regardless of the C4D staining the best predictors of DSA is the degree of microvascular inflammation (g,ptc, vi),like the case of C4D negative AMBR its complement indepenednt endothethial injury and this recently confirmed by using the molecular genetic microarrary biomarkers ENDAT which confrim the importance of cellular immune response with increase the expression of IFN-γ by cytotoxic T cells , NKC ,macrophage which is important for activation of class I and II antigens on endothelium and increases antibody binding to the endothelium, and trigger allograft inflammation and injury.so to conclude the Complement-independent activation of microvascular inflammation and DSA are more important predictors of poor allograft outcome than C4D positivity .
also keep in mind C4D is split product of classic complement pathway activation by antibody mediated immune response and cant predict the nonHLA abs , ABOI transplant with accomodiation , immunoabsorption of DSA by the graft.
References:
1-Hayde N, Bao Y, Pullman J, et al. The clinical and genomic significance of donor-specific antibody-positive/C4d-negative and donor-specific antibody-negative/C4d-negative transplant glomerulopathy. Clin J Am Soc Nephrol. 2013;8(12):2141-2148. doi:10.2215/CJN.04240413
yes it dose predict complement fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96% , its the split product of the classical complement activation by antibodies antigen interaction and its still one of important diagnostic criteria of early AMR but become less sensitive in the diagnosis of late AMR , like non- complement mediated AMR
Multiple studies have demonstrated that there is a correlation among positive C4d staining, DSAs, and histopathologic findings in patients with ABMR. In study of 16 indicated allograft biopsies from 10 patients with circulating DSA and histopathologic findings suggestive of ABMR, diffuse positive peri tubular capillaries, C4d staining was observed in all biopsies.
The sensitivity and specificity of C4d for DSA have also been investigated. In a study of 81 patients with acute rejection, 30 percent had detectable C4d. C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA.
In ABMR patients with circulating DSA ,it was found that the inferior graft function and survival was documented in C4d positive biopsies versus C4d negative ones ,that means C4d is a reliable marker of significant humoral injury.
C4d represent the footprint of complement activation and is not correlated to the presence of DSA for many reasons:
– In one study involving1036 kidney allograft biopsies from 1320 transplant recipients, 36% of cases with a histologic lesion characteristic of chronic ABMR had C4d-positive staining, despite the presence of DSAs in 73% of patients (1).
– Isolated C4d staining can be seen without DSA or other signs suggestive of immunological injury in the case of ABOI transplantation (accommodation) (2, 3).
– Many glomerular lesions may be associated with positive C4d staining due to an underlying auto-immune disease rather than DSA derived kidney injury (e.g. C4 glomerulopathy) (4).
It is also worth mentioning that Non-HLA DSA may also cause C4d staining (while the conventional investigation for the HLA DSA will be negative) (5).
References:
1) Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743.
2) Setoguchi K, Ishida H, Shimmura H, et al. Analysis of renal transplant protocol biopsies in ABO-incompatible kidney transplantation. Am J Transplant. 2008;8(1):86.
3) Haas M, Rahman MH, Racusen LC, et al. C4d and C3d staining in biopsies of ABO- and HLA-incompatible renal allografts: correlation with histologic findings. Am J Transplant. 2006;6(8):1829.
5) Sun Q, Liu Z, Yin G, et al. Detectable circulating antiendothelial cell antibodies in renal allograft recipients with C4d-positive acute rejection: a report of three cases. Transplantation. 2005;79(12):1759.
Dear Dr Ahmed
Excellent discussion, your reference was to chronic AMR where the presence of DSA and C4d positivity accounts for only 50% of the cases of CAMR.
Cases with Acute AMR may have positive C4d staining in less than 40 % of cases. However, DSA were present in 90% (18 of 20) of the C4d positive cases compared with 2% (1 of 47) in the C4d negative acute rejection cases (P<0.001) (1).
We can conclude from this study that C4d staining may not be detected in most Acute AMR cases, but if C4d staining is detected, the recipient will have a detectable DSA in more than 90% of patients (1).
References:
1) Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002;13(3):779.
yes, diffuse PTC C4d staining is highly sensitive and specific for DSA( > 95%).
Nazik Mahmoud
2 years ago
Yes positive C4d stain will predicts circulating donor specific antibodies because it the products of antigen antibody reaction in antibody mediated rejection,it highly sensitive but less specific due to many reaction can lead to deposition of C4d fragments like ABO incompatible transplant
Dalia Eltahir
2 years ago
Antibody-mediated rejection (AMR) is highly detrimental to the prolonged survival of transplanted kidneys. C4d has been regarded as a footprint of AMR tissue damage . Despite the general acceptance of the usefulness of C4d in the identification of acute AMR, the data for C4d staining in chronic AMR is variable. The presence of C4d in the majority of the biopsies with features of chronic antibody-mediated rejection is reported, but this rejection without C4d staining is observed as well, suggesting that C4d is specific but not sensitive.the specific 96% and sensitivity is 95% for presence of AMR .
Wee Leng Gan
2 years ago
C4d deposition in peritubular capillary is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
Reference 1)Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, et al. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol 2013;2013:678180.
Nandita Sugumar
2 years ago
C4D STAINING FOR DSA DETECTION
C4d deposition indicates lower graft survival.
Tubular HLA DR is closely linked with C4d deposition.
Strong correlation between C4d positive staining and circulating DSA
Humoral rejection identified
May not work for detecting ABMR in ABOi grafts.
Sensitive and specific for identification of DSA
On the other hand, limitations are seen commonly in smoldering and chronic ABMR.
Lack of C4d positivity could be due to decreased antigen expression, endothelial complement inactivation, or complement regulation at the level of the endothelium and lack of complement fixation by DSA and loss of PTC.
Reference :
Etta PK. C4d staining anf antibody mediated rejection in renal transplantation : current status. Ind J Trans; 2020; 14 : 197-201
Ahmed Fouad Omar
2 years ago
· Can C4d staining predict the presence of DSA?Substantiate your answer
Yes, many studies revealed the strong correlation between diffuse C4d staining(in the presence of histological changes) and the presence of complement fixing DSAs in acute AMR with a sensitivity of 95% and specificity of 96% but this sensitivity is reduced in late chronic AMR to less than 50%.
On the other side there are cases where DSAs are present but C4d is negative:
o Technical issues in detection of AB related to the type of fixative used
o Complement independent ABMR
o Non HLA-AB( AT1R)
References:
1) Praveen Kumar Etta.C4d staining and antibody-mediated rejection in renal transplantation: Current status. Commentary : 2020 | Volume : 14 | Issue : 3 | Page : 197-201
2) Troxell ML, Weintraub LA, Higgins JP, Kambham N. Comparison of C4d immune-staining methods in renal allograft biopsies. Clin J Am Soc Nephrol. 2006 May;1(3):583-91.
3) Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause.Am J Transplant. 2007;7(7):1743
Hamdy Hegazy
2 years ago
Can C4d staining predict the presence of DSA? Yes, C4d staining can predict the presence of DSA in 90% of cases. Almost 90% of patients with +ve C4d were found to have circulating DSA. 20-50% of indicated RTx biopsies revealed PTC C4d +ve. However, 2% of protocol biopsies had shown PTC C4d +ve. DSAs are either HLA or non-HLA. DSAs are detected by different techniques that differ in their sensitivity. Causes of C4d +ve/DSA -ve: 1-low level of DSA. 2-Non-HLA antibodies. 3-ABO incompatible graft without ABMR or TCMR indicates graft accommodation. Causes of C4d -ve/DSA +ve: 1-C4d negative ABMR. High ENDATs were reported in 60% of cases with late ABMR. 2- Technical problems: methods of C4d detection and type of fixation. 3-Complement independent ABMR. 4-DSAs with poor complement fixation. 5-ABMR because of anti- AT1R antibodies, and anti FcRIIA (Fc receptor on NK cells)
References:
1- Mauiyyedi S, Crespo M, Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Tolkoff-Rubin NE, Williams WW, Delmonico FL, Cosimi AB, Colvin RB. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002 Mar;13(3):779-787. doi: 10.1681/ASN.V133779. PMID: 11856785. 2- Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-Rubin N, Cosimi AB, Colvin RB. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol. 1999 Oct;10(10):2208-14. doi: 10.1681/ASN.V10102208. PMID: 10505698. 3- Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, Faleiros AC, dos Reis MA. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol. 2013;2013:678180. doi: 10.1155/2013/678180. Epub 2013 Jul 9. PMID: 23935649; PMCID: PMC3722852.
Akram Abdullah
2 years ago
Yes , it can predict the presence of DSA as C4d is as split product of complement activation pathway in AMR.(AMR with C4d positive ) .
Ramy Elshahat
2 years ago
DSA and C4D considered as AB evidence for diagnosis of ABMR Unfortunately, there is multiple types of DSA (HLA and non HLA) also there is multiple techniques in detection of DSA which differ in its sensitivity So there is some discrepancies in results of c4d sensitivity to DSA detection from 30% to 95% but there is agreement on the specificity of c4d which may results up to 98% a study was done in 2002 by Böhmig GA and his group on One hundred thirteen biopsies, obtained from 58 cadaveric kidney transplant recipients, were tested. circulating antibodies were evaluated by 2 techniques flow cytometric crossmatch (FCXM) testing and FlowPRA analysis of anti-HLA panel reactivity. and results showed
almost all biopsies with C4d deposits in PT were associated with positive T and B cell posttransplant FCXM.
Approximately 50% of the C4d(PTC)(-) biopsies were observed to be associated with donor-specific alloantibodies. Accordingly, high specificity (93%) but low sensitivity (31%) with FCXM testing as the standard method.
In one study involving1036 kidney allograft biopsies from 1320 transplant recipients, 36% of cases with a histologic lesion characteristic of chronic ABMR had C4d-positive staining, despite the presence of DSAs in 73% of patients References
Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743.
ahmed saleeh
2 years ago
complement fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96%.
Many studies showed the relation between C4d positivity and the presence of DSA .
C4d represent the footprint of complement activation.
C4d is sensitive in case of Acute antibody rejection while the sensitivity in chronic antibody rejection is less than 40%.
C4d negativity in presence of DSA is uncommon, but can be seen due to:
* Technical issues: type of fixative used
* poor fixation of Complement by some DSAs
* Complement independent AMR
* Autoantibodies to AT1R
* Fc receptor on NK cells
Abdullah Raoof
2 years ago
Yes
C4d is a product of complement activation , and it is a footprint of antibody mediated rejection.
In C4d positive patient, the DSA is present in more than 90 % of ABMR.
But in DSA positive patient , the C4d is positive only in about 40% of ABMR patient .
This rise a new form of ABMR ( C4D negative ABMR ).
It worth to mention that DSA could be negative , in C4d positive patient in the following situation
1- Technical error in detection of Ab ( non HLA Ab )
2- Ab sequestration by graft ( which may reappear after graft removal ).
3- Autoimmune disease (auto Ab – SLE )
4- ABO- I transplantation(accommodation ).
5- Vascular disease ( non Ab complement activation).
6- Immune complex disease ( glomerular deposition ,nonspecific) .
AMAL Anan
2 years ago
.Can C4d staining predict the presence of DSA?Yes, it predict presence of complement fixing DSA in Acute AMR with high sensitivity 95% and specificity 96% .its the split product of the classical complement activation by antibodies antigen interaction and its still one of important diagnostic criteria of early AMR but become less sensitive in the diagnosis of late AMR , like non- complement mediated AMR.
However, there is proved that
Following conditions are showing C4d positivity:
a. Acute AMR
b. Chronic antibody‑mediated rejection
c. A, B, O blood group ABO incompatible grafts
d. Accommodation.
The following conditions are showing C4d negativity:
a. T‑cell‑mediated rejection (TCMR)
b. A technical error like a type of fixatives,
immunofluorescence (IF) versus immunohistochemistry (IHC)
c. Fc receptor (FCR) on NK cells (FcRIIA) mediated rejection
d. Antibodies unable to fix the complement
e. Complement independent pathways of endothelial activation
f. C4d deposition is a very low in quantity for the identification limits of IF/IHC
g. Alloantibodies can direct endothelium injury to interact with major histocompatibility complex (MHC)
h. Increased expression of endothelial transcripts causing endothelium injury.
References
1. Nankivell BJ, Alexander SI. Rejection of the kidney allograft. N Engl J
Med 2010;363:1451‑62.
2. Mengel M, Sis B, Haas M, Colvin RB, Halloran PF, Racusen LC,
et al. Banff 2011 Meeting report: New concepts in antibody‑mediated
rejection. Am J Transplant 2012;12:563‑70.
3. Tait BD, Süsal C, Gebel HM, Nickerson PW, Zachary AA, Claas FH,
et al. Consensus guidelines on the testing and clinical management
issues associated with HLA and non‑HLA antibodies in transplantation.
Transplantation 2013;95:19‑47.
4. Monsinjon T, Gasque P, Chan P, Ischenko A, Brady JJ, Fontaine MC.
Regulation by complement C3a and C5a anaphylatoxins of cytokine
production in human umbilical vein endothelial cells. FASEB J
2003;17:1003‑14.
5. Chakravarti DN, Campbell RD, Porter RR. The chemical structure
of the C4d fragment of the human complement component C4. Mol
Immunol 1987;24:1187‑97.
