Naohiko Fukami

Antibodies to MHC class I induce autoimmunity: role in the pathogenesis of chronic rejection.

Alloimmunity to mismatched donor HLA-Ags and autoimmunity to self-Ags have been hypothesized to play an important role in immunopathogenesis of chronic rejection of transplanted organs. However, it is not known what role, if any, alloimmune response plays in inducing autoimmunity. To test whether Ab-developed posttransplantation to mismatched donor MHC induces autoimmunity and chronic rejection, we developed a murine model wherein anti-MHC class I Abs or control (C1.18.4/anti-keratin) were administered intrabronchially into native lungs. Animals receiving anti-MHC class I, but not control Abs, developed marked cellular infiltration around vessels and bronchiole of lung by day 15, followed by epithelial hyperplasia, fibrosis, and occlusion of the distal airways similar to chronic rejection following human lung transplantation. Lungs of mice receiving anti-MHC class I showed increased expression of chemokines, their receptors, and growth factors, and induced IL-17 as well as de novo Abs to self-Ags, K-α1 tubulin, and collagen V. IL-17 neutralization by anti-IL-17 resulted in reduction of autoantibody and lesions induced by anti-MHC class I Abs. Thus, our results indicate that Abs to donor MHC can induce autoimmunity, mediated by IL-17, which plays a pivotal role in chronic rejection postlung transplantation. Therefore, approaches to prevent autoimmunity should be considered for the treatment of chronic rejection postlung transplantation.

Synergistic effect of antibodies to human leukocyte antigens and defensins in pathogenesis of bronchiolitis obliterans syndrome after human lung transplantation.

BACKGROUND This study aims to determine the role of antibodies to donor-mismatched human leukocyte antigen (HLA) developed during the post-transplant period in inducing defensins and their synergistic role in the pathogenesis of chronic rejection, bronchiolitis obliterans syndrome (BOS), after human lung transplantation (LTx). METHODS Bronchoalveolar lavage (BAL) and serum from 21 BOS+ LTx patients were assayed for β-defensins human neutrophil peptides (HNP) 1-3 (enzyme-linked immunosorbent assay [ELISA]) and anti-HLA antibodies (Luminex, Luminex Corp, Austin, TX). Human airway epithelial cells (AEC) were treated with anti-HLA antibodies, HNP-1/2, or both, and the levels of β-defensin were measured by ELISA. Using a mouse model of obliterative airway disease induced by anti-major histocompatibility (MHC) class-I antibodies, we quantitatively and qualitatively determined neutrophil infiltration by myeloperoxidase (MPO) staining and activity by MPO assay, and defensin levels in the BAL. RESULTS In human LTx patients, higher defensin levels correlated with presence of circulating anti-HLA antibodies (p < 0.05). AEC treated with anti-HLA antibodies or HNP-1/2, produced β-defensin with synergistic effects in combination (612 ± 06 vs 520 ± 23 pg/ml anti-HLA antibody, or 590 ± 10 pg/ml for HNP treatment; p < 0.05). Neutrophil numbers (6-fold) and activity (5.5-fold) were higher in the lungs of mice treated with anti-MHC antibodies vs control. A 2-fold increase in α-defensin and β-defensin levels was also present in BAL on Day 5 after anti-MHC administrations. CONCLUSIONS Anti-HLA antibodies developed during the post-transplant period and α-defensins stimulated β-defensin production by epithelial cells, leading to increased cellular infiltration and inflammation. Chronic stimulation of epithelium by antibodies to MHC and resulting increased levels of defensins induce growth factor production and epithelial proliferation contributing to the development of chronic rejection after LTx.

An Obligatory Role for Lung Infiltrating B Cells in the Immunopathogenesis of Obliterative Airway Disease Induced by Antibodies to MHC Class I Molecules

Using a murine model, we demonstrated that endobronchial administration of antibodies (Abs) to major histocompatibility complex (MHC) class I results in cellular infiltration, epithelial metaplasia, fibrosis and obstruction of the small airways (obliterative airway disease [OAD]) mediated predominantly by Th17 responses to self‐antigens. This resembles bronchiolitis obliterans syndrome developed following human lung transplantation. Since B cells play a crucial role in induction of autoimmune responses, we defined the role of B cells and its antigen presenting properties in induction of OAD in this study. Anti‐MHC class I was administered endobronchially in B−/− and wild‐type mice. In contrast to wild type, B−/− animals did not demonstrate cellular infiltration, epithelial metaplasia and obstruction of airways following anti‐MHC. Frequency of K‐α1 tubulin and CollagenV‐specific IL‐17 cells was significantly decreased in B−/− mice. As expected, Abs against self‐antigens and germinal center formation were not developed in B−/− mice. Thus, we conclude that B cells and its antigen presenting capacity play an important role in induction of immune responses to self‐antigens and immunopathogenesis of OAD following the administration of anti‐MHC. Therefore, strategies to block B‐cell and its antigen presenting functions should be considered for preventing the development of chronic rejection.

