Formally established in 1990, the Division of Hepatic and Transplantation Pathology plays an integral part in the comprehensive transplant program at the University of Pittsburgh Medical Center and its satellite center in Palermo, Italy, and at least five separate multicenter trials sponsored by the Immune Tolerance Network and Clinical Trials in Organ Transplantation (CTOT) in heart, liver, and kidney allograft recipients, and soon to begin corporate projects (TransMedics) extra-corporeal perfusion. The mission of the Division is to provide start-of-the-art laboratory service support emphasizing continued excellence in patient care, to provide expert consultation, to foster an academic environment devoted to education and training, and to conduct translational and basic research in native liver, kidney, and transplantation pathology. A nucleus of professionals with expertise in pathology, immunology and molecular biology is actively involved in many transplantation related research projects at the Thomas E. Starzl Transplantation Institute
The Division offers a wide range of laboratory tests and tissue analyses for patients and experimental studies. Routine histology, specialized immunocytochemistry, multiplex labeling, in situ hybridization procedures, electron microscopy, and high resolution whole slide imaging and image analysis, are performed on native liver and kidney tissues from patients under consideration for transplantation, on native organ resections and on post-transplant biopsies. These procedures assure consistency of analysis and continuity of patient care. Post-transplant monitoring assays deal with detection of activation of cellular and humoral or antibody-mediated arms of the immune system, cytokine production, detection of a wide variety of viruses and other infectious agents, graft-versus-host disease, and immunosuppression-related neoplasia.
The division has established and maintains an active telepathology consultation service and offers a completely digital pathology workflow system for ITN and CTOT studies using specific HIPAA-compliant software that is used to triage and respond to cases and harvest data for studies.
Dr. Adriana Zeevi is the Director of the UPMC-Presbyterian Tissue Typing Laboratory, which offers histocompatibility-testing services to the organ transplantation program at the University of Pittsburgh Medical Center. This laboratory performed donor workups as follows: Bone Marrow (65), Cord Blood (2), T Lymphocyte Infusion (1), Heart (46), Deceased Donor Kidney (178), Living Donor Kidney (82), Kidney/Pancreas (11), Kidney/Liver (4), Pancreas (3), Deceased Donor Liver (106), Living Donor Liver (64), Lung (78) Lung/Bone Marrow (1), Lung/Liver (1), Multivisceral (4), Small Bowel (3). These numbers do not include donors that were evaluated and not transplanted. The laboratory provides services to UPMC Presbyterian, UPMC Hamot, UPMC Children’s Hospital of Pittsburgh, and the VAMC Pittsburgh for FY 2017-18 (7/1/17 – 6/30/18).
The Division offers comprehensive consultation in native and allograft liver, kidney, intestine, composite tissue, and solid organ transplantation pathology to community and university-based physicians. The scope of this service encompasses the evaluation of native and allograft liver, heart, intestinal, composite tissue, and kidney disease in prospective transplantation candidates, donor recipient histocompatibility issues, the examination of native explanted organs, and the evaluation of post-transplant biopsies or resections to evaluate the causes of allograft dysfunction such as infection, ischemia, rejection, technical complications, recurrent disease and post-transplant malignancies. These consultation services are also available through the Internet (http://path.upmc.edu/divisions/transpath/hepa00.html).ismet.
The Division is involved in the following research projects and receives annual funding as follows:
The Division has a strong commitment to research in native and allograft organ immunobiology, neoplasia, and transplantation. Each professional is actively engaged in research projects frequently in collaboration with members of other departments, in particular, Transplant Surgery and the Thomas E. Starzl Transplant Institute. Over the year, faculty of the Division contributed 29 refereed publications, invited reviews and book chapters. Thirty-five invited lectures and scientific meeting presentations were given outside the institution, 16 talks were held abroad. Several members serve on grant review committees and editorial boards of major professional journals. The division also operates a collaborative research histology and imaging laboratory for the Thomas E. Starzl Transplant Institute. We have obtained Clinical Laboratory Improvement Amendments (CLIA) certification and College of American Pathology certification of our Research Histology Services Laboratory.
