Diagnosis of Acute Cellular Rejection and Antibody-Mediated Rejection on Lung Transplant Biopsies: A Perspective From Members of the Pulmonary Pathology Society.
Allograft rejection can be cell mediated or antibody mediated. Cell-mediated rejection is much more common. It is mediated by T lymphocytes that recognize foreign human leukocyte antigens (HLAs) or other antigens. (2,6) In contrast, antibody-mediated (or humoral) rejection (AMR) occurs owing to binding of preformed or de novo recipient antibodies directed against antigens that are expressed on the donor organ cells. Acute cell-mediated rejection (ACR) and AMR can occur within days, months, or even years after transplant.
The clinical recognition of ACR and AMR can be difficult as the course might be variable, with some patients being asymptomatic or presenting with symptoms that overlap with other complications and diseases in this patient population. These symptoms might include dyspnea, fever, leukocytosis, and a widened alveolar-arterial oxygen gradient. (7) Although ancillary studies together with the clinical presentation of the patient sometimes suggest the presence of ACR or AMR, none of these findings are specific. Therefore, tissue diagnosis is necessary to support a diagnosis of allograft rejection. Transbronchial biopsy to obtain lung tissue is currently the gold standard to assess patients for lung allograft rejection and to distinguish rejection from its clinical mimics such as aspiration, infection, drug toxicity, and recurrent disease. Occasionally, wedge biopsies, explanted lungs (if a patient undergoes retransplant), or autopsy specimens also become available to the pathologist. Recently, the transbronchial cryobiopsy technique became available to obtain lung tissue. Cryobiopsies are reported to yield significantly larger specimens with more alveoli, bronchioles, veins, and venules, and less procedure-related artifact when compared to traditional forceps transbronchial biopsies (Figure 1, A and B). (8-10) Concern over higher complication rates in patients undergoing cryobiopsy and limited experience with cryobiopsy in the transplant setting have prevented widespread adoption of the technique in the routine workup of lung allograft recipients. However, a recent study (8) did not show a significant difference in complications between cryobiopsies and transbronchial biopsies in the lung allograft setting.
REQUIREMENTS FOR TRANSBRONCHIAL BIOPSIES IN THE EVALUATION OF LUNG ALLOGRAFTS
At least 5 pieces of well-expanded alveolated parenchyma are required for adequate morphologic evaluation of a transbronchial lung allograft biopsy specimen for acute rejection. (11) To ensure that these recommendations are fulfilled, the bronchoscopist may need to sample more than 5 pieces. Even more pieces might be necessary to provide biopsy samples of small airways. Specimens should be gently agitated in formalin. Although there are currently no recommendations for the use of cryobiopsies in this setting, in a recent study using cryobiopsies to evaluate rejection in lung allografts, a median of 3 pieces provided twice as many alveoli and small airways than a median of 10 pieces by conventional forceps biopsy. (8)
A minimum of 3 levels from the paraffin block for hematoxylin-eosin staining for histologic examination are required for examination. (11) In addition, "connective tissue stains" such as Trichrome or Verhoeff-Van Gieson stains (or another elastic stain) are recommended to evaluate small airways for the presence of submucosal fibrosis in chronic airways rejection and larger vessels for chronic vascular rejection, respectively. However, given that transbronchial biopsies usually lack larger vessels, these biopsies may be insufficient to assess for chronic vascular rejection. Stains for microorganisms, including Gomori-Grocott methenamine silver stain and a stain for acid-fast bacilli, may be added. While silver staining is routinely performed on lung allograft biopsies in some institutions, they are currently not mandated by the ISHLT because many microbiologic, serologic, and molecular techniques are available and used to identify infections in these patients. Furthermore, the limited sampling implicit in these biopsies may limit the negative predictive value of such stains. (11,12) Bronchoalveolar lavage may be performed at the time of biopsy and is useful for the exclusion of infection, but it currently has no clinical role in the diagnosis of acute rejection.
When evaluating a transbronchial biopsy for allograft rejection, all hematoxylin-eosin levels should be reviewed thoroughly, especially since low-grade rejection might only be seen focally, such as in 1 or 2 levels. Furthermore, a low-power view should precede examination under higher power, as most, but not all, rejection and its extent can be initially recognized under low-power microscopy.
