Ultrastructural changes in pulmonary allografts with antibody-mediated rejection

Mariam P. Alexander, Andrew Bentall, Patrice C.Abell Aleff, Manish J. Gandhi, John P. Scott, Anja C. Roden

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


BACKGROUND: Antibody-mediated rejection (AMR) is an important cause of lung allograft loss in some patients. Challenges with current diagnostic criteria limit timely detection. Ultrastructural studies of endothelia allow the early detection of AMR in kidney allografts. This study aimed to define the ultrastructural changes of the endothelium in lung allografts in the setting of AMR and determine its specificity for AMR. METHODS: Ultrastuctural studies were performed on lung allograft biopsies of 12 patients using glutaraldehyde-fixed or paraffin-embedded material. AMR had been classified according to the International Society of Heart and Lung Transplant 2016 consensus report criteria. Endothelial changes (swelling [ES], vacuolization [EV], surface irregularity, detachment, neutrophil margination [NM]) and basement membrane changes were graded semi quantitatively using electron microscopy (EM). Grades were compared between AMR, acute cellular rejection, and non-transplant controls. RESULTS: Significant differences were found between AMR and acute cellular reaction biopsies, particularly in ES (p = 0.006), EV (p = 0.023) and NM (p = 0.038). Using a combined score of all categories of assessment, the total EM score was significantly higher in AMR (p = 0.007) and provided excellent sensitivity and specificity with a receiver operator characteristic curve of 1.0. C4d did not correlate with EM changes associated with AMR. The use of paraffin-embedded material samples did not significantly affect the analysis compared with glutaraldehyde-fixed tissue, although ES was reduced in the former. CONCLUSIONS: Endothelial structural analysis using EM can facilitate improved diagnostic accuracy of AMR and needs to be validated in larger cohorts, but it also allows retrospective studies to be performed.

Original languageEnglish (US)
Pages (from-to)165-175
Number of pages11
JournalJournal of Heart and Lung Transplantation
Issue number2
StatePublished - Feb 2020


  • antibody-mediated rejection
  • donor-specific antibodies
  • endothelium
  • lung allograft
  • ultrastructural features

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine
  • Transplantation


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