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Keywords:

  • Acute humoral rejection;
  • HCV;
  • interferon

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

The use of interferon-alpha (IFN) in hepatitis C (HCV)-infected renal recipients has been associated with acute rejection and graft loss. We reviewed our recent experience in HCV (+) renal recipients treated with antiviral therapy for biopsy proven chronic hepatitis C. Twelve HCV (+) recipients who recently received antiviral therapy were analyzed. Post-treatment sera were tested for donor-specific human leukocyte antigen (HLA) antibodies (DSA). Within 6 months of initiating antiviral therapy, two of 12 patients (17%) developed acute rejection, which was characterized as acute humoral rejection (de novo DSA in serum and C4d deposits in peritubular capillaries). Both progressed to graft failure. Nine of the remaining 10 patients tested did not have DSA. The use of IFN was associated with severe acute humoral rejection (C4d +, DSA +). The recognition of IFN-associated acute humoral rejection in this series may explain the high rate of graft loss reported previously in renal recipients receiving IFN.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

Acute humoral rejection (AHR) or alloantibody mediated acute rejection in renal allografts is a rare but defined clinico-pathologic entity (1–6). AHR generally occurs in previously sensitized patients, early after transplantation and is often refractory to therapy. Pathognomonic or distinctive histopathologic features include neutrophils and complement C4d deposits in peritubular capillaries (4,6). These findings differentiate AHR from ‘classic’ cell-mediated acute rejection, which is characterized predominantly by tubulitis and endothelialitis. Anti-human leukocyte antigen (HLA) donor-specific antibodies (DSA) are usually detectable in recipient serum at the time of AHR (1–6).

Antiviral therapy with interferon-alpha (IFN) in hepatitis C (HCV)-infected renal transplant recipient remains controversial. In most patients IFN is not used, as it has been associated with triggering severe acute allograft rejection (7,8). An incidence of acute rejection varying from 15% to 64% has been reported after starting therapy with IFN (7–13). Other reports, however, have not documented allograft dysfunction after treatment with IFN in renal transplant recipients (14–16). The exact mechanism of acute rejection triggered by IFN is not clear. Suggested inciting pathways include increased cell surface expression of HLA alloantigens and induction of cytokine gene expression by IFN, or enhancement of antibody production by B cells (9,17,18). Of note, irreversible graft loss due to rejection has been reported (9,10,12,13), but evaluation of humoral responses by repeat cross-matches or staining of biopsies for C4d was not undertaken.

Despite its recognized risks, anti-HCV therapy with IFN may be required in a subset of renal recipients suffering from chronic active hepatitis that commonly progresses to cirrhosis culminating in liver failure (7,8). In this report, we review our recent experience in 12 HCV-infected renal transplant recipients treated with antiviral therapy for biopsy proven chronic active hepatitis C. Two of the 12 cases presented with biopsy proven AHR shortly after treatment with IFN and ribavirin.

Case 1

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

A 47-year-old Caucasian female received a one haplotype-matched kidney transplant from her brother in 1981, for end-stage renal disease secondary to chronic vesicoureteric reflux. This was her first transplant and the pre-transplant panel reactive antibody (PRA) titer was 4%. The immunosuppressive regimen consisted of prednisone and azathioprine. She had a stable post-transplant course for 19 years with a serum creatinine between 1.0 and 1.2 mg/dL without any episode of acute rejection. In March 1998, azathioprine was replaced with cyclosporine (CsA) in an effort to reduce the incidence of recurrent squamous cell cancers of the skin she had suffered. In August 1998, she developed both new onset diabetes mellitus requiring insulin therapy and elevated liver function tests. HCV infection was diagnosed by RT-PCR. The HCV genotype was 1a. A liver biopsy in April 2000 revealed chronic active hepatitis, the HCV serum titer was 518 640 copies/mL (normal < 2000 copies/mL). In view of deteriorating liver function tests, treatment with subcutaneous IFN (1.5 MU three times a week) and oral ribavirin (400 mg/day) was begun in July 2000 after discussing with the patient the possible risks and benefits of antiviral therapy. The combined therapy was well tolerated and an excellent biochemical and virologic response was achieved within 3 months. In December 2000, i.e. 5 months after initiating antiviral therapy, her serum creatinine increased from 1.5 to 5.2 mg/dL and she underwent an allograft biopsy. The biopsy revealed a mononuclear cell infiltrate with focal tubulitis, endothelialitis and patchy interstitial hemorrhages with scattered neutrophils and widespread C4d deposits in the peritubular capillaries. These findings were consistent with combined acute humoral and cellular rejection. Serum DSA against class I antigens were detectable both by enzyme-linked immunoassay (ELISA) and lymphocytotoxic assays. Antiviral therapy was discontinued and treatment with plasmapheresis (total five treatments), 500 mg methylprednisolone boluses (three doses) and tacrolimus (Tac)-mycophenolate mofetil (MMF) rescue began (3). Her renal function stabilized and the liver function tests continued to be normal, but the HCV viral load increased to > 850 000 copies/mL. In August 2001, because of uremic symptoms with a serum creatinine of 6.0 mg/dL, the patient was initiated on chronic ambulatory peritoneal dialysis and immunosuppression was discontinued.