Current research activities deal with a variety of projects:
1. The division evaluates tissue specimens from operationally tolerant adult and pediatric liver and kidney allograft recipients. Three studies are being conducted under the auspices of the Immune Tolerance Network. A fourth multi-center study will commence this year using ex vivo expanded autologous DCregulatory cells consisting of DCregs infused into the recipient to promote allograft acceptance to minimize the use of immunosuppressive medications. The specimens are from our own patient population and from sites involved in national and international multicenter studies of tolerance induction. Novel techniques are being applied to the evaluation of these specimens such as multiplex quantum dot labeling followed by high resolution whole slide imaging and automated morphometric analysis.
2. Translational studies on molecular and immune checkpoint analysis human cholangiocarcinoma are being conducted in collaboration with the Departments of Surgery (Dr. Wallis Marsh) and Hematology-Oncology) (Dr. Sun). Specifically, targeted exon sequencing is being carried out using the Ion Torrent comprehensive cancer panel and the same specimens are subjected to multiplex protein labeling for genotype-phenotype correlation with outcomes analysis.
3. The division has investigated significant time and monetary resources toward the development of digital pathology including multiplex staining of tissue specimens followed by high resolution whole slide imaging and automated image analysis. Currently, the division has several Mirax Midi scanners fully equipped for a combination of brightfield and multichannel fluorescence imaging, as well as two Zeiss Axiovision systems for 2 and 3 dimensional digital analysis of multiplex-labeled samples. This effort has supported multiple investigators throughout the University of Pittsburgh and we are currently collaborating with several external groups on various studies.
4. Alloantibodies in Liver, Kidney, and Cardiac Transplantation – Intervention, Outcomes and Mechanisms Antibodies directed against allograft antigens are being increasingly recognized as critical determinants of allograft outcomes in adults. Pediatric heart transplant candidates are frequently allosensitized based on prior exposure to blood products and homografts. To overcome the high wait-list mortality, transplantation across a donor-specific cross-match has recently been performed in several pediatric centers, with early encouraging results. This application brings together a group of six leading heart transplant centers and leading transplantation scientists to study the impact of preformed and de novo alloantibodies on pediatric heart transplant outcomes. A major effort during the past two years also resulted in a major publication of the role of allo-antibodies and C4d staining in liver allografts.
5. The Research Histology Laboratory of the Division serves as the Core Laboratory for at least four Immune Tolerance Network Studies (Liver and Kidney) and two Clinical Trials in Organ Transplantation (CTOT) studies (Heart and Liver. Data management and image analysis tools are being continually developed and updated for this application. The newest example is automated recognition of the cardiac microvascular for monitoring signaling molecules.
6. Lung Transplantation is the only therapeutic option for many fatal lung diseases. A number of various trials are being conducted and evaluated in the Tissue Typing Laboratory and in the Laboratory of Dr. Adrianna Zeevi.
7. The clinical outcome of patients with BK virus infection in the renal allograft is being modeled by multivariate statistics. Next generation sequencing of the T-cell receptor is under investigation as a potential tool to distinguish between rejection and BKV nephropathy. Quantitative PCR assays based on viral miRNAs are under evaluation as diagnostic and prognostic tools for patients with BKV infection. The interplay between host and viral immune factors in this disease is being investigated by defining the miRNA profiles of infected cells. Drugs with antiviral activity are being screened in an in-vitro culture model for possible future use in the clinical arena. BKV infection is one of the end points that is examined in a multicenter study being conducted by Chimerix Inc. to evaluate the efficacy of Brincidofovir against small DNA virus infections. An experimental model of polyomavirus infection is being utilized to determine if the gastrointestinal tract can act as a potential portal of entry for the virus into the body.