Balaji Kirushnan
2 years ago
C4d is a terminal product of C4b and is used as a footprint of antibody mediated rejection in renal allograft biopsies..
C4d staining has high specificity but less sensitivity…
80-90% of the C4d staining renal allograft biopsies had circulating DSA present…Cases in which C4d positivity and DSA negativity can be seen in conditions where there is very low level DSA, Non Complement binding DSA, DSA immunoadsorption in the graft or DSA to Non HLA antibody….
C4d staining implies IgG1 and IgG3 DSA which are strong compliment binding DSA are present…The intensity of the complement fixing reduces when IgG2 or IgG4 are present and they may be associated with C4d negative ABMR especially the late/chronic/indolent ABMR…
Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian J Transplant 2020;14:197-201
MICHAEL Farag
3 years ago
Can C4d staining predict the presence of DSA? the answer is yes, it does predict complement-fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96%
▪︎ The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
▪︎C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft.
▪︎There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
But,
▪︎C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. Some patients have morphologic evidence of ABMR and a positive DSA with little or no C4d staining.
Several trials have shown correlation between positive C4d staining, DSAs, and histopathologic features in ABMR. A study involving 16 indicated allograft biopsies from 10 patients with circulating DSA and histopathologic features of ABMR, diffuse positive peri tubular capillaries C4d staining was found in all biopsies.
A study showed 30% of 81 patients with acute rejection had detectable C4d. C4d had was found to be 95% sensitivity and 96% specificity for of DSA positivity. In ABMR patients with positive DSA ,it was found that the inferior graft function and survival was documented in C4d positive biopsies versus C4d negative biopsies. So,C4d can be considered reliable indicator of significant humoral injury. Referrences
–Böhmig GA, Exner M, Habicht A, et al. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol 2002; 13:1091
Theepa Mariamutu
3 years ago
Can C4d staining predict the presence of DSA
AMR
Studies have found that there was strong correlation between diffuse C4d staining of PTCs and the presence of DSA
Mauiyyedi et al 2002 reported sensitivity of 95% and specificity of 96% of diffuse C4d staining of PTCs and the presence of DSAs
C4d staining may not be associated with DSA in the case of non-HLA antibodies observed by the allograft.
C4d has significant limitation for the diagnosis of ABMR:
1. methodological issues ( Immunoperoxidase vs Immnunofluorescence,frozen vs paraffin)
2. poor understanding of the meaning of minimal and focal staining and its waxing and waning deposition
3. staining depends on the density of the capillary network
4. poor sensitivity in chronic settings
5. reported positive in the absence of other evidence of graft injury
CABMR
Loupy et al reported that C4d staining waxed and waned and was not a sensitive marker of parenchyma disease after 1 year of transplant -55% of C4d negative biopsies with ABMR had evidences of concomitant capillary inflammation.
Sis et al stated that 60% of kidneys with high endothelial activation and injury transcripts (ENDATs) and chronic ABMR or graft loss were C4d negative.
Einecke G et al stated that 63% of late kidney failures were noted to have ABMR but C4d was negative
References:
Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002;13(3):779.
Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743.
Böhmig GA, Exner M, Habicht A, Schillinger M, Lang U, Kletzmayr J, Säemann MD, Hörl WH, Watschinger B, Regele H. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol. 2002 Apr;13(4):1091-1099. doi: 10.1681/ASN.V1341091. PMID: 11912271.
Last edited 3 years ago by Theepa Mariamutu
CARLOS TADEU LEONIDIO
3 years ago
Yes, staining for C4d can predict the presence of DSA, however it is not representative of all existing DSAs. Therefore, we can present AMR with the presence of DSA and without C4d staining. Technical issues related to type of fixative used, different methods of C4d detection, poor complement fixation by some DSAs, comple- ment-independent pathway of ABMR are some causes of C4d negativity.
Reference:
– Khairwa A. The relevance of complement C4d staining in renal allograft biopsies. Indian J Transplant 2020;14:94-8.
MOHAMED Elnafadi
3 years ago
Can C4d staining predict the presence of DSA?
yes c4d staining can predict DSA in ABMR highly specific and sensitive .
Shereen Yousef
3 years ago
Serum immunoglobulin (IgG) molecules can be divided into four subclasses (IgG1–IgG4) with varying capacity to activate complement and recruit effector cells through the Fc receptor (IgG3 >IgG1 >IgG2 >IgG4).
The complement activation contributes to allograft damage in most cases of ABMR.
If complement-fixing DSAs (IgG1 or IgG3) are present and bind to donor cell antigens, the complement cascade will be activated via the classical pathway resulting in ABMR with complement C4d (C4d) deposition.
C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
Although C4d is mainly interpreted as a product of classical pathway activation, C4 can also be generated via the lectin pathway. Consequently, C4d may be generated without prior antibody binding.
NB ;Noncomplement-binding IgG4 DSA was associated with subclinical and chronic ABMR (C4d negative), late allograft injury with increased transplant glomerulopathy (TG).
So the presence of C4d is strong predictor of the presence of complement fixing DSA
Praveen Kumar Etta.C4d staining and antibody-mediated rejection in renal transplantation: Current status.COMMENTARY
Year : 2020 | Volume : 14 | Issue : 3 | Page : 197-201
Drtalib Salman
3 years ago
Can C4d staining predict the presence of DSA?
yes, it sensitivity for diagnose Ab mediated rejection more than 95 percentage especially if it is associated with histological diagnosis of Ab mediated rejection .
C4d staining indicated complement fixing Ab, anti HLA class 1 or both class one and 2,indicated early rejection.
but in absence of histological tissue injury its specifity low because it can occur with ABO or pregnancy and thrombotic microangiopathy
Amit Sharma
3 years ago
Can C4d staining predict the presence of DSA?
Yes.
Various studies have shown that there is a relation between the presence of DSA and C4d staining. The sensitivity and specificity of C4d positive staining in a patient with DSA (in acute AMR) is very high (more than 90%). (1-4) Although, with reference to chronic AMR, positive C4d stain has been found to be specific, but not sensitive, with low positivity rates of 50%. (5)
C4d negativity in presence of DSA is uncommon, but can be seen due to: (6)
1) Technical issues: type of fixative used, different methods of C4d detection
2) Poor complement fixation by some DSAs
3) Complement independent AMR
4) Amr due to autoantibodies to AT1R
5) Due to FcRIIA (Fc receptor on NK cells)
C4d positivity, in patients with AMR has been shown to be associated with poor graft prognosis, hence its addition in the Banff criteria for AMR.
References:
1) Troxell ML, Weintraub LA, Higgins JP, Kambham N. Comparison of C4d immunostaining methods in renal allograft biopsies. Clin J Am Soc Nephrol. 2006 May;1(3):583-91. doi: 10.2215/CJN.00900805. Epub 2006 Mar 29. PMID: 17699262.
2) Böhmig GA, Exner M, Habicht A, Schillinger M, Lang U, Kletzmayr J, Säemann MD, Hörl WH, Watschinger B, Regele H. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol. 2002 Apr;13(4):1091-1099. doi: 10.1681/ASN.V1341091. PMID: 11912271.
3) Mauiyyedi S, Crespo M, Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Tolkoff-Rubin NE, Williams WW, Delmonico FL, Cosimi AB, Colvin RB. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002 Mar;13(3):779-787. doi: 10.1681/ASN.V133779. PMID: 11856785.
4) Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-Rubin N, Cosimi AB, Colvin RB. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol. 1999 Oct;10(10):2208-14. doi: 10.1681/ASN.V10102208. PMID: 10505698.
5) Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, Faleiros AC, dos Reis MA. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol. 2013;2013:678180. doi: 10.1155/2013/678180. Epub 2013 Jul 9. PMID: 23935649; PMCID: PMC3722852.
6) Nigam LK, Vanikar AV, Kanodia KV, Patel RD, Suthar KS, Patel HV. C4d-negative antibody-mediated rejection: A pathologist’s perspective and clinical outcome. Saudi J Kidney Dis Transpl. 2018 Jan-Feb;29(1):39-49. doi: 10.4103/1319-2442.225206. PMID: 29456206.
Abdulrahman Ishag
3 years ago
In the olden literature, about 85%–90% of the patients with C4d positivity had circulating DSA, but these assays were less sensitive than currently available solid-phase assays.
Cases in which C4d staining are positive but DSA cannot be detected may result from DSA being below the level of detection due to immune adsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target antigens).
The 2017 Banff conference has modified the diagnostic criteria for ABMR by stating that both C4d staining and validated molecular assays could serve as potential alternatives to DSAs in the diagnosis of ABMR and it also recognized C4d and molecular classifiers as surrogate markers for DSA.
The recent update of the Banff classification introduced the diagnostic category “suspicious for ABMR” if C4d (in the presence of antibody) or alloantibody (in the presence of C4d) cannot be demonstrated, but morphologic evidence of ABMR is present.
Reference ;
Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, et al. The Banff 2017 kidney meeting report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018;18:293-307.
Mahmud Islam
3 years ago
C4d deposition in peritubular capillaries is a very specific indicator of the presence of circulating DSAs. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies. (<Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian J Transplant [serial online] 2020 [cited 2022 Apr 14];14:197-201. Available from: https://www.ijtonline.in/text.asp?2020/14/3/197/296882) **C4d serves as an “immunologic footprint” of complement activation and ABMR. c4d presence is highly suggestive of acute ABMR..
Wael Hassan
3 years ago
*C4D not essential for diagnosis of ABMR specially in chronic form
in ABMR we search for C4d positive more than 50%
and or histopathological changes
and or specific AB (2 of 3) can diagnose ABMR
also we say that C4d positive may be without ABMR as in ABO incompatibility also if its deposition not in peri tubular capillaries .
*we can’t diagnose ABMR without histopathological changes but if we found C4d positive we predict DSA and high susceptibility for Acute ABMR
Mohamed Ghanem
3 years ago
Yes :
First :
C4d is an essential coroner in the diagnosis of Acute ABM rejection according to Bannf 2017
with Fetuchi et al found that the presence of DSA raises the possibility of the presence of Antibodies against Kidney allograft
and C4d act as the footprint of Antibody response and now it’s the best useful single marker of the presence of antibodies in Acute ABM rejections (complement-fixing)
with sensitivity and high positivity
Second However in Chronic ABM Rejections
Many studies found no correlation between transplant glomerulopathy and diffuse C4d staining (as its absence despite the presence of histological changes )
make it specific but less sensitive
due to Protocol biopsy studies had shown that variability of staining of C4d over time, with the variability of positivity and negativity of C4d. In these biopsies, microvascular inflammation was present despite the absence of C4d staining
The Importance of C4d in Biopsies of Kidney Transplant Recipients
Rosana Rosa Miranda Corrêa,1Juliana Reis Machado,1,2 Marcos Vinícius da Silva,2 Fernanda Rodrigues Helmo,1 Camila Souza Oliveira Guimarães,1 Laura Penna Rocha,1 Ana Carolina Guimarães Faleiros,3 and Marlene Antônia dos Reis
C4d-Negative Antibody-Mediated Rejection: A Pathologist’s
Perspective and Clinical Outcome
Lovelesh Kumar Nigam1, Aruna V. Vanikar1, Kamal V. Kanodia1, Rashmi D. Patel1, Kamlesh S.Suthar1, Himanshu V. Patel2
Sahar elkharraz
3 years ago
C4d is a complement activation and it’s a marker of allograft rejection. C4d deposition in peritubular capillary is specific and indicator presence of DSA. According to banff classification 2017 has recognised C4d as surrogate marker of DSA. Praveen Kumar Etta et al. C4d staining and antibody-mediated rejection in renal transplantation: Current status:Department of Nephrology and Renal Transplantation, Virinchi Hospitals and Max Superspeciality Medical Centre, Hyderabad, Telangana, Indian; Year : 2020 | Volume : 14 | Issue : 3 | Page : 197-201.
C4d is a complement activation and it’s a marker of allograft rejection. C4d deposition in peritubular capillary is specific and indicator presence of DSA. According to banff classification 2017 has recognised C4d as surrogate marker of DSA.
References
Praveen Kumar Etta et al. C4d staining and antibody-mediated rejection in renal transplantation: Current status:Department of Nephrology and Renal Transplantation, Virinchi Hospitals and Max Superspeciality Medical Centre, Hyderabad, Telangana, Indian; Yea : 2020 | Volume : 14 | Issue : 3 | Page : 197-201.
Dalia Ali
3 years ago
*The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
*C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
*C4d serves as an “immunologic footprint” of complement activation and ABMR.
*Cases in which C4d staining are positive but DSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target antigens).
*However, in which cases C4d not helpful in diagnosis as in complement‐independent form of AMR or C4d‐negative AMR.
*the detection of AMR should be best reported based on morphological features such as tubulointerstitial, vascular, and glomerular histological changes, with a piece of legislation to the presence or absence of C4d. Despite all pitfalls C4d is excellent marker for AMR.
Reference
1-Etta PK. C4d staining and antibody‐mediated rejection in renal transplantation: Current status. Indian J Transplant 2020;14:197‐201.
2-Anju Khairwa* The Relevance of Complement C4d Staining in Renal Allograft Biopsies
Department of Pathology, ESIC Model Hospital, Gurugram, Haryana, India
Cd4 presence does predict the presence of DSA.In a study of 81 patients with acute rejection, 30 percent had detectable C4d. C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA.
