1. Interplay of subclinical fibrosis
and
inflammation
D. Serón
Nephrology Department
Hospital Vall d’Hebron
Barcelona

2. Inflammation with and without fibrosis
Surveillance biopsies
Inflammation with and without fibrosis
Inflammation and CHR
Innate immunity and inflammation

3. Inflammation with and without fibrosis
Surveillance biopsies
Inflammation with and without fibrosis
Inflammation and CHR
Innate immunity and inflammation

4. Inflammation and fibrosis in surveillance Bx
Graft survival
Inflammation
Graft survival
Dimény E, Clin Transplantation 1995; 58(11): 1195
Serón D, Kidney Int 1997; 51: 310
Nankivell BJ et al, Transplantation 2004; 78:242
Choi BS et al, Am J Transplant 2005; 5: 1354

5. SCR and CAN in paired biopsies n=598 Bx, (no SCR 462, SCRB 102, SCRA 34)
Nankivell BJ et al, Transplantation 2004; 78:242
Ibernon et al et al, Kidney Int 2006; 76: 557

6. Proper classification of inflammation and fibrosis
Normal (no inflammation no fibrosis)
Inflammation and fibrosis
Inflammation (no fibrosis)
Fibrosis (no inflammation)

7. SCR & IF/TA SCR + IF/TA SCR + IF/TA SCR + IF/TA
1 year protocol Bx
Normal
SCR + IF/TA
1 year protocol Bx
IF/TA without SCR
IF/TA without SCR
IF/TA with SCR
IF/TA with SCR
SCR + IF/TA
< 6 month protocol Bx
.25 .5
.75 1 50
100
150
200
months
Normal=186
SCR=74
IF/TA=110
IF/TA+SCR=65
Shishido et al, JASN 2003; 14: 1046
Cosio FG et al, Am J Transplant 2005; 5: 2464,
Moreso F et al Am J Transplant 2006; 6:747

8. High (upper tertile) and low (two lower tertiles) inflammation
Inflammation with or whitout IF/TA
High (upper tertile) and low (two lower tertiles) inflammation
High inflammation
Low inflammation
CD45
CD3
CD20
CD68
CD15
Moreso F et al. AJT 2007; 7: 2739

9. Interstitial infiltrating cells
500
1000
1500
2000
2500
NORMAL
SCRa
IF/TA
SCR+IF/TAa,c
300
600
900
1200
200
400
800
SCR
IF/TAa
SCR+IF/TAa,b,c
3000
3500
CD45 positive cells / mm2 interstitium
CD20 positive cells / mm2 interstitium
CD68 positive cells / mm2 interstitium
CD3 positive cells / mm2 interstitium
Moreso F et al. AJT 2007; 7: 2739

10. Renal allograft survival (univariate),2 ,4 ,6 ,8 1
Survival (%) 20 40 60 80
100
120
140
months T1 T2 T3
P=0.001
Moreso F et al Am J Transplant 2006; 6: 747

11. Renal allograft survival (multivariate)
Variable Univariate Multivariate
RR (95% CI) p RR (95% CI) p
Retransplant (yes) 2.5 ( ) ( ) ns
PRA > 50% 4.6 ( ) < ( ) 0.05
CD20 (upper tertile) 3.3 ( ) < ( ) 0.01
Moreso F et al Am J Transplant 2006; 6: 747

12. B cells, acute rejection and outcome in indication biopsies
B cells associated with poor outcome in AR
Sarwal et al. et al. NEJM 2003; 349: 125.
Hippen BE et al. Am J Transplant 2005; 5: 2248
Alausa M et al. Clin Transplant 2005; 10: 137
Eileen WT et al. Transplantation 2006; 82: 1769
Lehnhardt et al. Am J transplant 2006; 6: 847
Zarkhin V et al. Kidney Int 2008; 74: 664
Mourah MR et al. Pediatr Transplant 2009; 13
B cells not associated with poor outcome in AR
Scheepstra C et al. Transplantation 2008; 86:772
Bagnasco SM et al. Am J Transplant 2007; 7:

13. Immunophenotype in protocol biopsies from TAC vs CsA treated patients n= 44TAC vs 22 CsAns
P<0.05
Serón D et al, Transplantation 2007; 83:649

14. B cell survival in CHR after rituximab n=38 explanted grafts with CHR 2 after treatment with rituximab
Intragraft B cells
BAFF positivity
Thaunat et al. Transplantation 2008; 85:1648

15. SCR vs SCR+IF/TA and FoxP3
SCR SCR +
No IF/TA IF/TA p N
___________________________________________________
%FoxP3 + cells / /
Bestard et al. JASN 2008; 19: 2010

16. T regs in pts ACR and BL (indication (12 ACR, 12 BL) and surveillance (8ACR, 8 BL)
Taflin et al. Transplantation 2010; 89: 194

17. Surveillance Bx cytokine transcripts
Hueso M et al. Am J Pathol 2010; 176: 1696

18. Persistent inflammation?
Inflammation+IFTA
B cells
Tregs
IL10
Th2 response
Ag presentation
Persistent inflammation?
CHR?

