Clinical Significance of Macrophage Polarization in Antibody-Mediated Rejection of Renal Allograft.

BACKGROUND: The significance of proinflammatory M1 (classically activated) and profibrotic M2 (alternatively activated) macrophages in antibody-mediated rejection (ABMR) after kidney transplantation has not been investigated. METHODS: Fifty-five biopsy-confirmed ABMR samples were stained with MRP 8/14 (a marker of M1 macrophages) and CD163 (a marker of M2 macrophages), and positive cells were counted in glomeruli and the tubulointerstitium, respectively. Patients were classified into M1 and M2 polarization groups according to the glomerular and tubulointerstitial M1:M2 ratio, and the results were compared with Banff scores, serum creatinine level, estimated glomerular filtration rate (eGFR), and graft survival. RESULTS: The glomerular M2 polarization group showed significantly higher chronic glomerulopathy scores, serum creatinine levels, and lower eGFR at the time of biopsy (P = .019 and P = .015, respectively) and 3-month postbiopsy (P = .016 and P = .032, respectively) than the M1 polarization group. The tubulointerstitial M2 polarization group had significantly lower glomerulitis, arteritis, peritubular capillaritis, and glomerulitis + peritubular capillaritis scores than the M1 polarization group, but there was no significant difference in renal function. Long-term graft survival was not associated with macrophage polarization. CONCLUSION: Glomerular M2 polarization in ABMR biopsy samples is associated with chronic glomerular injury and poorer graft function, but without graft survival.

Concurrent Post-Transplantation Diabetes Mellitus in Renal Allograft Recipients With Immunoglobulin A Nephropathy.

BACKGROUND: The prevalence of post-transplantation immunoglobulin A nephropathy (PTIgAN) and diabetes mellitus (PTDM) increases with time after transplantation, and recognition and management of these conditions is becoming more important in renal allograft recipients as graft survival increases. METHODS: We explored the influence of concurrent PTDM on renal allograft histology and function in 111 cases with PTIgAN diagnosed from 2000 to 2010 at our institution. RESULTS: Sixteen patients (14.4%) had PTDM at the time of diagnosis of PTIgAN, which increased to 28 patients (25.2%) at the last follow-up (10.4 years after transplantation). Donor ages were younger in PTIgAN patients with concurrent PTDM. However, other clinical and demographic data were not significantly different between PTIgAN patients with and without PTDM. Histologically, Banff "mm" scores were higher and "M1" of the Oxford classification was more frequent in PTIgAN patients with concurrent PTDM than in patients without PTDM, but the difference did not reach statistical significance. Serum creatinine levels and proteinuria at the time of biopsy and overall graft survival did not vary according to the presence of PTDM both at biopsy and at the last follow-up. CONCLUSIONS: Concurrent PTDM does not significantly influence graft function or outcome for 10 years after transplantation in PTIgAN patients.

Immunohistochemical analysis of infiltrating inflammatory cells in the isolated v-lesion of allograft kidney.

The term "isolated v-lesion" was proposed at the 2009 Banff conference on allograft pathology. It is still debated whether the isolated v-lesion is a part of the antibody-mediated or T cell-mediated rejection and whether the isolated v-lesion has any prognostic significance of its own. To investigate the characteristics of the isolated v-lesion, we identified infiltrating inflammatory cells in renal allograft biopsy specimens with these lesions. We selected 11 allograft renal biopsy specimens which were compatible with the original definition of the isolated v-lesion (v1 or v2 with i ≤ 1 and t ≤ 1) and had enough paraffin-embedded tissue for immunohistochemistry. We performed immunohistochemistry for markers of T cells (CD3, CD4, and CD8), B cells (CD20), NK/T cells (CD56), and macrophages (CD68). The number of positive cells was counted in each compartment of the renal tissue including the arteries, peritubular capillaries, glomeruli, tubules, and interstitium. Arteries were infiltrated by CD3/CD8-positive T cells and CD68-positive macrophages. Three cases showed T cell-dominant infiltrates and four cases showed macrophage-dominant infiltrates. Glomeruli showed a similar inflammatory cell profile to that of arteries. Tubulitis was composed of CD3/CD8-positive T cells. The components of interstitial inflammation were more variable with the presence of CD20-positive B cells. In six cases, interstitial infiltrates were predominantly composed of CD3/CD8-positive T cells, and two of these cases showed almost exclusive infiltrates of T cells. However, four cases showed co-dominant infiltrates of T and B cells, and one case showed predominant B cell infiltrates. The isolated v-lesion has a heterogeneous pathogenesis, and B cell-predominant infiltrates in some cases suggest that this lesion could be related to an antibody-related process.

