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Abstracts / Human Immunology 73 (2012) 49–167
FRACTIONATED DONOR CHIMERISM (FDC) ANALYSIS IN THE DETECTION AND TREATMENT OF GVHD IN SOLID ORGAN TRANSPLANTATION – DIAGNOSTIC AND THERAPEUTIC IMPLICATIONS. Alexandra C. Amador, Jennifer McCue, Rogelio Gonzalez, Akin Tekin, Gennaro Selvaggi, Jennifer Garcia, Andreas G. Tzakis, Phillip Ruiz. Surgery-Transplant, University of Miami, Miami, FL, USA. Aim: Graft-versus-host disease (GVHD) a rare but serious complication following liver and multivisceral tx carries a poor prognosis with mortality approaching 90-95%. Diagnosis is often delayed due to early symptom similarity to more common diagnoses. Rapid detection of GVHD and early initiation of therapy, may lead to improved survival for patients. Purpose: Evaluate the efficacy of FDC analysis for rapid diagnosis and treatment initiation for GVHD. Methods: Donor Chimerism(DC) was evaluated using ABI STR reagents. Pre-txp donor and recipient genotypes were determined from pre-txp blood or FFPE tissues. Post txp peripheral blood fractionation for B, T and myeloid cells was performed (RoboSep, StemCell Tech.). Analysis was run on DNA from fractionated and unfractionated cells. Results: Multiviceral and liver txp patients with GVHD were tested using routine chimerism analysis. Those with P10% unfractionated DC had poor outcome despite treatment and eventually expired. Unfractionated analysis gave a skewed impression (DC = 22%) of patient’s chimerism while fractionation showed 100% donor T cells and recipient myeloid cells. Following extensive therapy, 100% donor T cells remained and the patient died. Another patient presented with <2% unfractionated DC. On fractionation, T cells were 7% donor. Patient was successfully treated and 0% DC was found within 2 weeks of therapy initiation. Conclusions: GVHD in solid organ transplantation can have dire consequences and once DC in T cells reaches certain levels, the outcome may be fatal. Early diagnosis in suspected GVHD should include fractionated chimerism analysis to differentiate from other common complications. Once documented, GVHD therapy may be followed with chimeric subpopulation values to ensure donor T cells are eliminated from the peripheral circulation.
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IMPACT OF DONOR SPECIFIC ANTIBODIES (DSA) IN RETRANSPLANTATION OF LIVER. Todd Brennan 1, Kadiyala Ravindra 1, Dong-Feng Chen 2, Deepak Vikraman-Sushama 1, Abigail Martin 1, Bradley Collins 1, Debra Sudan 1. 1 Department of Surgery, Duke University Medical Center, Durham, NC, USA; 2 Department of Pathology and Clinical Laboratories, Duke University Medical Center, Durham, NC, USA. Aim: With availability of specific and sensitive HLA antibody assays, the importance of donor specific antibodies (DSA) in liver transplant has grown. Patients undergoing 2nd liver transplant are at high risk of DSA. We present contrasting outcomes in 2 patients. Methods: We retrospectively reviewed the DSA in 2 liver recipients and compared them to the clinical outcomes. Results: Pt #1: A 28 year old woman with PBC underwent a living donor liver transplant in 2006. In the next 4 years she received her 2nd, 3rd and 4th liver transplants due to graft failures. Plasmapheresis and IVIG were used at the 3rd & 4th transplants due to high PRA. A positive B cell flow crossmatch was noted at the last transplant. DSA monitoring was initiated after the 4th transplant. Elevated levels of class II antibodies to DR4, DR53 and DQ8 persisted. Patient had recurrence of jaundice after 6 months and showed short lived response to thymoglobulin, plasmapheresis, IVIG and Rituximab with rebound of DSA within a month of antibody therapy. Coincidentally, donors 2, 3 and 4 all had DR4, DR53 and DQ8. The patient underwent Bortezomib therapy as liver biopsy continued to show mixed portal infiltrate & bile duct injury. Pt #2: A 25 yr old woman with autoimmune hepatitis underwent liver transplant in 2006. Graft function deteriorated following steroid non-responsive rejection treated with Thymoglobulin & OK T3. Retransplant was done in early 2011. B cell crossmatch was positive and patient received thymoglobulin, plasmapheresis and IVIG. DSA assay showed the presence of anti-A2, -A11, -DR53, and -DQ8. During a follow up of 11 months, graft function was excellent despite the persistence of high titers of Class II antibodies. In contrast, level of class I antibodies remain under cutoff. Conclusions: Sensitization status needs serious consideration in retransplantation of liver. Avoidance of donors with unacceptable antigens may be crucial in some liver retransplant recipients. A positive B cell crossmatch may portend a poor outcome.