19. Inflammation with and without fibrosis
Surveillance biopsies
Inflammation with and without fibrosis
Inflammation, IF/TA and CHR
Innate immunity and inflammation

20. SCR and CHR
Inflammation
CAN
Inflammation
Survival Tx

21. SCR and CHR
Inflammation
IF/TA
Inflammation
Survival Tx
CHR

22. SCR and Chronic humoral rejection 1988-2006
Protocol Bx n = 517
CHR 44
IF/TA nos 42
Recurrence 11
De novo GN 7
Acute rejection 4
Polyoma 1
Bx for cause: n = 109

23. Clinical characteristics at the time of biopsy
Variable CHR (44) IF/TA (42) p
Protocol biopsy
Time (m) 4.5 ± ± 3.3 ns
SCr (mol/L) 149 ± ± 44 ns
Proteinuria (g/d) 0.3 ± ± 0.2 ns
Biopsy for cause
Time (y) 6.4 ± ±
SCr (mol/L) ± ± 80 ns
Proteinuria (g/d) 2.3 ± ±

24. Clinical characteristics of patients
Variable CHR IF/TA p-value
(n=44) (n=42)
__________________________________________________
Donor age (years) 40 ± ± 15 ns
Donor gender (% male) ns
Patient age (years) 43 ± ± 12 ns
Patient gender (male) ns
PRA (%) 7 ± ± 10 ns
Virus hepatitis C ns
Re-transplants (%)
HLA DR mm 0.7 ± ± 0.6 ns
Cold ischemia time (hours) 23 ± ± 6 ns
Immunosuppression
CNI without MMF
CNI with MMF
CNI with mTOR-i 1 2
CNI free ns
Delayed graft function (%) ns
Acute rejection (%) ns
_________________________________________________________

25. Acute Banff score in surveillance Biopsies
Acute score
(p=0.003)

26. SCR, CHR and IF/TA CHR IF/TA p __________________________________
RR 95% CI p
__________________________________
SCR
ReTx ns

27. % of cases with CHR and IF/TA in the biopsy for cause
Dg category
in surveillance Bx
n=34
n=17
n=17
n=18

28. Is inflammation in SCR different from SCR + IFTA?
Surveillance biopsies
Is inflammation in SCR different from SCR + IFTA?
Are early Bx findings different in patients developing IFTA in comparison with patients developing CHR
Innate immune alterations and inflammation

29. Risk factors associated with early inflammation in surveillance biopsies
Immunosuppressive treatment
Acute rejection before surveillance Bx
Innate immunity & inflammation in the general population

30. TLR-2 expression in 6 m surveillance Bx is associated wit lower SCR 257 surveillance Bx 6w, 3m, 6m and 108 indication Bx
De Groot K et al. Am J Nephrol 2008; 28: 583

31. MBL 96KDa protein made of 3 identical 32 KDa structures
N-acetylglucosamine D-mannose
N-acetyl mannosamine
L-fructose
Carbohydrate recognition domain
Collagen like domain
N-terminal cross linking region
Bouwman LH et al. 2006; 67:247

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

33. MBL in Renal Transplants Mar 2005 –Oct 2006, 125 RT, 111 with a functioning graft at 3 m
Low MBL
N=42
T 2,3
High MBL
N=83
Log MBL
(ng/ml)

34. sTNFR2 before Tx soluble TNFR
p=0.05
Ibernon M et al. Transplantation 2009: 88: 272

35. 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

36. 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

37. Low MBL and SCR (n=60) P=0,0054 Ibernon M et al. Kidney Int (in press)37

38. Low MBL, subclinical rejection and Tx CAD
Arnt RF et al. Eur Heart J 2005; 26: 1660

39. C1q and MBL and rejection
Bohlson SS et al. Mol Immunol 2007; 44:33

40. C1q deficiency and acute rejection Heart transplant in C1q deficient miceWT
C1q-/-
Csencsits K et al. AJT 2008; 8: 1622

41. C1q deficiency and acute rejection Heart transplant in C1q deficient mice
T cell response is not enhanced
in C1q-/- mice
More intense anti-donor Ab response
Csencsits K et al. AJT 2008; 8: 1622

42. Tissue injury and repair
Normal
IFTA -
Innnate
Immunity
Inflammation
(SCR) Tx
Injury
Apotosis
Necrosis
Progression of injury
SCR + IFTA
CHR +