Ref : up to date
Ibrahim Omar
3 years ago
C4d staining usually predicts the presence of DSA.
if DSA are of complement-fixing type, C4d staining will predict it and even it means a significantly high titre of DSA.
if DSA are of non-complement fixing type, C4d staining will be -ve even DSA are of very high titre.
also, the patterns and methods of staining of C4d affects the results of C4d testing.
Huda Al-Taee
3 years ago
Can C4d staining predict the presence of DSA?
In the olden literature, about 85%–90% of the patients with C4d positivity had circulating DSA. Cases in which C4d staining is positive but DSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft, or it can also be due to the presence of non‑HLA antibodies.
The 2017 Banff conference has modified the diagnostic criteria for ABMR by stating that both C4d staining and validated molecular assays could serve as potential alternatives to DSAs in the diagnosis of ABMR and it also recognized C4d and molecular classifiers as surrogate markers for DSA.
The sensitivity and specificity of diffuse PTC C4d staining for the presence of DSA is > 95%.
References:
C4d Staining and Antibody‑mediated Rejection in Renal Transplantation: Current Status. Indian Journal of Transplantation. 2020 July- Sep;14(3).
Current issues and future direction in kidney transplantation textbook by Thomas Rath 2013.
Mohamed Essmat
3 years ago
YES , The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta. C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
Murad Hemadneh
3 years ago
It’s well known that C4d staining is considered “footprint” of AMR. C4d deposition in peritubular capillaries occurs because of complement activation due to AMR. C4d deposition is usually associated with DSA in ABR, but if there is no DSA it could result from anti-endothelial alloantibodies. Banff 2017 conference modified the criteria for ABR diagnosis as we can establish a diagnosis of ABR in the absence of DSA but in the presence of C4d staining and validated molecular assays as alternative to DSA.
Diffuse PTC C4d+ staining by IF on frozen sections, defined as >50% of peritubular capillaries staining positive, is highly associated with serum donor specific anti-HLA antibodies (DSA) and is reported to have 95% sensitivity and 96% specificity for circulating DSA. (1)
To note C4d staining can be negative although DSA is positive and there are histological features suggestive of ABR in cases of non-complement mediated ABR. On the other hand C4d staining could be falsely positive for many reasons as discussed in the second scenario for this week.
References:
Kedainis, R L et al. “Focal C4d+ in renal allografts is associated with the presence of donor-specific antibodies and decreased allograft survival.” American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons vol. 9,4 (2009): 812-9. doi:10.1111/j.1600-6143.2009.02555.x
Collins AB, Schneeberger EE, Pascual MA, et al. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol 1999; 10:2208
RuthSapir-Pichhadze,Simon P.Curran1et al (A systematic review of the role of C4d in the diagnosis of acute antibody-mediated rejection. Kidney International 2015:87( 1);182-194
saja Mohammed
3 years ago
Can C4d staining predict the presence of DSA? Substantiate your answer
C4D protein is the split product of the classic complement pathway activation during antibodies antigen immune response in complement mediated AMR its very sensitive and specific (1),and it considered one of the fundamental diagnostic criteria of acute humoral rejection (ABMR) according to updated Banff diagnostic criteria in 2017(2).
Devadas’s et al. stated in his study that the C4d scoring is not very sensitive marker of AMR, as it initially thought and the sensitivity of C4d in detecting acute AMR was only 55% and for chronic AMR was 23.5% (2), Histologically, marked microvascular inflammation (MVI) associated with diffuse C4d staining in comparison to focal C4d‑positive cases (2).
Evidence from recent studies confirmed that C4 D staining alone is not enough for the diagnosis of AMR, especially in late AMR (after 6 months) due to increased incidence of complement independent pathways of endothelial activation c4 d negative AMR
So, to conclude we need both the C4d staining and validated transcripts/ molecular marker to help in the diagnosis of ABMR especially late AMR.
Reference:
1- Acute humoral rejection in kidney ,transplant:11Morphology,immunology,andpathologicclassification,Mauiyyedi S,CrespoM,CollinsAB,schneeberger EE,Pascual MA,SaidmanSL,Tolkoff-Rubin NE,WilliamWW,DelmonicoFL,CosimiAB,colvin RB .J AM soc Nephrol.2002;13(3):779.
2- Devadass CW, Vanikar AV, Nigam LK, et al. Evaluation of Renal Allograft Biopsies for Graft Dysfunction and Relevance of C4d Staining in Antibody Mediated Rejection. J Clin Diagn Res. 2016;10(3):EC11-EC15. doi:10.7860/JCDR/2016/16339.7433.
agreed for chronic AMR but would you translate your answer to ACUTE AMR too
Jamila Elamouri
3 years ago
Yes, most of the time
Diffuse staining for C4d in peritubular capillaries is strongly associated with the appearance of anti donor HLA antibodies. And serves as a marker for humoral rejection.
Using a DSA threshold of 6000 MFI, a high specificity and negative predictive value for C4d staining were observed. DSA was also associated with the presence of AMR.
Even in a biopsy in which the usual features of AMR are not observed, the presence of C4d appears to be a sensitive indicator of anti-donor antibodies (DSA).
the correlation between C4d positivity and circulating antibody also applies to chronic rejection
C4d staining in arteries but not in peritubular capillaries occurs, perhaps due to non-HLA antigens expressed in arteries but not capillaries. Therefore; antibodies may not detect in this case.
negative for C4d; NO DSA
Using a DSA threshold of 6000 MFI, a high specificity and negative predictive value for C4d staining were observed. DSA was also associated with the presence of AMR. (1–4)
References:
1. Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-rubin N, et al. Complement Activation in Acute Humoral Renal Allograft Rejection : Diagnostic Significance of C4d Deposits in Peritubular Capillaries. 1999;(11):2208–14.
2. Garces JC, Giusti S, Staffeld-coit C, Bohorquez H, Ari J, Loss GE. Antibody-Mediated Rejection : A Review. 2017;46–55.
3. Santos LF, Manfro RC. a Rtigo o Riginal | o Riginal a RtiCle Correlações clinico-patológicas da marcação de C4d e sua. :329–37.
4. Peng DM, Boucek RJ, Law YM, Kemna MS, Nelson K, Warner P. The Journal of Heart and Lung Transplantation , Vol 30 , No 4S , April 2011. HEALUN [Internet]. 2011;30(4):S112. Available from: http://dx.doi.org/10.1016/j.healun.2011.01.329
In acute ABMR yes it predicts to high per cent> 90%
C4d positive staining in the peritubular capillary is highly sensitive and specific to the presence of DSA in Acute AMR. Although in chronic ABMR C4d staining is specific but not highly sensitive.
in ABO-incompatible graft and in accommodation, C4d can be positive but no detectable DSA.
If C4d staining is present in the arteries but not in PTC, it is usually due to non-HLA antigens expressed in arteries but not capillaries. Therefore; antibodies may not detect in this case.
C4d + with DSA + =
in Acute ABMR, C4d positive which mean > 90% chance for DSA to be positive
in chronic ABMR C4d positivity gives < 50% possibility fo detect DSA
C4d+ while DSA –
ABO-incompatibility+ accommodation + cABMR possible
C4d Neg while DSA pos
1- non-complement fixing ABs
2- alloantibodies that can damage the endothelium directly
Clinical relevance of Complement 4d: 1- Conditions associated with C4d positivity: a- Acute AMR b- Chronic AMR c- A, B, O blood group ABO-incompatible graft d- Accommodation.
2- C4d negative states: a- T-cell mediated rejection (TCMR) b- A technical error like a type of fixatives, IF, versus IHC c- Fc receptor (FCR) on NK cells (FcRIIA0 mediated rejection d- Non-fixing antibodies (AB that cannot fix complement) e- Complement independent pathways of endothelial activation f- C4d deposition is very low to be identified by IF/IHC g- Alloantibodies can directly damage the endothelium by interacting with MHC antigen h- an increased expression of endothelial transcripts causing endothelial injury.
Heba Wagdy
3 years ago
Yes,
C4d positivity is the most specific indicator for presence of DSA and its interaction with endothelial cells in the graft.
C4d deposition is strongly correlated with circulating DSA and is considered a surrogate marker for DSA
Banff 2017 classification considered C4d staining as potential alternative for DSA in diagnosing antibody mediated rejection.
However, there are cases with positive C4d staining but DSA are not detected due to presence of non-HLA antibodies or immunoadsorption of DSA by the graft (DSA are below level of detection), ABO blood group incompatible transplant and accommodation.
Other conditions where C4d is negative in presence of DSA include antibodies unable to fix complement, complement independent pathways of endothelial activation or if C4d is below level of detection.
Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian Journal of Transplantation. 2020 Jul 1;14(3):197.
Khairwa A. The relevance of complement C4d staining in renal allograft biopsies. Indian Journal of Transplantation. 2020 Apr 1;14(2):94.
Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, et al. The Banff 2017 kidney meeting report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018;18:293-307.
Cohen D, Colvin RB, Daha MR, Drachenberg CB, Haas M, Nickeleit V, et al. Pros and cons for C4d as a biomarker. Kidney Int 2012;81:628-39
well done though your answer could be more organised to reach a clear conclusion:
1.when is C4d + against DSA -.
2.when is C4d – against DSA+
3.Corrolation of sensitivity and specificity of a +C4d in prediction of DSAs according to BANFF 2017,19
Yes, C4d can predict the presence of DSA .
We need to be aware of the limitations of C4d and causes false positive C4d staining.
As discussed earlier, some patients may have non-complement fixing DSA.
In addition, there causes of false positive C4d staining, for example;
C4d may be another source other than DSA, like autoimmune disease.
There may be adsorption of the DSA into the graft and none in circulation.
The DSA level may be low for detection by current methods.
In a study by Peng et al 2013, found that there was a strong correlation between DSA MFI > 6000 and C4d positivity in paediatric heart transplant patients. At this MFI level they found a negative predictive value of 0.95 and a positive predictive value of 0.71.
Reem Younis
3 years ago
-Antibody-mediated rejection (AMR) is classified into hyperacute, subacute, and chronic AMR .
Diagnosis of acute AMR requires :
a) histopathological evidence of either acute tubular injury or capillaritis with neutrophil or mononuclear cell infiltrate, capillary thrombosis
b) serologic evidence of circulating DSA.
c) diffuse C4d positivity in peritubular capillaries (PTC) .
– Diffuse PTC C4d+ staining by IF on frozen sections, defined as >50% of peritubular capillaries staining positive, is highly associated with serum donor specific anti-HLA antibodies (DSA) and is reported to have 95% sensitivity and 96% specificity for circulating DSA .
-Diffuse PTC C4d+ correlates strongly with graft dysfunction and with chronic antibody-mediated rejection, reportedly detected in about 50% of cases with transplant glomerulopathy.
– Focal C4d+ defined as <50% of PTC staining positive, remains poorly understood. Most published studies either exclude biopsies with focal C4d+ or group these with diffusely positive C4d+ biopsies.
-A strong relation between diffuse C4d staining of PTCs and the presence of DSAs References:
– Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology and pathologic classification. J Am Soc Nephrol. 2002;13:779–787. [PubMed] [Google Scholar]
– Rotman S, Collins AB, Colvin RB. C4d detection in allografts: current concepts and interpretation. Transplant Rev. 2005;19:65–77. [Google Scholar]
– Crespo M, Pascual M, Tolkoff-Rubin N, et al. Acute humoral rejection in renal allograft recipients: I. Incidence, serology and clinical characteristics. Transplantation. 2001;15(71):652–658. [PubMed] [Google Scholar]
-Haas M, Rahman MH, Racusen LC, et al. C4d and C3d staining in biopsies of ABO-and HLA-incompatible renal allografts: correlation with histologic findings. Am J. Transplant. 2006;6:1829–1840. [PubMed] [Google Scholar]
Doaa Elwasly
3 years ago
The Banff 2017 working schema accepted C4d positivity as a surrogate for DSA in biopsies with MVI.
The multicenter DeKAF (Deterioration of Kidney Allograft Function) study, concluded even in the absence of detectable DSA,C4d positivity was a determinant of outcome in late graft dysfunction.
Senev et al’s study demonstrated that the positive predictive value of C4d staining for the presence of DSA (MFI > 500) in the context of ABMRh is 50%.
Earlier studies indicating a high specificity of C4d for DSA were conducted in nonselected biopsies and without the use of sensitive Luminex assays and single antigen bead testing.
As with all single center investigations that include histological assessment of MVI, C4d staining, and DSA testing, there are limitations to any definite conclusions that can be drawn, due to interobserver and interlaboratory variability.
Reference
Randhawa P.,RoufosseC. The expanding spectrum of antibody‐mediated rejection: Should we include cases where no anti‐HLA donor‐specific antibody is detected?Am J Transplant. 2019;19:622–624
Thanks, Dr Doaa What about the relation between C4d and DSA?
Tahani Ashmaig
3 years ago
■Can C4d staining predict the presence of DSA? the answer is yes, but not in all cases
▪︎NOTES:
__________________
▪︎ The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
▪︎C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft.
▪︎There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
But,
▪︎C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. Some patients have morphologic evidence of ABMR and a positive DSA with little or no C4d staining.
