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Ashoor IF, Engen RM, Puliyanda D, Hayde N, Peterson CG, Zahr RS, Solomon S, Kallash M, Garro R, Jain A, Harshman LA, McEwen ST, Mansuri A, Gregoski MJ, Twombley KE. Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant 2024; 28:e14734. [PMID: 38602171 PMCID: PMC11013566 DOI: 10.1111/petr.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes. METHODS Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined. RESULTS We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome. CONCLUSIONS In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.
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Affiliation(s)
- Isa F Ashoor
- Department of Pediatrics, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Dechu Puliyanda
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicole Hayde
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Caitlin G Peterson
- Division of Pediatric Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Rima S Zahr
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Sonia Solomon
- Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Boston Children's Health Physicians, Valhalla, New York, USA
| | - Mahmoud Kallash
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Amrish Jain
- Department of Pediatrics, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Scott T McEwen
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Asifhusen Mansuri
- Department of Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine E Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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2
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Hou YB, Chang S, Chen S, Zhang WJ. Intravenous immunoglobulin in kidney transplantation: Mechanisms of action, clinical applications, adverse effects, and hyperimmune globulin. Clin Immunol 2023; 256:109782. [PMID: 37742791 DOI: 10.1016/j.clim.2023.109782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
Intravenous immunoglobulin (IVIG) has been developed for over 40 years. The mechanisms of action of IVIG are complex and diverse, and there may be multiple mechanisms that combine to influence it. IVIG has been used in kidney transplantation for desensitization, treatment of antibody-mediated rejection, and ABO-incompatible transplantation. and treatment or prevention of some infectious diseases. Hyperimmune globulins such as cytomegalovirus hyperimmune globulin (CMV-IG) and hepatitis B hyperimmune globulin (HBIG) have also been used to protect against cytomegalovirus and hepatitis B virus, respectively. However, IVIG is also associated with some rare but serious adverse effects and some application risks, and clinicians need to weigh the pros and cons and develop individualized treatment programs to benefit more patients. This review will provide an overview of the multiple mechanisms of action, clinical applications, adverse effects, and prophylactic measures of IVIG, and hyperimmune globulin will also be introduced in it.
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Affiliation(s)
- Yi-Bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Wei-Jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China.
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3
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Jadaun SS, Agarwal S, Gupta S, Saigal S. Strategies for ABO Incompatible Liver Transplantation. J Clin Exp Hepatol 2023; 13:698-706. [PMID: 37440942 PMCID: PMC10333949 DOI: 10.1016/j.jceh.2022.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/18/2022] [Indexed: 07/15/2023] Open
Abstract
Liver transplantation (LT) is a definitive treatment for the decompensated liver cirrhosis and fulminant liver failure. With limited availability of cadaveric liver allograft, ABO incompatible (ABOi) living donor liver transplantation (LDLT) plays an important part in further expansion of donor pool. Over the years, with the introduction of Rituximab and improving desensitisation protocol, outcomes of ABOi LDLT are on par with ABO compatible LT. However, ABOi LDLT protocol varies markedly from centre to centre. Intravenous Rituximab followed by plasmapheresis or immunoadsorption effectively reduce ABO isoagglutinins titre before transplant, thereby reducing the risk of antibody mediated rejection in the post-transplant period. Local infusion therapy and splenectomy are not used routinely at most of the centres in Rituximab era. Post-transplant immunosuppression usually consists of standard triple drug regime, and tacrolimus trough levels are targeted at higher level compared to ABO compatible LT. Introduction of newer therapies like Belatacept and Obinutuzumab hold promise to further improve outcomes and reduce the risk of antibody mediated rejection related complications. ABOi LT in emergency situations like acute liver failure and deceased donor LT is challenging due to limited time period for desensitisation protocol before transplant, and available evidence are still limited but encouraging.
