A C T A O P H T H A L M O L O G I C A VOL. 56 1 9 7 8
From the Department of Ophthalmology (Head: Salme Vannas), University of Helsinki
HLA-B 12 AND HLA-B 27 ANTIGENS AND SUSCEPTIBILITY TO THE CORNEAL ALLOGRAFT REACTION BY
SALME VANNAS, ANJA TIILIKAINEN, ANTTI VANNAS and KARl KARJALAINEN
Our series comprised 100 penetrating corneal transplantations: 36 cases with HLA-B 12 and/or B 27 antigen in the recipient and, as controls, 64 cases without these antigens. The cornea was vascular in 44O/o of the HLA-B 12/B 27 group and in 40 O/o of the controls. In the HLA-B 12/B 27 group AR developed in 13 of 36 cases, 36O/o; but in the control group only in one case (2 "io). I n vascular and avascular cases the incidence of AR was equal. Among the high-risk cases of the HLA-B 12/B 27 group with definite mismatching of B 12 or B 27 antigens, 9 of the 14 recipients had developed AR. Six further recipients of this group had untyped grafts, and AR occurred in 4 of the 6, but in none of the 16 cases that were matched for B 12 or B 27 antigens. The value of a compatible graft, at least to the carriers of HLA-B 12 and/or B 27 antigens, is thus confirmed.
Key words: corneal transplantation - allograft reaction - antigens HLA-B 12 - HLA-B 27.
-
In our earlier series of patients with avascular keratoconus the risk of a corneal allograft reaction (AR) appeared to be highest among recipients bearing histocompatibility antigens HLA-B 12 and/or HLA-B 27 (Vannas et al. 1977 a,b). This led us to the working hypothesis that recipients bearing these Received April 4, 1978.
689
S. Vannas, A . Tiilikainen, A. Vannns and K . Karjalninen
antigens are generally susceptible to factors or agents promoting AR. In the present investigation we have tested this hypothesis further, paying special attention to the significance of vascularization of the corneal bed.
Patients and Methods Our corneal graft recipients included 36 with HLA-B 12 and/or B 27 antigen. For each of these subjects the two nearest control recipients were chosen. In the control group 8 patients received the antigen HLA-B 12 or B 27 in the graft, and they were excluded. Thus the whole series comprised 100 grafts. Corrosive eye injuries were not included in this study. The corneal lesions that led to transplantation are listed in Table I. Forty-three of the recipient corneal beds were vascularized. In each case corneal vessels were documented by fluorescein angiography, but the corneas were not grouped according to the extent of vascularization. T h e ages of the patients ranged from 6 to 81, with a mean of 41.8 years; 58 patients were male. T h e observation period varied from 4 months to 8 years and was equal in both series. In all recipients and, whenever possible in donors, H L A histocompatibility antigens were determined by the lymphocytotoxicity test a panel of well-de-
Table I .
Recipient series. Diagnosis
Number of cases
Keratoconus Fuch’s combined dystrophy
Salzmann’s nodular dystrophy Other dystrophies Phlyctenular keratitis Parenchymatous keratitis Herpetic keratitis Other inflammations Injuries Regraftings Others Total
52 5 3 5 7 8 7 3 5 2 3 100
690
HLA-B 12lB 27 and corneal allograft reaction Table II. Type of grafts.
Cryopreservation
53
M-K medium time storage
16
Fresh or moist chamber
31
100
fined antisera (Amos et al. 1969). The best possible donor was selected for each patient, considering A and B loci as well as ABO blood groups. If there were only 0-1 foreign antigens, the graft was regarded as well-matched. Possibilities for obtaining compatible grafts were greatly improved by corneal cryopreservation, started at our clinic in 1973 (Capella et al. 1965), and M-K medium time storage, introduced in 1975 (McCarey & Kaufman 1974). Our corneal graft material (Table 11) included 53 cryopreserved corneas. The longest preservation time was more than s1/r years, and the graft still had a regular endothelium.
