Updates in Kidney Transplantation From the 2022 Banff-Canadian Society of Transplantation Joint Meeting: Conference Report.

Purpose of the Conference: The 2022 Banff-Canadian Society of Transplantation Meeting in Banff, Alberta, brought together transplant professionals to review new developments across various aspects of solid organ transplantation (SOT) in Canada. Sources of Information: Presentations included consensus recommendations from expert-led forums; experiences with new procedures and legislation; reports from public health data repositories; original clinical and laboratory research; and industry updates regarding novel technologies. Speakers referenced articles and reports published in peer-reviewed journals and online, and unpublished data and preliminary findings. Methods: All authors attended presentations in-person or virtually. Recordings of select presentations were available for later review. Summaries emphasize concepts indicated by speakers as new and clinically relevant. Key Findings: The COVID-19 pandemic disproportionately affected solid organ transplant recipients (SOTRs), who experience worse outcomes of COVID-19 infection than the general population. Vaccinations demonstrate an attenuated immunological response in SOTRs yet provide meaningful protection. Monoclonal antibodies are effective for both passive immunization and treatment of COVID-19 in SOTRs. Infection control protocols have driven the development of virtual methods for clinical research, such as using home blood draws and virtual follow-up to evaluate vaccine efficacy in SOTRs; and patient care delivery, such as employing telerehabilitation post transplant. Access to living kidney donation is limited by various disincentives experienced by potential donors, which may be overcome by more efficient evaluations including a One-Day Living Kidney Donor Assessment Clinic. The International Donation and Transplantation Legislative and Policy Forum provided a means of establishing consensus guidance for organ donation and transplantation (ODT) program policy to standardize delivery across jurisdictions. The implementation of a deemed consent model for organ and tissue donation in Nova Scotia may provide insight as to whether this model indeed improves access to organs. Canada's Indigenous population experiences unique barriers to transplantation, prompting efforts for more inclusive ODT policy-making. The Pan-Canadian ODT Data and Performance Reporting System Project has defined performance quality indicators, of which iTransplant and other point-of-care software solutions may facilitate collection; however, these endeavors ultimately require information technology infrastructure that exceeds the capabilities of the existing Canadian Organ Replacement Register and Canadian Transplant Registry. Pig-to-human xenotransplantation requires genetic modification of pigs and xenoantibody testing in recipients but may yet prove viable. Serum cell-free DNA, urine biomarkers, and genetic markers offer an alternative to routine biopsy for identifying subclinical rejection. Modified perfusion temperatures and perfusion solutions with hydrogen sulfide donor compounds may improve organ preservation. Molecular compatibility tools provide another means of improving SOTR outcomes, and the Genome Canada Transplant Consortium has been examining important considerations of their implementation. Limitations: We were unable to capture all presentations and topics at the meeting due to the sizable quantity and variety. Topics ultimately excluded from this summary include those in pathology including Banff Classification updates; those unique to extra-renal SOT; as well as numerous abstract and poster presentations, allied health provider forums, and business meetings. A portion of the material was presented by speakers prior to peer-review or publication. Implications: The various conference presentations summarized in this report identify methods by which individual clinicians and provincial ODT programs may improve access, delivery, and quality of SOT care in Canada, while additionally identifying gaps in the literature that investigators are encouraged to pursue.

