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.

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Nephron-sparing surgery has been proven to positively impact the postoperative quality of life for the treatment of small renal tumors, possibly leading to functional improvements. Laparoscopic partial nephrectomy is still one of the most demanding procedures in urological surgery. Laparoscopic partial nephrectomy sometimes results in extended warm ischemic time and severe complications, such as open conversion, postoperative hemorrhage and urine leakage. Robot-assisted partial nephrectomy exploits the advantages offered by the da Vinci Surgical System to laparoscopic partial nephrectomy, equipped with 3-D vision and a better degree in the freedom of surgical instruments. The introduction of the da Vinci Surgical System made nephron-sparing surgery, specifically robot-assisted partial nephrectomy, safe with promising results, leading to the shortening of warm ischemic time and a reduction in perioperative complications. Even for complex and challenging tumors, robotic assistance is expected to provide the benefit of minimally-invasive surgery with safe and satisfactory renal function. Warm ischemic time is the modifiable factor during robotassisted partial nephrectomy to affect postoperative kidney function. We analyzed the predictive factors for extended warm ischemic time from our robot-assisted partial nephrectomy series. The surface area of the tumor attached to the kidney parenchyma was shown to significantly affect the extended warm ischemic time during robot-assisted partial nephrectomy. In cases with tumor-attached surface area more than 15 cm 2 , we should consider switching robot-assisted partial nephrectomy to open partial nephrectomy under cold ischemia if it is imperative. In Japan, a nationwide prospective study has been carried out to show the superiority of robot-assisted partial nephrectomy to laparoscopic partial nephrectomy in improving warm ischemic time and complications. By facilitating robotic technology, robot-assisted partial nephrectomy will be more frequently carried out as a safe, effective and minimally-invasive nephronsparing surgery procedure.

Objectives To assess the impact of two cycles of neoadjuvant chemotherapy (NAC) in patients who underwent nephroureterectomy for high‐risk cN0M0 upper tract urothelial carcinoma (UTUC), and to evaluate the efficacy of NAC in patients with localised disease (≤cT2). Patients and Methods We retrospectively analysed patients with high‐risk cN0M0 UTUC who received NAC followed by surgery, compared with a matched cohort who underwent initial surgery at Fujita Health University during 2005–2019. Baseline and tumour characteristics, overall survival (OS), cancer‐specific survival (CSS), and recurrence‐free survival (RFS) were compared between the cohorts. Cox proportional hazards models were used to identify predictors of survival. Results There were 117 and 67 patients in the study group and the control group, respectively. Significantly higher pathological downstaging (pDS) and lower lymphovascular invasion (LVI) were observed in the study group than in the control group (48% vs 22%, P = 0.008 and 29% vs 46%, P = 0.045, respectively). The NAC group had significantly better 5‐year OS (79% vs 53%, P = 0.003), 5‐year CSS (84% vs 66%, P = 0.008), and 5‐year RFS (80% vs 61%, P = 0.001) than the control group. The OS benefit of NAC was observed even in patients with localised (≤cT2) disease (P = 0.019). Patients with LVI showed significantly worse CSS both in pathologically locally advanced (≥pT3) and in localised (≤pT2) tumours (P = 0.048 and P = 0.018, respectively). Multivariate analysis identified LVI, NAC, and pDS as independent predictors of OS. Male sex and post‐NAC LVI were identified as predictors of worse survival in patients who underwent NAC. Conclusions Two cycles of NAC improved the survival of patients with high‐risk UTUC, even in patients with localised disease. Although two cycles of NAC appear to be effective in cN0M0 high‐risk UTUC including localised disease, additional larger sample size multicentre prospective studies comparing short‐course NAC regimens followed by surgery and surgery alone are required.

BACKGROUND This study aims to determine the role of antibodies (Abs) to donor mismatched HLA developed during the post-transplant period in inducing defensins and their synergistic role in the pathogenesis of chronic rejection, Bronchiolitis Obliterans Syndrome (BOS), following human lung transplantation (LTx). METHODS Bronchoalveolar Lavage (BAL) and serum from twenty-one BOS+ LTx patients were assayed for β-defensins HNP1-3 (ELISA) and Anti-HLA Abs (Luminex). Human Airway Epithelial Cells (AEC) were treated with anti-HLA Abs, HNP-1/2 or both and the levels of β-defensin was measured by ELISA. Using a mouse model of obliterative airway disease induced by anti-MHC class-I Abs, we quantitatively and qualitatively determined neutrophil infiltration (Myeloperoxidase (MPO) staining) and activity (MPO assay) and defensin levels in the BAL. RESULTS In human LTx patients, higher defensin levels correlated with presence of circulating anti-HLA Abs (p<0.05). AEC treated with anti-HLA Abs or HNP-1/2, produced β-defensin with synergistic effects in combination (612±06 vs. 520±23 anti-HLA Ab or 590±10 pg/ml for HNP treatment, p<0.05).Neutrophil numbers (6 fold) and activity (5.5 folds) was higher in the lungs of mice treated with anti-MHC Abs compared to control. Two-fold increase in α-defensin and β-defensin levels was also present in BAL on day 5 following anti-MHC administrations. CONCLUSIONS Anti-HLA Abs developed during the post-transplant period and α-defensins stimulate β-defensin production by epithelial cells leading to increased cellular infiltration and inflammation. Chronic stimulation of epithelium by Abs to MHC and resulting increased levels of defensins induce growth factor production and epithelial proliferation contributing towards development of chronic rejection following LTx.