Mechanism of accommodation in a sensitized human leukocyte antigen transgenic murine cardiac transplant model

Background. Presence of donor-specific antibodies (Abs) is detrimental to posttransplant allograft function. Some sensitized recipients have successfully undergone transplantation after pretransplant conditioning regimen using plasmapheresis and/or intravenous immunoglobulin therapy, but underlying mechanisms that confer such allograft protection are undefined. Methods. We developed a single human leukocyte antigen (HLA)-mismatched heterotopic murine heart transplant model (HLA-A2 into HLA-A2-sensitized-C57BL/6) to determine whether pretreatment of donors with low concentration of HLA class I (W6/32) or control Ab (C1.18.4) will confer protection. Expression levels of survival genes, Bcl-2 and heme oxygenase-1, were analyzed by gene array analysis and quantitative real-time polymerase chain reaction. Expression levels of cytokine panel were analyzed by Luminex. Role of Bcl-2 in the induction of allograft protection was analyzed by silencing the Bcl-2 expression in the donor hearts using a small hairpin (shRNA) specific for Bcl-2. Results. Control Ab-pretreated hearts were rejected in less than 5 days demonstrating hemorrhage, Ab, and C4 deposition. In contrast, W6/32-pretreated hearts were rejected at 15 days (P<0.05) that was prolonged to 25 days with antilymphocyte serum treatment. W6/32-pretreated hearts on day 5 exhibited increased expression of Bcl-2 (5.5-folds), Bcl-xl (5.5-folds), and heme oxygenase-1 (4.4-folds); decreased expression of ICAM-1, VCAM-1 (3.2-fold), along with reduced levels of cytokines interleukin (IL)-1&bgr; (4.4-folds), tumor necrosis factor &agr; (3.7-folds), IL-6 (7.5-folds), IL-12 (2.3-folds) and chemokines monocyte chemotactic protein 1 (4.5-folds), MIG (4.4-folds), MIP-1&agr; (3.4-folds), and IL-8 (3.1-folds). Silencing of Bcl-2 in accommodated hearts before transplant resulted in loss of protection with rejection (9±3 vs. 15±2days, P<0.05). Conclusion. Pretreatment of hearts with low levels of anti-HLA Abs increases expression of antiapoptotic genes that inhibits caspases, leading to decreased inflammatory cytokines and chemokines, which promote allograft survival.

LMP-420, a small molecular inhibitor of TNF-α, prolongs islet allograft survival by induction of suppressor of cytokine signaling-1: synergistic effect with cyclosporin-A.

Inflammatory insults following islet transplantation (ITx) hinders engraftment and long-term function of the transplanted (Tx) islets. Using a murine model of ITx, we determined the role of LMP-420, a novel TNF-α inhibitor, both individually and in combination with the immunosuppressant cyclosporine A (CSA) in islet engraftment and survival. Diabetic C57BL/6 mice were Tx with 500 BALB/c islets under the kidney capsule. Four cohorts were used: LMP-420 only, CSA only, combination of LMP-420 and CSA (LMP+CSA), and control (n = 12 per cohort). Serial monitoring of blood glucose levels revealed that LMP+CSA (35 ± 5 days) prolonged stable blood insulin levels compared to control (6 ± 4 days). Immunohistology demonstrated that coadministration (LMP+CSA) results in a significant decrease in CD8+ T-cell infiltration (LMP+CSA: 31 ± 18 vs. control: 224 ± 51 cells, p < 0.001). Serum cytokine analysis revealed that LMP-420 administration resulted in an increase in the anti-inflammatory cytokine IL-10 (2.5-fold), and a decrease in TNF-α (threefold) with no change in IL-2. However, coadministration resulted in a marked decrease in both IL-2 and TNF-α (threefold) along with increase in IL-10 (threefold). Coadministration also demonstrated increase of antiapoptotic SOCS-1 and Mn-SOD expression and significant reduction of donor-specific antibodies (p < 0.005). In conclusion, LMP-420 administration with CSA results in the upregulation of anti-inflammatory and antiapoptotic mechanisms which facilitate islet allograft engraftment and survival.