The prevalence of C4d-negative chronic ABMR ranges from 30% to 60%, as observed in patients who have other evidences of ABMR such as DSA with capillaritis or TG or increased levels of endothelial gene transcripts.
___________
Ref
Praveen K.et al “C4d staining and antibody-mediated rejection in renal transplantation: Current status” Volume:14 Issue: Page:197-201
C4d is the footprint of ABMR and in 2017 Banff classification considered as an alternative to DSA,hence staining of c4d predict the presence of DSA in more than 85%,but not always.
Sometime c4d staining is associated with negative DSA due to-
1.Adsorption of Ab in graft leading to
undetectable level.
2.presence of non HLA ab.
Abdul Rahim Khan
3 years ago
Can C4d staining predict the presence of DSA?
Substantiate your answer
My answer in No. The C4d is a potential marker for ABMR but its sensitivity is quite less. There is obvious co relation with of C4d and DSA but it’s not predictor of presence of DSA. There is obvious involvement of compliment system activation in ABMR and C4d is marker of compliment system involvement in ABMR. C4d positive ABMR has worse outcome as compared to C4d negative ABMR. C4d positivity can be seen in Acute AMR , Chronic AMR, ABO incompatibility and accommodation.
In one study by Rasa et al 368 biopsies from 301 patients with graft dysfunction and proteinuria over 5 years, DSA at the time of biopsy was present in 79% of diffuse C4d positive cases. Allograft survival at 40 moths was lower in C4d positive group as compared to C4d negative group – P=0.014.
Reference.
Rasa l Kedainis- Focal C4d + in Renal Allograft is Associated with the Presence of Donor Specific Antibodies and Decreased Allograft Survival. Am J Transplant. 2009 Apr; 9(4): 812–819.
All first-year posttransplant biopsy results from January 2004 through June 2014 were reviewed and correlated with the presence of donor-specific antibodies (DSA). C4d-negative AMR patients were not different from C4d-positive AMR patients on any baseline characteristics, including immunologic risk factors (panel reactive antibody, prior transplant, HLA mismatch, donor type, DSA class, and anti-HLA/ABO-incompatibility). C4d-positive AMR patients were significantly more likely to have a clinical presentation.
PTC has characteristic histological alterations, as well as DSA and C4d deposits. As C4d is the end product of typical complement pathway activation following the binding of alloantibodies to graft tissue, it is estimated that up to 90% of C4d positive cases are related to circulating DSA. As a result, the Banff group recommends regular staining for C4d in all graft biopsies. Nonetheless – It is possible to have DSA in the presence of C4d deposits.
1- Collins AB, Schneeberger EE, Pascual MA, et al. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries.
2-Am J Transplant. 2016 Jan;16(1):213-20.doi: 10.1111/ajt.13434.Epub 2015 Aug 28.
Yes it is estimated that up to 90% of C4d positive cases are related to circulating DSA
Esmat MD
3 years ago
Both C4d positive and negative staining can be associated with the presence of DSAs.
C4d is a split product of C4 involved in the classical complement pathway. C4b is converted to C4d, and it is a marker of complement activation.
C4d staining can be present in the absence of AMR or CMR and most commonly is seen in ABO-incompatible recipients.
C4d staining is not obviously associated with short- or long-term deleterious effect of graft survival.
Although the presence of linear staining for the C4d in the endothelium is highly suggestive of AMR, some patients with morphologic evidence of ABMR and positive DSA may have little or no C4d staining. Patients with C4d-negative AMR often have DSA and chronic microvascular inflammation that leads to chronic microvascular remodeling. There is a difference in C4d staining depending on the type of transplant, timing of biopsy and techniques used. C4d negative AMR also may be seen in the antibody mediated injury in the absence of activation of complement. T cells are the predominant infiltrating cell in the glomerulus in acute rejection associated with negative C4d staining, while the monocyte may be the predominant type of infiltrating glomerular cell associated with C4d-positive acute rejection.
One study reported that C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA. In the presence of high ENDATs (correlated with ABMR) and positive DSA, C4d negative staining was reported in 60% of cases of late ABMR. The AMR are left untreated is associated with a high rate of progression to transplant glomerulopathy. In patients with circulating DSA, graft function and survival are inferior in those with C4d-positive versus -negative staining, suggesting that C4d is a marker of more significant humoral injury. C4d positive AMR is more likely to have a clinical presentation and presents substantially earlier post transplantation.
Thanks, Esmat
I like your study “One study reported that C4d was found to be 95 per cent sensitive and 96 per cent specific for the presence of DSA. In the presence of high ENDATs (correlated with ABMR) and positive DSA, C4d negative staining was reported in 60% of cases of late ABMR. If AMR left untreated is associated with a high rate of progression to transplant glomerulopathy. In patients with circulating DSA, graft function and survival are inferior in those with C4d-positive versus -negative staining, suggesting that C4d is a marker of more significant humoral injury. C4d positive AMR is more likely to have a clinical presentation and presents substantially earlier post-transplantation.
Ban Mezher
3 years ago
Immunoglobulin can be divided into 4 subgroups( IgG1-4) with different affinity to complement activation ( IgG3>IgG1>IgG2>IgG4). In most cases of ABMR it result of complement activation leading to graft dysfunction.
If ABMR caused by complement-fixing DSA which bind to donor antigens, the complement will be activated through classical pathway with subsequent C4d deposition in endothelial cells of graft.
Non complement-fixing DSA usually associated with subclinical & chronic ABMR (C4d negative ABMR).
C4d positive staining is highly specific for DSA positivity in serum & its interaction with endothelial cells. So there is a strong correlation between C4d positive staining & circulating DSA.
Reference:
Etta P. C4d Staining and Antibody-mediated Rejection in Renal Transplantation: Current Status.Indian Journal of Transplantation. 2020,14(3):197-201.
Answer is No in which C4d staining are positive butDSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target .
There is a strong correlation between the presence of C4d deposition and circulating DSA. Banff group has considered that C4d staining is indispensable and advised to stain all renal allograft biopsies for C4d. IF in frozen sections remains the technique of choice, with triple-layer IF probably the most sensitive. C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. The 2013 Banff conference has accepted the entity of C4d-negative ABMR. The 2017 Banff conference has recognized C4d and molecular classifiers as surrogate markers for DSA.
References
1.
Etta PK. Comprehensive management of the renal Transplant recipient. Indian J Transplant 2019;13:240-51. Back to cited text no. 1
[Full text]
2.
DeVos JM, Gaber AO, Knight RJ, Land GA, Suki WN, Gaber LW, et al. Donor-specific HLA-DQ antibodies may contribute to poor graft outcome after renal transplantation. Kidney Int 2012;82:598-604. Back to cited text no. 2
3.
Kramer CS, Israeli M, Mulder A, Doxiadis II, Haasnoot GW, Heidt S, et al. The long and winding road towards epitope matching in clinical transplantation. Transpl Int 2019;32:16-24.
C4d is specific but not sensitive marker of ABMR.
The sensitivity and specificity of C4d for predict the presence of DSA have been investigated,In a study of 81 patients with acute rejection.30 % had detectable C4d. was found to be 95% sensitive and 96% specific for the presence of DSA
The complement activation contributes to allograft damage in most cases ABMR. complement-fixing DSA(IgG1 OR IgG3) are present and bind to donor cell antigens.the complement cascade will be activated via the classical pathway resulting in ABMR with complement c4d deposition.
recent evidence showed that complement- binding IgG3 subclass of DSA was more pathogenic and was associated with active ABMR and.increased microcirculation injury,and C4d deposition
IF in frozen section s remains the technique of choice .to detect C4d deposition conclusion
There is a strong correlation between the presence of C4d deposition and circulating DSA .unless C4d false positive Reference:
1) Renal allograft rejection with normal renal function in simultaneous kidney/pancreas recipients: does dissynchronous rejection really exist?
Shapiro R, Jordan ML, Scantlebury VP, Vivas CA, Jain A, McCauley J, Egidi MF, Randhawa P, Chakrabarti P, Corry RJ
Transplantation. 2000;69(3):440.
2)Subclinical rejection and borderline changes in early protocol biopsy specimens after renal transplantation.
Roberts IS, Reddy S, Russell C, Davies DR, Friend PJ, Handa AI, Morris PJ
Transplantation. 2004;77(8):1194.
3) The significance of subclinical rejection and the value of protocol biopsies.
Nankivell BJ, Chapman JR
Am J Transplant. 2006;6(9):2006.
4) Untreated rejection in 6-month protocol biopsies is not associated with fibrosis in serial biopsies or with loss of graft function.
Scholten EM, Rowshani AT, Cremers S, Bemelman FJ, Eikmans M, van Kan E, Mallat MJ, Florquin S, Surachno J, ten Berge IJ, Bajema IM, de Fijter JW
J Am Soc Nephrol. 2006;17(9):2622. Epub 2006 Aug 9.
The accommodation is defined as C4d deposition in PTCs in the absence of active rejection with or without DSA positivity, mostly seen in ABO‐incompatible graft transplantation.
The circulating DSA are most specifically associated with C4d deposition in PTC and its interactivity with endothelial cells in the graft.
Currently, C4d has become an essential investigation for AMR according to Banff update 2017.
both C4d and validated transcripts/classifiers/molecular marker can serve as potential alternatives and complements to DSAs in the diagnosis of ABMR.
There is entity of AMR DSA negative AMR, which characterized negative DSA/lack of DSA detection, moderate MVI with (g + ptc) scores of ≥2) as per Banff 2013 with or without C4d positivity.
C4d appears to be a less sensitive marker than initially thought.
The C4d as a biomarker lack of utility as a marker for antibody‐mediated injury in biopsies of ABO‐incompatible allografts
However, in which cases C4d not helpful in diagnosis whereas molecular studies have furnished perceptiveness evocative of a complement‐independent form of AMR or C4d‐negative AMR.
Despite all pitfalls C4d is excellent marker for AMR
Reference:
The Relevance of Complement C4d Staining in Renal Allograft Biopsies
Anju Khairwa*
Department of Pathology, ESIC Model Hospital, Gurugram, Haryana, India
Complement system is deeply involved in ABMR and can therefore provide potential biomarkers related to this process.
The C4d deposition has been considered the gold standard for ABMR diagnosis for several years, indicating activation of Classical pathway of Complement; however, all Complement pathways have been proved to be involved in ABMR, leading to recruitment and activation of leukocytes such as Natural Killer cells, monocytes/macrophages, and lymphocytes
.
The absence of detectable DSA should not discard the involvement of an antibody-mediated process .
Following conditions are showing C4d positivity,
A- Acute AMR
B- Chronic antibody mediated rejection
C- A, B, O blood group ABO incompatible grafts
d. Accommodation.
The following conditions are showing C4d negativity,
a. T cellmediated rejection (TCMR)
b. A technical error like a type of fixatives, immunofluorescence (IF) versus immunohistochemistry (IHC)
c. Fc receptor (FCR) on NK cells (FcRIIA) mediated rejection
d. Antibodies unable to fix the complement
e. Complement independent pathways of endothelial activation
f. C4d deposition is a very low in quantity for the identification limits of IF/IHC
g. Alloantibodies can direct endothelium injury to interact with major histocompatibility complex (MHC)
h. Increased expression of endothelial transcripts causing
endothelium injury.
Diagnosis of AMR depends on presence of evidence of tissue damage plus either +ve c4d or +ve detectable DSA.
so, there are c4d -ve AMR and AMR without detectable DSA.
so, neither of them can predict the other
· C4d negative AMR in spite of +ve DSA may be due to(1) :
1. Technical errors
2. Different method of c4d detection (IF vs IHC).
3. Very low amount of c4d (difficult detection).
4. Poor complement fixation by DSA
5. Complement independent pathway AMR or antibody dependent cell mediated cytotoxicity.
6. Antibodies against Angiotensin II type 1 receptors
7. fc receptors of Nk may have a role c4d negative AMR.
8. Increased expression of endothelial transcripts causing endothelium injury.
9. Sure pure TCMR will have -ve c4d.however, mixed rejection may be either c4d +ve or -ve.
Non detectable or -ve DSA AMR in spite of +ve c4d also can occur due to:
Non HLA antibodies (2) which are not routinely screened.
immunoadsorption of the DSA in graft (so not present in adequate detectable amount in serum).
ABO incompatible transplant with accomodation.
References:
Nigam LK, Vanikar AV, Kanodia KV, Patel RD, Suthar KS, Patel HV. C4d-negative antibody-mediated rejection: A pathologist’s perspective and clinical outcome. Saudi Journal of Kidney Diseases and Transplantation. 2018 Jan 1;29(1):39.
Tait BD, Süsal C, Gebel HM, Nickerson PW, Zachary AA, Claas FH, Reed EF, Bray RA, Campbell P, Chapman JR, Coates PT. Consensus guidelines on the testing and clinical management issues associated with HLA and non-HLA antibodies in transplantation. Transplantation. 2013 Jan 15;95(1):19-47.
diagnosis of AMR requires presence of
1- Characterstic histological changes , DSA and C4d deposits in PTC . It is estimated that Upto 90 % of C4d + cases are associated with circulating DSA as C4d is the end product of classic complement pathway activation after binding of alloantibodies to graft tissue, thus the Bannuf group recommend routine staing for C4d in all graft biopsies . However –ve DSA in presence of C4d deposits may occur, as in
-very low level of circulating DSA due to graft adsorption , that can’t be detected
– Presence of non HLA DSA .