Operative technique. The grafts varied in diameter from 7-8 mm. They were mostly sutured with a 10-0 monofilament, either with interrupted stitches or with a running suture. In the earliest patients, the suture material was 9-0 virgin silk. Single stitches were removed after 4 to 6 weeks and running sutures after 6 to 8 months. Postoperatively, the patients were given corticosteroids both locally and orally in a low dosage. In vascular cases immunosuppressive therapy was given (Imurel). AR occurred in 14 of the 100 patients at intervals ranging from 4 weeks to 4 years after the operation.
Results Frequency of AR in HLA-B 1218 27 carriers and controls
In our HLA-B 12iB 27 group (Table 111), AR developed in 13 of the 36 patients (360/0), as compared with l of the 64 patients of the control group (2 O/O); the difference is highly significant (P < 0.01). In the HLA-B 12/B 27 group the frequency of AR increased in parallel 69 1
S. Vannas, A . Tiilikainen, A . Vannas and K . Karjalainen Table iii. Frequency of AR in the HLA-B 12/R 27 group in relation to histoincompability matches.
Control series
HLA-B 12/B 27 series
No. of HLA
mismatches
cases
2
Not known Total
AR +
AR + No. of No.
1
No. of cases O/o
No.
I
Vo
12
0
0
31
1
3
12
5
42
16
0
0
6
4
67
3
0
0
6
4
67
14
0
0
36
13
36
64
1
2
with the histoincompatibility; of the 6 patients with untyped grafts 4 developed AR. By contrast, among the controls only one patient developed AR; in this patient histoincompatibility could not be demonstrated. Thus, the control group failed to demonstrate an unfavourable influence of histoincompatibility. Frequency of AR in relation to vascularization of recipient corneal bed
The whole series. AR developed in 14 O / o of recipients with vascular beds and in 14 O / o with avascular beds (Table IV). The equal frequency may be explained by the fact
a)
that the grafts for vascular recipient beds were more cautiously selected; 44 O / o of the vascular cases had well-matched grafts as compared to 32 O/O of the avascular cases. But despite this, considering this selection of grafts, there seemed to be a fairly similar tendency to AR in both avascular and vascular corneals beds.
b) The HLA-B 12/B 27 group. Among the vascular and avascular cases of the HLA-B 12/B 27 group AR developed in 31 o / o and 400/0,respectively (Table V). Neither this nor the control group gave conclusive evidence as to whether vascularization contri692
HLA-B 121B 27 and corneal allograft reaction
Vascular
Total
Avascular
43
43
57
57
buted to AR. AR was especially frequent in patients with the B 12 and/or B 27 antigen, whether the donor beds were vascular or avascular. However, AR did not develop in all such cases, and vascularization was not a decisive prognostic factor, even in the B 12IB 27 group. Influence of matched or mismatched HLA-B 12 and/or B 27 antigens on the occurrence of AR
No AR (Table VI) occurred in the 16 cases in which the recipient and the graft had matching HLA-B 12 or B 27 antigens, despite some other incom-
Table V . Relation between AR and vascularization of the recipient corneal bed in the HLA-B 12iB 27 and control groups.
1 AR
I
HLA-B 121B 27 group Vascular
Avascular
Control group Vascular
No.
Ola
No.
AR +
5
31
8
40
1
AR -
11
69
12
60
Total
16
100
20
100
010
693
Avascular No.
010
4
0
0
26
96
37
100
27
100
37
100
No.
010
S. Vannas, A. Tiilikainen, A . Vannas and K . Karjalainen Table VI. Incidence of AR when recipient had HLA-B 12 and/or B 27 antigens.
AR t No.
Recipient /graft
AR No.