DIAGNOSIS OF ACUTE CELLULAR REJECTION IN LUNG ALLOGRAFT BIOPSIES
Acute cellular rejection can affect both vasculature and small airways. (11) It is characterized by a mononuclear cell infiltrate around small vessels and capillaries ("acute rejection") and/or small airways ("small airways inflammation" or "lymphocytic bronchiolitis"). The ISHLT published a revision of the "working formulation for the standardization of nomenclature in the diagnosis of lung rejection" in 2007, which established the diagnostic criteria for ACR. (11) This working formulation provides not only the characteristic morphologic features of ACR but also a grading scheme for both acute rejection and small airways inflammation. Grading of ACR is important as treatment and follow-up of the patient are adjusted accordingly. In general, patients with ACR of grade A2 and higher are treated with increased immunosuppression, while treatment of grade A1 rejection is variable and controversial and largely depends on whether the patient is symptomatic or asymptomatic. (3,13) However, usually any ACR will prompt closer follow-up biopsy. The treatment of persistent or recurrent ACR is challenging and treatment might include a repeated course of corticosteroids, switch from cyclosporine to tacrolimus, and/or alternative immunosuppressive agents including polyclonal anti-thymocyte globulin, anti-interleukin 2 receptor antagonists, or muromonab-CD3. Evidence also suggests that alemtuzumab, an anti-CD52 monoclonal antibody, might be helpful in refractory ACR. In contrast to ACR, treatment of small airways inflammation/lymphocytic bronchiolitis is not standardized but might include inhaled steroids. Evidence also suggests that azithromycin might be useful in the treatment of small airways inflammation/lymphocytic bronchiolitis. (14)
Although interobserver and intraobserver variability in grading have been recognized and shown to potentially impact treatment and outcome, (8,15-18) this grading scheme is the recommended tool to evaluate posttransplant lung transbronchial biopsies in a standardized fashion. Grading is based on the extent of mononuclear cell infiltrates and the presence or absence of an accompanying acute lung injury; however, clinical findings are not considered in the grading scheme. Interestingly, although cryobiopsies are larger, interobserver reproducibility did not improve with the use of cryobiopsies in a recent study. (8)
Given the small nature of traditional forceps transbronchial biopsies, sampling bias can occur, as changes in rejection can be quite patchy.
Grading of Acute Cellular Rejection According to the ISHLT Working Formulation
Grading of ACR is described in great detail elsewhere.11 In short, ACR is divided into acute rejection or the "A grade" (Figure 2, A through I) and small airways rejection/ lymphocytic bronchiolitis or the "B grade" (Figure 3, A through D) (Table 1). Higher grades of acute rejection are commonly associated with small airways inflammation.
Acute rejection is characterized by a perivascular mononuclear cell infiltrate with or without endothelialitis. (11) Most mononuclear cells in acute rejection are T cells, although a few studies have described increased populations of B cells. (11,19,20) Overall, the grade of acute rejection increases as the cellular infiltrate becomes more extensive. Beginning in the perivascular stroma, the infiltrate may spread into the adjacent interalveolar septa and, subsequently, into the alveoli. ISHLT grade AO lacks any morphologic features of acute rejection. In grade A1 rejection, occasional small blood vessels in the alveolated lung parenchyma, particularly venules, are surrounded by a thin ring (2-3 layers) of mononuclear cells. Grade A2 is characterized by more layers of lymphocytes surrounding small vessels. In addition, chronic inflammatory infiltrates are more frequent and might contain occasional eosinophils. Endothelialitis, characterized by subendothelial mononuclear cells, may be noted but is not required for a diagnosis of rejection. In grade A3 rejection, dense perivascular mononuclear cell infiltrates are commonly associated with endothelialitis, eosinophils, and even occasional neutrophils. The inflammatory cell infiltrate extends into the adjacent interalveolar septa and occasionally might extend into adjacent alveoli. Histologic features of acute lung injury may become apparent. Grade A4 is characterized by diffuse perivascular, interstitial, and air space infiltrates of mononuclear cells with prominent alveolar pneumocyte damage and endothelialitis. Paradoxical diminution of perivascular infiltrates can occur as lymphocytes extend into interalveolar septa and alveoli, where they admix with macrophages. High-grade rejection, in general, has morphologic evidence of acute lung injury including organizing pneumonia, fibrin deposition, or hyaline membranes. While grades A1 and A2 are regarded as low-grade rejection, grades A3 and A4 are viewed as high-grade rejection.
While higher-grade acute rejection can usually be readily noted on low-power view, grade A1 rejection might only be detected at higher-power analysis, especially in specimens with procedural artifacts and atelectasis.
Small airways inflammation/lymphocytic bronchiolitis or ISHLT B grade only applies to small airways such as terminal or respiratory bronchioles. Bronchi should be described separately. If no small airways are identified or the biopsy demonstrates overt evidence of infection, the grade "BX" should be used. While ISHLT grade BO is used if no bronchiolar inflammation is identified, grade B1R (R denotes revision) is defined by lymphocytes in the submucosa of bronchioles. Grade B2R is characterized by a marked infiltrate of both the small airway mucosa and wall. Epithelial damage becomes apparent including necrosis, metaplasia, and/or marked intraepithelial lymphocytic infiltration. Epithelial ulceration, fibrinopurulent exudate, cellular debris, and neutrophilic infiltration might occur.
