Clinical Study Of The Association Between SCD30 & HGF And Acute Kidney Allograft Rejection

Kidney transplantation is an ideal supplementary therapy for patients with end stage renal disease.The six-month renal acute rejection(AR) rate has been reduced from 43.5%in the early 1990s to 13.5%of the early new century for the advances in transplant immunology and pharmacotherapy.However,AR may lead to graft loss either immediately or chronic allograft nephropathy,which continues to be a significant problem after transplantation.Intensity of acute rejection and effect of treatment have direct impact on the long-term outcome of the graft.The half-life of graft in recipients experienced posttransplantation acute rejection is only increased 1.8 years,as compared with 5.9 years for those without AR.Acute rejection,the most important complication following renal transplantation,has been widely studied.In current clinical practice,conventional rejection diagnosis,such as serum creatinine measurement,clinical manifestations,lab assessment,and imaging examination,can't recognize rejection at an early stage.It may also delay treatment because of lacking specificity and sensitivity.Moreover,typical clinical manifestations of acute rejection,such as pain of renal region,oliguria,hematuria, fever,hypertension have changed with modern immunosuppression.Besides,the concentration of serum creatinine will not increase as soon as allograft immunity is activated.It was reported that the concentration of serum creatinine doesn't determine the intensity of acute rejection.30%of patients with stable renal function may suffer subclinical rejection,with no creatinine level increase.Ultrasonic examination by Doppler's method is a conventional posttransplantation monitoring tool.Despite the resistant index(RI) can reflect a blood decrease during relaxing period in most cases, it is not specific enough for the diagnosis of AR.Needle biopsy,the gold standard in diagnosis,is limited by biopsy-associated complications,such as sampling errors, hematuria,bleeding,arteriovenous fistulas,and even graft loss can occur.And it needs experienced pathologists and multitude samples to make accurate diagnosis.The development of noninvasive techniques community with high specificity and sensitivity for the early detection of acute rejection would be desirable in the transplantation.Posttransplantation monitoring of neopterin and other immunologic mediators,such as soluble interleukin 2 receptor and soluble tumor necrosis factor receptor,are limited in their use because urinary retention or dialysis significantly affects serum levels of these proteins.CD30,a large transmembrane glycoprotein, was identified on the surface of T cells.After activation of CD30+ T cells,a soluble form of CD30(sCD30) is released into the bloodstream.The concentration of sCD30 in blood serum is significantly related with CD30 level.It is reported that sCD30 measurement before transplantation could be used for the prediction of kidney graft outcome except panel reactive antibodies(PRA).The new technique is especially effective in patients without PRA.The aim of the present study was to determine whether monitoring of sCD30 during the early posttransplantation period can be used to differentiate patients with an acute allograft rejection and evaluate the therapeutic effect of AR.Hepatocyte growth factor(HGF) is a member of growth factor with a variety of known activities,including angiogenesis promotion and antiapoptotic action.HGF is related to the protection or reconstruction of kidney when at acute rejection after transplantation.We'll also study the relative influence of HGF dynamic change and acute rejection after renal transplantation.The whole paper contains three parts:ChapterⅠA dynamic observation on posttransplantation sCD30Objective To study the relationship between soluble CD30(sCD30) levels and acute renal rejectionMethods A total of 56 patients with kidney transplant at our center were separated into three groups.Twenty-five patients with primary graft function and an uncomplicated course without acute rejection within a month were categorized as group A.Ten patients showing a prolonged phase of function recovery without evidence of acute rejection,such as CsA poisoning,ATN and arteriostenosis,were categorized as group B.Twenty-one patients who experienced an acute rejection during the first month were categorized as group C,including 16 diagnosed of glucocorticoids sensitive acute rejection(GSAR) and 5 glucocorticoids resistant acute