Total
Incidence of AR 010
HLA-match of B 121B 12 B 271B 27 HLA-mismatch of B 12/BX:> B 27lBY'> HLA-match: not known Total
13
16
16
0
5 2
14 6
64 67
23
36
36
' BX: some other B antigen than 12 BY: some other B antigen than 27.
patibilities. AR developed in 9 of the 14 cases with mismatched HLA-B 12 and/or B 27 antigens, and in 4 of 6 further cases in which the graft was not tissue-typed. Of the 16 cases of matched B 12 or B 27 grafts (Table VII), only 3 were fully compatible, whereas 13 had 1 or 2 incompatible antigens, but no patient
Table VII. Relation of HLA-B 12/B 27 and other mismatches to the development of AR.
vv Matched for B 12 and/or B 27
Total No. of H L A mismatches
Total
Mismatched for B 121B 27
0
5
0
4
1
80
0
0
0
5
2
71
0
16
0
9
5
64
694
HLA-B 12lB 27 and corneal allograft reaction
developed AR. I n the cases of mismatched B 12/B 27 grafts, AR developed in 9 of the 14 cases. Other incompatible antigens were slightly more numerous in the AR cases than in those where the graft remained clear. The frequency of AR thus seems to increase with histoincompatibility. In 5 cases no AR has yet developed, although they have a mismatched B 12 or B 27 antigen. These patients do not differ from the rest of the group in regard to diagnosis or vascularization.
Discussion As our results show, patients with B 12 and/or B 27 antigens have a higher frequency of AR, whether the recipient corneal bed is avascular or vascular. The frequency of AR in the avascular cases of this series was lower than in our earlier study (Vannas et al. 19i6, 197713). The slight difference may depend on the increased number of well-matched grafts with 0-1 foreign HLA antigens, grafts with 3-4 mismatches having been avoided. In the control group (without HLA-B 12 or B 27 antigens) no AR developed in avascular recipient corneas. Vascularization of the recipient cornea was not associated with AR, except in one complicated case. In this case, however, AR probably resulted from the unfavourable influence of anterior synechia, although the effects of other immunological factors, such as HLA-D antigens and antigens of other loci, cannot be excluded. In our HLA-B 12/B 27 group, AR was correlated with histoincompatibility. A mismatch of HLA-B 12 or B 27 seemed especially liable to promote the development of AR. Five of these mismatched patients have not yet developed AR but this situation may change with time, because the longest interval from surgery to AR in all series is 4 years. As stated earlier (Vannas et al. 1977a), AR was mainly of the late type and often triggered by a somatic infection.
References Amos D. B., Bashir H., Boyle W., Mac Queen M. & Tiilikainen A. (1969) A simple microcytotoxicity test. Transplantation 7, 220-222. Capella J. A., Kaufman H. E. & Robbins J. E. (1965) Preservation of viable corneal tissue. Cryobiology 2, 116-121. Ehlers N. & Kissmeyer-Nielsen F. (1973) Influence of histocompatibility on the fate of the corneal transplant. In: Corneal graft failure. Ciba Foundation Symposium 15 (n. s.), pp. 307-319. Associated Scientific Publishers, Amsterdam. 695
S. Vannas, A. Tiilikainen, A. Vannas and K. Karjalainen Gibbs D. C., Batchelor J. R. & Casey T. A. (1973) Influence of HL-A compatibility on the fate of corneal grafts. In: Corneal graft failure. Ciba Foundation Symposium 15 (n. s.), pp. 293-306. Associated Scientific Publishers, Amsterdam. McCarey B. E. & Kaufman H. E. (1974) Iniproved corneal storage. Invest. Ophthul. 13, 165-173. Vannas S., Karjalainen K., Ruusuvaara P. & Tiilikainen A. (1976) HLA-compatible donor cornea for prevention of allograft reaction. Albrecht v. Graefes Arch. klin. exp. Ophthal. 198, 217-222. Vannas S., Vannas A. & Karjalainen K. (1977a) HLA-Antigene und Allograftreaktion bei Keratokonus. Klin. Mbl. Augenheilk. l i 0 , 391-396. Vannas S., Vannas A. & Tiilikainen A. (1977b) Corneal transplantation reaction in avascular keratoconus patients due to HLA-associated immune aberration against infection. A hypothesis. Invest. Ophthal. Visual Sci. 16, 644-646.
Author’s address: Salme Vannas, Prof., M. D., Department of Ophthalmology, University of Helsinki, SF-00290 Helsinki 29, Finland.