Mimickers of Acute Cellular Rejection
Histologic features of ACR such as perivascular inflammatory infiltrates can overlap with those of infection. (21) In addition, small airways infections usually present with peribronchiolar inflammation. Moreover, ACR and infection can occur together. Therefore, the grading of ACR requires the exclusion of a concurrent infection. (11) Specifically in patients with high clinical suspicion for infection, the evaluation of a biopsy for rejection should be done with great caution; in certain situations it might not even be possible to definitely ascribe histologic findings to rejection.
Abundant neutrophils, necrosis, granulomas, and viral cytopathic effect are more commonly seen in infection than in ACR. The presence of histiocytic inflammation and/or mixed chronic and acute inflammation might also favor infection or aspiration over rejection. Predominant neutrophils in the epithelium and submucosa of small airways might favor infection over rejection. (22) Evidence suggests that the number of mucosal T cells is higher in small airways rejection/ lymphocytic bronchiolitis than in infectious processes. (23)
Stains for microorganisms (eg, Gomori-Grocott methenamine silver stain, stains for viruses including cytomegalovirus, respiratory syncytial virus, and varicella zoster virus) and correlation with clinical presentation, and culture studies can be helpful and are highly recommended in this regard.
Mimickers of severe acute rejection include conditions that might present with acute lung injury. These conditions include infection, drug toxicity, aspiration, AMR, harvest/reperfusion injury, or recurrence of the primary lung disease. While perivascular chronic inflammation is helpful in the diagnosis of acute rejection, this finding is not entirely specific.
Marked perivascular and/or peribronchiolar or interstitial mononuclear infiltrates might also raise the possibility of posttransplant lymphoproliferative disease (PTLD). In cases that are suggestive of PTLD, an appropriate workup should be performed, including studies for Epstein-Barr virus. Correlation with clinical, radiologic, and culture findings is necessary to rule out or evaluate almost all potential mimics of ACR, especially given the limitations of sample size.
Bronchus-associated lymphatic tissue (BALT) occasionally can mimic ACR. BALT is found in the vicinity of airways, usually contains black anthracotic pigment, and presents as a nodular collection of chronic inflammatory cells that typically does not surround a vessel but might be seen asymmetrically around a vessel (unlike ACR). Deeper sections might be helpful to show these features. Also, epithelial injury, neutrophils, or eosinophils should not be seen in BALT collections. (11)
DIAGNOSIS OF ANTIBODY-MEDIATED REJECTION IN LUNG ALLOGRAFT BIOPSIES
While diagnostic features of AMR are well established in other organs such as kidney and heart, no specific features of AMR have been established in lung allografts. Nevertheless, AMR likely results in acute and chronic graft dysfunction/failure in a subset of patients. (24) Circulating preformed (due to pregnancy, blood transfusions, previous organ transplant) or de novo (occurring after transplant) recipient antibodies are thought to cause AMR. Immune stimulation by prior infections or autoimmunity may also contribute to the development of antibodies in susceptible patients. About 10% to 15% of lung transplant recipients are presensitized to HLA antigens. (25) More sensitive and specific assays to detect circulating antibodies suggest that the incidence of preformed anti-HLA antibodies might be higher than previously thought. These preexisting or de novo antibodies can react with antigens that are expressed on donor organ cells, leading to immediate graft loss (hyperacute rejection), accelerated AMR, and/or BOS. (26) In fact, studies have consistently demonstrated an increased incidence of acute rejection, (27) persistent rejection, BOS, (28) or worse overall survival (29) in patients with anti-HLA antibodies. Although the optimal treatment of AMR in lung is currently not known owing to difficulties in making the diagnosis and lack of clinical trials, treatment typically includes plasmapheresis, and occasionally, intravenous immunoglobulin or immunomodulatory medications such as rituximab and bortezomib, among others.
Given the potential short- and long-term complications and need for immediate treatment, the diagnosis of AMR is important in patients with lung allografts. However, no morphologic, immunologic, clinical, or radiologic findings specific to lung AMR have been established, making the diagnosis of AMR challenging and likely resulting in its underdiagnosis. The current recommendations of assessment of AMR are summarized in Table 2.