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Affiliation(s)
- Shekhar S. Jadaun
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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4
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Ramifications of the HLA-I Allelic Reactivity of Anti-HLA-E*01:01 and Anti-HLA-E*01:03 Heavy Chain Monoclonal Antibodies in Comparison with Anti-HLA-I IgG Reactivity in Non-Alloimmunized Males, Melanoma-Vaccine Recipients, and End-Stage Renal Disease Patients. Antibodies (Basel) 2022; 11:antib11010018. [PMID: 35323192 PMCID: PMC8944535 DOI: 10.3390/antib11010018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/07/2022] [Accepted: 02/22/2022] [Indexed: 01/19/2023] Open
Abstract
Serum anti-HLA-I IgG are present in non-alloimmunized males, cancer patients, and transplant recipients. Anti-HLA-I antibodies are also present in intravenous immunoglobulin (IVIg), prepared from the plasma of thousands of healthy donors. However, the HLA-Ia reactivity of IVIg diminishes markedly after passing through HLA-E HC-affinity columns, suggesting that the HLA-I reactivity is due to antibodies formed against HLA-E. Hence, we examined whether anti-HLA-E antibodies can react to HLA-I alleles. Monoclonal IgG antibodies (mAbs) against HCs of two HLA-E alleles were generated in Balb/C mice. The antibodies were analyzed using multiplex bead assays on a Luminex platform for HLA-I reactivity. Beads coated with an array of HLA heterodimers admixed with HCs (LABScreen) were used to examine the binding of IgG to different HLA-Ia (31-HLA-A, 50-HLA-B, and 16-HLA-C) and Ib (2-HLA-E, one each of HLA-F and HLA-G) alleles. A striking diversity in the HLA-Ia and/or HLA-Ib reactivity of mAbs was observed. The number of the mAbs reactive to (1) only HLA-E (n = 25); (2) all HLA-Ib isomers (n = 8); (3) HLA-E and HLA-B (n = 5); (4) HLA-E, HLA-B, and HLA-C (n = 30); (5) HLA-E, HLA-A*1101, HLA-B, and HLA-C (n = 83); (6) HLA-E, HLA-A, HLA-B, and HLA-C (n = 54); and (7) HLA-Ib and HLA-Ia (n = 8), in addition to four other minor groups. Monospecificity and polyreactivity were corroborated by HLA-E monospecific and HLA-I shared sequences. The diverse HLA-I reactivity of the mAbs are compared with the pattern of HLA-I reactivity of serum-IgG in non-alloimmunized males, cancer patients, and ESKD patients. The findings unravel the diagnostic potential of the HLA-E monospecific-mAbs and immunomodulatory potentials of IVIg highly mimicking HLA-I polyreactive-mAbs.
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5
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Pilon C, Bigot J, Grondin C, Thiolat A, Lang P, Cohen JL, Grimbert P, Matignon M. Phenotypic and Transcriptomic Lymphocytes Changes in Allograft Recipients After Intravenous Immunoglobulin Therapy in Kidney Transplant Recipients. Front Immunol 2020; 11:34. [PMID: 32038663 PMCID: PMC6993066 DOI: 10.3389/fimmu.2020.00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/08/2020] [Indexed: 11/18/2022] Open
Abstract
High dose intravenous immunoglobulin (IVIG) are widely used after kidney transplantation and its biological effect on T and B cell phenotype in the context of maintenance immunosuppression was not documented yet. We designed a monocentric prospective cohort study of kidney allograft recipients with anti-HLA donor specific antibodies (DSA) without acute rejection on screening biopsies treated with prophylactic high-dose IVIG (2 g/kg) monthly for 2 months. Any previous treatment with Rituximab was an exclusion criterion. We performed an extensive analysis of phenotypic and transcriptomic T and B lymphocytes changes and serum cytokines after treatment (day 60). Twelve kidney transplant recipients who completed at least two courses of high-dose IVIG (2 g/kg) were included in a median time of 45 (12–132) months after transplant. Anti-HLA DSA characteristics were similar before and after treatment. At D60, PBMC population distribution was similar to the day before the first infusion. CD8+ CD45RA+ T cells and naïve B-cells (Bm2+) decreased (P = 0.03 and P = 0.012, respectively) whereas Bm1 (mature B-cells) increased (P = 0.004). RORγt serum mRNA transcription factor and CD3 serum mRNA increased 60 days after IVIG (P = 0.02 for both). Among the 25 cytokines tested, only IL-18 serum concentration significantly decreased at D60 (P = 0.03). In conclusion, high dose IVIG induced limited B cell and T cell phenotype modifications that could lead to anti-HLA DSA decrease. However, no clinical effect has been isolated and the real benefit of prophylactic use of IVIG after kidney transplantation merits to be questioned.