Objectifs de la conférence: En 2022, le congrès annuel de la Société canadienne de transplantation qui s'est tenu à Banff (Alberta) a réuni des professionnels de la transplantation qui se sont penchés sur les nouveaux développements dans divers aspects de la transplantation d'organes solides (TOS) au Canada. Sources: Les présentations portaient notamment sur : les recommandations consensuelles issues de forums dirigés par des experts; l'expérience avec les nouvelles procédures et lois; des rapports provenant de dépôts de données de santé publique; des recherches cliniques et des recherches de laboratoire originales; et les mises à jour du secteur sur les nouvelles technologies. Les intervenants ont fait référence à des articles et rapports publiés en ligne et dans des revues évaluées par les pairs, ainsi qu'à des données non publiées et des conclusions préliminaires. Méthodologie: Tous les auteurs ont assisté aux présentations en personne ou virtuellement. Les enregistrements de certaines présentations étaient disponibles pour visionnement ultérieur. Les résumés mettent l'accent sur les concepts jugés comme nouveaux et cliniquement pertinents par les intervenants. Principaux résultats: La pandémie de COVID-19 a affecté les receveurs d'une transplantation d'organe solide (RTOS) de manière disproportionnée; ces derniers ayant suivi une évolution plus défavorable que la population générale à la suite d'une infection à la COVID-19. La vaccination, bien qu'elle offre une protection significative, montre une réponse immunologique plus faible chez les RTOS. Les anticorps monoclonaux sont efficaces à la fois pour l'immunization passive et le traitement de la COVID-19 chez les RTOS. Les protocoles de contrôle des infections ont mené au développement de méthodes virtuelles pour la recherche clinique (p. ex. prélèvements sanguins à domicile, suivi virtuel pour évaluer l'efficacité du vaccin chez les RTOS) et la prestation de soins aux patients (p. ex. rééducation à distance) après la transplantation. L'accès au don de rein vivant est limité par divers facteurs dissuasifs pour les donneurs potentiels, mais ces obstacles peuvent être surmontés par des évaluations plus efficaces, notamment par une clinique d'un jour pour évaluer la candidature des donneurs vivants de rein. Le Forum législatif et politique international sur le don et la transplantation a fourni un moyen d'établir des lignes directrices consensuelles pour la politique du program de dons d'organes et de transplantation (DOT), dans l'objectif de normaliser la prestation d'une juridiction à l'autre. La mise en œuvre en Nouvelle-Écosse du consentement présumé pour le don d'organes et de tissus pourrait aider à déterminer si un tel modèle améliore effectivement l'accès aux organes. Les populations autochtones du Canada sont confrontées à des obstacles uniques en matière de transplantation, ce qui encourage les efforts visant l'élaboration de politiques plus inclusives en matière de DOT. Le Projet de système pancanadien de données et de mesure de la performance pour les DOT a défini des indicateurs de performance, dont iTransplant et d'autres solutions logicielles pour les points de soins, qui peuvent faciliter la collecte des données; ces derniers nécessitent toutefois une infrastructure informatique qui dépasse les capacités du Registre canadien des insuffisances et des transplantations d'organes et du Registre canadien de transplantation. La xénogreffe de porc à humain requiert une modification génétique des porcs et le dépistage de xénoanticorps chez les receveurs, mais elle peut encore s'avérer viable. L'ADN acellulaire sérique, les biomarqueurs urinaires et les marqueurs génétiques offrent une alternative à la biopsie de routine pour identifier les rejets subcliniques. Des températures de perfusion modifiées et des solutions de perfusion contenant des composés générateurs de sulfure d'hydrogène peuvent améliorer la conservation des organes. Les outils de compatibilité moléculaire offrent un autre moyen d'améliorer les résultats des RTOS, et le Genome Canada Transplant Consortium a examiné les aspects importants à prendre en considération pour leur mise en œuvre. Limites: Nous n'avons pas été en mesure d'assister à toutes les présentations en raison du grand nombre et de la grande diversité des sujets abordés. Les sujets exclus de ce résumé incluent la pathologie, notamment les mises à jour de la classification Banff; les sujets propres à la TOS extrarénale; ainsi que de nombreux résumés et présentations d'affiches, forums de prestataires de soins de santé alliés et réunions d'affaires. Une partie du matériel présenté l'a été avant l'examen par les pairs ou la publication. Conclusion: Les présentations du congrès qui sont résumées dans le présent rapport identifient les méthodes que les programs provinciaux de DOT et les cliniciens pourraient employer pour améliorer l'accès, la prestation et la qualité des soins en TOS au Canada, et soulignent des lacunes dans la littérature que les chercheurs sont encouragés à creuser.

Development of a consortium to examine organ donation legislative and system reforms: A report from the LEADDR consortium.

In April 2019, the province of Nova Scotia became the first jurisdiction in North America to pass legislation that incorporated deemed consent for deceased organ donation. The reform included many other important updates, including the hierarchy for consent, enabled donor and recipient contact, and mandatory referral of potential deceased donors. Additionally, system reforms were implemented to improve the deceased donation system in Nova Scotia. A collection of national colleagues identified the magnitude of the opportunity to develop a comprehensive strategy to measure and evaluate the impact of the legislative and system reforms. This article describes the successful development of a consortium from both national and provincial jurisdictions that included experts from a variety of backgrounds and clinical and administrative disciplines. In describing the creation of this group, we hope to offer our case example as a model for the evaluation of other health system reforms from a multidisciplinary perspective.

Hmx4 regulates Sonic hedgehog signaling through control of retinoic acid synthesis during forebrain patterning.

Mutations in H6-homeobox (HMX) genes are linked to neural mispatterning and neural tube closure defects in humans. We demonstrate that zebrafish Hmx4 regulates the signaling of two morphogens critical for neural development, retinoic acid (RA) and Sonic hedgehog (Shh). Hmx4-depleted embryos have a strongly narrowed eye field and reduced forebrain Shh target gene expression. hmx4 morphants fail to properly transcribe the Shh signal transducer gli3, and have reduced ventral forebrain specification. Hmx4-depleted embryos also have neural tube patterning defects that phenocopy RA-deficiency. We show that Hmx4 is required for the initiation and maintenance of aldh1a2, the principal RA-synthesizing gene. Loss of RA is the primary defect in Hmx4-depleted embryos, as RA treatment rescues a number of the neural patterning defects. Surprisingly, RA treatment also rescues forebrain morphology, gli3 transcription, and Shh signaling. We propose that Hmx4 is a critical regulator of retinoic acid synthesis in a developing embryo, and that this regulation is essential for controlling Shh signaling and forebrain development.

Hindbrain patterning requires fine-tuning of early krox20 transcription by Sprouty 4.

