Alloimmunity to mismatched donor HLA-Ags and autoimmunity to self-Ags have been hypothesized to play an important role in immunopathogenesis of chronic rejection of transplanted organs. However, it is not known what role, if any, alloimmune response plays in inducing autoimmunity. To test whether Ab-developed posttransplantation to mismatched donor MHC induces autoimmunity and chronic rejection, we developed a murine model wherein anti-MHC class I Abs or control (C1.18.4/anti-keratin) were administered intrabronchially into native lungs. Animals receiving anti-MHC class I, but not control Abs, developed marked cellular infiltration around vessels and bronchiole of lung by day 15, followed by epithelial hyperplasia, fibrosis, and occlusion of the distal airways similar to chronic rejection following human lung transplantation. Lungs of mice receiving anti-MHC class I showed increased expression of chemokines, their receptors, and growth factors, and induced IL-17 as well as de novo Abs to self-Ags, K-α1 tubulin, and collagen V. IL-17 neutralization by anti-IL-17 resulted in reduction of autoantibody and lesions induced by anti-MHC class I Abs. Thus, our results indicate that Abs to donor MHC can induce autoimmunity, mediated by IL-17, which plays a pivotal role in chronic rejection postlung transplantation. Therefore, approaches to prevent autoimmunity should be considered for the treatment of chronic rejection postlung transplantation.

Background Bronchiolitis obliterans syndrome (BOS) is a major cause of morbidity and mortality post lung transplantation (LTx). We sought to determine the relationship between alloimmune responses and autoimmunity, and subsequently how autoimmunity leads to chronic rejection. Methods We analyzed the development of donor specific antibodies (Abs) in LTx by flow PRA and the development of Abs to K-α1 tubulin (K-α1T) and collagen V (ColV) by ELISA. The frequency of K-α1T and ColV specific T cells that secrete IFN-γ, IL-17 and IL-10 in LTx recipients was measured by ELSIPOT. Results In a retrospective analysis of 42 LTx recipients, we demonstrated a strong correlation between development of donor specific anti-HLA Abs, Abs to self-antigens, and BOS (p<0.05). To test the hypothesis that alloimmunity is related to an immune response to self-antigens, we analyzed 103 LTx patients prospectively for the development of donor specific Abs (DSA) and Abs to self-antigens. 42.7% of recipients developed DSA and 30.1% developed Abs to K-α1T and ColV. Development of DSA preceded development of Abs to self-antigens. BOS+ patients had higher frequency of T-cells secreting IL-17 (p<0.01) and IFNγ (p<0.05) with decreased IL-10 (p<0.05) compared to BOS- patients. Conclusion Based on these results we propose that alloimmune responses to donor HLA can induce autoimmune responses to airway epithelial self-antigens, characterized by activation of the IL-17 pathway. These immune responses to self-antigens along with alloimmunity contribute to the pathogenesis of BOS. Strategies to prevent development of autoimmunity may be important in preventing the development of chronic rejection.

Background Primary graft dysfunction (PGD) is a known risk factor for bronchiolitis obliterans syndrome (BOS) following lung transplantation. Here we report that preformed antibodies to self-antigens increase PGD risk and promote BOS. Methods Adult lung transplant recipients (n=142) were included in the study. PGD and BOS were diagnosed based on ISHLT guidelines. Antibodies to self-antigens K alpha-1 tubulin, collagen type V and collagen I, were quantitated using standardized ELISA while cytokines were analyzed using Luminex. HLA-antibodies were measured using Flow-PRA. Results Lung transplant recipients with pre-transplant antibodies to self-antigens had increased risk of PGD (Odds 3.09, 95% CI 1.2 – 8.1, p=0.02) compared to those without. Conversely, in patients with PGD, 34.7% were positive for pre-transplant antibodies while in the PGD negative group only 14.6% had antibodies (p=0.03). Antibody positive patients demonstrated high levels of pro-inflammatory cytokines IL-1 (2.1 fold increase), IL-2 (3.0), IL-12 (2.5), IL-15 (3.0) and chemokines IP-10 (3.9) and MCP-1 (3.1, p<0.01 for all). On 5-yr follow-up, patients without antibodies showed greater freedom from development of HLAantibodies compared to those with antibodies (Class I:67% versus 38%, p=0.001; Class II: 71% Vs 41%, p<0.001 ). Patients with pre-transplant antibodies were found to have an independent relative risk of 2.3 (95% CI 1.7 – 4.5, p=0.009) for developing BOS. Conclusions Presence of antibodies to self-antigens pre-transplant increases the risk of PGD immediately post-transplant period and BOS on long-term follow-up. PGD is associated with an inflammatory cascade that augments the alloimmune (anti-HLA) response that predisposes to BOS.

The development of antibodies (Abs) to major histocompatibility (MHC) class I related chain A (MICA) and human leukocyte antigen (HLA) and their role in the immunopathogenesis of chronic rejection (bronchiolitis obliterans syndrome (BOS)) following human lung transplantation (LTx) was analyzed. Sera from 80 LTx recipients were analyzed for anti-MICA and anti-HLA Abs using Luminex and flow PRA (panel reactive assay). Development of Abs either to MICA alone or MICA and HLA together significantly correlated (P<0.01) with development of BOS. Kinetic analysis in the post-LTx period revealed that development of anti-HLA Abs (7.6±4.7 months) preceded the development of anti-MICA Abs (10.0±3.5 months). Abs to MICA alleles (*001 and *009) developed approximately 6 months following LTx and peak titers were present at the time of clinical diagnosis of BOS (16.3±2.7 months). The development of Abs to both MICA and HLA was strongly associated with the development of BOS thereby suggesting a synergistic effect. Furthermore, immune response to mismatched HLA can lead to development of Abs to other MHC related antigens expressed on the airway epithelial cells. Cumulatively, these immune responses contribute to the pathogenesis of chronic rejection following human LTx.

Background Immune responses to mismatched donor HLA antigens play a significant role in the pathogenesis of chronic rejection. The study objective was to evaluate whether erythrocyte bound C4d (E-C4d) is associated with known alloimmune and autoimmune markers of antibody mediated rejection (AMR) following human lung transplantation (LTx). Methods 22 LTx recipients and 15 normal subjects were analyzed for E-C4d using flow cytometry. Development of antibodies (Abs) to donor mismatched HLA (DSA) and Abs to HLA were determined using solid phase method by Luminex. Development of Abs to self-antigens, K-alpha-1-tubulin (KA1T) and collagen V (Col-V) were measured by ELISA. C3d deposition in lung biopsies was determined by immunohistochemical staining. Results Percent E-C4d (%E-C4d) levels in LTx patients were higher compared to normal subjects (19.9% vs. 3.7%, p = 0.02). DSA+ patients had higher E-C4d levels compared to DSA- patients (34.1% vs. 16.7%, p = 0.02). In 5 patients with preformed anti-HLA, E-C4d levels were not significantly different compared to 13 patients with no detectable anti-HLA (p=0.1). Higher E-C4d levels were noted in patients who developed Abs to KA1T (p = 0.02) and Col-V (p = 0.03). Recipients with C3d tissue deposition had higher E-C4d levels compared to patients with C3d negative biopsy results (p = 0.01). Conclusions Increased % E-C4d levels are found in patients with positive DSA, high Abs titers to KA1T and Col-V, and have C3d positive lung biopsy findings. Therefore, % E-C4d can serve as a potential marker for AMR following LTx.