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Affiliation(s)
- Caroline Pilon
- APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Centre d'Investigation Clinique Biothérapie, Créteil, France.,Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France
| | - Jeremy Bigot
- Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France
| | - Cynthia Grondin
- APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Centre d'Investigation Clinique Biothérapie, Créteil, France
| | - Allan Thiolat
- Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France
| | - Philippe Lang
- Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France.,APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Nephrology and Transplantation Department, Créteil, France
| | - José L Cohen
- APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Centre d'Investigation Clinique Biothérapie, Créteil, France.,Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France
| | - Philippe Grimbert
- APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Centre d'Investigation Clinique Biothérapie, Créteil, France.,Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France.,APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Nephrology and Transplantation Department, Créteil, France
| | - Marie Matignon
- APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Centre d'Investigation Clinique Biothérapie, Créteil, France.,Université Paris-Est, UMR_S955, UPEC, Créteil, France.,Inserm, U955, Equipe 21, Créteil, France.,APHP (Assistance Publique-Hôpitaux de Paris), Hôpital H. Mondor-A. Chenevier, Nephrology and Transplantation Department, Créteil, France
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6
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Han DJ. Complication from Desensitization. KIDNEY TRANSPLANTATION IN SENSITIZED PATIENTS 2020. [PMCID: PMC7122531 DOI: 10.1007/978-981-10-7046-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sensitization to human leukocyte antigens (HLAs) has been one of the major clinical challenges for successful kidney transplantation. In end-stage renal disease, kidney transplantation provides benefits compared with dialysis in terms of improved patient survival better quality of life, and lower ongoing costs after the first year. Living donor kidney transplantation has an advantage with improved allograft survival, and performed earlier and electively compared with deceased donor transplantation. However sensitized patients are increasing in number on transplant waiting lists, and their prospect of getting a transplant is less than nonsensitized patients due to immunological incompatibility with the donor. Strategy for sensitized patients are listing for a compatible deceased donor transplant or, if they have a living donor, either selecting a kidney exchange program or undergoing a desensitization procedure. Desensitization procedures may be undertaken to increase access to either living or deceased donor transplants, and in some situations may also be employed to facilitate participation in a kidney exchange, in less immunological barrier to be overcome. The question of whether individuals are better off with a desensitization treatment followed by HLA-incompatible living donor transplantation or waiting on the deceased donor kidney transplant list for a compatible transplant has recently been addressed by two large multicenter studies, with conflicting results. A multicenter study from the United States published in the New England Journal of Medicine [365;318 326.2011] concluded that there was a strong survival benefit for sensitized patients undergoing desensitization followed by HLA-incompatible living donor kidney transplant compared with those remaining on the waiting list. Of interest, a second study, published in the Lancet, [389;727 734.2017] found no significant survival advantage for desensitized patients compared with similar patients remaining on the waiting list in the United Kingdom. Controversies still remain regarding how desensitization can be achieved and which techniques are effective and safe. In this chapter various complications from the desensitization will be dealt with in current use of medications or armamentum.
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Su H, Zhang CY, Lin JH, Hammes HP, Zhang C. The Role of Long-Lived Plasma Cells in Antibody-Mediated Rejection of Kidney Transplantation: An Update. KIDNEY DISEASES 2019; 5:211-219. [PMID: 31768378 DOI: 10.1159/000501460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/12/2019] [Indexed: 12/26/2022]
Abstract
Background Antibody-mediated rejection (ABMR) following kidney transplant is closely associated with poor prognosis of the recipients. Long-lived plasma cells (LLPCs) produce alloantibodies as long as life time and play a crucial role in ABMR. Summary LLPCs generate from germinal centers and reside in survival niches in the bone marrow as well as the inflamed tissues. They are the main and long-term source of the antibodies. LLPCs mediate ABMR via the generation of preformed antibodies in sensitized patients and de novo antibodies after transplantation. They have been acknowledged as the leading causes of ABMR; however, LLPCs are insensitive to traditional immunosuppressive therapy that removes B cells. Strategies targeting LLPCs, such as antithymocyte globulin, proteasome inhibitors as well as monoclonal antibodies, are promising methods to persistently and thoroughly clear the entire PC pool. Key Message LLPCs play an important role in ABMR by producing alloantibodies continually, and targeting LLPCs might be a novel and effective approach against ABMR.