Also DSA may present and and cause AMR without associated C4d deposit , known as c4d negative AMR via complement independent pathway
# Can C4d staining predict the presence of DSA?
The central diagnostic criterion for humoral rejection is the demonstration of C4d in PTC and vasa recta. There is a strong correlation between the presence of C4d deposition and circulating DSA. Banff group has considered that C4d staining is indispensable and advised to stain all renal allograft biopsies for C4d. IF in frozen sections remains the technique of choice, with triple-layer IF probably the most sensitive. C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. The 2013 Banff conference has accepted the entity of C4d-negative ABMR.
*** The 2017 Banff conference has recognized C4d and molecular classifiers as surrogate markers for DSA.
DeVos JM, Gaber AO, Knight RJ, Land GA, Suki WN, Gaber LW, et al. Donor-specific HLA-DQ antibodies may contribute to poor graft outcome after renal transplantation. Kidney Int 2012;82:598-604. Back to cited text no. 23.
Kramer CS, Israeli M, Mulder A, Doxiadis II, eHaasnoot GW, Heidt S, et al. The long and winding road towards epitope matching in clinical transplantation. Transpl Int 2019;32:16-24. Back to cited text no. 3
Simple question but many of you did not focus on the answer
regardless of the C4D staining the best predictors of DSA is the degree of microvascular inflammation (g,ptc, vi),like the case of C4D negative AMBR its complement indepenednt endothethial injury and this recently confirmed by using the molecular genetic microarrary biomarkers ENDAT which confrim the importance of cellular immune response with increase the expression of IFN-γ by cytotoxic T cells , NKC ,macrophage which is important for activation of class I and II antigens on endothelium and increases antibody binding to the endothelium, and trigger allograft inflammation and injury.so to conclude the Complement-independent activation of microvascular inflammation and DSA are more important predictors of poor allograft outcome than C4D positivity .
also keep in mind C4D is split product of classic complement pathway activation by antibody mediated immune response and cant predict the nonHLA abs , ABOI transplant with accomodiation , immunoabsorption of DSA by the graft.
References:
1-Hayde N, Bao Y, Pullman J, et al. The clinical and genomic significance of donor-specific antibody-positive/C4d-negative and donor-specific antibody-negative/C4d-negative transplant glomerulopathy. Clin J Am Soc Nephrol. 2013;8(12):2141-2148. doi:10.2215/CJN.04240413
Thanks, Dr Saja
Dose C4d positivity predicts DSA?
yes it dose predict complement fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96% , its the split product of the classical complement activation by antibodies antigen interaction and its still one of important diagnostic criteria of early AMR but become less sensitive in the diagnosis of late AMR , like non- complement mediated AMR
Thank You
still there is challenge how to manage highly sensitizing patient with preformed Ab and positive C4d and no histological finding of rejection ??
Multiple studies have demonstrated that there is a correlation among positive C4d staining, DSAs, and histopathologic findings in patients with ABMR. In study of 16 indicated allograft biopsies from 10 patients with circulating DSA and histopathologic findings suggestive of ABMR, diffuse positive peri tubular capillaries, C4d staining was observed in all biopsies.
The sensitivity and specificity of C4d for DSA have also been investigated. In a study of 81 patients with acute rejection, 30 percent had detectable C4d. C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA.
In ABMR patients with circulating DSA ,it was found that the inferior graft function and survival was documented in C4d positive biopsies versus C4d negative ones ,that means C4d is a reliable marker of significant humoral injury.
Referrences
–Collins AB, Schneeberger EE, Pascual MA, et al. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol 1999; 10:2208.
–Böhmig GA, Exner M, Habicht A, et al. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol 2002; 13:1091
EXCELLENT
Yes, C4d was found to be 95% sensitive and 96% specific for the presence of DSA.
Can C4d staining predict the presence of DSA?
My answer is: No
C4d represent the footprint of complement activation and is not correlated to the presence of DSA for many reasons:
– In one study involving1036 kidney allograft biopsies from 1320 transplant recipients, 36% of cases with a histologic lesion characteristic of chronic ABMR had C4d-positive staining, despite the presence of DSAs in 73% of patients (1).
– Isolated C4d staining can be seen without DSA or other signs suggestive of immunological injury in the case of ABOI transplantation (accommodation) (2, 3).
– Many glomerular lesions may be associated with positive C4d staining due to an underlying auto-immune disease rather than DSA derived kidney injury (e.g. C4 glomerulopathy) (4).
It is also worth mentioning that Non-HLA DSA may also cause C4d staining (while the conventional investigation for the HLA DSA will be negative) (5).
References:
1) Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743.
2) Setoguchi K, Ishida H, Shimmura H, et al. Analysis of renal transplant protocol biopsies in ABO-incompatible kidney transplantation. Am J Transplant. 2008;8(1):86.
3) Haas M, Rahman MH, Racusen LC, et al. C4d and C3d staining in biopsies of ABO- and HLA-incompatible renal allografts: correlation with histologic findings. Am J Transplant. 2006;6(8):1829.
4) S. Sethi and F. C. Fervenza. C4 glomerulopathy. © 2022 UpToDate. (Accessed on 10 April 2022).
5) Sun Q, Liu Z, Yin G, et al. Detectable circulating antiendothelial cell antibodies in renal allograft recipients with C4d-positive acute rejection: a report of three cases. Transplantation. 2005;79(12):1759.
Good
Dear Dr Ahmed
Excellent discussion, your reference was to chronic AMR where the presence of DSA and C4d positivity accounts for only 50% of the cases of CAMR.
What about Acute AMR?
Dear Dr Ahmed,
What about Acute AMR?
Cases with Acute AMR may have positive C4d staining in less than 40 % of cases. However, DSA were present in 90% (18 of 20) of the C4d positive cases compared with 2% (1 of 47) in the C4d negative acute rejection cases (P<0.001) (1).
We can conclude from this study that C4d staining may not be detected in most Acute AMR cases, but if C4d staining is detected, the recipient will have a detectable DSA in more than 90% of patients (1).
References:
1) Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002;13(3):779.
yes, diffuse PTC C4d staining is highly sensitive and specific for DSA( > 95%).
Yes positive C4d stain will predicts circulating donor specific antibodies because it the products of antigen antibody reaction in antibody mediated rejection,it highly sensitive but less specific due to many reaction can lead to deposition of C4d fragments like ABO incompatible transplant
Antibody-mediated rejection (AMR) is highly detrimental to the prolonged survival of transplanted kidneys. C4d has been regarded as a footprint of AMR tissue damage . Despite the general acceptance of the usefulness of C4d in the identification of acute AMR, the data for C4d staining in chronic AMR is variable. The presence of C4d in the majority of the biopsies with features of chronic antibody-mediated rejection is reported, but this rejection without C4d staining is observed as well, suggesting that C4d is specific but not sensitive.the specific 96% and sensitivity is 95% for presence of AMR .
C4d deposition in peritubular capillary is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
Reference
1)Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, et al. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol 2013;2013:678180.
C4D STAINING FOR DSA DETECTION
Reference :
Etta PK. C4d staining anf antibody mediated rejection in renal transplantation : current status. Ind J Trans; 2020; 14 : 197-201
· Can C4d staining predict the presence of DSA? Substantiate your answer
Yes, many studies revealed the strong correlation between diffuse C4d staining(in the presence of histological changes) and the presence of complement fixing DSAs in acute AMR with a sensitivity of 95% and specificity of 96% but this sensitivity is reduced in late chronic AMR to less than 50%.
On the other side there are cases where DSAs are present but C4d is negative:
o Technical issues in detection of AB related to the type of fixative used
o Complement independent ABMR
o Non HLA-AB( AT1R)
References:
1) Praveen Kumar Etta.C4d staining and antibody-mediated rejection in renal transplantation: Current status. Commentary : 2020 | Volume : 14 | Issue : 3 | Page : 197-201
2) Troxell ML, Weintraub LA, Higgins JP, Kambham N. Comparison of C4d immune-staining methods in renal allograft biopsies. Clin J Am Soc Nephrol. 2006 May;1(3):583-91.
3) Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743
Can C4d staining predict the presence of DSA?
Yes, C4d staining can predict the presence of DSA in 90% of cases.
Almost 90% of patients with +ve C4d were found to have circulating DSA.
20-50% of indicated RTx biopsies revealed PTC C4d +ve. However, 2% of protocol biopsies had shown PTC C4d +ve.
DSAs are either HLA or non-HLA. DSAs are detected by different techniques that differ in their sensitivity.
Causes of C4d +ve/DSA -ve:
1-low level of DSA.
2-Non-HLA antibodies.
3-ABO incompatible graft without ABMR or TCMR indicates graft accommodation.
Causes of C4d -ve/DSA +ve:
1-C4d negative ABMR. High ENDATs were reported in 60% of cases with late ABMR.
2- Technical problems: methods of C4d detection and type of fixation.
3-Complement independent ABMR.
4-DSAs with poor complement fixation.
5-ABMR because of anti- AT1R antibodies, and anti FcRIIA (Fc receptor on NK cells)
References:
1- Mauiyyedi S, Crespo M, Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Tolkoff-Rubin NE, Williams WW, Delmonico FL, Cosimi AB, Colvin RB. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002 Mar;13(3):779-787. doi: 10.1681/ASN.V133779. PMID: 11856785.
2- Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-Rubin N, Cosimi AB, Colvin RB. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol. 1999 Oct;10(10):2208-14. doi: 10.1681/ASN.V10102208. PMID: 10505698.
3- Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, Faleiros AC, dos Reis MA. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol. 2013;2013:678180. doi: 10.1155/2013/678180. Epub 2013 Jul 9. PMID: 23935649; PMCID: PMC3722852.
Yes , it can predict the presence of DSA as C4d is as split product of complement activation pathway in AMR.(AMR with C4d positive ) .
DSA and C4D considered as AB evidence for diagnosis of ABMR
Unfortunately, there is multiple types of DSA (HLA and non HLA) also there is multiple techniques in detection of DSA which differ in its sensitivity
So there is some discrepancies in results of c4d sensitivity to DSA detection from 30% to 95% but there is agreement on the specificity of c4d which may results up to 98%
a study was done in 2002 by Böhmig GA and his group on One hundred thirteen biopsies, obtained from 58 cadaveric kidney transplant recipients, were tested. circulating antibodies were evaluated by 2 techniques
flow cytometric crossmatch (FCXM) testing and
FlowPRA analysis of anti-HLA panel reactivity.
and results showed
In one study involving1036 kidney allograft biopsies from 1320 transplant recipients, 36% of cases with a histologic lesion characteristic of chronic ABMR had C4d-positive staining, despite the presence of DSAs in 73% of patients
References
complement fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96%.
Many studies showed the relation between C4d positivity and the presence of DSA .
C4d represent the footprint of complement activation.
C4d is sensitive in case of Acute antibody rejection while the sensitivity in chronic antibody rejection is less than 40%.
C4d negativity in presence of DSA is uncommon, but can be seen due to:
* Technical issues: type of fixative used
* poor fixation of Complement by some DSAs
* Complement independent AMR
* Autoantibodies to AT1R
* Fc receptor on NK cells
Yes
C4d is a product of complement activation , and it is a footprint of antibody mediated rejection.
In C4d positive patient, the DSA is present in more than 90 % of ABMR.
But in DSA positive patient , the C4d is positive only in about 40% of ABMR patient .
This rise a new form of ABMR ( C4D negative ABMR ).
It worth to mention that DSA could be negative , in C4d positive patient in the following situation
1- Technical error in detection of Ab ( non HLA Ab )
2- Ab sequestration by graft ( which may reappear after graft removal ).
3- Autoimmune disease (auto Ab – SLE )
4- ABO- I transplantation(accommodation ).
5- Vascular disease ( non Ab complement activation).
6- Immune complex disease ( glomerular deposition ,nonspecific) .
.Can C4d staining predict the presence of DSA?Yes, it predict presence of complement fixing DSA in Acute AMR with high sensitivity 95% and specificity 96% .its the split product of the classical complement activation by antibodies antigen interaction and its still one of important diagnostic criteria of early AMR but become less sensitive in the diagnosis of late AMR , like non- complement mediated AMR.
However, there is proved that
Following conditions are showing C4d positivity:
a. Acute AMR
b. Chronic antibody‑mediated rejection
c. A, B, O blood group ABO incompatible grafts
d. Accommodation.
The following conditions are showing C4d negativity:
a. T‑cell‑mediated rejection (TCMR)
b. A technical error like a type of fixatives,
immunofluorescence (IF) versus immunohistochemistry (IHC)
c. Fc receptor (FCR) on NK cells (FcRIIA) mediated rejection
d. Antibodies unable to fix the complement
e. Complement independent pathways of endothelial activation
f. C4d deposition is a very low in quantity for the identification limits of IF/IHC
g. Alloantibodies can direct endothelium injury to interact with major histocompatibility complex (MHC)
h. Increased expression of endothelial transcripts causing endothelium injury.
References
1. Nankivell BJ, Alexander SI. Rejection of the kidney allograft. N Engl J
Med 2010;363:1451‑62.