Abbreviations & Acronyms AUC = area under the receiver operating characteristic curve BMI = body mass index CNN = convolutional neural network DL = deep learning Grad-CAM = gradientweighted class activation mapping IQR = interquartile range ML = machine learning MRI = magnetic resonance imaging MUL = membranous urethral length NADT = neoadjuvant antiandrogen deprivation therapy NS = nerve sparing PC = prostate cancer PPUI = post-prostatectomy urinary incontinence PSA = prostate-specific antigen PV = prostate volume QOL = quality of life RARP = robot-assisted radical prostatectomy UI = urinary incontinence VGG-16 = Visual Geometry Group-16

Using a murine model, we demonstrated that endobronchial administration of antibodies (Abs) to MHC class I results in cellular infiltration, epithelial metaplasia, fibrosis and obstruction of the small airways (Obliterative Airway Disease (OAD)) mediated predominantly by Th17 responses to self-antigens. This resembles bronchiolitis obliterans syndrome developed following human lung transplantation. Since B cells play a crucial role in induction of autoimmune responses, we defined the role of B cells and its antigen presenting properties in induction of OAD in this study. Anti-MHC class I was administered endobronchially in B−/− and wild type mice. In contrast to wild type, B−/− animals did not demonstrate cellular infiltration, epithelial metaplasia and obstruction of airways following anti-MHC. Frequency of Kα1-tubulin and CollagenV specific IL-17 cells was significantly decreased in B−/− mice. As expected, Abs against self-antigens and germinal center formation were not developed in B−/− mice. Thus we conclude that B cells and its antigen presenting capacity play an important role in induction of immune responses to self-antigens and immunopathogenesis of OAD following administration of anti-MHC. Therefore, strategies to block B cell and its antigen presenting functions should be considered for preventing the development of chronic rejection.

Background Presence of donor specific antibodies (Abs) is detrimental to post transplant allograft function. Some sensitized recipients have successfully undergone transplantation following pretransplant conditioning regimen utilizing plasmapheresis and/or intravenous immunoglobulin therapy, but underlying mechanisms that confer such allograft protection are undefined. Methods We developed a single HLA mismatched heterotopic murine heart transplant model (HLA-A2 into HLA-A2-sensitized-C57BL/6 ) to determine whether pretreatment of donors with low concentration of HLA class I(W6/32) or control Ab(C1.18.4) will confer protection. Expression levels of survival genes, Bcl2 and HO-1 were analyzed by gene array analysis and quantitative real-time PCR. Expression levels of cytokine panel were analyzed by Luminex. Role of Bcl2 in the induction of allograft protection was analyzed by silencing the Bcl2 expression in the donor hearts using a shRNA specific for Bcl2. Results Control Ab pretreated hearts were rejected in <5 days demonstrating hemorrhage, Ab and C4 deposition. In contrast, W6/32 pretreated hearts were rejected at 15 days (P<0.05) that was prolonged to 25 days with anti-lymphocyte serum (ALS) treatment. W6/32 pretreated hearts on day 5 exhibited increased expression of Bcl-2(5.5folds), Bcl-xl(5.5folds) and HO-1(4.4folds); decreased expression of ICAM-1, VCAM-1(3.2 fold), along with reduced levels of cytokines IL-1β(4.4folds), TNF-α(3.7folds), IL-6(7.5folds), IL-12(2.3folds) and chemokines MCP-1(4.5folds), MIG(4.4folds), MIP-1α(3.4folds) and IL-8(3.1folds). Silencing of Bcl2 in accommodated hearts prior to transplant resulted in loss of protection with rejection (9±3Vs.15±2days,p<0.05). 3 Conclusion Pretreatment of hearts with low levels of anti-HLA Abs increases expression of anti-apoptotic genes that inhibits caspases, leading to decreased inflammatory cytokines and chemokines which promote allograft survival.