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Abstracts / Human Immunology 73 (2012) 49–167
FRACTIONATED DONOR CHIMERISM (FDC) ANALYSIS IN THE DETECTION AND TREATMENT OF GVHD IN SOLID ORGAN TRANSPLANTATION – DIAGNOSTIC AND THERAPEUTIC IMPLICATIONS. Alexandra C. Amador, Jennifer McCue, Rogelio Gonzalez, Akin Tekin, Gennaro Selvaggi, Jennifer Garcia, Andreas G. Tzakis, Phillip Ruiz. Surgery-Transplant, University of Miami, Miami, FL, USA. Aim: Graft-versus-host disease (GVHD) a rare but serious complication following liver and multivisceral tx carries a poor prognosis with mortality approaching 90-95%. Diagnosis is often delayed due to early symptom similarity to more common diagnoses. Rapid detection of GVHD and early initiation of therapy, may lead to improved survival for patients. Purpose: Evaluate the efficacy of FDC analysis for rapid diagnosis and treatment initiation for GVHD. Methods: Donor Chimerism(DC) was evaluated using ABI STR reagents. Pre-txp donor and recipient genotypes were determined from pre-txp blood or FFPE tissues. Post txp peripheral blood fractionation for B, T and myeloid cells was performed (RoboSep, StemCell Tech.). Analysis was run on DNA from fractionated and unfractionated cells. Results: Multiviceral and liver txp patients with GVHD were tested using routine chimerism analysis. Those with P10% unfractionated DC had poor outcome despite treatment and eventually expired. Unfractionated analysis gave a skewed impression (DC = 22%) of patient’s chimerism while fractionation showed 100% donor T cells and recipient myeloid cells. Following extensive therapy, 100% donor T cells remained and the patient died. Another patient presented with <2% unfractionated DC. On fractionation, T cells were 7% donor. Patient was successfully treated and 0% DC was found within 2 weeks of therapy initiation. Conclusions: GVHD in solid organ transplantation can have dire consequences and once DC in T cells reaches certain levels, the outcome may be fatal. Early diagnosis in suspected GVHD should include fractionated chimerism analysis to differentiate from other common complications. Once documented, GVHD therapy may be followed with chimeric subpopulation values to ensure donor T cells are eliminated from the peripheral circulation.
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IMPACT OF DONOR SPECIFIC ANTIBODIES (DSA) IN RETRANSPLANTATION OF LIVER. Todd Brennan 1, Kadiyala Ravindra 1, Dong-Feng Chen 2, Deepak Vikraman-Sushama 1, Abigail Martin 1, Bradley Collins 1, Debra Sudan 1. 1 Department of Surgery, Duke University Medical Center, Durham, NC, USA; 2 Department of Pathology and Clinical Laboratories, Duke University Medical Center, Durham, NC, USA. Aim: With availability of specific and sensitive HLA antibody assays, the importance of donor specific antibodies (DSA) in liver transplant has grown. Patients undergoing 2nd liver transplant are at high risk of DSA. We present contrasting outcomes in 2 patients. Methods: We retrospectively reviewed the DSA in 2 liver recipients and compared them to the clinical outcomes. Results: Pt #1: A 28 year old woman with PBC underwent a living donor liver transplant in 2006. In the next 4 years she received her 2nd, 3rd and 4th liver transplants due to graft failures. Plasmapheresis and IVIG were used at the 3rd & 4th transplants due to high PRA. A positive B cell flow crossmatch was noted at the last transplant. DSA monitoring was initiated after the 4th transplant. Elevated levels of class II antibodies to DR4, DR53 and DQ8 persisted. Patient had recurrence of jaundice after 6 months and showed short lived response to thymoglobulin, plasmapheresis, IVIG and Rituximab with rebound of DSA within a month of antibody therapy. Coincidentally, donors 2, 3 and 4 all had DR4, DR53 and DQ8. The patient underwent Bortezomib therapy as liver biopsy continued to show mixed portal infiltrate & bile duct injury. Pt #2: A 25 yr old woman with autoimmune hepatitis underwent liver transplant in 2006. Graft function deteriorated following steroid non-responsive rejection treated with Thymoglobulin & OK T3. Retransplant was done in early 2011. B cell crossmatch was positive and patient received thymoglobulin, plasmapheresis and IVIG. DSA assay showed the presence of anti-A2, -A11, -DR53, and -DQ8. During a follow up of 11 months, graft function was excellent despite the persistence of high titers of Class II antibodies. In contrast, level of class I antibodies remain under cutoff. Conclusions: Sensitization status needs serious consideration in retransplantation of liver. Avoidance of donors with unacceptable antigens may be crucial in some liver retransplant recipients. A positive B cell crossmatch may portend a poor outcome.