2. Mengel M, Sis B, Haas M, Colvin RB, Halloran PF, Racusen LC,
et al. Banff 2011 Meeting report: New concepts in antibody‑mediated
rejection. Am J Transplant 2012;12:563‑70.
3. Tait BD, Süsal C, Gebel HM, Nickerson PW, Zachary AA, Claas FH,
et al. Consensus guidelines on the testing and clinical management
issues associated with HLA and non‑HLA antibodies in transplantation.
Transplantation 2013;95:19‑47.
4. Monsinjon T, Gasque P, Chan P, Ischenko A, Brady JJ, Fontaine MC.
Regulation by complement C3a and C5a anaphylatoxins of cytokine
production in human umbilical vein endothelial cells. FASEB J
2003;17:1003‑14.
5. Chakravarti DN, Campbell RD, Porter RR. The chemical structure
of the C4d fragment of the human complement component C4. Mol
Immunol 1987;24:1187‑97.
C4d is a terminal product of C4b and is used as a footprint of antibody mediated rejection in renal allograft biopsies..
C4d staining has high specificity but less sensitivity…
80-90% of the C4d staining renal allograft biopsies had circulating DSA present…Cases in which C4d positivity and DSA negativity can be seen in conditions where there is very low level DSA, Non Complement binding DSA, DSA immunoadsorption in the graft or DSA to Non HLA antibody….
C4d staining implies IgG1 and IgG3 DSA which are strong compliment binding DSA are present…The intensity of the complement fixing reduces when IgG2 or IgG4 are present and they may be associated with C4d negative ABMR especially the late/chronic/indolent ABMR…
Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian J Transplant 2020;14:197-201
Can C4d staining predict the presence of DSA? the answer is yes, it does predict complement-fixing DSA in acute AMR with high sensitivity of 95% and specificity of 96%
▪︎ The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
▪︎C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft.
▪︎There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
But,
▪︎C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. Some patients have morphologic evidence of ABMR and a positive DSA with little or no C4d staining.
Böhmig GA, Exner M, Habicht A, et al. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol 2002; 13:1091
Several trials have shown correlation between positive C4d staining, DSAs, and histopathologic features in ABMR. A study involving 16 indicated allograft biopsies from 10 patients with circulating DSA and histopathologic features of ABMR, diffuse positive peri tubular capillaries C4d staining was found in all biopsies.
A study showed 30% of 81 patients with acute rejection had detectable C4d. C4d had was found to be 95% sensitivity and 96% specificity for of DSA positivity.
In ABMR patients with positive DSA ,it was found that the inferior graft function and survival was documented in C4d positive biopsies versus C4d negative biopsies. So,C4d can be considered reliable indicator of significant humoral injury.
Referrences
–Böhmig GA, Exner M, Habicht A, et al. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol 2002; 13:1091
Can C4d staining predict the presence of DSA
AMR
Studies have found that there was strong correlation between diffuse C4d staining of PTCs and the presence of DSA
Mauiyyedi et al 2002 reported sensitivity of 95% and specificity of 96% of diffuse C4d staining of PTCs and the presence of DSAs
C4d staining may not be associated with DSA in the case of non-HLA antibodies observed by the allograft.
C4d has significant limitation for the diagnosis of ABMR:
1. methodological issues ( Immunoperoxidase vs Immnunofluorescence,frozen vs paraffin)
2. poor understanding of the meaning of minimal and focal staining and its waxing and waning deposition
3. staining depends on the density of the capillary network
4. poor sensitivity in chronic settings
5. reported positive in the absence of other evidence of graft injury
CABMR
Loupy et al reported that C4d staining waxed and waned and was not a sensitive marker of parenchyma disease after 1 year of transplant -55% of C4d negative biopsies with ABMR had evidences of concomitant capillary inflammation.
Sis et al stated that 60% of kidneys with high endothelial activation and injury transcripts (ENDATs) and chronic ABMR or graft loss were C4d negative.
Einecke G et al stated that 63% of late kidney failures were noted to have ABMR but C4d was negative
References:
Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002;13(3):779.
Sis B, Campbell PM, Mueller T, et al. Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause. Am J Transplant. 2007;7(7):1743.
Böhmig GA, Exner M, Habicht A, Schillinger M, Lang U, Kletzmayr J, Säemann MD, Hörl WH, Watschinger B, Regele H. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol. 2002 Apr;13(4):1091-1099. doi: 10.1681/ASN.V1341091. PMID: 11912271.
Yes, staining for C4d can predict the presence of DSA, however it is not representative of all existing DSAs. Therefore, we can present AMR with the presence of DSA and without C4d staining. Technical issues related to type of fixative used, different methods of C4d detection, poor complement fixation by some DSAs, comple- ment-independent pathway of ABMR are some causes of C4d negativity.
Reference:
– Khairwa A. The relevance of complement C4d staining in renal allograft biopsies. Indian J Transplant 2020;14:94-8.
Can C4d staining predict the presence of DSA?
yes c4d staining can predict DSA in ABMR highly specific and sensitive .
Serum immunoglobulin (IgG) molecules can be divided into four subclasses (IgG1–IgG4) with varying capacity to activate complement and recruit effector cells through the Fc receptor (IgG3 >IgG1 >IgG2 >IgG4).
The complement activation contributes to allograft damage in most cases of ABMR.
If complement-fixing DSAs (IgG1 or IgG3) are present and bind to donor cell antigens, the complement cascade will be activated via the classical pathway resulting in ABMR with complement C4d (C4d) deposition.
C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
Although C4d is mainly interpreted as a product of classical pathway activation, C4 can also be generated via the lectin pathway. Consequently, C4d may be generated without prior antibody binding.
NB ;Noncomplement-binding IgG4 DSA was associated with subclinical and chronic ABMR (C4d negative), late allograft injury with increased transplant glomerulopathy (TG).
So the presence of C4d is strong predictor of the presence of complement fixing DSA
Praveen Kumar Etta.C4d staining and antibody-mediated rejection in renal transplantation: Current status.COMMENTARY
Year : 2020 | Volume : 14 | Issue : 3 | Page : 197-201
Can C4d staining predict the presence of DSA?
yes, it sensitivity for diagnose Ab mediated rejection more than 95 percentage especially if it is associated with histological diagnosis of Ab mediated rejection .
C4d staining indicated complement fixing Ab, anti HLA class 1 or both class one and 2,indicated early rejection.
but in absence of histological tissue injury its specifity low because it can occur with ABO or pregnancy and thrombotic microangiopathy
Can C4d staining predict the presence of DSA?
Yes.
Various studies have shown that there is a relation between the presence of DSA and C4d staining. The sensitivity and specificity of C4d positive staining in a patient with DSA (in acute AMR) is very high (more than 90%). (1-4) Although, with reference to chronic AMR, positive C4d stain has been found to be specific, but not sensitive, with low positivity rates of 50%. (5)
C4d negativity in presence of DSA is uncommon, but can be seen due to: (6)
1) Technical issues: type of fixative used, different methods of C4d detection
2) Poor complement fixation by some DSAs
3) Complement independent AMR
4) Amr due to autoantibodies to AT1R
5) Due to FcRIIA (Fc receptor on NK cells)
C4d positivity, in patients with AMR has been shown to be associated with poor graft prognosis, hence its addition in the Banff criteria for AMR.
References:
1) Troxell ML, Weintraub LA, Higgins JP, Kambham N. Comparison of C4d immunostaining methods in renal allograft biopsies. Clin J Am Soc Nephrol. 2006 May;1(3):583-91. doi: 10.2215/CJN.00900805. Epub 2006 Mar 29. PMID: 17699262.
2) Böhmig GA, Exner M, Habicht A, Schillinger M, Lang U, Kletzmayr J, Säemann MD, Hörl WH, Watschinger B, Regele H. Capillary C4d deposition in kidney allografts: a specific marker of alloantibody-dependent graft injury. J Am Soc Nephrol. 2002 Apr;13(4):1091-1099. doi: 10.1681/ASN.V1341091. PMID: 11912271.
3) Mauiyyedi S, Crespo M, Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Tolkoff-Rubin NE, Williams WW, Delmonico FL, Cosimi AB, Colvin RB. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification. J Am Soc Nephrol. 2002 Mar;13(3):779-787. doi: 10.1681/ASN.V133779. PMID: 11856785.
4) Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-Rubin N, Cosimi AB, Colvin RB. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries. J Am Soc Nephrol. 1999 Oct;10(10):2208-14. doi: 10.1681/ASN.V10102208. PMID: 10505698.
5) Corrêa RR, Machado JR, da Silva MV, Helmo FR, Guimarães CS, Rocha LP, Faleiros AC, dos Reis MA. The importance of C4d in biopsies of kidney transplant recipients. Clin Dev Immunol. 2013;2013:678180. doi: 10.1155/2013/678180. Epub 2013 Jul 9. PMID: 23935649; PMCID: PMC3722852.
6) Nigam LK, Vanikar AV, Kanodia KV, Patel RD, Suthar KS, Patel HV. C4d-negative antibody-mediated rejection: A pathologist’s perspective and clinical outcome. Saudi J Kidney Dis Transpl. 2018 Jan-Feb;29(1):39-49. doi: 10.4103/1319-2442.225206. PMID: 29456206.
In the olden literature, about 85%–90% of the patients with C4d positivity had circulating DSA, but these assays were less sensitive than currently available solid-phase assays.
Cases in which C4d staining are positive but DSA cannot be detected may result from DSA being below the level of detection due to immune adsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target antigens).
The 2017 Banff conference has modified the diagnostic criteria for ABMR by stating that both C4d staining and validated molecular assays could serve as potential alternatives to DSAs in the diagnosis of ABMR and it also recognized C4d and molecular classifiers as surrogate markers for DSA.
The recent update of the Banff classification introduced the diagnostic category “suspicious for ABMR” if C4d (in the presence of antibody) or alloantibody (in the presence of C4d) cannot be demonstrated, but morphologic evidence of ABMR is present.
Reference ;
Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, et al. The Banff 2017 kidney meeting report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018;18:293-307.
C4d deposition in peritubular capillaries is a very specific indicator of the presence of circulating DSAs. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies. (<Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian J Transplant [serial online] 2020 [cited 2022 Apr 14];14:197-201. Available from: https://www.ijtonline.in/text.asp?2020/14/3/197/296882)
**C4d serves as an “immunologic footprint” of complement activation and ABMR. c4d presence is highly suggestive of acute ABMR..
*C4D not essential for diagnosis of ABMR specially in chronic form
in ABMR we search for C4d positive more than 50%
and or histopathological changes
and or specific AB (2 of 3) can diagnose ABMR
also we say that C4d positive may be without ABMR as in ABO incompatibility also if its deposition not in peri tubular capillaries .
*we can’t diagnose ABMR without histopathological changes but if we found C4d positive we predict DSA and high susceptibility for Acute ABMR
Yes :
First :
C4d is an essential coroner in the diagnosis of Acute ABM rejection according to Bannf 2017
with Fetuchi et al found that the presence of DSA raises the possibility of the presence of Antibodies against Kidney allograft
and C4d act as the footprint of Antibody response and now it’s the best useful single marker of the presence of antibodies in Acute ABM rejections (complement-fixing)
with sensitivity and high positivity
Second
However in Chronic ABM Rejections
Many studies found no correlation between transplant glomerulopathy and diffuse C4d staining (as its absence despite the presence of histological changes )
make it specific but less sensitive
due to Protocol biopsy studies had shown that variability of staining of C4d over time, with the variability of positivity and negativity of C4d. In these biopsies, microvascular inflammation was present despite the absence of C4d staining
The Importance of C4d in Biopsies of Kidney Transplant Recipients
Rosana Rosa Miranda Corrêa,1 Juliana Reis Machado,1,2 Marcos Vinícius da Silva,2 Fernanda Rodrigues Helmo,1 Camila Souza Oliveira Guimarães,1 Laura Penna Rocha,1 Ana Carolina Guimarães Faleiros,3 and Marlene Antônia dos Reis
C4d-Negative Antibody-Mediated Rejection: A Pathologist’s
Perspective and Clinical Outcome
Lovelesh Kumar Nigam1, Aruna V. Vanikar1, Kamal V. Kanodia1, Rashmi D. Patel1, Kamlesh S.Suthar1, Himanshu V. Patel2
C4d is a complement activation and it’s a marker of allograft rejection. C4d deposition in peritubular capillary is specific and indicator presence of DSA. According to banff classification 2017 has recognised C4d as surrogate marker of DSA. Praveen Kumar Etta et al. C4d staining and antibody-mediated rejection in renal transplantation: Current status:Department of Nephrology and Renal Transplantation, Virinchi Hospitals and Max Superspeciality Medical Centre, Hyderabad, Telangana, Indian; Year : 2020 | Volume : 14 | Issue : 3 | Page : 197-201.
C4d is a complement activation and it’s a marker of allograft rejection. C4d deposition in peritubular capillary is specific and indicator presence of DSA. According to banff classification 2017 has recognised C4d as surrogate marker of DSA.
References
Praveen Kumar Etta et al. C4d staining and antibody-mediated rejection in renal transplantation: Current status:Department of Nephrology and Renal Transplantation, Virinchi Hospitals and Max Superspeciality Medical Centre, Hyderabad, Telangana, Indian; Yea : 2020 | Volume : 14 | Issue : 3 | Page : 197-201.