Case 2

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

A 40-year-old Caucasian male received a two antigen-mismatched cadaveric renal allograft in March 1998 for end-stage renal disease secondary to focal segmental glomerulosclerosis. This was his first transplant and the pre-transplant PRA was 7%. His immunosuppressive regimen consisted of CsA, prednisone and MMF, and did not have any episode of acute rejection. He was known to have HCV infection (genotype 2a/2c) at the time of transplantation. Approximately 2 years post-transplant, he developed chronic graft dysfunction with a serum creatinine of 2.3 and 24-h protein excretion of 400 mg. Serum C3 and C4 were normal, rheumatoid factor and cryocrit were negative. An allograft biopsy revealed mild interstitial fibrosis with some areas of isolated focal dense interstitial mononuclear infiltrates consisting of mature lymphocytes and plasma cells, but no evidence of tubulitis, endothelialitis or C4d deposits. Special stains ruled out Epstein–Barr or polyoma virus infection, or a post-transplant lymphoproliferative disorder. Over the next few months, his serum creatinine continued to increase to 2.9 mg/dL. A second biopsy revealed similar findings. In the absence of any other explainable cause, the mononuclear aggregates were attributed to HCV infection, as described previously (19). A liver biopsy was performed which revealed chronic active hepatitis, despite normal liver function tests. The serum HCV titer was 564 000 copies/mL. In October 2000, antiviral treatment with subcutaneous IFN (1.5 MU three times a week) and oral ribavirin at 400 mg/day was initiated. The dose of IFN was subsequently increased to 3 MU three times a week, and ribavirin was reduced to 200 mg/day due to hemolytic anemia. A complete virologic response was achieved after 2 months. Three months after starting antiviral therapy, the serum creatinine increased to 6.2 mg/dL. A new allograft biopsy demonstrated a mononuclear cell infiltrate with marked endothelial swelling, in addition to the previous findings. Peritubular capillaries now showed widespread C4d deposits. Based on the above findings, a pathologic diagnosis of AHR was made. DSA against class I antigens were detectable by both ELISA and lymphocytotoxic assays. Antiviral therapy was discontinued, and rescue treatment was initiated. However, his renal function continued to deteriorate and chronic hemodialysis was begun in January 2001.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

Between 1980 and 2000, 1275 renal transplants were performed in 1071 patients at the Massachusetts General Hospital. Of these, 694 patients had functioning allografts at the time of the current study. Fifty-four patients had positive HCV serology documented either before or after transplantation by second-generation ELISA (Ortho Diagnostic Systems, Raritan, NJ, USA). Of the 54 HCV (+) patients, 12 patients who received antiviral therapy with IFN ± ribavirin for biopsy proven chronic hepatitis were included in this analysis. The diagnosis of HCV infection was confirmed by RT-PCR (Roche Amplicor, Roche Pharmacenticals, Nutley, NJ, USA) in all cases.

Clinical information, renal and liver function tests, side-effects of antiviral therapy, biochemical and virologic response to treatment, and pathologic studies were reviewed. The hepatic activity and fibrosis scores on pre-treatment liver biopsies were assessed using the modified Knodell index (20). Complete response to antiviral therapy was defined as normalization of liver function tests with clearance of viremia. A biochemical response to antiviral therapy was defined as normalization of liver function tests only, and a virologic response was defined as clearance of viremia. Clinical and transplant-related information was obtained by chart review and using the Transplantation Unit database. Stored post-transplant serum samples were used for DSA testing using ELISA (One Lambda Inc., Canoga Park, CA, USA) and/or lymphocytoxicity assay (assays for anti-HLA class I and II DSA were performed). In all patients, IFN was initiated at 1.5 MU subcutaneously three times a week, and the dose was increased to 3 MU three times a week as tolerated; the dose of ribavirin ranged from 200 to 800 mg orally per day (adjusted for renal function). In three patients, IFN was subsequently changed to pegylated IFN (peg-IFN) at a dose of 1–1.5 μg/kg body weight subcutaneously once a week.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