696
From the Department of Ophthalmology (Head: Salme Vannas), University of Helsinki
HLA-B 12 AND HLA-B 27 ANTIGENS AND SUSCEPTIBILITY TO THE CORNEAL ALLOGRAFT REACTION BY
SALME VANNAS, ANJA TIILIKAINEN, ANTTI VANNAS and KARl KARJALAINEN
Our series comprised 100 penetrating corneal transplantations: 36 cases with HLA-B 12 and/or B 27 antigen in the recipient and, as controls, 64 cases without these antigens. The cornea was vascular in 44O/o of the HLA-B 12/B 27 group and in 40 O/o of the controls. In the HLA-B 12/B 27 group AR developed in 13 of 36 cases, 36O/o; but in the control group only in one case (2 "io). I n vascular and avascular cases the incidence of AR was equal. Among the high-risk cases of the HLA-B 12/B 27 group with definite mismatching of B 12 or B 27 antigens, 9 of the 14 recipients had developed AR. Six further recipients of this group had untyped grafts, and AR occurred in 4 of the 6, but in none of the 16 cases that were matched for B 12 or B 27 antigens. The value of a compatible graft, at least to the carriers of HLA-B 12 and/or B 27 antigens, is thus confirmed.
Key words: corneal transplantation - allograft reaction - antigens HLA-B 12 - HLA-B 27.
-
In our earlier series of patients with avascular keratoconus the risk of a corneal allograft reaction (AR) appeared to be highest among recipients bearing histocompatibility antigens HLA-B 12 and/or HLA-B 27 (Vannas et al. 1977 a,b). This led us to the working hypothesis that recipients bearing these Received April 4, 1978.
689
S. Vannas, A . Tiilikainen, A. Vannns and K . Karjalninen
antigens are generally susceptible to factors or agents promoting AR. In the present investigation we have tested this hypothesis further, paying special attention to the significance of vascularization of the corneal bed.
Patients and Methods Our corneal graft recipients included 36 with HLA-B 12 and/or B 27 antigen. For each of these subjects the two nearest control recipients were chosen. In the control group 8 patients received the antigen HLA-B 12 or B 27 in the graft, and they were excluded. Thus the whole series comprised 100 grafts. Corrosive eye injuries were not included in this study. The corneal lesions that led to transplantation are listed in Table I. Forty-three of the recipient corneal beds were vascularized. In each case corneal vessels were documented by fluorescein angiography, but the corneas were not grouped according to the extent of vascularization. T h e ages of the patients ranged from 6 to 81, with a mean of 41.8 years; 58 patients were male. T h e observation period varied from 4 months to 8 years and was equal in both series. In all recipients and, whenever possible in donors, H L A histocompatibility antigens were determined by the lymphocytotoxicity test a panel of well-de-
Table I .
Recipient series. Diagnosis
Number of cases
Keratoconus Fuch’s combined dystrophy
Salzmann’s nodular dystrophy Other dystrophies Phlyctenular keratitis Parenchymatous keratitis Herpetic keratitis Other inflammations Injuries Regraftings Others Total
52 5 3 5 7 8 7 3 5 2 3 100
690
HLA-B 12lB 27 and corneal allograft reaction Table II. Type of grafts.
Cryopreservation
53
M-K medium time storage
16
Fresh or moist chamber
31
100
fined antisera (Amos et al. 1969). The best possible donor was selected for each patient, considering A and B loci as well as ABO blood groups. If there were only 0-1 foreign antigens, the graft was regarded as well-matched. Possibilities for obtaining compatible grafts were greatly improved by corneal cryopreservation, started at our clinic in 1973 (Capella et al. 1965), and M-K medium time storage, introduced in 1975 (McCarey & Kaufman 1974). Our corneal graft material (Table 11) included 53 cryopreserved corneas. The longest preservation time was more than s1/r years, and the graft still had a regular endothelium.
