The Food and Drug Administration (FDA) held an open public workshop in June 2010 to discuss the current state of science related to antibody-mediated rejection (AMR) in kidney transplantation. Desensitization, acute AMR and chronic AMR (CAMR) were considered in the context of clinical trial design. Participants discussed experiences with HLA antibody detection and quantitation and the utility of monitoring donorspecific antibodies (DSAs) to inform the management of patients with AMR. The role for animal models was discussed. Diagnostic and prognostic features of histology were presented, followed by discussion of sensitivity and specificity of various criteria. The published literature on treatment of acute AMR was summarized, which consisted of case series and limited data from controlled clinical trials. Considerations for future clinical trials were presented, including endpoints and statistical evaluations of outcome. Although many issues need further consideration, the meeting enabled an important exchange of ideas between experts in the field.

The Food and Drug Administration (FDA) held an open public workshop in September 2011 to discuss the current state of science related to the effects of ischemia reperfusion injury (IRI) on outcomes in kidney transplantation. Topics included the development of IRI and delayed graft function (DGF), histology and biomarkers, donor factors, recipient factors, organ quality and organ preservation by means of cold storage solutions or machine perfusion. Various mechanisms of injury and maladaptive response to IRI were discussed as potential targets of intervention. Animal models evaluating specific pathophysiological pathways were presented, as were the limitations of extrapolating animal results to humans. Clinical trials of various drug products administered in the peritransplant period were summarized; a few demonstrated early improvements in DGF, but none demonstrated an improvement in late graft function. Clinical trial design for IRI and DGF were also discussed.

Human stool is a heterogeneous mixture of non-digestible food residues, bacteria, cells exfoliated from the gastrointestinal mucosa and other secretory products. We have demonstrated that fresh human stools dispersed in a buffered saline solution can be fractionated over Percoll/BSA gradients to yield 9 discrete bands of cells in the density range of rho 1.033 to 1.139 and which could be further purified over Histopaque 1077. Enzyme-linked immunoassays (ELISA) for colon-specific antigen (CSA) and cytokeratins (CK) were positive. Western blot analysis showed the presence of 3 cytokeratin bands in the 40-kDa to 60-kDa range suggestive of cytokeratins 8, 18, and 19. Fluorescence flow-cytometric analysis of these cells using antibodies against CSA, CK, the blood-group antigens, carcinoembryonic antigen (CEA), non-mucus-secreting columnar-epithelium-specific MAb PR1A3, and to mucus-secreting colonic-epithelium-specific MAb PR5D5 showed varying degrees of reactivity. Expression of the blood-group phenotype suggests that cells from the proximal half of the colon had survived the transit, since in the adult expression of this marker is limited to cells from the proximal region of the colon. In this report we demonstrate the feasibility of studying, non-invasively, cell-specific markers on exfoliated cells isolated from stools. The evidence strongly suggests that almost all the cells are of colonic origin.

Rats were nursed by dams fed a diet containing adequate (6 micrograms/g) or deficient (0.6 micrograms/g) Cu during the lactation period and weaned to the same diet. Splenic mononuclear cells were isolated and the phenotypic profile determined by flow cytometry after immunolabelling with monoclonal antibodies to cell surface markers. Total splenic mononuclear cell yield and the relative percentage and absolute number of T-cells and the CD4+ (helper) and CD8+ (cytotoxic) T-subsets were decreased in Cu-deficient male rats. The relative percentage, but not the absolute numbers, of splenic B-cells and macrophages was increased by Cu deficiency. The percentage of splenic mononuclear cells from male rats that expressed interleukin-2 receptors and transferrin receptors in vivo was increased by Cu deficiency. In contrast, dietary Cu deficiency did not affect the yield and phenotypic profile of splenic mononuclear cells in female rats. Reactivity of splenic mononuclear cells to T-cell mitogens was decreased in Cu-depleted male and female rats. However, mitogen-induced increases in levels of interleukin-2 receptor and transferrin receptor were similar in cultures of splenic mononuclear cells obtained from control rats and rats subjected to restricted dietary intake of Cu only during the postlactation period. Thus, decreased mitogenic blastogenesis on exposure of cells from Cu-deficient rats does not reflect a nonspecific impairment of cellular activation.

Despite major advances in understanding the pathophysiology of antibody-mediated rejection (AMR); prevention, diagnosis and treatment remain unmet medical needs. It appears that early T cell-mediated rejection, de novo donor-specific antibody (dnDSA) formation and AMR result from patient or physician initiated suboptimal immunosuppression, and represent landmarks in an ongoing process rather than separate events. On April 12 and 13, 2017, the Food and Drug Administration sponsored a public workshop on AMR in kidney transplantation to discuss new advances, importance of immunosuppressive medication nonadherence in dnDSA formation, associations between AMR, cellular rejection, changes in glomerular filtration rate, and challenges of clinical trial design for the prevention and treatment of AMR. Key messages from the workshop are included in this summary. Distinction between type 1 (due to preexisting DSA) and type 2 (due to dnDSA) phenotypes of AMR needs to be considered in patient management and clinical trial design. Standardization and more widespread adoption of routine posttransplant DSA monitoring may permit timely diagnosis and understanding of the natural course of type 2 and chronic AMR. Clinical trial design, especially as related to type 2 and chronic AMR, has specific challenges, including the high prevalence of nonadherence in the population at risk, indolent nature of the process until the appearance of graft dysfunction, and the absence of accepted surrogate endpoints. Other challenges include sample size and study duration, which could be mitigated by enrichment strategies.