HRCT features of acute rejection in patients with bilateral lung transplantation: the usefulness of lesion distribution.

PURPOSE: This study sought to evaluate the high-resolution computed tomography (HRCT) features of acute rejection and to assess the diagnostic accuracy of HRCT for acute rejection considering distribution of lesions in patients with bilateral lung transplantation (BLT). MATERIALS AND METHODS: Between March 2010 and June 2012, 48 transbronchial lung biopsies (TBLBs) and HRCT were performed simultaneously in 26 patients who underwent BLT. We evaluated the presence of ground glass opacity (GGO), consolidation, nodule, bronchial wall thickening, interlobular septal thickening, pleural effusion, atelectasis, bronchiectasis, and cardiomegaly on the HRCT images. The distribution of lesions was analyzed according to bilaterality or upper/lower predominance. Acute rejection was determined on the basis of the pathologic results of TBLB. We evaluated potential correlations of HRCT features with acute rejection, then assessed overall diagnostic accuracy of various HRCT features in combination to diagnose acute rejection in the transplanted lung. RESULTS: Among the 48 TBLBs, 8 were diagnosed as acute rejection (A1, 4 cases; A2, 2 cases; and A3, 2 cases) pathologically. Two A1 rejections and one A2 rejection appeared normal on computed tomography images. Without considering the distribution of lesions, interlobular septal thickening was significantly associated with acute rejection (P = .010) only. Regarding the distribution of lesions on HRCT images, not only interlobular septal thickening but also GGO was significantly associated with acute rejection (P < .05). The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the HRCT scan in the evaluation of acute rejection were 50%, 97.5%, 80%, 90.1%, and 89.6%, when the bilateral GGO and interlobular septal thickening with lower predominance were considered as the positive finding. CONCLUSIONS: HRCT findings considering lesion distribution could be a useful tool in diagnosing acute rejection in patients with BLT.

The impact of time-zero biopsy on early graft outcomes after living donor kidney transplantation.

BACKGROUND: In contrast with deceased donor transplantation, the clinical significance of pathologic findings in time-zero biopsies after living donor kidney transplantation are rarely reported, due to the expectation that histologic findings and renal function are normal. The aim of this study was to identify subclinical pathologic findings in living donors and examine the effect on early graft renal function. METHODS: Between December 2006 and July 2011, 146 living-donor kidney transplant recipients were enrolled in this study. We retrospectively analyzed donor and recipient-related clinical parameters, and post-transplant 6 months and 1 year estimated glomerular filtration rate (eGFR) as early graft renal function. Time-zero biopsies were evaluated using the 2007 Banff criteria. RESULTS: Most abnormal histologic findings were of mild degree as determined by Banff scores. Global glomerulosclerosis (GS, 35.6%), tubular atrophy (CT, 36.3%), interstitial fibrosis (CI, 20.5%), vascular fibrous intimal thickening (CV, 4.1%), arteriolar hyaline thickening (AH, 14.4%), interstitial inflammation (I, 3.4%) were pathologic findings in time-zero biopsies. The univariate analysis revealed that donor age and gender were significantly associated with eGFR at post-transplant 6 months and at 1 year (P < .05). Furthermore, GS and CT were significantly associated with early graft renal function (P < .05). However, multivariate linear regression analysis showed only donor age was significantly associated with early graft renal function (P = .001). CONCLUSION: A mild degree of subclinical, pathologic findings on time-zero biopsy did not affect early graft renal function in living-donor kidney transplantation.