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Affiliation(s)
- Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Yun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ji-Hong Lin
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hans-Peter Hammes
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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8
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Colvin MM, Cook JL, Chang PP, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller DV, Rodriguez ER, Tyan DB, Zeevi A. Sensitization in Heart Transplantation: Emerging Knowledge: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e553-e578. [DOI: 10.1161/cir.0000000000000598] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sensitization, defined as the presence of circulating antibodies, presents challenges for heart transplant recipients and physicians. When present, sensitization can limit a transplantation candidate’s access to organs, prolong wait time, and, in some cases, exclude the candidate from heart transplantation altogether. The management of sensitization is not yet standardized, and current therapies have not yielded consistent results. Although current strategies involve antibody suppression and removal with intravenous immunoglobulin, plasmapheresis, and antibody therapy, newer strategies with more specific targets are being investigated.
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9
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Desensitisation strategies in high-risk children before kidney transplantation. Pediatr Nephrol 2018; 33:2239-2251. [PMID: 29332219 DOI: 10.1007/s00467-017-3882-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/19/2017] [Accepted: 12/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transplantation is the preferred modality for renal replacement therapy in children. With increasing rates of re-transplantation within the paediatric population, there are more sensitised children on waiting lists. One issue with developing strategies to treat these children is the number of different definitions of sensitisation. and we would therefore recommend an immunological risk stratification approach. METHODS We discuss methods of sensitisation prevention, assessment and management, including paired exchange programmes and desensitisation protocols. RESULTS There are limited published evidence-based data for desensitisation in adults and none in children; thus, we present information on the available therapies currently in use. DISCUSSION Further research is required to investigate strategies which prevent sensitisation in children, including the healthcare utility of incorporating epitope-based matching into organ allocation algorithms. Controlled studies are also needed to establish the most appropriate desensitisation regimen(s).
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10
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Do W, Lee JH, Kim KJ, Han MH, Jung HY, Choi JY, Park SH, Kim YL, Kim CD, Cho JH, Yang Y, Kim M, Hwang I, Kim KY, Yim T, Kim YJ. Bortezomib Treatment for Refractory Antibody-Mediated Rejection Superimposed with BK Virus-Associated Nephropathy during the Progression of Recurrent C3 Glomerulonephritis. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.3.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Wonseok Do
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong-Hak Lee
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Kyung Joo Kim
- Department of Pathology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Youngae Yang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Minjung Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Inryang Hwang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kyu Yeun Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Taehoon Yim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Jin Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
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Successful Desensitization of T cell Flow Cytometry Crossmatch Positive Renal Transplant Recipients Using Plasmapheresis and Super High-Dose Intravenous Immunoglobulin. Transplant Direct 2018; 4:e336. [PMID: 29399625 PMCID: PMC5777667 DOI: 10.1097/txd.0000000000000753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/07/2017] [Indexed: 11/27/2022] Open