In 2013, the Pathology Council of the ISHLT recommended a multidisciplinary approach to the diagnosis of AMR, using the "triple test" including "presence of clinical allograft dysfunction, circulating donor-specific antibodies [DSAs], and pathologic finding." (30) Morphologic features and clinical and serologic findings that should prompt immunostaining of a lung allograft biopsy specimen for complement 4d (C4d) either by immunoperoxidase or by immunofluorescence techniques are listed in Table 3, and an example of AMR is shown in Figure 4, A through C. More than 50% of capillary staining by C4d is considered positive. However, a subsequent survey of histopathologists found that cases with these morphologic criteria, specifically, neutrophilic margination, neutrophilic capillaritis and arteritis, and immunophenotypic evidence of AMR, are actually quite uncommon, creating further challenges to identification of cases for AMR workup. (31)
Deposition of C4d, a complement split product, on the capillary endothelium has been suggested as a surrogate marker for AMR in heart, kidney, liver, and pancreas transplants. (32-42) The role of C4d deposition in the diagnosis of AMR in lung allografts, however, is still unclear. Moreover, reproducibility of C4d deposition in allograft lung transbronchial biopsies is problematic, even among pathologists who routinely evaluate C4d in lung allograft biopsies. (43) C4d is often difficult to interpret in small lung biopsy specimens because of a relatively high background due to nonspecific binding, such as to elastic fibers and intracapillary serum. In addition, staining is frequently only focal. Moreover, C4d deposition is not specific to AMR, as it can also be seen in infection and harvest/reperfusion injury, or any process that is associated with complement activation.
In 2016 the ISHLT proposed a staging of AMR. (31) The proposed staging of clinical AMR (allograft dysfunction, defined as "alterations in pulmonary physiology, gas exchange properties, radiologic features, or deteriorating functional performance," which may be asymptomatic) is summarized in Table 4. In subclinical AMR (normal allograft function), histologic criteria of AMR are detected on surveillance transbronchial biopsies (with or without C4d and with or without the presence of DSAs) in the absence of allograft dysfunction. When DSAs are identified without other manifestations of AMR (histology, C4d staining, allograft dysfunction), heightened surveillance for allograft dysfunction was recommended. It was noted that ACR and AMR can occur concurrently, but other causes should be excluded. As for ACR, infection needs to be excluded before a diagnosis of AMR should be made.
The ISHLT consensus further recommends that the DSA level and function should not be assessed by using the mean fluorescence intensity of the single antigen bead assay but rather by the antibody titer, as the latter is indicative of antibody load. Immunoglobulin G (IgG) subclasses might also play a role with complement-fixing subclasses, such as IgG1 and IgG3, which may be more damaging. The C1q assay might be suitable to stratify risk in patients with DSAs. However, because of the lack of large data sets and sufficient experience, no recommendations were made in regard to standardization of immunophenotyping and DSA testing.
The 2016 Banff study of the pathology of allograft lungs from patients with circulating DSAs confirmed capillary inflammation, acute lung injury, and endothelialitis as morphologic features in lung allograft biopsies that correlate with the presence of DSAs. (44) However, it was emphasized again that none of these histopathologic features were specific to patients with DSAs and that the reproducibility of interpreting these morphologic features is quite problematic even among experienced lung transplant pathologists. Morphologic findings of acute lung injury with diffuse alveolar damage had the highest odds ratio for the presence of DSAs. This study also cautioned the use of C4d immunohistochemical staining for the diagnosis of AMR in lung allografts because of its infrequent diffuse positivity.
Taken together, although a definite diagnosis of AMR cannot be established on morphologic grounds alone at this time, in the correct clinical context, the histopathologic features seen in an allograft transbronchial biopsy may aid in the diagnosis of AMR if other relevant clinical and serologic findings are present.
CONCLUSIONS AND FUTURE DIRECTIONS
Acute cellular rejection should be assessed and graded according to the 2007 working formulation of the ISHLT. While morphologic features of ACR are well defined, there are currently no morphologic, immunophenotypic, clinical, and/or serologic features specific to AMR. At this time, the triple test (clinical allograft dysfunction, DSAa, pathologic findings) is the best approach for the diagnosis of AMR and can guide the clinician to initiate appropriate treatment. C4d by immunofluorescence or immunoperoxidase technique might be performed when morphologic, clinical, and/or serologic features suggestive of AMR are identified. Infection should be excluded before a diagnosis of ACR or AMR is made.
Further research on AMR pathogenesis and diagnosis is needed, as prevention and treatment of AMR appears to be important, based on limited data in lung allografts and experience from other solid organ transplants. Research should be performed in a collaborative effort including pathologists, transplant clinicians, immunologists, and basic science researchers. New diagnostic venues should be explored to gain better understanding and diagnostic accuracy of AMR in lung allografts. For instance, a recent study of kidney allografts used molecular and immune cell functional assays to identify patients with subclinical AMR and ACR.45 In a study by the ISHLT on heart allograft biopsies, natural killer cells and inflammatory genes were assessed.46 This study showed that gene expression sets correlated with endothelial cell injury, DSAs, and AMR. These assays were thought to potentially improve the diagnosis of AMR in heart allografts. Furthermore, gaining experience with transbronchial cryobiopsies and its broader availability might help to make this technique more commonly available for monitoring of lung allograft rejection and its mimickers.