A comparison of inflammatory mediator expression between palmoplantar pustulosis and pompholyx.

BACKGROUND: Both palmoplantar pustulosis (PPP) and pompholyx are clinically characterized by acute eruptions of vesicles or pustules on the palms or soles. OBJECTIVES: This study aims to compare the expression of certain inflammatory mediator genes and proteins between patients with PPP and pompholyx using skin tissue samples. METHODS: Skin biopsies obtained from lesional skin from patients with PPP (n = 7) and pompholyx (n = 5) were analysed by quantitative RT-PCR to measure the mRNA levels of nine genes, including IL-4, IL-8, IL-9, IL-17, IL-22, IFN-γ, CCL-20, granzyme and perforin. For immunohistochemical analysis, 34 paraffin-embedded skin specimens (PPP, n = 22; pompholyx, n = 12) were stained with anti-IL-8, IL-17A, IL-22 and granzyme B antibodies. RESULTS: Of genes analysed, IL-8 and IL-17A mRNA expression levels were significantly higher in the PPP group than the pompholyx group (P = 0.012 in both), whereas the mRNA expression of granzyme B was significantly higher in pompholyx when compared with PPP (P = 0.004). Regarding the IL-17A immunohistochemical staining, tissue from the PPP lesions contained significantly more IL-17A(+) cells in both the epidermis and papillary dermis when compared with pompholyx (P < 0.001 and P = 0.019 respectively). Moreover, the intensity of the IL-8 immunoreactivity was also greater in the PPP skin lesions than the pompholyx tissue (P < 0.001). CONCLUSIONS: IL-8 and IL-17A, both are increased in PPP tissue, may represent important immunologic mediators that help to differentiate this clinical entity from pompholyx. This study may provide useful clues in distinguishing PPP from pompholyx, as well as helping to understand the pathogeneses of these two diseases.

Accompanying renal injuries did not impact graft survival in patients with transplant glomerulopathy.

Transplant glomerulopathy (TG) a morphological feature of chronic active antibody-mediated rejection, is associated with donor-specific antibody, peritubular capillary deposition of C4d, and multilayering of peritubular capillary basement membranes. To evaluate the significance of accompanying nonimmunologic injuries in TG, we retrospectively reviewed 2839 renal allograft cases at our institute among which TG was diagnosed in 81 patients (2.9%). Among TG cases, 48 samples showed accompanying diseases such as chronic calcineurin inhibitor toxicity, hepatitis viral infection, posttransplant diabetes, and glomerulonephritis. Comparing the pure form of TG with TG-mixed diseases, there was no difference in patient demography, serum creatinine values, and proteinuria. Among histological parameters, severe hyalinosis was more frequently observed among the TG plus other diseases group. The two groups did not show significant difference in graft survival (P = .216).

C4d deposition and multilayering of peritubular capillary basement membrane in posttransplantation membranous nephropathy indicate its association with antibody-mediated injury.

Membranous nephropathy (MN) may develop as recurrence or de novo after transplantation. Recently, autoimmune or alloimmune responses to unspecified glomerular antigens have been considered as a pathogenetic mechanism. To explore the relationship between antibody-mediated injury and posttransplantation MN, we tested C4d positivity using polyclonal antibody in renal allograft biopsy samples diagnosed as posttransplantation MN. A total of 19 cases (16 males and 3 females), including 2 recurrent and 7 de novo forms, were the subject of the study. On light microscopy, stage II was the most common (n = 9). In addition to glomerular capillary immunoglobulin (Ig)G deposits, all but 2 cases having only sclerotic glomeruli were C4d-positive in glomerular capillary walls. Twelve cases were also positive in cortical peritubular capillaries (PTCs): diffuse in 8 cases and focal in 4 cases. Two of 3 cases associated with acute rejection and 3 of 4 cases associated with chronic rejection were PTC C4d-positive. The frequency of C4d positivity in PTCs was significantly higher than that of posttransplantation IgA nephropathy (P = .028). In conclusion, a higher frequency of PTC C4d positivity suggests an involvement of chronic antibody-mediated injury in the evolution of posttransplantation MN.

