMR (PTC, C4d, g, v)

• 7 / 10 “subclinical” AMR re-biopsied:

o 1 persistent subclinical AMR

o 3 subclinical AMR + cAMR

o 3 clinical AMR + cAMR

Evidence suggesting that Stable

de novo DSA patients will progress

Wiebe et al AJT 2012; 12: 1157-1167

(updated Dec 2013)

What could explain the lack of

dysfunction in this group?

• de novo DSA titer affecting rate

of progression

• Differences in C1q binding or IgG

subclass

• Differences in epitope

immunogenicity or expression

• Regulation of antibody

responses

Th1

7

Th1 Treg

Bre

g

Early Inflammatory

Event(s)

Graft LossTransplant

De Novo Class II (I?) DSA

Peritubular Capillaritis

+/- C4d

Glomerulitis

IFTA +/- TG

Rising Cr /Proteinuria

Time

NormalHistology

SubclinicalInjury

ClinicalDysfunction

+/- Cellular Rejection

Proposed Natural History of dnDSA*

De Novo DSA

TCMR

with capillaritis

IFN g

Th

MHC II B TFH

Model linking TCMR, de novo DSA, ABMR with Graft Loss

Wiebe et al AJT (2012) 12: 1157-1167

(modified from Smith et al AJT (2008) 8:1662-1672)

Plasma Cell

Donor-Specific

Anti-Class II Ab

De Novo DSA Treatment Options?

Donor HLA II

B

TFh

+

Costimuli

APC

Allo-peptide

Donor HLA II

REGIONAL LYMPH NODE/SPLEEN

Bm

Tacrolimus / MMF ± Prednisone

IVIG ± Pheresis [FDA ~Std of Care, AJT 2011]

Rituximab (anti-CD20)

Bortezomib (Proteosome Inhibitor)

Eculizumab (C5a Inhibitor)

GRAFT

MICROCIRCULATION

Donor HLA II

FcgRIII

NK

C1q

MØ

C3a/C5a R

C3a C5a

MAC

2008 Routine screen de novo Class II DSA (DQ4)

Tacrolimus, MMF, Prednisone

Creatinine 108 umol/L

2006 Deceased Donor Kidney Transplant

cPRA 0%

Flow crossmatch negative

HLA mismatch 0A 2B 1DR 2DQ

Tacrolimus, MMF, Prednisone

Creatinine 100-120 umol/L

35 yr male

Biopsy

Mild Tx glomerulitis (g1,cg0)

with mononuclear cells

(circled)

C4d

Peritubular capillaritis (ptc2):

• Diffuse moderate mononuclear inflammatory cell accumulation

PTCs diffuse C4d +

De novo DSA related Subclinical AMR

Can we shut off the process?

Tac/MMF + IVIG (2g/kg)/mo x 3

Optimizing Tac/MMF, Pulse Steroids and IVIG appears to be insufficient

DSA

Banff Acute

Banff Chronic

Banff Acute

Banff Chronic

G I T V PTC C4d G I T V G I T V PTC C4d G I T V

DR12 DQ4,7 0 2 2 0 2 Pos 0 0 1 1 2 2 1 0 2 Neg 2 2 2 0

DQ4 1 1 1 0 2 Pos 0 0 1 0 2 2 1 0 2 Pos 0 1 0 0

DQ9 0 0 0 3 0 Neg 0 0 0 1 1 1 1 1 2 Pos 0 1 1 2

DQ7 0 1 1 0 2 Pos 0 0 1 0 0 1 1 0 2 Pos 0 0 1 0

Wiebe et al AJT 2012; 12: 1157-1167

6

mo

De novo DSA related Subclinical AMR

Evidence of concommitant TCMR

Optimizing Tac/MMF, Pulse Steroids and IVIG appears to be insufficient

DSA

Banff Acute

Banff Chronic

Banff Acute

Banff Chronic

G I T V PTC C4d G I T V G I T V PTC C4d G I T V

DR12 DQ4,7 0 2 2 0 2 Pos 0 0 1 1 2 2 1 0 2 Neg 2 2 2 0

DQ4 1 1 1 0 2 Pos 0 0 1 0 2 2 1 0 2 Pos 0 1 0 0

DQ9 0 0 0 3 0 Neg 0 0 0 1 1 1 1 1 2 Pos 0 1 1 2

DQ7 0 1 1 0 2 Pos 0 0 1 0 0 1 1 0 2 Pos 0 0 1 0

6

mo

Tac/MMF + IVIG (2g/kg)/mo x 3

Nickerson et al AJT 2013; 13: 2239-2240

Bx: g1, i1t1, ptc2, C4d+, cg0

Rx: Tac/MMF, monthly Pred + IVIG 2g/kg x3

de novo DQ4 DSA

Bx: g0, i2t1, ptc2, C4d-, cg3, ci3ct3, cv2, ptc bml 8

Rx: conservative

Bx: g2, i2t1, ptc2, C4d+, cg0

Subclinical ABMR Early Graft Failure

month

Subclinical 33 months

< 6mo

77%

88%

40±17

66±31

> 6mo

35%

54%

27±12

37±25

Walsh et al, Transplantation (2011) 91:1218

Immunologic Response

% of patients with >50% decline in DSA MFI D14 post-treat

Histologic Response

% patients resolved or resolving with repeat bx

Allograft Function Response

Mean pre-treatment eGFR (ml/min/1.73m2)

Mean post-treatment eGFR (ml/min/1.73m2)

De novo DSA associated ABMR

Prevention is Key:

• HLA DR and DQ matching (avoid high epitope load/immunodominant)

• Optimize immunosuppression to avoid sensitization (Tacrolimus/MMF)

• Non-adherence recognize and intervene early

• Avoid minimization in at risk individuals (epitope load, early TCMR)

Novel Therapeutics and Clinical Trials are needed to:

• Optimize induction to avoid early TCMR and/or ABMR

Avoid/control repopulation with effector memory T and B cells

• Augment T reg cells post-transplant

• Early recognition and treatment of de novo DSA associated ABMR

“Are there not human tissue groups allowing acceptable

compatibility?”

“Is it possible to prevent incompatible graft death

through pharmacodynamic properties of some drugs?”

J. Hamburger, J. d’Urologie (1947) 53:563-567

Acknowledgements

Transplant Manitoba

Adult and Pediatric Kidney Programs

David Rush

Chris Wiebe

Julie Ho

Martin Karpinski

Leroy Storsley

Patricia Birk

Tom Blydt-Hansen

Aviva Goldberg

Transplant Immunology

Laboratory (DSM)

Denise Pochinco Dawn Kelm

Kendra Hacking Iga Dembinski Willy Laidlaw

Cathy Krasnianski Brenda Schultz

Manitoba Centre for

Proteomics & Systems Biology

John Wilkins

Ang Gao

Oleg Krokhin

Department of Pathology

Ian Gibson

Department of Immunology

Kent HayGlass

Universität Basel

Stefan Schaub

Patricia Hirt-Minkowski

Gideon Hönger

Jürg Steiger