Vertebrate hindbrain segmentation is an evolutionarily conserved process that involves a complex interplay of transcription factors and signalling pathways. Fibroblast growth factor (FGF) signalling plays a major role, notably by controlling the expression of the transcription factor Krox20 (Egr2), which is required for the formation and specification of two segmental units: rhombomeres (r) 3 and 5. Here, we explore the molecular mechanisms downstream of FGF signalling and the function of Sprouty 4 (Spry4), a negative-feedback regulator of this pathway, in zebrafish. We show that precise modulation of FGF signalling by Spry4 is required to determine the appropriate onset of krox20 transcription in r3 and r5 and, ultimately, rhombomere size in the r3-r5 region. FGF signalling acts by modulating the activity of krox20 initiator enhancer elements B and C; in r5, we show that this regulation is mediated by direct binding of the transcription factor MafB to element B. By contrast, FGF signalling does not control the krox20 autoregulatory element A, which is responsible for amplification and maintenance of krox20 expression. Therefore, early krox20 transcription sets the blueprint for r3-r5 patterning. This work illustrates the necessity for fine-tuning in a common and fundamental patterning process, based on a bistable cell-fate choice involving the coupling of an extracellular gradient with a positive-feedback loop. In this mode of patterning, precision and robustness can be achieved by the introduction of a negative-feedback loop, which, in the hindbrain, is mediated by Spry4.

Aberrant forebrain signaling during early development underlies the generation of holoprosencephaly and coloboma.

In this review, we highlight recent literature concerning the signaling mechanisms underlying the development of two neural birth defects, holoprosencephaly and coloboma. Holoprosencephaly, the most common forebrain defect, occurs when the cerebral hemispheres fail to separate and is typically associated with mispatterning of embryonic midline tissue. Coloboma results when the choroid fissure in the eye fails to close. It is clear that Sonic hedgehog (Shh) signaling regulates both forebrain and eye development, with defects in Shh, or components of the Shh signaling cascade leading to the generation of both birth defects. In addition, other intercellular signaling pathways are known factors in the incidence of holoprosencephaly and coloboma. This review will outline recent advances in our understanding of forebrain and eye embryonic pattern formation, with a focus on zebrafish studies of Shh and retinoic acid pathways. Given the clear overlap in the mechanisms that generate both diseases, we propose that holoprosencephaly and coloboma can represent mild and severe aspects of single phenotypic spectrum resulting from aberrant forebrain development. This article is part of a Special Issue entitled Zebrafish Models of Neurological Diseases.

Intrauterine position effects on anogenital distance and digit ratio in male and female mice.

Anogenital distance (AGD) and the ratio of the second (index) to fourth (ring) digit lengths (2D:4D) are two widely used indicators of prenatal androgen exposure. The former is commonly used in rodent models, while the latter is principally used in human studies. We investigated variation in these two traits in C57BL/6J mice to test the hypothesis that variation in these two traits reflect a common underlying variable, presumably testosterone exposure. AGD is a sexually dimorphic trait used to sex young rodents. This distance typically increases and becomes more male-like in female pups when their uterine neighbors are male. 2D:4D is sexually dimorphic in a number of species, including humans and other great apes. Lower digit ratios may be associated with greater exposure to androgens during fetal development in humans. We found the expected sexual dimorphism in AGD, but no significant sex difference in 2D:4D, and no correlation between 2D:4D and AGD. Gestating next to males increased a pup's 2D:4D ratio, but it had no effect on AGD. The lack of correlation between 2D:4D and AGDs in this mouse strain suggests that these two measures do not reflect a common influence of androgen exposure. The possible roles of temporal and localized effects of masculinization are discussed.

Zebrafish model of holoprosencephaly demonstrates a key role for TGIF in regulating retinoic acid metabolism.

Holoprosencephaly (HPE) is the most common human congenital forebrain defect, affecting specification of forebrain tissue and subsequent division of the cerebral hemispheres. The causes of HPE are multivariate and heterogeneous, and include exposure to teratogens, such as retinoic acid (RA), and mutations in forebrain patterning genes. Many of the defects in HPE patients resemble animal models with aberrant RA levels, which also show severe forebrain abnormalities. RA plays an important role in early neural patterning of the vertebrate embryo: expression of RA-synthesizing enzymes initiates high RA levels in the trunk, which are required for proper anterior-posterior patterning of the hindbrain and spinal cord. In the forebrain and midbrain, RA-degrading enzymes are expressed, protecting these regions from the effects of RA. However, the mechanisms that regulate RA-synthesizing and RA-degrading enzymes are poorly understood. Mutations in the gene TGIF are associated with incidence of HPE. We demonstrate in zebrafish that Tgif plays a key role in regulating RA signaling, and is essential to properly pattern the forebrain. Tgif is necessary for normal initiation of genes that control RA synthesis and degradation, resulting in defects in RA-dependent central nervous system patterning in Tgif-depleted embryos. The loss of the forebrain-specific RA-degrading enzyme cyp26a1 causes a forebrain phenotype that mimics tgif morphants. We propose a model in which Tgif controls forebrain patterning by regulating RA degradation. The consequences of abnormal RA levels for forebrain patterning are profound, and imply that in human patients with TGIF deficiencies, increased forebrain RA levels contribute to the development of HPE.