Operative technique. The grafts varied in diameter from 7-8 mm. They were mostly sutured with a 10-0 monofilament, either with interrupted stitches or with a running suture. In the earliest patients, the suture material was 9-0 virgin silk. Single stitches were removed after 4 to 6 weeks and running sutures after 6 to 8 months. Postoperatively, the patients were given corticosteroids both locally and orally in a low dosage. In vascular cases immunosuppressive therapy was given (Imurel). AR occurred in 14 of the 100 patients at intervals ranging from 4 weeks to 4 years after the operation.
Results Frequency of AR in HLA-B 1218 27 carriers and controls
In our HLA-B 12iB 27 group (Table 111), AR developed in 13 of the 36 patients (360/0), as compared with l of the 64 patients of the control group (2 O/O); the difference is highly significant (P < 0.01). In the HLA-B 12/B 27 group the frequency of AR increased in parallel 69 1
S. Vannas, A . Tiilikainen, A . Vannas and K . Karjalainen Table iii. Frequency of AR in the HLA-B 12/R 27 group in relation to histoincompability matches.
Control series
HLA-B 12/B 27 series
No. of HLA
mismatches
cases
2
Not known Total
AR +
AR + No. of No.
1
No. of cases O/o
No.
I
Vo
12
0
0
31
1
3
12
5
42
16
0
0
6
4
67
3
0
0
6
4
67
14
0
0
36
13
36
64
1
2
with the histoincompatibility; of the 6 patients with untyped grafts 4 developed AR. By contrast, among the controls only one patient developed AR; in this patient histoincompatibility could not be demonstrated. Thus, the control group failed to demonstrate an unfavourable influence of histoincompatibility. Frequency of AR in relation to vascularization of recipient corneal bed
The whole series. AR developed in 14 O / o of recipients with vascular beds and in 14 O / o with avascular beds (Table IV). The equal frequency may be explained by the fact
a)
that the grafts for vascular recipient beds were more cautiously selected; 44 O / o of the vascular cases had well-matched grafts as compared to 32 O/O of the avascular cases. But despite this, considering this selection of grafts, there seemed to be a fairly similar tendency to AR in both avascular and vascular corneals beds.
b) The HLA-B 12/B 27 group. Among the vascular and avascular cases of the HLA-B 12/B 27 group AR developed in 31 o / o and 400/0,respectively (Table V). Neither this nor the control group gave conclusive evidence as to whether vascularization contri692
HLA-B 121B 27 and corneal allograft reaction
Vascular
Total
Avascular
43
43
57
57
buted to AR. AR was especially frequent in patients with the B 12 and/or B 27 antigen, whether the donor beds were vascular or avascular. However, AR did not develop in all such cases, and vascularization was not a decisive prognostic factor, even in the B 12IB 27 group. Influence of matched or mismatched HLA-B 12 and/or B 27 antigens on the occurrence of AR
No AR (Table VI) occurred in the 16 cases in which the recipient and the graft had matching HLA-B 12 or B 27 antigens, despite some other incom-
Table V . Relation between AR and vascularization of the recipient corneal bed in the HLA-B 12iB 27 and control groups.
1 AR
I
HLA-B 121B 27 group Vascular
Avascular
Control group Vascular
No.
Ola
No.
AR +
5
31
8
40
1
AR -
11
69
12
60
Total
16
100
20
100
010
693
Avascular No.
010
4
0
0
26
96
37
100
27
100
37
100
No.
010
S. Vannas, A. Tiilikainen, A . Vannas and K . Karjalainen Table VI. Incidence of AR when recipient had HLA-B 12 and/or B 27 antigens.
AR t No.
Recipient /graft
AR No.