Patient characteristics

The baseline data of the 12 HCV (+) renal allograft recipients are summarized in Table 1. The mean age at the time of initiation of treatment was 48 years. Ten patients received cadaveric allografts and two were from living related donors. The underlying etiologies of renal failure were primary focal segmental glomerulosclerosis (n = 3), membranous nephropathy (n = 2), HCV-associated membranoproliferative glomerulonephritis (n = 1), IgA nephropathy (n = 1), diabetic nephropathy (n = 1), hypertensive nephrosclerosis (n = 1), reflux nephropathy (n = 1), and unknown (n = 2). All patients were hepatitis B surface antigen negative and HIV-negative. The maintenance immunosuppression at the time of initiation of antiviral therapy was CsA-prednisone-azathioprine (n = 2), CsA-prednisone-MMF (n = 3), Tac-prednisone-MMF (n = 5), and CsA or Tac-prednisone (n = 2).

Table 1.  Baseline patient characteristics (n = 12)
CharacteristicMean values (range)
  1. HLA: human leukocyte antigen; PRA; panel reactive antibodies.

Age (years) 48 (30–75)
Gender: male/female  9/3
Race: Caucasian/Hispanic 10/2
Donor: cadaver/living 10/2
Retransplantation  4
PRA: peak (%) 20 (0–100)
PRA at transplant (%) 13 (0–72)
Number of HLA mismatches2.7 (0–6)

Clinical course and outcome (Table 2)

Table 2.  Clinical course and outcome (n = 12)
PtTime from Tx to liver Bx (mo)Hepatic activity indexHepatic fibrosis scoreTime from Tx to Rx (mo)IFN ± RLength of Rx (mo)F/U after Rx (mo)HCV RNA before RxHCV RNA at last F/USGOT pre-RxSGOT at last F/UCreat pre-RxCreat post-Rx /at last F/UDSA post- RxOutcome
  1. AHR: acute humoral rejection; AR: acute rejection; Bx: biopsy; creat: creatinine; DSA: donor-specific antibodies; F/U: follow-up; IFN: interferon-alpha; mo: months; Pt: patient; R: ribavirin; Rx: treatment; Tx: transplant. The clinical courses of patients 10 (case 2) and 12 (case 1) are detailed under Case Reports.

 1before TX30  3IFN + R1919> 1 MU< 300357 271.11.2NoDoing well, switched to peg-IFN
 2  361  3IFN + R12.529> 750 000< 300 (cirrhosis)232 411.31.5Not doneDied secondary to HCV-associated liver failure
 3  484  6IFN + R2222> 1 MU> 850 000121 762.42.2NoDoing well
 4  762  7IFN1555> 120 M< 0.2 M110 282.41.5NoDoing well, Rx stopped
 5  964  9IFN + R 3 3598 33037 5901382201.61.7NoDied secondary to HCV- associated liver failure + CMV infection 3 month after initiation of Rx
 6 3123 31IFN + R 9 9> 850 000556 000 99 341.21.1NoDoing well
 7 1433 15IFN + R 7 7> 850 000> 850 000 24 311.11.1NoDoing well
 8 1731 21IFN + R898914 552> 850 000258 352.11.5NoDoing well
 9 2120 23IFN + R 3 3> 850 000450 000121 581.32.9NoImmune-complex glomerulonephritis, no rejection, switched to peg-IFN
10 3052 31IFN + R 5 4564 000< 300 24 172.96.2YesAHR and Graft loss initiated on HD 4 month after initiation of Rx
11 8372 84IFN + R3232> 850 000736 000473 412.12.4NoDoing well, switched to peg-IFN
1223584238IFN + R 312518 640< 300132 271.55.2YesAHR and Graft loss initiated on CAPD 13 month after initiation on Rx

Eleven patients received both IFN and ribavirin and one received IFN alone. The mean time from transplantation to initiation of antiviral therapy was 38 months (median: 13 months), and the mean follow-up after the initiation of treatment was 24 months (median: 16 months).

