The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.
(60)| Volume 40, ISSUE 4, SUPPLEMENT , S35, April 2021

Heart Allograft Quilty Lesions are Associates with a Tolerant Gene Profile and Normal Allograft Function

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      Quilty lesions (lymphoid aggregates) are frequently encountered in heart allograft biopsies without morphologic evidence of rejection. However, their biologic nature and precise function remains unclear. Previously, in 42 cardiac allograft biopsies, we demonstrated that the presence of Foxp3+ innate and TGF- β+ adaptive regulatory lymphocytes in Quilty lesions (QL) are associated with higher allograft acceptance. In the current study, we aimed to characterize immunomodulatory pathways associated with QL by measuring mRNA expression.


      Endomyocardial biopsies of heart allograft from nine patients were included in this study, four with unremarkable endomyocardium (control group) and five with at least one QL (Quilty group). No acute T-cell or antibody mediated rejection was present histologically in any of these specimens. Total RNA was extracted from formalin fixed paraffin tissue. Multiplexed mRNA measurement was performed using the nCounter system (NanoString Technologies, Seattle, WA), and data were analyzed with nSolver software (NanoString Technologies, Seattle, WA).


      Of 771 gene mRNA levels measured in the NanoString Transplant Immunology Panel, 274 were upregulated in the QL group over the control group, with approximately one third related to adaptive immunity and 5% to innate immunity. Higher levels of mRNA expression in the QL group were also shown in pathways for hematopoiesis (11%), cytokine (9%), chemokine (7%), cell-extracellular matrix interaction (7%), and apoptosis & cell cycle regulation (5%). More specifically, the mRNA expression of TH2 tolerance-associated immunity markers, including Foxp3, TGF-β, and CTLA4, were higher in the Quilty group (2.82, 1.42, and 3.97 fold increase, respectively, with p < 0.05). Markers of rejection-associated TH1 immunity, including IL-2 and INF-γ, although lower in the quilty group, were not statistically different.


      Heart allografts with QL have dominant adaptive immunity related mRNA expression with significantly higher expression of TH2 tolerant immunity markers. These data suggest that QL, far from passive bystanders, may serve an immunomodulatory role in cardiac allografts. The presence of intra-allograft regulatory T-lymphocyte related signaling in QL may help to reduce the risk of rejection and foster allograft acceptance.