rejections(GRAR).We collected blood samples by conventional clinical blood drawing from all the patients with kidney transplantation before and at the 3rd,5th, 7th,10th,14th and the 21st day after operation.Patients with acute rejection in Group C were also monitored before and after the treatment of high dosage of methylprednisolone(MP).Then we tested sCD30 level in serum by ELISA. Repetitive measurements analysis of variance was used to compare the posttransplantation sCD levels in respective time points and groups to analyze the regular change of sCD30.Results:1.The sCD30 serum level of Group C before transplantation,at 3rd and 5th day after transplantation was(120±23)U/ml,(117±24)U/ml,(118±28)U/ml,respectively, and it decreased continuously after the 7th day.However,there is a continuous decrease in group A and group B after transplantation.2.Since no AR was observed in group A or B,they can be combined as non-acute rejection group(No-AR Group).The difference between group No-AR and group C patients was statistically significant before transplantation(No-AR vs.C: (120±23)U/ml vs.(99±22)U/ml;P=0.001).3.At the sampling time points of day 3,5,7,10,14,group C patients exhibited a higher sCD30 concentration than patients in group A and group B.The difference between group C and group A or group B patients was statistically significant on day 3,5 and 7(P＜0.05).4.Antirejection therapy with methylprednisolone caused a respective statistical decrease of serum sCD30 in GSAR patients by 35%((96±19)U/ml vs.(62±19)U/ml) and GRAR patients by 13%((144±26)U/ml vs.(125±21)U/ml).There was a statistical higher serum sCD30 level in GRAR patients than GSAR patients (P=0.045).Conclusion The result indicated that increased sCD30 serum levels before transplantation are associated with graft loss and measurement of serum sCD30 during the early posttransplantation period is helpful for predicting recipients with acute rejection.A nondecreasing sCD30 level during the first 3 to 5 posttransplantation days is a reliable predictor of impending graft rejection and sCD30 may play a role in the development of AR.Serum sCD30 level at the 3rd,5th and 7th day may be used in the differential diagnosis of patients after renal transplantation.Besides,serum sCD30 is also an indicator of subclinical renal allograft rejection.For monitoring of sCD30 to be clinical meaningful,it's suggested that only patients with higher serum sCD30 level need a further examination by needle biopsy to identify subclinical rejection,which will be at a lower cost to patients.The serum sCD30 in GRAR patients was higher than that in GSAR patients. Besides,sCD30 measurement is more sensitive than creatinine monitoring in terms of predicting response to antirejection therapy and eliminating side effects of drugs, especially for OKT3 use at the early period.ChapterⅡA dynamic observation on posttransplantation HGFObjective To investigate the relationship between serum HGF levels and acute renal rejectionMethods 56 patients with kidney transplant were divided into 3 groups as the methods mentioned in ChapterⅠ.We tested HGF level in blood samples by ELISA. Then repetitive measurements analysis of variance was used to compare the posttransplantation HGF levels in respective time points and groups to analyze the regular change of HGF. Results:1.The HGF serum level of Group C pretransplantation,at the 3rd,5th,7th day posttransplantaion were(1975±338)pg/ml,(1953±385)pg/ml,(1972±285)pg/ml,(1984±346)pg/ml,respectively,and it decreased continuously after the 7th day. However,there is a continuous decrease in group A after transplantation.Patients with prolonged phase of recovery decreased steadily after the 3rd day.2.The difference between group C and group No-AR patients was statistically significant before transplantation(C vs.No-AR:(1975±338) pg/ml vs.(1754±332) pg/ml;P=0.020).3.The posttranplantation serum HGF level in group C was higher than others in group A or group B at different time points.A statistically higher HGF level was observed in group C patients than that in group A at the 3rd,5th,7th,10th,and 14th day after transplantation.At the sampling time points of 5th,7th,10th,14th day, group C patients exhibited a significantly higher HGF concentration than patients in group B.There is also a statistical difference found between group B and group A patients at the 3rd,5th,7th day.4.Antirejection therapy with methylprednisolone caused a statistical decrease of serum HGF in GSAR patients by 20%((1962±358) pg/ml vs.1565±351) pg/ml) and GRAR patients by 8%((2373±179) pg/ml vs.