Expression of interleukin-17 is correlated with interferon-α expression in cutaneous lesions of lupus erythematosus.

BACKGROUND: Type I interferon (IFN) has been reported to have an important role in the development of cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE). A new subset of CD4+ T cells, T helper (Th)17 cells, also plays a role in the development of autoimmunity. AIM: To investigate expression of interleukin (IL)-17 and IFN-α in different CLE subsets, and their associations with the pathogenesis of LE. METHODS: Skin tissue samples from 33 cases, including chronic discoid LE (n = 24), acute (A)CLE (n = 4), subacute CLE (n = 1) and lupus panniculitis (n = 4) were collected for immunohistochemistry. Expression of IL-6, IL-17A, IFN-α, IFN-γ, myxovirus protein (Mx)A and transforming growth factor (TGF)-ß was assessed in these samples. RESULTS: All LE specimens had staining for IL-6 and TGF-ß in the infiltrated inflammatory cells. IL-17A staining was seen in 84.8% of specimens, and IFN-α or MxA was seen in 93.9%. TGF-ß expression in ACLE was significantly greater than that in both chronic cutaneous (CC)LE and in lupus panniculitis (P = 0.02 for both). Expression of IL-17A was positively associated with expression of IFN-α and MxA (Spearman's ρ = 0.56 and 0.39, respectively). In addition, the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) correlated positively with expression of IFN-α and MxA (ρ = 0.40 for both), whereas there was no correlation with IL-17A expression. CONCLUSIONS: Two major cytokines, IL-17A and IFN-α, may play roles in the pathogenesis of CLE. Their patterns of expression positively correlated with each other.

Biodegradation of estrogen conjugates by bacteria isolated from river sediments.

The objective of this study was to investigate the ability of E. coli in river sediments to degrade estrogen conjugates. Biodegradation experiments on glucuronide estrogens (E1-GLU, E2-GLU and E3-GLU) using E. coli, non-E. coli bacteria as well as sediment crude extracts were carried out in batch mode. A pure identified E. coli strain (KCTC 2571) was used for comparison of enzyme activity. The results showed that the degradation rate of estrogen conjugates by KCTC 2571 and E. coli isolated from sediments followed a similar trend. Fecal bacteria showed a high ability to deconjugate glucuronided estrogens. Approximately 50% of glucuronide moieties were cleaved within 4 h of contact time in experiments using pure E. coli. The degradation rate was slower in experiments using crude extracts of sediments, and conjugated estrogens were not completely degraded even after 12 h of reaction. These results provide a clear understanding of the fate and behavior of estrogen by bacteria in the environment.

AEB-071 versus tacrolimus monotherapy to prevent acute cardiac allograft rejection in the rat: a preliminary report.

Inhibition of T-cell activation is the most efficient way to prevent transplant rejection. Protein kinase C (PKC) is an important signaling enzyme in the activation and regulation of T lymphocytes. AEB-071 (AEB) is a low-molecular-weight compound that blocks early T-cell activation via selective inhibition of PKC, a mechanism that differs from that of the calcineurin inhibitors. The present study sought to compare the effects of AEB versus tacrolimus (Tac) to prevent acute rejection in rats that had undergone heterotopic heart transplantation. We investigated the Brown Norway-Lewis rat strain combination for cardiac graft survival over 30 days after transplantation using varying doses of oral AEB and Tac monotherapy. Grafts were monitored by daily palpation; cessation of palpable ventricular contraction was considered to be rejection. Apart from necropsy, we performed histologic examinations of cardiac graft at 7 days after transplantation. In untreated recipients, allograft mean survival times (MST) was 6.83+/-0.41 days. AEB at 15, 30, or 60 mg/kg versus Tac at 1.2 mg/kg significantly prolonged graft survival to a MST of 12.33+/-1.21, 16.67+/-1.21, and 19.33+/-3.83, versus 17.00+/-6.90 days, respectively. Histologic assessment at 7 days after transplantation showed that high-dose AEB significantly decreased the histologic rejection score, indicative of decreased inflammatory cell infiltration into the graft. These results suggested that the administration of AEB (medium or high-dose), a PKC inhibitor, mitigated acute rejection and displayed significantly longer MST, similar to high-dose Tac after heterotopic heart transplantation in the rat.