8. Optimizing outcome after pediatric heart transplantation. This project focuses on different aspects of pediatric heart transplantation and how to optimize outcomes and minimize drug-related complications. This project is particularly focused on the role of sensitization and allo-antibodies
9. Another important area of research is the pre- and post-transplant sensitization of solid organ transplant recipients. We are interested to evaluate the development of anti-HLA and non-HLA antibodies in transplant recipients and the impact of various immunosuppressive strategies.
10. Clinical research of antibody-mediated immune response in solid-organ transplantation is another area of investigation. The detection, specificity and functional analysis of pre-formed and post-transplant developed antibodies are important components of humoral allo-response dynamics, while outcome association reveals the clinical impact of humoral/mixed forms of graft rejection.
11. Participation in the Hepatitis B Research Network as pathologist member of Data Coordinating Committee (Steve Belle Ph.D., P.I. RFA-DK-07-011) and member of Pathology Subcommittee. The network comprises a long-term multicenter study of hepatitis B patients to further clarify the biology and clinical progression of this disease, and carry out a number of clinical trials with supportive scientific studies to examine the efficacies of newer antiviral drugs and drug combinations.
12. We continue to investigate the pathophysiology of allograft dysfunction after liver, kidney, heart, intestinal, and composite tissue transplantation. Examples include evaluation of donor biopsies in suitability of organs for transplantation, recurrence of native and new diseases after transplantation, enhanced methods or diagnoses of causes of allograft dysfunction, such as multiplex staining of tissue for markers of interest that correlate with immunologic effector mechanisms or cellular responses to injury and repair.
13. Dr. Demetris serves as the core laboratory for TransMedics extra-corporeal perfusion for FDA-sponsored trials for human liver transplantation. This initiative also encompasses an experimental animal effort.
14. The Division is represented on the Scientific Advisory Board of Transplant Genomics Inc, a commercial venture that is developing molecular tests for the diagnosis of T-cell mediated rejection in transplant recipients.
15. Divisional faculty are on the End-Point Adjudication Committee for the Chimerix Inc. sponsored CMX-001 Study, which is a randomized, double blind, placebo controlled, parallel group, multicenter, phase 3 study of the safety, tolerability, and efficacy of Brincidofovir for the prevention of cytomegalovirus infection in CMV seropositive hematopoietic stem cell transplant recipients.
The Division is strongly devoted to teaching and training in transplantation pathology. Professional staff directed graduate students and medical students in subjects, such as Cancer Biology, Digestion & Nutrition, Immunology & Inflammation, Kidney Pathology, Molecular Pathology, Immunology and Human Disease and Basics of Personalized Medicine. The division also heads the Banff Working Group on Liver Allograft Pathology and Telepathology and the Banff Working Group on Borderline Change and T-cell mediated rejection in the kidney. It participates in additional working groups on Quality Assurance, Isolated Intimal Arteritis, Implantation Biopsies, Polyomavirus Infection, and Vascularized Composite Allograft Pathology. These groups set international guidelines for allograft biopsy interpretation and meet every two years to present new findings in the field and discuss future directions. The last meeting was held in Barcelona, Span in March 2017.
The Division is represented on the Diseases Transmission Advisory Committee of the OPTN/UNOS, which reviews and provides guidance for cases of suspected donor disease transmission to transplant recipients. The committee has recently published a resource document (Am J Transplant 11:1140-1147, June 2011) to serve as a central information source regarding transplantation in this circumstance. Members of the division are also involved in the Organ Procurement Committee to develop standardized reporting forms for the evaluation of donor livers – a web-based resource will be used to enable pathologists to compare local findings with standardized diagrams and images of important findings.
Divisional faculty currently chair the American Society of Transplantation (AST) Transplant Diagnostics Community of Practice. This is a network of dedicated professionals including transplant pathologists, immunogeneticists, and other laboratory medicine specialists. Members of the community work together to create and promote best practices through communication, implementation, and maintenance of the highest diagnostic and quality assurance standards in organ transplantation. Educational material is regularly posted on the AST Hub, which is an online tool that hosts discussions, blog posts, case presentations, and bibliographic references of interest to this community.
