title: Pig kidney transplantation in baboons: anti-Gal(alpha)1-3Gal IgM alone is associated with acute humoral xenograft rejection and disseminated intravascular coagulation.
abstract: BACKGROUND
  Kidneys harvested from miniature swine or pigs transgenic for human decay-accelerating factor (hDAF) were transplanted into baboons receiving an anti-CD154 monoclonal antibody (mAb) and either a whole body irradiation (WBI)- or cyclophosphamide (CPP)-based immunosuppressive regimen.
  
  
  METHODS
  Group 1 baboons (n=3) underwent induction therapy with WBI and thymic irradiation, pretransplantation antithymocyte globulin, and immunoadsorption of anti-Gal(alpha)1-3Gal (Gal) antibody (Ab). After transplantation of a miniature swine kidney, maintenance therapy comprised cobra venom factor, mycophenolate mofetil, and an anti-CD154 mAb (for 14-28 days). In group 2 (n=2), WBI was replaced by CPP in the induction protocol. Group 3 (n=3) animals received the group 2 regimen, but underwent transplantation with hDAF pig kidneys.
  
  
  RESULTS
  Group 1 and 2 animals developed features of disseminated intravascular coagulation (DIC), with reductions of fibrinogen and platelets and increases of prothrombin time, partial thromboplastin time, and fibrin split products. Graft survival was for 6-13 days. Histology showed mild acute humoral xenograft rejection (AHXR) of the kidneys, but severe rejection of the ureters. Group 3 animals developed features of DIC in two of three cases during the fourth week, with AHXR in the third case. Graft survival was for 28 (n=1) or 29 (n=2) days. Histology of day 15 biopsy specimens showed minimal focal mononuclear cellular infiltrates, with predominantly CD3+ cells. By days 28 and 29, kidneys showed mild-to-moderate features of AHXR. In all groups, the humoral response was manifest by reappearance of anti-Gal IgM below baseline level, with no or low return of anti-Gal IgG. All excised kidneys showed IgM deposition, but no complement and no or minimal IgG deposition. No baboon showed a rebound of anti-Gal Ab immediately after excision of the graft, and anti-Gal Ab increased over pretransplantation levels only when anti-CD154 mAb was discontinued.
  
  
  CONCLUSIONS
  DIC was observed with WBI- or CPP-based therapy, and after miniature swine or hDAF kidney transplantation. AHXR+/-DIC was observed in all recipients even in the absence of complement and no or low levels of anti-Gal IgG, but was significantly delayed in the hDAF recipients. These results confirm our earlier observation that CD154 blockade prevents T cell-dependent sensitization in baboons to pig antigens, but that baseline natural anti-Gal Ab production is not inhibited. We suggest that IgM deposition, even in the absence of IgG and complement, leads to endothelial cell activation with the development of DIC, even when there are only minimal histologic changes of AHXR.
authors.affiliation: Transplantation Biology Research Center, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston 02129, USA.
authors.forename: L
authors.initials: L
authors.lastname: Bühler
authors.forename: K
authors.initials: K
authors.lastname: Yamada
authors.forename: H
authors.initials: H
authors.lastname: Kitamura
authors.forename: I P
authors.initials: IP
authors.lastname: Alwayn
authors.forename: M
authors.initials: M
authors.lastname: Basker
authors.forename: J Z
authors.initials: JZ
authors.lastname: Appel
authors.forename: R B
authors.initials: RB
authors.lastname: Colvin
authors.forename: M E
authors.initials: ME
authors.lastname: White-Scharf
authors.forename: D H
authors.initials: DH
authors.lastname: Sachs
authors.forename: S C
authors.initials: SC
authors.lastname: Robson
authors.forename: M
authors.initials: M
authors.lastname: Awwad
authors.forename: D K
authors.initials: DK
authors.lastname: Cooper
mesh_terms: D000208:Acute Disease; D000818:Animals; D030801:Animals, Genetically Modified / Q000235:genetics; D000906:Antibodies / Q000032:analysis; D000917:Antibody Formation; D001777:Blood Coagulation; D018958:CD55 Antigens / Q000235:genetics; D004187:Disaccharides / Q000276:immunology*; D004211:Disseminated Intravascular Coagulation / Q000097:blood / Q000276:immunology*; D006084:Graft Rejection / Q000276:immunology* / Q000473:pathology; D006085:Graft Survival; D006801:Humans; D007075:Immunoglobulin M / Q000032:analysis* / Q000276:immunology*; D007668:Kidney / Q000473:pathology; D016030:Kidney Transplantation / Q000276:immunology*; D010215:Papio; D013552:Swine; D013556:Swine, Miniature; D013997:Time Factors; D014183:Transplantation, Heterologous / Q000276:immunology*; D014513:Ureter / Q000473:pathology / Q000637:transplantation
chemical_list: D000906:Antibodies; D018958:CD55 Antigens; D004187:Disaccharides; D007075:Immunoglobulin M; C055075:galactosyl-(1-3)galactose