*The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
*C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
*C4d serves as an “immunologic footprint” of complement activation and ABMR.
*Cases in which C4d staining are positive but DSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target antigens).
*However, in which cases C4d not helpful in diagnosis as in complement‐independent form of AMR or C4d‐negative AMR.
*the detection of AMR should be best reported based on morphological features such as tubulointerstitial, vascular, and glomerular histological changes, with a piece of legislation to the presence or absence of C4d. Despite all pitfalls C4d is excellent marker for AMR.
Reference
1-Etta PK. C4d staining and antibody‐mediated rejection in renal transplantation: Current status. Indian J Transplant 2020;14:197‐201.
2-Anju Khairwa* The Relevance of Complement C4d Staining in Renal Allograft Biopsies
Department of Pathology, ESIC Model Hospital, Gurugram, Haryana, India
http://www.ijtonline.in on Monday, February 7, 2022, IP: 10.232.74.26]
Cd4 presence does predict the presence of DSA.In a study of 81 patients with acute rejection, 30 percent had detectable C4d. C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA.
Ref : up to date
In the olden literature, about 85%–90% of the patients with C4d positivity had circulating DSA. Cases in which C4d staining is positive but DSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft, or it can also be due to the presence of non‑HLA antibodies.
The 2017 Banff conference has modified the diagnostic criteria for ABMR by stating that both C4d staining and validated molecular assays could serve as potential alternatives to DSAs in the diagnosis of ABMR and it also recognized C4d and molecular classifiers as surrogate markers for DSA.
The sensitivity and specificity of diffuse PTC C4d staining for the presence of DSA is > 95%.
References:
YES , The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta. C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft. There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
It’s well known that C4d staining is considered “footprint” of AMR. C4d deposition in peritubular capillaries occurs because of complement activation due to AMR. C4d deposition is usually associated with DSA in ABR, but if there is no DSA it could result from anti-endothelial alloantibodies. Banff 2017 conference modified the criteria for ABR diagnosis as we can establish a diagnosis of ABR in the absence of DSA but in the presence of C4d staining and validated molecular assays as alternative to DSA.
Diffuse PTC C4d+ staining by IF on frozen sections, defined as >50% of peritubular capillaries staining positive, is highly associated with serum donor specific anti-HLA antibodies (DSA) and is reported to have 95% sensitivity and 96% specificity for circulating DSA. (1)
To note C4d staining can be negative although DSA is positive and there are histological features suggestive of ABR in cases of non-complement mediated ABR. On the other hand C4d staining could be falsely positive for many reasons as discussed in the second scenario for this week.
References:
Can C4d staining predict the presence of DSA?
Substantiate your answer
C4D protein is the split product of the classic complement pathway activation during antibodies antigen immune response in complement mediated AMR its very sensitive and specific (1),and it considered one of the fundamental diagnostic criteria of acute humoral rejection (ABMR) according to updated Banff diagnostic criteria in 2017(2).
Devadas’s et al. stated in his study that the C4d scoring is not very sensitive marker of AMR, as it initially thought and the sensitivity of C4d in detecting acute AMR was only 55% and for chronic AMR was 23.5% (2), Histologically, marked microvascular inflammation (MVI) associated with diffuse C4d staining in comparison to focal C4d‑positive cases (2).
Evidence from recent studies confirmed that C4 D staining alone is not enough for the diagnosis of AMR, especially in late AMR (after 6 months) due to increased incidence of complement independent pathways of endothelial activation c4 d negative AMR
So, to conclude we need both the C4d staining and validated transcripts/ molecular marker to help in the diagnosis of ABMR especially late AMR.
Reference:
1- Acute humoral rejection in kidney ,transplant:11Morphology,immunology,andpathologicclassification,Mauiyyedi S,CrespoM,CollinsAB,schneeberger EE,Pascual MA,SaidmanSL,Tolkoff-Rubin NE,WilliamWW,DelmonicoFL,CosimiAB,colvin RB .J AM soc Nephrol.2002;13(3):779.
2- Devadass CW, Vanikar AV, Nigam LK, et al. Evaluation of Renal Allograft Biopsies for Graft Dysfunction and Relevance of C4d Staining in Antibody Mediated Rejection. J Clin Diagn Res. 2016;10(3):EC11-EC15. doi:10.7860/JCDR/2016/16339.7433.
agreed for chronic AMR but would you translate your answer to ACUTE AMR too
Yes, most of the time
References:
1. Collins AB, Schneeberger EE, Pascual MA, Saidman SL, Williams WW, Tolkoff-rubin N, et al. Complement Activation in Acute Humoral Renal Allograft Rejection : Diagnostic Significance of C4d Deposits in Peritubular Capillaries. 1999;(11):2208–14.
2. Garces JC, Giusti S, Staffeld-coit C, Bohorquez H, Ari J, Loss GE. Antibody-Mediated Rejection : A Review. 2017;46–55.
3. Santos LF, Manfro RC. a Rtigo o Riginal | o Riginal a RtiCle Correlações clinico-patológicas da marcação de C4d e sua. :329–37.
4. Peng DM, Boucek RJ, Law YM, Kemna MS, Nelson K, Warner P. The Journal of Heart and Lung Transplantation , Vol 30 , No 4S , April 2011. HEALUN [Internet]. 2011;30(4):S112. Available from: http://dx.doi.org/10.1016/j.healun.2011.01.329
Please read my comment below and try again.
In acute ABMR yes it predicts to high per cent> 90%
C4d positive staining in the peritubular capillary is highly sensitive and specific to the presence of DSA in Acute AMR. Although in chronic ABMR C4d staining is specific but not highly sensitive.
in ABO-incompatible graft and in accommodation, C4d can be positive but no detectable DSA.
If C4d staining is present in the arteries but not in PTC, it is usually due to non-HLA antigens expressed in arteries but not capillaries. Therefore; antibodies may not detect in this case.
C4d + with DSA + =
in Acute ABMR, C4d positive which mean > 90% chance for DSA to be positive
in chronic ABMR C4d positivity gives < 50% possibility fo detect DSA
C4d+ while DSA –
ABO-incompatibility+ accommodation + cABMR possible
C4d Neg while DSA pos
1- non-complement fixing ABs
2- alloantibodies that can damage the endothelium directly
Clinical relevance of Complement 4d:
1- Conditions associated with C4d positivity:
a- Acute AMR
b- Chronic AMR
c- A, B, O blood group ABO-incompatible graft
d- Accommodation.
2- C4d negative states:
a- T-cell mediated rejection (TCMR)
b- A technical error like a type of fixatives, IF, versus IHC
c- Fc receptor (FCR) on NK cells (FcRIIA0 mediated rejection
d- Non-fixing antibodies (AB that cannot fix complement)
e- Complement independent pathways of endothelial activation
f- C4d deposition is very low to be identified by IF/IHC
g- Alloantibodies can directly damage the endothelium by interacting with MHC antigen
h- an increased expression of endothelial transcripts causing endothelial injury.
Yes,
C4d positivity is the most specific indicator for presence of DSA and its interaction with endothelial cells in the graft.
C4d deposition is strongly correlated with circulating DSA and is considered a surrogate marker for DSA
Banff 2017 classification considered C4d staining as potential alternative for DSA in diagnosing antibody mediated rejection.
However, there are cases with positive C4d staining but DSA are not detected due to presence of non-HLA antibodies or immunoadsorption of DSA by the graft (DSA are below level of detection), ABO blood group incompatible transplant and accommodation.
Other conditions where C4d is negative in presence of DSA include antibodies unable to fix complement, complement independent pathways of endothelial activation or if C4d is below level of detection.
Etta PK. C4d staining and antibody-mediated rejection in renal transplantation: Current status. Indian Journal of Transplantation. 2020 Jul 1;14(3):197.
Khairwa A. The relevance of complement C4d staining in renal allograft biopsies. Indian Journal of Transplantation. 2020 Apr 1;14(2):94.
Haas M, Loupy A, Lefaucheur C, Roufosse C, Glotz D, Seron D, et al. The Banff 2017 kidney meeting report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018;18:293-307.
Cohen D, Colvin RB, Daha MR, Drachenberg CB, Haas M, Nickeleit V, et al. Pros and cons for C4d as a biomarker. Kidney Int 2012;81:628-39
well done though your answer could be more organised to reach a clear conclusion:
1.when is C4d + against DSA -.
2.when is C4d – against DSA+
3.Corrolation of sensitivity and specificity of a +C4d in prediction of DSAs according to BANFF 2017,19
The above in ABMR offcourse.
Yes, C4d can predict the presence of DSA .
We need to be aware of the limitations of C4d and causes false positive C4d staining.
As discussed earlier, some patients may have non-complement fixing DSA.
In addition, there causes of false positive C4d staining, for example;
C4d may be another source other than DSA, like autoimmune disease.
There may be adsorption of the DSA into the graft and none in circulation.
The DSA level may be low for detection by current methods.
In a study by Peng et al 2013, found that there was a strong correlation between DSA MFI > 6000 and C4d positivity in paediatric heart transplant patients. At this MFI level they found a negative predictive value of 0.95 and a positive predictive value of 0.71.
-Antibody-mediated rejection (AMR) is classified into hyperacute, subacute, and chronic AMR .
Diagnosis of acute AMR requires :
a) histopathological evidence of either acute tubular injury or capillaritis with neutrophil or mononuclear cell infiltrate, capillary thrombosis
b) serologic evidence of circulating DSA.
c) diffuse C4d positivity in peritubular capillaries (PTC) .
– Diffuse PTC C4d+ staining by IF on frozen sections, defined as >50% of peritubular capillaries staining positive, is highly associated with serum donor specific anti-HLA antibodies (DSA) and is reported to have 95% sensitivity and 96% specificity for circulating DSA .
-Diffuse PTC C4d+ correlates strongly with graft dysfunction and with chronic antibody-mediated rejection, reportedly detected in about 50% of cases with transplant glomerulopathy.
– Focal C4d+ defined as <50% of PTC staining positive, remains poorly understood. Most published studies either exclude biopsies with focal C4d+ or group these with diffusely positive C4d+ biopsies.
-A strong relation between diffuse C4d staining of PTCs and the presence of DSAs
References:
– Mauiyyedi S, Crespo M, Collins AB, et al. Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology and pathologic classification. J Am Soc Nephrol. 2002;13:779–787. [PubMed] [Google Scholar]
– Rotman S, Collins AB, Colvin RB. C4d detection in allografts: current concepts and interpretation. Transplant Rev. 2005;19:65–77. [Google Scholar]
– Crespo M, Pascual M, Tolkoff-Rubin N, et al. Acute humoral rejection in renal allograft recipients: I. Incidence, serology and clinical characteristics. Transplantation. 2001;15(71):652–658. [PubMed] [Google Scholar]
-Haas M, Rahman MH, Racusen LC, et al. C4d and C3d staining in biopsies of ABO-and HLA-incompatible renal allografts: correlation with histologic findings. Am J. Transplant. 2006;6:1829–1840. [PubMed] [Google Scholar]
The Banff 2017 working schema accepted C4d positivity as a surrogate for DSA in biopsies with MVI.
The multicenter DeKAF (Deterioration of Kidney Allograft Function) study, concluded even in the absence of detectable DSA,C4d positivity was a determinant of outcome in late graft dysfunction.
Senev et al’s study demonstrated that the positive predictive value of C4d staining for the presence of DSA (MFI > 500) in the context of ABMRh is 50%.
Earlier studies indicating a high specificity of C4d for DSA were conducted in nonselected biopsies and without the use of sensitive Luminex assays and single antigen bead testing.
As with all single center investigations that include histological assessment of MVI, C4d staining, and DSA testing, there are limitations to any definite conclusions that can be drawn, due to interobserver and interlaboratory variability.
Reference
Randhawa P., RoufosseC. The expanding spectrum of antibody‐mediated rejection: Should we include cases where no anti‐HLA donor‐specific antibody is detected?Am J Transplant. 2019;19:622–624
Thanks, Dr Doaa
What about the relation between C4d and DSA?
■Can C4d staining predict the presence of DSA? the answer is yes, but not in all cases
▪︎NOTES:
__________________
▪︎ The central diagnostic criterion for humoral rejection/ABMR is the demonstration of C4d in peritubular capillaries (PTCs) and vasa recta.
▪︎C4d deposition in PTC is the most specific indicator of the presence of circulating DSA and its interaction with endothelial cells in the graft.
▪︎There is a strong correlation between the presence of C4d deposition and circulating anti-donor HLA antibodies.
But,
▪︎C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. Some patients have morphologic evidence of ABMR and a positive DSA with little or no C4d staining.
The prevalence of C4d-negative chronic ABMR ranges from 30% to 60%, as observed in patients who have other evidences of ABMR such as DSA with capillaritis or TG or increased levels of endothelial gene transcripts.
___________
Ref
Praveen K.et al “C4d staining and antibody-mediated rejection in renal transplantation: Current status” Volume:14 Issue: Page:197-201
Thanks
C4d is the footprint of ABMR and in 2017 Banff classification considered as an alternative to DSA,hence staining of c4d predict the presence of DSA in more than 85%,but not always.
Sometime c4d staining is associated with negative DSA due to-
1.Adsorption of Ab in graft leading to
undetectable level.
2.presence of non HLA ab.
Can C4d staining predict the presence of DSA?