Pretreatment with the tumor nerosis factor-alpha blocker etanercept attenuated ischemia-reperfusion renal injury.

INTRODUCTION: Tumor necrosis factor (TNF)-alpha mediates inflammation and apoptosis in ischemia-reperfusion (IR) injury of the kidneys. Etanercept, a soluble TNF-alpha receptor, has shown anti-inflammatory and anti-apoptotic effects in several animal models of renal injury, including chronic insufficiency and unilateral ureteral obstruction. We evaluated the protective effect of etanercept against experimental renal IR injury. METHODS: Male Sprague-Dawley (SD) rats were divided into 4 groups: saline-treated sham rats, etanercept-treated sham rats, saline-treated IR rats, and etanercept-treated IR rats. Renal messenger RNA (mRNA) levels of TNF-alpha and monocyte chemotactic protein-1 (MCP-1) were measured by real-time polymerase chain reaction (PCR) at 24 hours after IR injury. The protein levels of renal Bcl-2 associated X (Bax), B-cell lymphoma 2 (Bcl), extracellular signal-regulated kinase (ERK), and caspase-3 activation were evaluated using Western blot analysis. The degree of apoptosis of renal tubular cells was determined using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assays. RESULTS: At 24 hours after IR injury, the serum levels of blood urea nitrogen (BUN) and creatinine were significantly lower among etanercept-treated than saline-treated IR rats. Renal mRNA levels of TNF-alpha and MCP-1 in saline-treated IR rats were significantly higher than the levels in saline-treated sham rats, and TNF-alpha and MCP-1 mRNA levels in etanercept-treated IR rats were significantly lower than those in saline-treated IR rats. Etanercept pretreatment of IR-injured rats significantly increased EKR phosphorylation and reduced the renal Bcl-2/Bax ratio, the renal caspase-3 activation, and the number of TUNEL-positive apoptotic cells. CONCLUSION: Etanercept improved resistance to renal injury during IR by enhancing the activation of ERK and increasing the Bcl-2/Bax ratio.

IgG nephropathy - confusion and overlap with C1q nephropathy.

BACKGROUND: IgG nephropathy is one of the most recently described glomerulopathies, which frequently overlaps with C1q nephropathy. To clarify this entity, we evaluated renal biopsy cases with IgG deposits as a sole or predominant immunoglobulin. METHODS: Fourteen cases demonstrating IgG as a predominantly deposited immunoglobulin in patients without infectious or autoimmune diseases between 1997 and 2008 were studied. Twelve patients had glomerular disease in the native kidney and the other 2 were renal allograft recipients. RESULTS: Clinical presentation was microscopic hematuria, proteinuria, or both and nephrotic syndrome was observed in 3 patients. Segmental glomerulosclerosis was observed in 4 patients and mesangial hypercellularity was present in 7. Tubulointerstitial changes were not evident except for allograft biopsies. On immunofluorescence, mesangial or capillary wall IgG deposits were present in all cases, and C1q was observed in 11 cases in a similar pattern with IgG, co-dominant in 5 cases and dominant in 1. CONCLUSIONS: Since a significant overlap is frequently observed in these two rare conditions, we suggest a tentative diagnosis of IgG/C1q nephropathy in such cases.

Acute poststreptococcal glomerulonephritis superimposed on IgA nephropathy.