Total
Incidence of AR 010
HLA-match of B 121B 12 B 271B 27 HLA-mismatch of B 12/BX:> B 27lBY'> HLA-match: not known Total
13
16
16
0
5 2
14 6
64 67
23
36
36
' BX: some other B antigen than 12 BY: some other B antigen than 27.
patibilities. AR developed in 9 of the 14 cases with mismatched HLA-B 12 and/or B 27 antigens, and in 4 of 6 further cases in which the graft was not tissue-typed. Of the 16 cases of matched B 12 or B 27 grafts (Table VII), only 3 were fully compatible, whereas 13 had 1 or 2 incompatible antigens, but no patient
Table VII. Relation of HLA-B 12/B 27 and other mismatches to the development of AR.
vv Matched for B 12 and/or B 27
Total No. of H L A mismatches
Total
Mismatched for B 121B 27
0
5
0
4
1
80
0
0
0
5
2
71
0
16
0
9
5
64
694
HLA-B 12lB 27 and corneal allograft reaction
developed AR. I n the cases of mismatched B 12/B 27 grafts, AR developed in 9 of the 14 cases. Other incompatible antigens were slightly more numerous in the AR cases than in those where the graft remained clear. The frequency of AR thus seems to increase with histoincompatibility. In 5 cases no AR has yet developed, although they have a mismatched B 12 or B 27 antigen. These patients do not differ from the rest of the group in regard to diagnosis or vascularization.
Discussion As our results show, patients with B 12 and/or B 27 antigens have a higher frequency of AR, whether the recipient corneal bed is avascular or vascular. The frequency of AR in the avascular cases of this series was lower than in our earlier study (Vannas et al. 19i6, 197713). The slight difference may depend on the increased number of well-matched grafts with 0-1 foreign HLA antigens, grafts with 3-4 mismatches having been avoided. In the control group (without HLA-B 12 or B 27 antigens) no AR developed in avascular recipient corneas. Vascularization of the recipient cornea was not associated with AR, except in one complicated case. In this case, however, AR probably resulted from the unfavourable influence of anterior synechia, although the effects of other immunological factors, such as HLA-D antigens and antigens of other loci, cannot be excluded. In our HLA-B 12/B 27 group, AR was correlated with histoincompatibility. A mismatch of HLA-B 12 or B 27 seemed especially liable to promote the development of AR. Five of these mismatched patients have not yet developed AR but this situation may change with time, because the longest interval from surgery to AR in all series is 4 years. As stated earlier (Vannas et al. 1977a), AR was mainly of the late type and often triggered by a somatic infection.
References Amos D. B., Bashir H., Boyle W., Mac Queen M. & Tiilikainen A. (1969) A simple microcytotoxicity test. Transplantation 7, 220-222. Capella J. A., Kaufman H. E. & Robbins J. E. (1965) Preservation of viable corneal tissue. Cryobiology 2, 116-121. Ehlers N. & Kissmeyer-Nielsen F. (1973) Influence of histocompatibility on the fate of the corneal transplant. In: Corneal graft failure. Ciba Foundation Symposium 15 (n. s.), pp. 307-319. Associated Scientific Publishers, Amsterdam. 695
S. Vannas, A. Tiilikainen, A. Vannas and K. Karjalainen Gibbs D. C., Batchelor J. R. & Casey T. A. (1973) Influence of HL-A compatibility on the fate of corneal grafts. In: Corneal graft failure. Ciba Foundation Symposium 15 (n. s.), pp. 293-306. Associated Scientific Publishers, Amsterdam. McCarey B. E. & Kaufman H. E. (1974) Iniproved corneal storage. Invest. Ophthul. 13, 165-173. Vannas S., Karjalainen K., Ruusuvaara P. & Tiilikainen A. (1976) HLA-compatible donor cornea for prevention of allograft reaction. Albrecht v. Graefes Arch. klin. exp. Ophthal. 198, 217-222. Vannas S., Vannas A. & Karjalainen K. (1977a) HLA-Antigene und Allograftreaktion bei Keratokonus. Klin. Mbl. Augenheilk. l i 0 , 391-396. Vannas S., Vannas A. & Tiilikainen A. (1977b) Corneal transplantation reaction in avascular keratoconus patients due to HLA-associated immune aberration against infection. A hypothesis. Invest. Ophthal. Visual Sci. 16, 644-646.
Author’s address: Salme Vannas, Prof., M. D., Department of Ophthalmology, University of Helsinki, SF-00290 Helsinki 29, Finland.
696