Anja C. Roden, MD; Dara L. Aisner, MD, PhD; Timothy Craig Allen, MD, JD; Marie Christine Aubry, MD; Roberto J. Barrios, MD; Mary B. Beasley, MD; Philip T. Cagle, MD; Vera L. Capelozzi, MD; Sanja Dacic, MD; Yimin Ge, MD; Lida P. Hariri, MD; Sylvie Lantuejoul, MD; Ross A. Miller, MD; Mari Mino-Kenudson, MD; Andre L. Moreira, MD; Kirtee Raparia, MD; Natasha Rekhtman, MD; Lynette Sholl, MD; Maxwell L. Smith, MD; Ming S. Tsao, MD; Marina Vivero, MD; Yasushi Yatabe, MD; Eunhee S. Yi, MD
Accepted for publication September 29, 2016.
Published as an Early Online Release November 7, 2016.
From the Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota (Drs Roden, Aubry, and Yi); the Department of Pathology, University of Colorado, Denver (Dr Aisner); the Department of Pathology, University of Texas Medical Branch, Galveston (Dr Allen); the Department of Pathology and Genomic Medicine, Methodist Hospital, Houston, Texas (Drs Barrios, Cagle, Ge, and Miller); the Department of Pathology, Mount Sinai Health System, Icahn School of Medicine, New York, New York (Dr Beasley); the Department of Pathology, University of Sao Paolo, Brazil (Dr Capelozzi); the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Dacic); the Department of Pathology, Massachusetts General Hospital, and Harvard Medical School, Boston (Drs Hariri and Mino-Kenudson); Departement de Biopathologie, Centre Leon Berard, Lyon, Universite Joseph Fourier INSERM U 823, Institut A. Bonniot, La Tronche, France (Dr Lantuejoul); the Department of Pathology, New York University Langone Medical Center, New York, New York (Dr Moreira); the Department of Pathology, Northwestern University, Chicago, Illinois (Dr Raparia); the Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (Dr Rekhtman); the Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (Drs Sholl and Vivero); the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Dr Smith); the Department of Pathology, University Health Network/Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada (Dr Tsao); and the Department of Pathology and Molecular Diagnostics, Aichi Cancer Center, Nagoya, Japan (Dr Yatabe).
The authors have no relevant financial interest in the products or companies described in this article.
Reprints: Timothy C. Allen, MD, JD, Departments of Pathology and Laboratory Services, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555 (email: firstname.lastname@example.org).
(1.) Yusen RD, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Lung and Heart-Lung Transplantation Report--2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant. 2015;34(10):1264-1277.
(2.) Martinu T, Chen DF, Palmer SM. Acute rejection and humoral sensitization in lung transplant recipients. Proc Am Thorac Soc. 2009;6(1):54-65.
(3.) Martinu T, Pavlisko EN, Chen DF, Palmer SM. Acute allograft rejection: cellular and humoral processes. Clin Chest Med. 2011;32(2):295-310.
(4.) Glanville AR, Aboyoun CL, Havryk A, Plit M, Rainer S, Malouf MA. Severity of lymphocytic bronchiolitis predicts long-term outcome after lung transplantation. Am J Respir Crit Care Med. 2008;177(9):1033-1040.
(5.) Verleden SE, Ruttens D, Vandermeulen E, et al. Bronchiolitis obliterans syndrome and restrictive allograft syndrome: do risk factors differ? Transplantation. 2013;95(9):1167-1172.
(6.) Haque MA, Mizobuchi T, Yasufuku K, et al. Evidence for immune responses to a self-antigen in lung transplantation: role of type V collagen-specific T cells in the pathogenesis of lung allograft rejection. J Immunol. 2002; 169(3):1542-1549.
(7.) DeVito Dabbs A, Hoffman LA, lacono AT, ZulloTG, McCurry KR, Dauber JH. Are symptom reports useful for differentiating between acute rejection and pulmonary infection after lung transplantation? Heart Lung. 2004;33(6):372-380.
(8.) Roden AC, Kern RM, Aubry MC, et al. Transbronchial cryobiopsies in the evaluation of lung allografts: do the benefits outweigh the risks? Arch Pathol Lab Med. 2015;140(4):303-311.
(9.) Yarmus L, Akulian J, Gilbert C, et al. Cryoprobe transbronchial lung biopsy in patients after lung transplantation: a pilot safety study. Chest. 2013;143(3): 621-626.