Mizoribine—An inosine monophosphate dehydrogenase inhibitor—acts synergistically with cyclosporine A in prolonging survival of murine islet cell and heart transplants across major histocompatibility barrier☆ , ☆☆

INTRODUCTION Mizoribine (MZR) is an inosine monophosphate dehydrogenase inhibitor. It has been widely used in Japan in the treatment of autoimmune diseases and is known to inhibit T and B cell proliferation. The aim of this study was to evaluate the efficacy of MZR as an immunosuppressive agent and determine its ability to synergize with a commonly used calcineurin inhibitor Cyclosporine A (CsA) in prolonging survival of murine islet cells and heart transplanted across major histocompatibility barrier. METHODS Murine allogeneic islet cell transplantation between Balb/c donor mice and C57BL/6 recipient mice and heterotopic heart transplantation was done between C3H/He donor mice and Balb/c recipient mice. Recipients were divided into groups based on immunosuppression: Group 1-No immunosuppression, Group 2-MZR alone (20 mg/kg/day), Group 3-CsA alone (20 mg/kg/day), Group 4-MZR+CsA (20 mg/kg/day). Donor specific IFN-γ, IL-10, IL-2, IL-4 secreting cells were enumerated by ELISpot. Serum cytokine and chemokine concentration was measured by Luminex. RESULTS Islet cell allograft recipients treated with CsA and MZR had prolonged islet function compared to other groups [normoglycemia (blood glucose <200 mg/dL) up to 32±4 days, p<0.05]. Similarly, heart allograft survival was significantly improved in mice treated with CsA and MZR compared to other groups (50% 30-day survival, p=0.04). Donor specific IFN-γ, IL-4, IL-2 secreting cells were significantly decreased in recipients treated with CsA and MZR with marked increase in IL-10 secreting cells (p<0.05). There was also an increase in serum IL-10 with decrease in IFN-γ, IL-4, IL-2, MCP-1, and IL-6 in mice treated with CsA and MZR CONCLUSION: MZR and CsA when used in combination are potent immunosuppressive agents in murine islet cell and heart transplantation models. These agents lead to a decrease in donor specific IFN-γ with increase in IL-10 secreting cells leading to improved allograft survival and function.

Increased Serum Sodium Values in a Brain-Dead Donor Do Not Influence the Long-Term Kidney Function

Kidney transplantation is often performed with brain-dead donors with associated endocrine disorders. Diabetes insipidus, the most common complication, results in hypernatremia, hypovolemia, and increased plasma osmolality. Hypernatremia in donors is one of the strongest risk factors for the loss of a transplanted liver or heart because of cell swelling and a resultant increased severity of reperfusion-mediated injury. However, the influence of donor hypernatremia on the early and late kidney graft function has not yet been conclusively established. In this study, the post-transplant outcomes of renal allografts recovered from brain-dead donors with hypernatremia were compared to those of donors without hypernatremia. Methods We analyzed data for 765 kidney recipients from 386 brain-dead donors from 1999–2016 using the Japan Organ Transplant Network (JOT) database. Donors were divided into 2 groups based on sodium concentrations of <150 or ≥150 mmol/L and <160 or ≥160 mmol/L. The differences in the graft survival among the groups were examined with the Kaplan-Meier method and compared using a log-rank test. Results The mean donor age was 44.5±15.1 years, and the mean recipient age was 47.3±13.5 years. The median total ischemic time was 546 minutes (range 169–1365). The median final serum creatinine level measured in donors before procurement was 0.79 mg/dl (range 0.10-10.37). The cause of death of the donor was cerebrovascular disease in 51.1% and head trauma in 19.7%. We compared the long-term graft survivals among the sodium concentration groups. The 1-, 2-, 3- and 5-year graft survivals in the <150 mmol/L sodium group (233 grafts) were 96.6%, 96.1%, 93.3% and 90.8%, respectively. The 1-, 2-, 3- and 5-year graft survivals in the ≥150 mmol/L sodium group (532 grafts) were 98.1%, 97.2%, 96.6% and 96.6%, respectively. There were no significant differences between these 2 groups (p=0.098). The 1-, 2-, 3- and 5-year graft survivals in the <160 mmol/L sodium group (477 grafts) were 97.7%, 96.6%, 96.6% and 95.1%, respectively. The 1-, 2-, 3- and 5-year graft survivals in the ≥160 mmol/L sodium group (288 grafts) were 97.6%, 97.6%, 96.8% and 96.4%, respectively. There were no significant differences between these 2 groups (p=0.429). Conclusion An excellent graft function and long-term graft survival were observed after kidney transplantation from brain-dead donors in Japan. High serum sodium concentrations and increased plasma osmolality in brain-dead kidney donors may suggest an adverse effect on the graft function, probably due to the initiation of inflammation processes. However, our results showed that the serum sodium concentration had no marked influence on the long-term graft survival. Given the severe organ shortage, we should not discard kidney grafts simply because the donor’s serum sodium concentration is high. Figure. No caption available.