Side-effects.  The most common side-effects observed with IFN were flu-like symptoms (n = 4) such as myalgias and fatigue, leukopenia (n = 4), thrombocytopenia (n = 3) and depression (n = 2). Two patients required temporary discontinuation of IFN therapy because of side-effects, with resumption after a few weeks. Ribavirin was discontinued in six patients (50%) because of hemolytic anemia.

Renal function.  Two of 12 (17%) patients (case reports, patients 10 and 12) developed acute rejection within 6 months of initiation of antiviral therapy. In both cases, the rejection was diagnosed as AHR based on the detection of de novo serum DSA and histopathologic findings of C4d deposits with neutrophils in peritubular capillaries. Both of these cases progressed to end-stage allograft failure requiring dialysis in spite of attempted rescue therapy.

In the remaining 10 patients, renal function remained stable in nine (mean serum creatinine before and at the end of treatment/last follow-up: 1.7 ± 0.6 mg/dL and 1.6 ± 0.5 mg/dL, respectively). The other patient (patient 9) had an increase in serum creatinine from 1.3 to 2.9 mg/dL. Allograft biopsy revealed membrano-proliferative glomerulonephritis, without cellular or humoral rejection. None of the nine patients in whom serum was available post-treatment had DSA detected by ELISA, and in four cases by lymphocytotoxicty assays as well.

Response to antiviral therapy.  Complete response (both virologic and biochemical) was achieved in four (33%) and biochemical response alone in five patients (total response rate: 75%). There was no response in the remaining three patients, two of whom developed cirrhosis and died secondary to the complications of end-stage liver failure at 3 and 29 months of follow-up.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References

The use of antiviral therapy, particularly IFN, remains controversial in renal transplant recipients. For example, in a recent review it was recommended that IFN therapy not be used in renal transplant recipients, except in patients with fibrosing cholestatic hepatitis (7). The reported rates of acute rejection after initiating IFN have varied from 15% to 64%, with allograft losses due to severe rejection being observed in a number of cases (7,8). However, in a subset of renal transplant recipients with chronic active hepatitis C, IFN therapy may be indicated as increasing evidence suggests that untreated chronic active hepatitis results in increased morbidity and mortality in these patients (7,8). In the current report, we describe our recent experience with the use of antiviral therapy (IFN and ribavirin) in renal transplant recipients. All our patients had biopsy proven chronic active hepatitis C, and antiviral therapy was initiated after extensively discussing the potential risks and benefits with the patients.

Two of 12 patients (17%) developed irreversible acute rejection, a finding that is consistent with other previous reports. Histopathologically, both patients with acute rejection were found to have AHR (C4d deposits in peritubular capillaries), a finding that was associated with the concurrent detection of anti-HLA DSA in the recipient sera. None of the other 10 patients in whom serum was available for testing (n = 9) had detectable circulating DSA. It should be emphasized that AHR has been described as a rare early event occurring in 4–8% of renal transplant recipients (1–6). Previously, we have not found HCV infection to be a predisposing factor for AHR in the early post-transplant period. In the late post-transplant period (> 6 months), none of the 42 HCV (+) patients in this series who did not receive IFN suffered from AHR.

In the past, ‘acute vascular rejection’ has been described in patients receiving IFN, but it could not be determined whether this represented AHR as no testing for DSA in serum or immuno-staining for C4d deposits in biopsies were performed (9,10,12). In view of our findings, it can be speculated that these cases may also have been AHR. This would help to explain the refractoriness to therapy reported in patients suffering acute rejection after IFN therapy, as AHR is often refractory to therapy (1–5). The mechanism of IFN-induced AHR remains unclear. IFN may cause increased cell surface expression of HLA antigens and induction of cytokine gene expression with subsequent stimulation of antibody production (17,18). Alternatively, IFN may primarily enhance DSA production. Interestingly, the use of IFN therapy for recurrent HCV infection in liver transplant recipients has not been found to be associated with an increased incidence of acute rejection (8). It is important to note that in contrast to the kidney, the liver is an organ that is less susceptible to antibody-mediated rejection. Whether DSA production is enhanced in liver transplant recipients receiving IFN (without causing liver dysfunction) remains to be determined.