(10.) Fruchter O, Fridel L, Rosengarten D, Raviv Y, Rosanov V, Kramer MR. Transbronchial cryo-biopsy in lung transplantation patients: first report. Respirology. 2013;18(4):669-673.
(11.) Stewart S, Fishbein MC, Snell GI, et al. Revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection. J Heart Lung Transplant. 2007;26(12):1229-1242.
(12.) Troxell ML, Lanciault C. Practical applications in immunohistochemistry: evaluation of rejection and infection in organ transplantation. Arch Pathol Lab Med. 2016;140(9):910-925.
(13.) Gordon IO, Bhorade S, Vigneswaran WT, et al. SaLUTaRy: survey of lung transplant rejection. J Heart Lung Transplant. 2012;31(9):972-979.
(14.) Vos R, Verleden SE, Ruttens D, et al. Azithromycin and the treatment of lymphocytic airway inflammation after lung transplantation. Am J Transplant. 2014;14(12):2736-2748.
(15.) Chakinala MM, Ritter J, Gage BF, et al. Reliability for grading acute rejection and airway inflammation after lung transplantation. J Heart Lung Transplant. 2005;24(6):652-657.
(16.) Colombat M, Groussard O, Lautrette A, et al. Analysis of the different histologic lesions observed in transbronchial biopsy for the diagnosis of acute rejection: clinicopathologic correlations during the first 6 months after lung transplantation. Hum Pathol. 2005;36(4):387-394.
(17.) Stephenson A, Flint J, English J, et al. Interpretation of transbronchial lung biopsies from lung transplant recipients: inter- and intraobserver agreement. Can Respir J. 2005;12(2):75-77.
(18.) Bhorade SM, Husain AN, Liao C, et al. Interobserver variability in grading transbronchial lung biopsy specimens after lung transplantation. Chest. 2013; 143(6):1717-1724.
(19.) Yousem SA, Martin T, Paradis IL, Keenan R, Griffith BP. Can immunohistological analysis of transbronchial biopsy specimens predict responder status in early acute rejection of lung allografts? Hum Pathol. 1994;25(5):525-529.
(20.) Reams BD, Musselwhite LW, Zaas DW, et al. Alemtuzumab in the treatment of refractory acute rejection and bronchiolitis obliterans syndrome after human lung transplantation. Am J Transplant. 2007;7(12):2802-2808.
(21.) Tazelaar H. Perivascular inflammation in pulmonary infections: implications for the diagnosis of lung rejection. J Heart Lung Transplant. 1991;10(3):437-441.
(22.) Husain AN, Garrity ER. Lung transplantation: the state of the airways. Arch Pathol Lab Med. 2016;140(3):241-244.
(23.) Tavora F, Drachenberg C, Iacono A, Burke AP. Quantitation of T lymphocytes in posttransplant transbronchial biopsies. Hum Pathol. 2009;40(4): 505-515.
(24.) Roux A, Bendib Le Lan I, Holifanjaniaina S, et al. Antibody-mediated rejection in lung transplantation: clinical outcomes and donor-specific antibody characteristics. Am J Transplant. 2016;16(4):1216-1228.
(25.) Appel JZ III, Hartwig MG, Davis RD, Reinsmoen NL. Utility of peritransplant and rescue intravenous immunoglobulin and extracorporeal immunoadsorption in lung transplant recipients sensitized to HLA antigens. Hum Immunol. 2005;66(4):378-386.
(26.) Colvin RB, Smith RN. Antibody-mediated organ-allograft rejection. Nat Rev Immunol. 2005;5(10):807-817.
(27.) Girnita AL, McCurry KR, Iacono AT, et al. HLA-specific antibodies are associated with high-grade and persistent-recurrent lung allograft acute rejection. J Heart Lung Transplant. 2004;23(10):1135-1141.
(28.) Palmer SM, Davis RD, Hadjiliadis D, et al. Development of an antibody specific to major histocompatibility antigens detectable by flow cytometry after lung transplant is associated with bronchiolitis obliterans syndrome. Transplantation. 2002;74(6):799-804.
(29.) Hadjiliadis D, Chaparro C, Reinsmoen NL, et al. Pre-transplant panel reactive antibody in lung transplant recipients is associated with significantly worse post-transplant survival in a multicenter study. J Heart Lung Transplant. 2005;24(7 suppl):S249-S254.
(30.) Berry G, Burke M, Andersen C, et al. Pathology of pulmonary antibody-mediated rejection: 2012 update from the Pathology Council of the ISHLT. J Heart Lung Transplant. 2013;32(1):14-21.
(31.) Levine DJ, Glanville AR, Aboyoun C, et al. Antibody-mediated rejection of the lung: a consensus report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2016;35(4):397-406.