Superimposition of poststreptococcal glomerulonephritis (PSGN) on the course of IgA nephropathy (IgAN) is uncommon. A case of PSGN during IgA nephropathy is presented. A 30-year-old man who had alternating gross and microscopic hematuria for 7 months underwent a renal biopsy. The first renal biopsy revealed IgAN with mesangial deposits of IgA and C3. Two months later, the patient suffered generalized edema, proteinuria, hematuria, an increased ASO titer and a decreased C3 level. A second renal biopsy revealed diffuse endocapillary proliferative glomerulonephritis with epimembranous hump-like electron-dense deposits of C3, but the original mesangial IgA deposits had disappeared. A diagnosis of acute PSGN was indicated. Two months after the onset of acute nephritic syndrome, the patient remained asymptomatic, except for microscopic hematuria and proteinuria. Some cases with persistent proteinuria or hematuria after PSGN are probably related to preexisting IgAN.

Malignant mixed müllerian tumor of fallopian tube with multiple distinct heterologous components.

We experienced a case of primary malignant mixed müllerian tumors (MMMTs) of the fallopian tube of FIGO stage I. In addition to endometrioid adenocarcinomas, multiple apparent heterologous elements encompassing myxoid chondrosarcoma, osteosarcoma, myxoid liposarcoma, and well-differentiated angiosarcoma were recognized separately in each nodule. Those findings that divergent sarcomatoid differentiations are apparently present masquerading malignant mesenchymoma have not been described in MMMTs of the female genital tract.

Granulocytic sarcoma of the uterine cervix.

Granulocytic sarcoma (GS) is a rare manifestation of leukemia and has been reported in 3-5% of acute myelogenous leukemia (AML) patients. GS in the uterine cervix is very rare and is also called chloroma because of its greenish appearance. We present the case of a patient whose disease relapsed as chloroma of the uterine cervix after bone marrow transplantation (BMT). She remained in continuous complete remission for 2 years after allogeneic BMT. However, she visited the hospital because of painless vaginal bleeding. She was diagnosed as having chloroma by cervical smear and colposcopically directed biopsy of the cervix. Systemic chemotherapy was administered on the presumption that myelogenous leukemia had recurred as chloroma, and a good clinical response was achieved. We describe the first case of AML that relapsed as chloroma of the uterine cervix after complete remission of the AML, which had complete response to only systemic chemotherapy.

Thymoma with pseudosarcomatous stroma.

Thymoma with psuedosarcomatous stroma is a recently described, rare variant of thymomas that are characterized by having a biphasic histologic pattern which consists of both an epithelial and a spindle cell stromal component. So far only 11 cases having similar histologic findings have been reported worldwide. At this time we report a case of this rare variant of thymoma which occurred in a 53-year-old Korean man. This previously healthy patient presented with coughing and an anterior mediastinal mass was then detected radiographically. Mediastinal exploration revealed a 9 x 8 x 8 cm-sized well- encapsulated, ovoid, cystic mass. Histological examination showed a biphasic neoplasm composed of anastomosing nests of epithelial cells and somewhat cellular stromal spindle cells that had advanced degenerative changes. Immunohistochemical staining using the antibodies for cytokeratins, EMA, e-cadherin, and p75NGFR showed a strong expression of these markers in the epithelial component but no expression in the spindle stromal cells. The epithelial tumor cells showed no reactivity to CD5 and L26 and a high proportion of the infiltrated lymphocytes were the cortical type that expressed CD99 and terminal deoxynucleotidyl transferase. Ultrastructural examinations revealed tonofilaments in the spindle cells. Follow up has been done for 5 years after the surgical excision and the patient has been free of disease during that period. Similar to previous reports, this patient had a benign clinical course that was unassociated with myasthenia gravis which appears to be a characteristic of this histologic variant of thymoma. However, our case also showed advanced degenerative features and we could demonstrate ultrastructural evidence of epithelial differentiation in the stromal spindle cells that were not mentioned in the previously reported cases. Based on the results of our studies, we suggest this entity is a distinct type of organotypic thymoma that shows cortical differentiation and abundant cellular stroma.