(2182±212) pg/ml),respectively.There was a statistical higher serum HGF level in GRAR patients than GSAR patients (P=0.011).Conclusion The result indicated that HGF measurement is a clinical meaningful technique for predicting recipients with acute rejection.HGF levels were rapidly increased during acute rejection.We reported that serum HGF levels in group C patients with posttransplantation acute rejection experienced a markedly higher increase compared with group B.However,a continuous decrease was observed in group A.It suggested that HGF should have the potential for differential diagnosis of the outcome of kidney transplantation.HGF level decreased stronger in the 16 GSAR patients than in the 5 GRAR patients,which is conductive to differentiate patients with GRAR from those with GSAR.We also considered HGF should have the potential for clinical use in acute or chronic allograft injury.ChapterⅢThe measurement of sCD30 and HGF in the diagnosis of acute renal rejectionObjective To analyze the diagnostic value of acute rejection with detection of sCD30 and HGF.Methods A conventional receiver operating characteristic(ROC) curve was constructed to determine sensitivities and specificities of the measurements for patients with acute rejection,delayed function and normal function.The clinical value was determined by calculating the area under the ROC curve(AUC).Results:1.sCD30 allowed a differentiation of recipients who subsequently developed acute allograft rejection from recipients with an uncomplicated course.The cut-off value at the 3rd,5th,7th day were 90U/ml(AUC 0.929,sensitivity 95%,specificity 84%),84U/ml(AUC 0.941,sensitivity 90%,specificity 88%),70U/ml(AUC 0.944, sensitivity 90%,specificity 84%). 2.Patients with acute rejection had significantly a greater sCD30 concentration than patients with delayed graft function.The cut-off value at the 3rd,5th,7th day were 97U/ml(AUC 0.874,sensitivity 81%,specificity 80%),94 U/ml(AUC 0.843, sensitivity 81%,specificity 70%),81U/ml(AUC 0.929,sensitivity 86%,specificity 90%),respectively.3.Patients with acute rejection had significantly greater HGF level than patients with an uncomplicated course.The cut-off value at the 3rd,5th,7th,10th and 14th day were 1652pg/ml(AUC 0.879,sensitivity 81%,specificity 80%),1536pg/ml (AUC 0.985,sensitivity 95%,specificity 92%),1523pg/ml(AUC 0.973,sensitivity 91%,specificity 96%),1274 pg/ml(AUC 0.966,sensitivity 91%,specificity 92%),892 pg/ml(AUC 0.750,sensitivity 76%,specificity 72%).4.The HGF level was significant higher in patients than those with delayed recovery of renal graft function.The cut-off value at the 5th,7th,10th,and 14th day were 1852pg/ml(AUC 0.719,sensitivity 71%,specificity 60%),1442pg/ml(AUC 0.919,sensitivity 95%,specificity 80%),1280pg/ml(AUC 0.921,sensitivity 91%, specificity 80%),879 pg/ml(AUC 0.740,sensitivity 76%,specificity 70%).5.Patients were divided into sCD30 positive group and sCD30 negative group, basing on 70%of pretransplantation sCD30 level.At the cut-off value of 1623 pg/ml HGF(AUC 0.909,sensitivity 91%,specificity 80%),HGF level shows a suitable marker for the diagnosis of acute rejection at the 5th posttransplantation day.Patients were allocated into HGF positive and HGF negative groups based on the value.For the combined analysis of HGF and sCD30,samples scoring positive in both parameters were referred to as "double-positive" and those scoring negative in both parameters were referred to as "double-negative".Acute rejection happened in all double-positive patients,however double-negative patients without acute rejection.Conclusion The monitoring of sCD30 and HGF may be an important and new noninvasive approach for detection of acute rejection,CsA poisoning,acute tubular necrosis,subclinical rejection and so on.Besides,Individuals with higher pretransplantation sCD30 level demonstrated higher risk of acute rejection.It should be strongly considered acute rejection for patients with continuous high HGF level 5 days after transplantation.Those with lower sCD30 and HGF levels are unlikely to suffer from acute rejection,sCD30 is an active marker for identifying homograft immunity response.Routine monitoring of sCD30 combining with HGF will be helpful in risk assessment,therapeutic effect evaluation and improving survival rate. Further investigations are needed involving larger numbers of patients,preferably in the relative basic research.There will be a promising prospect in dignosis of acute rejection with sCD30 and HGF as development of further investigation.