(32.) Choi J, Cho YM, YangWS, Park TJ, ChangJW, ParkSK. Peritubular capillary C4d deposition and renal outcome in post-transplant IgA nephropathy. Clin Transplant. 2007;21(2):159-165.
(33.) Herman J, Lerut E, Van Damme-Lombaerts R, Emonds MP, Van Damme B. Capillary deposition of complement C4d and C3d in pediatric renal allograft biopsies. Transplantation. 2005;79(10):1435-1440.
(34.) Moll S, Pascual M. Humoral rejection of organ allografts. Am J Transplant. 2005;5(11):2611-2618.
(35.) Fedson SE, Daniel SS, Husain AN. Immunohistochemistry staining of C4d to diagnose antibody-mediated rejection in cardiac transplantation. J Heart Lung Transplant. 2008;27(4):372-379.
(36.) Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation, II: morphology, immunopathology, and pathologic classification. I Am Soc Nephrol. 2002;13(3):779-787.
(37.) Mauiyyedi S, Pelle PD, Saidman S, et al. Chronic humoral rejection: identification of antibody-mediated chronic renal allograft rejection by C4d deposits in peritubular capillaries. J Am Soc Nephrol. 2001;12(3):574-582.
(38.) Rodriguez ER, Skojec DV, Tan CD, et al. Antibody-mediated rejection in human cardiac allografts: evaluation of immunoglobulins and complement activation products C4d and C3d as markers. Am J Transplant. 2005;5(11):2778-2785.
(39.) Smith RN, Brousaides N, Grazette L, et al. C4d deposition in cardiac allografts correlates with alloantibody. J Heart Lung Transplant. 2005;24(9):1202-1210.
(40.) Tan CD, Baldwin WM III, Rodriguez ER. Update on cardiac transplantation pathology. Arch Pathol Lab Med. 2007;131(8):1169-1191.
(41.) de Kort H, Munivenkatappa RB, Berger SP, et al. Pancreas allograft biopsies with positive c4d staining and anti-donor antibodies related to worse outcome for patients. Am J Transplant. 2010;10(7):1660-1667.
(42.) DemetrisAJ, Bellamy C, Hubscher SG, et al. 2016 Comprehensive update of the Banff Working Group on Liver Allograft Pathology: introduction of antibody-mediated rejection [published online ahead of print June 7, 2016]. Am J Transplant. doi:10.1111/ajt.13909.
(43.) Roden AC, Maleszewski JJ, Yi ES, et al. Reproducibility of complement 4d deposition by immunofluorescence and immunohistochemistry in lung allograft biopsies. J Heart Lung Transplant. 2014;33(12):1223-1232.
(44.) Wallace WD, Li N, Andersen CB, et al. Banff study of pathologic changes in lung allograft biopsy specimens with donor-specific antibodies. J Heart Lung Transplant. 2016;35(1):40-48.
(45.) Crespo E, Roedder S, Sigdel T, et al. Molecular and functional noninvasive immune monitoring in the ESCAPE study for prediction of subclinical renal allograft rejection [published online ahead of print June 29, 2016]. Transplantation. doi:10.1097/TP.0000000000001287.
(46.) Afzali B, Chapman E, Racape M, et al. Molecular assessment of microcirculation injury in formalin-fixed human cardiac allograft biopsies with antibody-mediated rejection [published online ahead of print July 12, 2016]. Am J Transplant. doi:10.1111/ajt.13956.
Please Note: Illustration(s) are not available due to copyright restrictions.
Caption: Figure 1. Conventional transbronchial forceps biopsy specimens (A) are smaller and usually show more procedural artifacts than transbronchial cryobiopsy specimens (B). While the transbronchial forceps biopsy resulted in a specimen of 0.03 cm3 with 2652 alveoli and no bronchioles, a subsequent transbronchial cryobiopsy from the same patient (but separate procedure) generated a 0.65 cm3 specimen that contained 9956 alveoli and 2 bronchioles (hematoxylin-eosin, scanning magnification).
Caption: Figure 2. Grading of acute cellular rejection according to the International Society for Heart and Lung Transplantation (A-grade). A and B, Grade A1. In this cryobiopsy specimen that has well-expanded airspaces, a low-power view shows a cellular infiltrate (A, arrow) that on high power is composed of only a few layers of lymphocytes surrounding a venule (B). C, Grade A2. A pronounced lymphocytic infiltrate surrounds a small vessel. D through F, Grade A3. A marked cellular infiltrate is appreciated at low power (D, arrows), which extends into the adjacent interalveolar septa (E, arrow). Occasional lymphocytes are within the (sub)endothelium to suggest endotheliitis (F, arrow). G through I, Grade A4. Mild (G) and minimal (H) lymphocytic infiltrates surround capillaries (G and H, arrows point toward venules). Fibrinous organizing pneumonia is also identified (I) (hematoxylin-eosin, original magnifications X40 [A and D], X400 [B and F], X200 [C, E, and H], and X100 [G and I]).