In summary, the use of IFN was associated with severe AHR in 17% of renal recipients resulting in allograft loss. The recognition of AHR in this series may explain the high rate of allograft loss reported previously in recipients receiving IFN. Biochemical or complete response to therapy was observed in the majority of patients. Our results further indicate that the potential benefits of IFN therapy need to be weighed against the risk of allograft rejection in renal transplant recipients. Safer and more effective strategies are required to treat renal transplant patients with HCV infection.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case 1
  5. Case 2
  6. Materials and Methods
  7. Results
  8. Discussion
  9. References
  • 1
    Halloran PF, Wadgymar A, Ritchie S, Falk J, Solez K, Srinivasa NS. The significance of anti-class I antibody response. Clinical and pathologic features of anti-class I mediated rejection. Transplantation 1990: 49: 8591.
  • 2
    Halloran PF, Schlaut J, Solez K et al. The significance of anti-class I antibody response. II. Clinical and pathologic features of renal transplants with anti-class I-like antibody. Transplantation 1992; 53: 550555.
  • 3
    Pascual M, Saidman S, Tolkoff-Rubin N et al. Plasma exchange and tacrolimus-mycophenolate rescue for acute humoral rejection in kidney transplantation. Transplantation 1998; 66: 14601464.
  • 4
    Collins AB, Schneeberger EE, Pascual MA et al. Complement activation in acute humoral renal allograft rejection. diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol 1999; 10: 22082214.
  • 5
    Crespo M, Pascual M, Tolfoff-Rubin N et al. Acute humoral rejection in renal allograft recipients: Incidence, serology and clinical characteristics. Transplantation 2001; 71: 652658.
  • 6
    Mauiyyedi S, Crespo M, Collins AB et al. Acute humoral rejection in kidney transplantation. II. Morphology, immunopathology and pathologic classification. J Am Soc Nephrol 2002; 13: 779787.
  • 7
    Morales JM, Campistol JM. Transplantation in the patient with hepatitis C. J Am Soc Nephrol 2000; 11: 13431353.
  • 8
    Baid S, Cosimi AB, Tolkoff-Rubin N, Colvin RB, Williams WW, Pascual M. Renal disease associated with hepatitis C infection after kidney and liver transplantation. Transplantation 2000; 70: 255261.
  • 9
    Kramer P, Ten Kate FWJ, Bijnen AB, Jeekel J, Weimar W. Recombinant leucocyte interferon A induces steroid-resistant acute vascular rejection episodes in renal transplant recipients. Lancet 1984; 1: 989990.
  • 10
    Kovarik J, Mayer G, Pohanka E et al. Adverse effect of low-dose prophylactic human recombinant leukocyte interferon-α treatment in renal transplant recipients: Cytomegalovirus infection prophylaxis leading to an increased incidence of irreversible rejections. Transplantation 1988; 45: 402405.
  • 11
    Thervet E, Pol S, Legendre MF, Cavalcanti R, Kreis H. Low-dose recombinant leukocyte interferon-α treatment of hepatitis C viral infection in renal transplant recipients: a pilot study. Transplantation 1994; 58: 625627.
  • 12
    Magnone M, Holley JL, Shapiro R et al. Interferon-α induced acute renal allograft rejection. Transplantation 1995; 59: 10681070.
  • 13
    Durlik M, Gaciong Z, Rowinska D et al. Long-term results of treatment of chronic hepatitis B, C and D with interferon-alpha in renal allograft recipients. Transpl Int 1998; 11: 135139.
  • 14
    Hirsch MS, Schooley RY, Cosimi AB et al. Effects of interferon-alpha on cytomegalovirus reactivation syndromes in renal transplant recipients. N Engl J Med 1983; 308: 14891493.
  • 15
    Gallay BJ, Alpers CE, Davis CL, Schultz MF, Johnson RJ. Glomerulonephritis in renal allografts associated with hepatitis C infection: a possible relationship with transplant glomerulopathy in two cases. Am J Kidney Dis 1995; 26: 662667.
  • 16
    Toth CM, Pascual M, Chung RT et al. Hepatitis C virus-associated fibrosing cholestatic hepatitis after renal transplantation. Transplantation 1998; 66: 12541256.
  • 17
    Gisler RH, Lindahl P, Gresser I. Effects of interferon on antibody synthesis in vitro. J Immunol 1974; 113: 438444.
  • 18
    Rhodes J, Jones DH, Bleehen NM. Increased expression of human monocyte HLA-DR antigens and Fcγ receptors in response to human interferon in vivo. Clin Exp Imunol 1983; 53: 739743.
  • 19
    Schifferli JA, French LE, Tissot JD. Hepatitis C virus infection, cryoglobulinemia, and glomerulonephritis. Adv Nephrol Necker Hosp 1995: 24: 107129.
  • 20
    Ishak K, Baptista A, Bianchi L et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995; 22: 696699.