Combination Therapy with BCAA Intake and Physical Therapy Improved Leg Strength in Japanese Elderly Kidney Transplant Recipients Diagnosed as Sarcopenia

Introduction and Objectives Sarcopenia has been defined as involuntary loss of skeletal muscle mass, strength and function. Chronic kidney disease is one of risk factors of sarcopenia. Especially in elderly kidney transplantation (KTx) recipients, a long term of chronic renal failure before transplantation and immunosuppression must be risk factors for developing sarcopenia. Methods: In this study, we investigated the state of sarcopenia in Japanese elderly KTx patients and proved the effect of combination therapy with BCAA intake and exercise for recover leg strength. One hundred twenty eight KTx patients were measured body muscle mass using bioimpedance analysis (BIA) device (Inbody430, Takumi, Japan).In 38 KTx recipients(25 male,13 female) over 60 y.o, sarcopenia diagnosis was made according to European Working Group on Sarcopenia in Older People (EWSOG) criteria. Combination therapy with BCAA intake (7500mg/week) and exercise (cycle ergometer and resistance training) was administered to 10 elderly KTx patients diagnosed as sarcopenia. Hip Flexion,Hip Abduction, Knee Extention, Ankle Plantarflexion were measured by HandHeld dynamometer before and 12 weeks after combination therapy. Results In 128 KTx recipients, average of total body muscle volume was 23.05kg, total body fat volume was 13.8kg and %BMI was 19.3kg/m2. Their body weight (54.9kg) and %BMI (21.9kg/m2) were well controled. However, adjustment of muscle mass was +4.1kg and fat was -4.28kg. Twenty six (68.4%) in 38 patients aged over 60y.o was diagnosed as sarcopenia in accordance with EWSOG diagnostic criteria including gait speed, grip strength and muscle mass. After 12 weeks combination physical therapy administration, strength of Hip Flexion,Hip Abduction, Knee Extention, Ankle Plantarflexion were increased significantly(p=0.04,0.02,0.01,0.05). Conclusion In conclusion,Japanese renal transplant recipients was in a state of so-called sarcopenia obesity. In patients over 60 years old, 68% were diagnosed as sarcopenia. Combination therapy with BCAA and physical therapy improved increasing leg strength for 12 weeks. Figure. No caption available.

Long-Term Graft Survival Was Affected By Several Donor’s Factors in Renal Transplants Engrafting DCD Kidneys. - Based On Data From a Single Center Having Recovered Over 500 DCD Renal Grafts.: Abstract# 652