Another nationally recognized educational activity of the division is membership in The American Journal of Kidney Diseases (AJKD) Blog Team. AJKD is the official journal of the National Kidney Foundation and is recognized worldwide as a leading clinical kidney journal. Every month AJKD publishes clinically oriented original investigations, review articles, case reports, editorials, quizzes, and teaching cases and materials describing the latest findings in kidney diseases, hypertension, dialysis, and kidney transplantation. The charge of the AJKD blog is to highlight selected journal content in an engaging, timely format. The blog hosts interviews with authors, podcasts, video, quizzes, commentaries on controversial topics, annnotated slides, and links to recent AJKD articles and classic papers.
Dr. Nalesnik currently chairs the Malignancy portion of the WHO-affiliated Project NOTIFY maintained by the Centro Nazionale Trapianti (Italian National Transplant Center), which has produced a comprehensive library providing guidance on donor-transmitted disease transmission and complications in the setting of organ and tissue transplantation. The library is located at http://www.notifylibrary.org/.
Many pathology residents have rotated through the Division to receive training in transplantation, hepatic and renal pathology. This rotation is designed to provide a basic understanding of the molecular, cellular and histopathologic mechanisms of transplant immunity, allograft rejection opportunistic infections, organ preservation injury, recurrent disease, drug toxicity graft versus host disease and lymphoproliferative disease. During this rotation, the residents attended various transplant conferences, research meetings and special lectures. The division recently completed the transplant pathology fellowship training of Dr. Nour Yadak. She will begin her position in September 2018 as an Anatomic and Clinical Pathologist at Methodist University Hospital, The University of Tennessee Health Science Center in Memphis, TN. Dr. Hugo Kaneku Nagahama began his fellowship in the Transplant Pathology division in July of 2018 and will finish his fellowship in June of 2019. Pathology residents (years 1-4) also rotate through the Tissue Typing Laboratory to become informed regarding the principles of clinical testing for Immunogenetics and Allosensitization.
Various members of the division also host visiting post-docs, physicians, and fellows, including Dr. Betul Celik from Turkey, Dr. Sören Weidemann from Germany, Dr. Tangul Bulut from Turkey, and Dr. Osama Elkhider from Granada, West Indies. The Division conducts weekly interdisciplinary conferences on heart, kidney, kidney/pancreas, intestine, liver and native liver pathology as well as a monthly heart transplant and bone marrow transplant biopsy conferences. Conferences in conjunction with Transplant Surgery deal with liver transplant tumors and Transplant Grand Rounds. There are also bimonthly meetings to discuss research progress within the Division and weekly journal clubs.
Transplant Pathology Internet Services (TPIS): An Interactive Platform for the Standardization of Transplantation Pathology Practice, is a freely available worldwide web-based venture of the Division of Transplantation Pathology and was originally designed to foster collaboration and diagnostic standardization among transplant institution.s TPIS is in compliance with Health on the Net HONCode principles and is certified by this organization (https://www.healthonnet.org/HONcode/Conduct.html?HONConduct538944). TPIS presently comprises over 4,500 pages and approximately 20,000 files for a total size of 3.5 gigabytes. It has evolved into an educational and interactive medium promoting both communication and standardization of transplant pathology practice. It performs this role using a three-pronged approach:
· The third component that encourages standardized practice is an interactive portion directed toward altering the practice of the individual pathologist. We have added a drug toxicity searcher specific for both liver and for kidney on the Home Page. The user simply types in the drug/medication and the site automatically returns a comprehensive search of articles describing the toxic effects of the medication for the particular organ. This has direct applicability to clinical cases and improves our ability to direct attention to potential hepatotoxic or nephrotoxic agents when appropriate microscopic features are present. As another example, TPIS serves as a download site for specialized software, for example, software that performs HLA matching using the CREG approach and written within our group. A third approach uses Java applets to perform medical calculations, allowing the user to perform calculations directly through the web browser. We have integrated 5 separate formulas that calculate creatinine clearance based on different clinical variables and offer all of these within our site. Similar calculations can be performed for determination of hepatic iron index.