Caption: Figure 3. Grading of small airways rejection/lymphocytic bronchiolitis according to the International Society for Heart and Lung Transplantation (Bgrade). A, Grade B1R. A bronchiole is surrounded by a small rim of mononuclear cells that is confined to the submucosa of the airway B through D, Grade B2R. A dense cellular infiltrate is present in the submucosa and mucosa of a bronchiole (B). This infiltrate is predominantly composed of lymphocytes and only has scattered neutrophils and extends into the mucosa of the airway (C). Squamous metaplasia is also apparent (D) (hematoxylin-eosin, original magnifications X200 [A and B] and X400 [C and D]).
Caption: Figure 4. Possible antibody-mediated rejection. This patient with lung allograft presented with rather acute hypoxia. A transbronchial allograft biopsy revealed patchy interstitial thickening and alveolar infiltrates (A). On high magnification neutrophilic margination in interstitial capillaries and neutrophils in the interstitium extending into the adjacent alveoli are seen (B). Patchy C4d deposition in capillaries was identified (C, arrows) on immunoperoxidase stain (hematoxylin-eosin, original magnifications X40 [A] and X400 [B]; C4d immunoperoxidase, original magnification X400 [C]).
Table 1. Classification of Acute Cellular Rejection According to the 2007 Working Formulation of the International Society for Heart and Lung Transplantation (ISHLT) (a) Acute Rejection Small Airways Inflammation- Lymphocytic Bronchiolitis ISHLT ISHLT Grade Definition Grade Definition A0 None B0 None A1 Minimal B1R Low grade A2 Mild B2R High grade A3 Moderate BX Ungradable A4 Severe (a) Data derived from Stewart et al. (11) Table 2. Recommendations for the Diagnosis of Antibody-Mediated Rejection in Lung Allografts (a) "Triple Test" Recommendations and Characteristics Clinical features Donor-specific Donor-specific antibody level and antibodies function should be assessed by the antibody titer. Pathologic findings Capillary inflammation. Acute lung injury with or without diffuse alveolar damage and endothelialitis. C4d immunostaining (by immunofluorescence or immunoperoxidase technique) either as routine adjunct test or at least in cases with morphologic and/or clinical or immunologic findings suggestive of AMR. More than 50% of capillary staining by C4d is considered positive. C3d immunostaining is currently not supported for routine clinical purposes. Abbreviation: AMR, antibody-mediated rejection. (a) Data derived from Berry et al (30) and Levine et al. (31) Table 3. Features That Should Prompt Immunostaining of a Lung Allograft Biopsy Specimen for C4d as Recommended by the Pathology Council of the International Society for Heart and Lung Transplantation (ISHLT) (a) Feature Characteristics Morphology Neutrophilic capillaritis ISHLT definition: "patchy or diffuse process composed of dense neutrophilic septal infiltrates associated with neutrophilic karyorrhectic debris and fibrin with or without platelet-fibrin thrombi in the microvasculature, alveolar hemorrhage, and flooding of neutrophils into adjacent airspaces" Neutrophilic septal margination ISHLT definition: "neutrophilic infiltrates within the interstitial capillaries and septa in the absence of karyorrhectic changes and fibrinous accumulations" High-grade acute rejection (grade A3 or A4) Persistent/recurrent acute rejection (grades A1-4) Acute lung injury pattern/diffuse alveolar damage High-grade lymphocytic bronchiolitis (grade B2R) Persistent low-grade lymphocytic bronchiolitis (grade B1R) Obliterative bronchiolitis (grade C1) Arteritis in the absence of infection or acute rejection Graft dysfunction without morphologic explanation De novo donor-specific antibodies (a) Data derived from Berry et al. (30) Table 4. Staging of Clinical Antibody-Mediated Rejection as Proposed by the 2016 International Society for Heart and Lung Transplantation Consensus Report (a) AMR Stage Criteria Definite Probable Possible Donor-specific + 2 of the 3 1 of the 3 antibodies criteria criteria Histology suggestive + are is of antibody-mediated present present rejection C4d deposition + Abbreviations: AMR, antibody-mediated rejection; +, present. (a) Data derived from Levine et al. (31)
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|Title Annotation:||Special Articles|
|Author:||Roden, Anja C.; Aisner, Dara L.; Allen, Timothy Craig; Aubry, Marie Christine; Barrios, Roberto J.;|
|Publication:||Archives of Pathology & Laboratory Medicine|
|Date:||Mar 1, 2017|
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