Abstract
Background High-dose IVIG (2 g/kg) alone or low-dose IVIG (100 mg/kg) in conjunction with plasma exchange is typically administered as a renal transplantation desensitization therapy. Herein, we monitored changes in T cell and B cell flow cytometry crossmatch (FCXM) to assess the effects of short-term super high-dose IVIG (4 g/kg) administration with plasmapheresis before living-donor renal transplantation. Methods Seventeen patients, each showing positive T cell FCXM (median ratio, ≥ 1.4) after 2 rounds of double-filtration plasmapheresis, received 4-day regimens of IVIG (1 g/kg per day) over 1-week periods. T cell and B cell FCXM determinations were obtained after every IVIG dose and again up to 4 weeks after initiating IVIG to ascertain negative conversion of T cell FCXM (median ratio < 1.4). The primary study endpoint was the percentage of patients achieving T cell FCXM-negative status after the 4-dose IVIG regimen. Results Upon completion (4 g/kg total) or discontinuation of IVIG administration, 8 (47.1%) of 17 patients displayed negative T cell FCXM. Based on Kaplan-Meier estimates, the cumulative T cell FCXM-negative conversion rate 4 weeks after IVIG administration initiation was 60.3%. The T cell FCXM-negative conversion rates after cumulative doses of 1, 2, 3, and 4 g/kg IVIG were 29.4%, 35.3%, 56.3%, and 46.7%, respectively. Conclusions Desensitization of donor-specific antibody-positive renal transplant recipients seems achievable in only a subset of recipients through IVIG dosing (1 g/kg × 4) within 1 week after double-filtration plasmapheresis. The T cell FCXM-negative conversion rate resulting from a cumulative IVIG dose of 3 g/kg or greater surpassed that attained via conventional single-dose IVIG (2 g/kg) protocol. This short-term high-dose IVIG desensitization protocol may be an alternative to conventional protocols for recipients with donor-specific antibody.
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12
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Ekezue BF, Sridhar G, Forshee RA, Izurieta HS, Selvam N, Mintz PD, Anderson SA, Menis MD. Occurrence of acute renal failure on the same day as immune globulin product administrations during 2008 to 2014. Transfusion 2017; 57:2977-2986. [PMID: 29027208 DOI: 10.1111/trf.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 07/21/2017] [Accepted: 07/26/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute renal failure (ARF) is a rare serious adverse event after immune globulin (IG) use. Our large claims-based study evaluated occurrence of same-day ARF after administration of different IGs and ascertained potential risk factors, during the 2008 to 2014 study period. STUDY DESIGN AND METHODS A retrospective cohort study was conducted using a large commercial administrative database. The cohort included individuals exposed to IG products as identified by procedure codes. ARF was ascertained using ICD-9-CM diagnoses. Unadjusted same-day ARF rates (per 1000 persons exposed) were estimated overall and by age, sex, and IG products. Regression analyses were conducted to control for confounding and assess potential risk factors. RESULTS Of 20,440 persons exposed, 163 (7.97 per 1000) had a recorded same-day ARF. The unadjusted nonzero same-day ARF rates (per 1000) ranged from 1.92 (95% confidence interval [CI], 0.05-10.69) for Hizentra to 16.97 (95% CI, 11.36-24.37) for Privigen and differed by sex. In multivariate analyses, compared to Gammagard Liquid, no significantly elevated ARF risks were identified with any IGs. A significantly lower odds ratio was identified with Gamunex, 0.53 (95% CI, 0.30-0.93). Age 45 and over, prior renal impairment, hypertension, and other factors were associated with increased risk of same-day ARF. CONCLUSION The study showed variation in the risk of IG-related ARF by age, sex, and IG products. The study results suggest the importance of recipient factors, such as older age and underlying health conditions. Variations in ARF occurrence may also be explained by product dosage, administration route and rate, and manufacturing processes, which warrant further evaluation.