652 Long-Term Graft Survival Was Affected By Several Donor’s Factors in Renal Transplants Engrafting DCD Kidneys. – Based On Data From a Single Center Having Recovered Over 500 DCD Renal Grafts. K. Hoshinaga,1 M. Kusaka,1 H. Takahashi,2 Y. Kubota,1 N. Fukami,1 H. Sasaki,1 T. Kenmochi,3 R. Shiroki.1 1Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 2Division of Medical Statistics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 3Department of Organ Transplant Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan. The kidneys procured from deceased donors in donation after cardiac death (DCD) hold great potential to expand the donor pool. In this study, the posttransplant outcome of renal allografts recovered from DCD donors is investigated and the risk factors affecting the renal prognoses were analyzed. From 1979, 537 kidneys were retrieved from 271 DCD donors at our center, using in situ regional cooling technique.443 grafts transplanted since 1983 through 2011 were enrolled. The age of the donors and recipients ranged from 0.7 to 75 (mean; 47.6) and from 7 to 72 (mean; 41.7). The warm ischemic time ranged from 1 to 71 minutes (mean; 11.7). The serum creatinine level before cardiac arrest ranged from 0.4 to 5.4 mg/dl (mean; 1.49). Following renal transplants, primary non function (PNF) was noted in 27 (6.5%), immediate function (IF) was 58 (13.1%), and DGF was 358 (80.9%). The 1, 3, 5, and 10 year graft survival rates were 86.1%, 75.6%, 68.5%, and 52.8%, respectively. Upon Cox multivariate analysis, age ≥ 50 years, hypertension, highest sCr ≥ 1.5 mg/dl and WIT ≥ 30 min were identifi ed as independent predictors for long-term graft failure. Univariate Multivariate HR (95%CI) P value HR (95%CI) P value Male 1.10 (0.85-1.42) 0.46 Age ≥ 50 years 1.78 (1.36-2.33) <0.0001 2.00 (1.45-2.74) <0.0001 Hypertension 1.71 (1.32-2.21) <0.0001 1.62 (1.18-2.22) 0.0028 Cerebrovascular death 1.36 (1.03-1.79) 0.031 1.02 (0.72-1.44 0.91 sCr ≥ 1.5 mg/dl (Highest) 1.55 (1.14-2.13) 0.0059 1.40 (1.00-1.96) 0.047 sCr ≥ 1.0 mg/dl (admission) 1.33 (1.02-1.73) 0.034 1.26 (0.94-1.68) 0.12 WIT ≥ 30 min 1.68 (1.16-2.44) 0.0060 1.69 (1.07-2.67) 0.023 TIT ≥ 24 hr 0.87 (0.57-1.32) 0.51 In contrast, for short-term graft failure (PNF), only WIT ≥ 30min was the independent predictor. Renal grafts recovered from DCDs had good renal function as well as excellent long term graft survival, when in situ regional cooling technique was applied. DCD donors should be the excellent resources of deceased donor kidneys, and they can increase the number of renal transplantation in the era of sever organ shortage. Abstract# 653 Combined Predictive Value of ECD Criteria for Long-Term Graft Survival of Kidneys From Donors After Cardiac Death. M. Kusaka,1 Y. Kubota,1 H. Takahashi,2 N. Fukami,1 H. Sasaki,1 T. Kenmochi,3 R. Shiroki,1 K. Hoshinaga.1 1Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 2Division of Medical Statistics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 3Department of Organ Transplant Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan. Introduction: Kidneys procured from deceased donors after cardiac death (DCD) hold great potential to expand the donor pool. This study investigated the posttransplant outcomes of renal allografts recovered from DCD and identifi ed risk factors affecting the renal prognosis. In addition, the long-term survival of renal grafts from DCD was compared according to the number of ECD risk factors. Methods: Since 1979, 537 kidneys were retrieved from 271 DCD donors using the in situ regional cooling technique. A total of 443 grafts transplanted between 1983 and 2011 were assessed. Results: Among donor’s factors, an age ≥ 50 years, hypertension, highest sCr ≥ 1.5 mg/dl and WIT ≥ 30 minutes were identifi ed as independent predictors of long-term graft failure in a Cox multivariate analysis. Regarding the ECD criteria for marginal donors, cerebrovascular disease, hypertension and highest sCr ≥ 1.5 mg/dl were identifi ed as signifi cant predictors in a Cox univariate analysis after adjustment for WIT ≥ 30 minutes and sCr ≥ 1.0 mg/dl on admission. To assess the combined predictive value of signifi cant ECD risk criteria, the patients were divided into three groups: no ECD risk factors (no risk group), one ECD risk factor (single-risk) and two or more ECD risk factors (multiple-risk). Following adjustment for WIT and sCr, the single-and multiple-risk groups had 2.04and 2.51-fold higher risks of graft failure than the no risk group. 653 Combined Predictive Value of ECD Criteria for Long-Term Graft Survival of Kidneys From Donors After Cardiac Death. M. Kusaka,1 Y. Kubota,1 H. Takahashi,2 N. Fukami,1 H. Sasaki,1 T. Kenmochi,3 R. Shiroki,1 K. Hoshinaga.1 1Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 2Division of Medical Statistics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 3Department of Organ Transplant Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan. Introduction: Kidneys procured from deceased donors after cardiac death (DCD) hold great potential to expand the donor pool. This study investigated the posttransplant outcomes of renal allografts recovered from DCD and identifi ed risk factors affecting the renal prognosis. In addition, the long-term survival of renal grafts from DCD was compared according to the number of ECD risk factors. Methods: Since 1979, 537 kidneys were retrieved from 271 DCD donors using the in situ regional cooling technique. A total of 443 grafts transplanted between 1983 and 2011 were assessed. Results: Among donor’s factors, an age ≥ 50 years, hypertension, highest sCr ≥ 1.5 mg/dl and WIT ≥ 30 minutes were identifi ed as independent predictors of long-term graft failure in a Cox multivariate analysis. Regarding the ECD criteria for marginal donors, cerebrovascular disease, hypertension and highest sCr ≥ 1.5 mg/dl were identifi ed as signifi cant predictors in a Cox univariate analysis after adjustment for WIT ≥ 30 minutes and sCr ≥ 1.0 mg/dl on admission. To assess the combined predictive value of signifi cant ECD risk criteria, the patients were divided into three groups: no ECD risk factors (no risk group), one ECD risk factor (single-risk) and two or more ECD risk factors (multiple-risk). Following adjustment for WIT and sCr, the single-and multiple-risk groups had 2.04and 2.51-fold higher risks of graft failure than the no risk group. Conclusions: Renal grafts recovered from DCD have a good renal function with excellent long-term graft survival. However, an increased number of ECD risk factors affects the incidence of graft failure. Abstract# 654 Determinants of Discard of Kidneys From Expanded Criteria Donors Undergoing Donation After Circulatory Death. S. Singh,1,4 S. Kim.1,2,3,4 1Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada; 2Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, ON, Canada; 3Division of Nephrology and the Renal Transplant Program, St. Michael’s Hospital, Toronto, ON, Canada; 4Institute of Health Policy, Managment and Evaluation, University of Toronto, Toronto, ON, Canada. 654 Determinants of Discard of Kidneys From Expanded Criteria Donors Undergoing Donation After Circulatory Death. S. Singh,1,4 S. Kim.1,2,3,4 1Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada; 2Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, ON, Canada; 3Division of Nephrology and the Renal Transplant Program, St. Michael’s Hospital, Toronto, ON, Canada; 4Institute of Health Policy, Managment and Evaluation, University of Toronto, Toronto, ON, Canada.