Substantiate your answer
My answer in No. The C4d is a potential marker for ABMR but its sensitivity is quite less. There is obvious co relation with of C4d and DSA but it’s not predictor of presence of DSA. There is obvious involvement of compliment system activation in ABMR and C4d is marker of compliment system involvement in ABMR. C4d positive ABMR has worse outcome as compared to C4d negative ABMR. C4d positivity can be seen in Acute AMR , Chronic AMR, ABO incompatibility and accommodation.
In one study by Rasa et al 368 biopsies from 301 patients with graft dysfunction and proteinuria over 5 years, DSA at the time of biopsy was present in 79% of diffuse C4d positive cases. Allograft survival at 40 moths was lower in C4d positive group as compared to C4d negative group – P=0.014.
Reference.
Rasa l Kedainis- Focal C4d + in Renal Allograft is Associated with the Presence of Donor Specific Antibodies and Decreased Allograft Survival. Am J Transplant. 2009 Apr; 9(4): 812–819.
Thanks
All first-year posttransplant biopsy results from January 2004 through June 2014 were reviewed and correlated with the presence of donor-specific antibodies (DSA). C4d-negative AMR patients were not different from C4d-positive AMR patients on any baseline characteristics, including immunologic risk factors (panel reactive antibody, prior transplant, HLA mismatch, donor type, DSA class, and anti-HLA/ABO-incompatibility). C4d-positive AMR patients were significantly more likely to have a clinical presentation.
PTC has characteristic histological alterations, as well as DSA and C4d deposits. As C4d is the end product of typical complement pathway activation following the binding of alloantibodies to graft tissue, it is estimated that up to 90% of C4d positive cases are related to circulating DSA. As a result, the Banff group recommends regular staining for C4d in all graft biopsies. Nonetheless – It is possible to have DSA in the presence of C4d deposits.
1- Collins AB, Schneeberger EE, Pascual MA, et al. Complement activation in acute humoral renal allograft rejection: diagnostic significance of C4d deposits in peritubular capillaries.
2-Am J Transplant. 2016 Jan;16(1):213-20. doi: 10.1111/ajt.13434. Epub 2015 Aug 28.
Yes
it is estimated that up to 90% of C4d positive cases are related to circulating DSA
Both C4d positive and negative staining can be associated with the presence of DSAs.
C4d is a split product of C4 involved in the classical complement pathway. C4b is converted to C4d, and it is a marker of complement activation.
C4d staining can be present in the absence of AMR or CMR and most commonly is seen in ABO-incompatible recipients.
C4d staining is not obviously associated with short- or long-term deleterious effect of graft survival.
Although the presence of linear staining for the C4d in the endothelium is highly suggestive of AMR, some patients with morphologic evidence of ABMR and positive DSA may have little or no C4d staining. Patients with C4d-negative AMR often have DSA and chronic microvascular inflammation that leads to chronic microvascular remodeling. There is a difference in C4d staining depending on the type of transplant, timing of biopsy and techniques used. C4d negative AMR also may be seen in the antibody mediated injury in the absence of activation of complement. T cells are the predominant infiltrating cell in the glomerulus in acute rejection associated with negative C4d staining, while the monocyte may be the predominant type of infiltrating glomerular cell associated with C4d-positive acute rejection.
One study reported that C4d was found to be 95 percent sensitive and 96 percent specific for the presence of DSA. In the presence of high ENDATs (correlated with ABMR) and positive DSA, C4d negative staining was reported in 60% of cases of late ABMR. The AMR are left untreated is associated with a high rate of progression to transplant glomerulopathy. In patients with circulating DSA, graft function and survival are inferior in those with C4d-positive versus -negative staining, suggesting that C4d is a marker of more significant humoral injury. C4d positive AMR is more likely to have a clinical presentation and presents substantially earlier post transplantation.
Haas M. C4d-negative antibody-mediated rejection in renal allografts: evidence for itsexistence and effect on graft survival. Clin Nephrol 2011; 75:271.
Presentation and Outcomes of C4d-Negative Antibody-Mediated Rejection After Kidney TransplantationB J Orandi 1, N Alachkar 2, E S Kraus 2, F Naqvi 2, B E Lonze 1, L Lees 3, K J Van Arendonk 1, C Wickliffe 1, S M Bagnasco 4, A A Zachary 2, D L Segev 1, R A Montgomery 1
Thanks, Esmat
I like your study “One study reported that C4d was found to be 95 per cent sensitive and 96 per cent specific for the presence of DSA. In the presence of high ENDATs (correlated with ABMR) and positive DSA, C4d negative staining was reported in 60% of cases of late ABMR. If AMR left untreated is associated with a high rate of progression to transplant glomerulopathy. In patients with circulating DSA, graft function and survival are inferior in those with C4d-positive versus -negative staining, suggesting that C4d is a marker of more significant humoral injury. C4d positive AMR is more likely to have a clinical presentation and presents substantially earlier post-transplantation.
Immunoglobulin can be divided into 4 subgroups( IgG1-4) with different affinity to complement activation ( IgG3>IgG1>IgG2>IgG4). In most cases of ABMR it result of complement activation leading to graft dysfunction.
If ABMR caused by complement-fixing DSA which bind to donor antigens, the complement will be activated through classical pathway with subsequent C4d deposition in endothelial cells of graft.
Non complement-fixing DSA usually associated with subclinical & chronic ABMR (C4d negative ABMR).
C4d positive staining is highly specific for DSA positivity in serum & its interaction with endothelial cells. So there is a strong correlation between C4d positive staining & circulating DSA.
Reference:
Etta P. C4d Staining and Antibody-mediated Rejection in Renal Transplantation: Current Status.Indian Journal of Transplantation. 2020,14(3):197-201.
Thanks Ban
Answer is No in which C4d staining are positive butDSA cannot be detected may result from DSA being below the level of detection due to immunoadsorption by the graft or it can also be due to the presence of non-HLA antibodies (directed against non-MHC endothelial target .
There is a strong correlation between the presence of C4d deposition and circulating DSA. Banff group has considered that C4d staining is indispensable and advised to stain all renal allograft biopsies for C4d. IF in frozen sections remains the technique of choice, with triple-layer IF probably the most sensitive. C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. The 2013 Banff conference has accepted the entity of C4d-negative ABMR. The 2017 Banff conference has recognized C4d and molecular classifiers as surrogate markers for DSA.
References
1.
Etta PK. Comprehensive management of the renal Transplant recipient. Indian J Transplant 2019;13:240-51. Back to cited text no. 1
[Full text]
2.
DeVos JM, Gaber AO, Knight RJ, Land GA, Suki WN, Gaber LW, et al. Donor-specific HLA-DQ antibodies may contribute to poor graft outcome after renal transplantation. Kidney Int 2012;82:598-604. Back to cited text no. 2
3.
Kramer CS, Israeli M, Mulder A, Doxiadis II, Haasnoot GW, Heidt S, et al. The long and winding road towards epitope matching in clinical transplantation. Transpl Int 2019;32:16-24.
Thanks
C4d is specific but not sensitive marker of ABMR.
The sensitivity and specificity of C4d for predict the presence of DSA have been investigated,In a study of 81 patients with acute rejection.30 % had detectable C4d. was found to be 95% sensitive and 96% specific for the presence of DSA
The complement activation contributes to allograft damage in most cases ABMR. complement-fixing DSA(IgG1 OR IgG3) are present and bind to donor cell antigens.the complement cascade will be activated via the classical pathway resulting in ABMR with complement c4d deposition.
recent evidence showed that complement- binding IgG3 subclass of DSA was more pathogenic and was associated with active ABMR and.increased microcirculation injury,and C4d deposition
IF in frozen section s remains the technique of choice .to detect C4d deposition
conclusion
There is a strong correlation between the presence of C4d deposition and circulating DSA .unless C4d false positive
Reference:
1) Renal allograft rejection with normal renal function in simultaneous kidney/pancreas recipients: does dissynchronous rejection really exist?
Shapiro R, Jordan ML, Scantlebury VP, Vivas CA, Jain A, McCauley J, Egidi MF, Randhawa P, Chakrabarti P, Corry RJ
Transplantation. 2000;69(3):440.
2)Subclinical rejection and borderline changes in early protocol biopsy specimens after renal transplantation.
Roberts IS, Reddy S, Russell C, Davies DR, Friend PJ, Handa AI, Morris PJ
Transplantation. 2004;77(8):1194.
3) The significance of subclinical rejection and the value of protocol biopsies.
Nankivell BJ, Chapman JR
Am J Transplant. 2006;6(9):2006.
4) Untreated rejection in 6-month protocol biopsies is not associated with fibrosis in serial biopsies or with loss of graft function.
Scholten EM, Rowshani AT, Cremers S, Bemelman FJ, Eikmans M, van Kan E, Mallat MJ, Florquin S, Surachno J, ten Berge IJ, Bajema IM, de Fijter JW
J Am Soc Nephrol. 2006;17(9):2622. Epub 2006 Aug 9.
Thanks
The accommodation is defined as C4d deposition in PTCs in the absence of active rejection with or without DSA positivity, mostly seen in ABO‐incompatible graft transplantation.
The circulating DSA are most specifically associated with C4d deposition in PTC and its interactivity with endothelial cells in the graft.
Currently, C4d has become an essential investigation for AMR according to Banff update 2017.
both C4d and validated transcripts/classifiers/molecular marker can serve as potential alternatives and complements to DSAs in the diagnosis of ABMR.
There is entity of AMR DSA negative AMR, which characterized negative DSA/lack of DSA detection, moderate MVI with (g + ptc) scores of ≥2) as per Banff 2013 with or without C4d positivity.
C4d appears to be a less sensitive marker than initially thought.
The C4d as a biomarker lack of utility as a marker for antibody‐mediated injury in biopsies of ABO‐incompatible allografts
However, in which cases C4d not helpful in diagnosis whereas molecular studies have furnished perceptiveness evocative of a complement‐independent form of AMR or C4d‐negative AMR.
Despite all pitfalls C4d is excellent marker for AMR
Reference:
The Relevance of Complement C4d Staining in Renal Allograft Biopsies
Anju Khairwa*
Department of Pathology, ESIC Model Hospital, Gurugram, Haryana, India
Thanks
.
Following conditions are showing C4d positivity,
A- Acute AMR
B- Chronic antibody mediated rejection
C- A, B, O blood group ABO incompatible grafts
d. Accommodation.
The following conditions are showing C4d negativity,
a. T cellmediated rejection (TCMR)
b. A technical error like a type of fixatives, immunofluorescence (IF) versus immunohistochemistry (IHC)
c. Fc receptor (FCR) on NK cells (FcRIIA) mediated rejection
d. Antibodies unable to fix the complement
e. Complement independent pathways of endothelial activation
f. C4d deposition is a very low in quantity for the identification limits of IF/IHC
g. Alloantibodies can direct endothelium injury to interact with major histocompatibility complex (MHC)
h. Increased expression of endothelial transcripts causing
endothelium injury.
References, please.
· C4d negative AMR in spite of +ve DSA may be due to(1) :
1. Technical errors
2. Different method of c4d detection (IF vs IHC).
3. Very low amount of c4d (difficult detection).
4. Poor complement fixation by DSA
5. Complement independent pathway AMR or antibody dependent cell mediated cytotoxicity.
6. Antibodies against Angiotensin II type 1 receptors
7. fc receptors of Nk may have a role c4d negative AMR.
8. Increased expression of endothelial transcripts causing endothelium injury.
References:
Thanks
Can C4d staining predict the presence of DSA
diagnosis of AMR requires presence of
1- Characterstic histological changes , DSA and C4d deposits in PTC . It is estimated that Upto 90 % of C4d + cases are associated with circulating DSA as C4d is the end product of classic complement pathway activation after binding of alloantibodies to graft tissue, thus the Bannuf group recommend routine staing for C4d in all graft biopsies . However –ve DSA in presence of C4d deposits may occur, as in
-very low level of circulating DSA due to graft adsorption , that can’t be detected
– Presence of non HLA DSA .
Also DSA may present and and cause AMR without associated C4d deposit , known as c4d negative AMR via complement independent pathway
Thanks Fatima
# Can C4d staining predict the presence of DSA?
The central diagnostic criterion for humoral rejection is the demonstration of C4d in PTC and vasa recta. There is a strong correlation between the presence of C4d deposition and circulating DSA. Banff group has considered that C4d staining is indispensable and advised to stain all renal allograft biopsies for C4d. IF in frozen sections remains the technique of choice, with triple-layer IF probably the most sensitive. C4d has a relatively low sensitivity as a marker for ABMR in late renal allograft biopsies. The 2013 Banff conference has accepted the entity of C4d-negative ABMR.
*** The 2017 Banff conference has recognized C4d and molecular classifiers as surrogate markers for DSA.
DeVos JM, Gaber AO, Knight RJ, Land GA, Suki WN, Gaber LW, et al. Donor-specific HLA-DQ antibodies may contribute to poor graft outcome after renal transplantation. Kidney Int 2012;82:598-604. Back to cited text no. 23.
Kramer CS, Israeli M, Mulder A, Doxiadis II, eHaasnoot GW, Heidt S, et al. The long and winding road towards epitope matching in clinical transplantation. Transpl Int 2019;32:16-24. Back to cited text no. 3
Thanks Elaf