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Affiliation(s)
| | | | - Richard A Forshee
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Hector S Izurieta
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - Paul D Mintz
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Anderson
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Mikhail D Menis
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Lee EC, Kim SH, Park SJ. Outcomes after liver transplantation in accordance with ABO compatibility: A systematic review and meta-analysis. World J Gastroenterol 2017; 23:6516-6533. [PMID: 29085201 PMCID: PMC5643277 DOI: 10.3748/wjg.v23.i35.6516] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/07/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the differences in outcomes between ABO-incompatible (ABO-I) liver transplantation (LT) and ABO-compatible (ABO-C) LT. METHODS A systematic review and meta-analysis were performed by searching eligible articles published before No-vember 28, 2016 on MEDLINE (PubMed), EMBASE, and Cochrane databases. The primary endpoints were graft survival, patient survival, and ABO-I-related complications. RESULTS Twenty-one retrospective observational studies with a total of 8247 patients were included in this meta-analysis. Pooled results of patient survival for ABO-I LT were comparable to those for ABO-C LT. However, ABO-I LT showed a poorer graft survival than ABO-C LT (1-year: OR = 0.66, 95%CI: 0.57-0.76, P < 0.001; 3-year: OR = 0.74, 95% CI 0.64-0.85, P < 0.001; 5-yearr: OR =0.75, 95%CI: 0.66-0.86, P < 0.001). Furthermore, ABO-I LT was associated with more incidences of antibody-mediated rejection (OR = 74.21, 95%CI: 16.32- 337.45, P < 0.001), chronic rejection (OR =2.28, 95%CI: 1.00-5.22, P = 0.05), cytomegalovirus infection (OR = 2.64, 95%CI: 1.63-4.29, P < 0.001), overall biliary complication (OR = 1.52, 95%CI: 1.01-2.28, P = 0.04), and hepatic artery complication (OR = 4.17, 95%CI: 2.26-7.67, P < 0.001) than ABO-C LT. In subgroup analyses, ABO-I LT and ABO-C LT showed a comparable graft survival in pediatric patients and those using rituximab, and ABO-I LT showed an increased acute cellular rejection in cases involving deceased donor grafts. CONCLUSION Although patient survival in ABO-I LT was comparable to that in ABO-C LT, ABO-I LT was inferior to ABO-C LT in graft survival and several complications. Graft survival of ABO-I LT could be comparable to that of ABO-C LT in pediatric patients and those using rituximab.
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Affiliation(s)
- Eung Chang Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
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Matignon M, Pilon C, Commereuc M, Grondin C, Leibler C, Kofman T, Audard V, Cohen J, Canoui-Poitrine F, Grimbert P. Intravenous immunoglobulin therapy in kidney transplant recipients with de novo DSA: Results of an observational study. PLoS One 2017; 12:e0178572. [PMID: 28654684 PMCID: PMC5487035 DOI: 10.1371/journal.pone.0178572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023] Open
Abstract
Background Approximately 25% of kidney transplant recipients develop de novo anti-HLA donor-specific antibodies (dnDSA) leading to acute antibody-mediated rejection (ABMR) in 30% of patients. Preemptive therapeutic strategies are not available. Methods We conducted a prospective observational study including 11 kidney transplant recipients. Inclusion criteria were dnDSA occurring within the first year after transplant and normal allograft biopsy. All patients were treated with high-dose IVIG (2 g/kg 0, 1 and 2 months post-dnDSA). The primary efficacy outcome was incidence of clinical and subclinical acute ABMR within 12 months after dnDSA detection as compared to a historical control group (IVIG-). Results Acute ABMR occurred in 2 or 11 patients in the IVIG+ group and in 1 of 9 patients in the IVIG- group. IVIG treatment did not affect either class I or class II DSA, as observed at the end of the follow-up. IVIG treatment significantly decreased FcγRIIA mRNA expression in circulating leukocytes, but did not affect the expression of any other markers of B cell activation. Conclusions In this first pilot study including kidney allograft recipients with early dnDSA, preemptive treatment with high-dose IVIG alone did not prevent acute ABMR and had minimal effects on DSA outcome and B cell phenotype.