2268 SERUM LIVER-TYPE FATTY ACID BINDING PROTEIN DURING THE EARLY POSTOPERATIVE PERIOD PREDICTS THE RECOVERY OF GRAFT FUNCTION AFTER KIDNEY TRANSPLANTATION FROM DONORS AFTER CARDIAC DEATH

immunohistocemical staining of MCP and complement after the diagnosis of ATCMR type I and type II. The expression of MCP was then examined for the functional outcome of the graft and clinicopathological correlations. Graft function was determined by serum creatinine measurements, before biopsy, at the time of biopsy, at 2 and 12 months. Graft failure was defined as the resumption of dialysis. ATCMR was generally treated with glucocorticoids and deoxyspergualin. RESULTS: C3b deposition in renal tubular cells was observed in 60 patients (93.8 %), but no C4d deposition was detected in renal tubular cells. No difference in serum creatinine levels were found between the patients with high and low MCP expression before and at the time of biopsy. After the anti-rejection treatment, patients with high MCP expression had lower creatinine levels compared to those with low MCP expression (1.47 0.40 mg/dL v.s. 1.76 0.79 mg/dL at 2 months after biopsy, 1.50 0.40 mg/dL v.s. 1.85 0.66 mg/dL at 12 months after biopsy, Tab. 2). Graft loss was observed in 6 patients (17.6 %) in the low MCP expression graft and 3 patients (10 %) in the high MCP expression group. 5-year graft survival was better in patients with high MCP expression compared to those with low MCP expression, 100 % versus 76.6 % respectively (p 0.042). The age of the donor in the high MCP expression group was significantly lower than that of the low MCP expression group in both univariate and multivariate analyses (p 0.003, p 0.001, respectively, Tab. 3). CONCLUSIONS: We first showed the possibility that MCP expression in renal tubular cells during ATCMR may influence the outcome of treatment and graft survival. Grafts from older donors may be a risk factor for decreased expression of MCP in renal tubular cells. The clinical application of MCP and complement regulatory drugs is considered to have some potential for suppressing ATCMR after transplantation and to improve graft outcome.