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Affiliation(s)
- Marie Matignon
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department and CIC Biothérapies 504, Créteil, France
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
- * E-mail:
| | - Caroline Pilon
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
- AP-HP, Henri Mondor Hospital, CIC Biothérapies 504, Créteil France
| | - Morgane Commereuc
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department, Créteil, France
| | - Cynthia Grondin
- AP-HP, Henri Mondor Hospital, CIC Biothérapies 504, Créteil France
- INSERM U955, Team 21, Créteil, France
| | - Claire Leibler
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department, Créteil, France
| | - Tomek Kofman
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department, Créteil, France
| | - Vincent Audard
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department, Créteil, France
| | - José Cohen
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
- AP-HP, Henri Mondor Hospital, CIC Biothérapies 504, Créteil France
| | - Florence Canoui-Poitrine
- AP-HP, Henri-Mondor Hospital, Public Health Department, Creteil, France
- Paris-Est University, UPEC, IMRB-EA 7376 CEpiA unit (Clinical Epidemiology And Ageing), Creteil, France
| | - Philippe Grimbert
- AP-HP, Henri Mondor Hospital, Nephrology and Transplantation Department and CIC Biothérapies 504, Créteil, France
- INSERM U955, Team 21, Créteil, France and Paris Est University (UPEC), Créteil, France
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Yasuda M, Ikegami T, Imai D, Wang H, Bekki Y, Itoh S, Yoshizumi T, Soejima Y, Shirabe K, Maehara Y. The changes in treatment strategies in ABOi living donor liver transplantation for acute liver failure. THE JOURNAL OF MEDICAL INVESTIGATION 2017; 62:184-7. [PMID: 26399345 DOI: 10.2152/jmi.62.184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Living donor liver transplantation (LDLT) using ABO-incompatible (ABOi) graft for acute liver failure (ALF) is a developing treatment modality. METHODS We reviewed the changes in our treatment strategies in applying ABOi LDLT for FH over our fourteen years of experience. RESULTS Five patients with ALF received LDLT in adults using ABOi grafts, with different but gradually renewed protocols. The etiologies for acute liver failure included autoimmune hepatitis (n=3) and unknown (n=2). The desensitization protocol for ABOi barrier included Case #1; local infusion (portal vein)+plasma exchange (PE), Case #2; local infusion (hepatic artery)+rituximab+PE, Case #3 and #4; rituximab+PE, and Case #5; rituximab+PE under high-flow continuous hemodiafiltration. Local infusion was abandoned since Case #3, because Case #1 had portal vein thrombosis resulting in graft necrosis and Case #2 had hepatic artery dissection. The patients (Case #2 and #3), who received rituximab within 7 days before LDLT, experienced antibody-mediated rejection. Thus, the most recent protocol for ABOi-LDLT is that rituximab is given 2 weeks before LDLT, followed by high-flow continuous hemodiafiltration to obstacle hepatic encephalopathy until LDLT. The four patients except Case #1 are doing well with good graft function over 3.8±3.7 years. CONCLUSION Rituximab-based ABOi-LDLT, most-recently under high-flow hemodiafiltration for treating encephalopathy, is a feasible option for applying LDLT for ALF.
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Affiliation(s)
- Mitsuhiro Yasuda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University
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In Kidney Transplant Recipients With a Positive Virtual Crossmatch, High PRA was Associated With Lower Incidence of Viral Infections. Transplantation 2016; 100:655-61. [PMID: 26760571 DOI: 10.1097/tp.0000000000001061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is little information on the incidence, risk factors, and outcomes associated with CMV and BK infections in sensitized patients. METHODS We examined 254 consecutive kidney transplant recipients with positive virtual crossmatch and negative flow crossmatch. RESULTS A total of 111 patients (43%) developed CMV disease or BK infection or nephropathy (BKVN). Specifically, 78 patients (30.7%) developed BK infection, 19 (7.5%) had BKVN, and 33 (12.9%) presented with CMV disease. Four patients (1.5%) developed both infections. Mean time from transplant to diagnosis for BK and CMV was 4.07 ± 3.10 and 8.35 ± 5.20 months, respectively. African American (HR, 2.64; 95% CI, 1.37-5.07; P = 0.003), thymoglobulin induction (HR, 2.18; 95% CI, 1.38-3.43; P = 0.0008), DSA greater than 500 MFI at transplant (HR, 1.64; 95% CI, 1.05-2.57; P = 0.03), history of diabetes (HR, 1.62; 95% CI, 1.01-2.60; P = 0.04), CMV D+/R- (HR, 2.30; 95% CI, 1.06-5.01; P = 0.03), and acute rejection (HR, 1.49; 95% CI, 0.99-2.24; P = 0.05) were associated with increase incident of BK/CMV, whereas rituximab (HR, 0.47; 95% CI, 0.24-0.91; P = 0.02), peak PRA greater than 80% (HR, 0.48; 95% CI, 0.27-0.84; P = 0.01), and living donor transplant (HR, 0.57; 95% CI, 0.36-0.87; P = 0.01) were associated with a lower likelihood of infection. Thymoglobulin induction (HR, 2.50; 95% CI, 1.02-6.13; P = 0.04), and peak PRA greater than 80% (HR, 0.45; 95% CI, 0.23-0.86; P = 0.02) remained significant predictors of infection after multivariate adjustment. CONCLUSIONS Although more than 40% of patients with a positive virtual crossmatch presented with BK infection/CMV disease, high PRA greater than 80% seemed to be protective.
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17
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Results of ABO-incompatible liver transplantation using a simplified protocol at a single institution. Transplant Proc 2015; 47:723-6. [PMID: 25891718 DOI: 10.1016/j.transproceed.2015.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 01/25/2015] [Accepted: 02/09/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Because of the development of various desensitization strategies, ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has become a feasible option for patients with end-stage liver disease. However, there has been no united desensitization protocol for ABOi LDLT. We analyzed the outcomes after establishment of simplified protocol without splenectomy, intravenous immunoglobulin, and local infusion therapy. METHODS We analyzed 19 ABOi LDLT cases that had been performed between January 2012 and December 2013, without splenectomy and local infusion. We used a single dose of rituximab (375 mg/m(2)) 10 days before transplantation and several series of plasma exchange according to the recipients' iso-agglutinin titer-to-target titer ratio of 1:32. RESULTS Nineteen recipients received ABOi LTs from living donors. The mean initial immunoglobulin (Ig) M and IgG anti-ABO titers were 76.63 ± 78.81 (range, 8∼256) and 162.53 ± 464.1 (0∼2048). We performed preoperative plasma exchange to 16 recipients (mean number of sessions, 3.58; range, 1-10). After surgery, 9 patients received plasma exchange (mean, 1.84; range 1∼14). One death occurred as the result of pneumonia (5.3%). There were 4 cases of acute rejections (21.1%), and all of them were treated successfully with steroid pulse or thymoglobulin. Antibody-mediated rejection and graft failure did not occur. Six cases of postoperative complications (31.6%) occurred, including 3 cases of infections. There were 2 cases of biliary anastomotic stricture (10.5%) and 1 case of portal vein stenosis (5.3%). CONCLUSIONS ABOi LDLT with the use of simplified protocol can be safely performed without increased risk of antibody-mediated rejection and other complications.
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Long-term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation: A Comparative Analysis. Transplant Proc 2015; 47:1720-6. [DOI: 10.1016/j.transproceed.2015.05.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/27/2015] [Indexed: 12/30/2022]
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James A, Mannon RB. The Cost of Transplant Immunosuppressant Therapy: Is This Sustainable? CURRENT TRANSPLANTATION REPORTS 2015; 2:113-121. [PMID: 26236578 PMCID: PMC4520417 DOI: 10.1007/s40472-015-0052-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A solid organ transplant is life-saving therapy that engenders the use of immunosuppressive medications for the lifetime of the transplanted organ and its recipient. Conventional therapy includes both induction therapy (a biologic that is infused peri-operatively) followed by maintenance therapy. The cost of these medications is a constant concern and the advent of generics has brought this cost down modestly. For those lacking long term insurance coverage, this may be a significant out of pocket expense that is not affordable. Moreover, transplant Centers are managing higher risk transplant recipients that require more complex induction regimens and longer term use of such biologic agents in the context of desensitization or abrogation of de novo antibody mediated injury. While in kidney transplantation, Medicare part B covers three years of medication, there is frequent non-adherence due to cost after that time-point. The impact of the Affordable Care Act remains uncertain at this time. Finally the pipeline of new therapies is limited due to the cost of development of a drug, the inherent cost of clinical studies, and lack of defined endpoints for newer therapies in high risk patients. These new therapies are of high value to the community but will contribute additional burden to current drug costs.
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Affiliation(s)
- Alexandra James
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, AL
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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20
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Stein MR. The New Generation of Liquid Intravenous Immunoglobulin Formulations in Patient Care: A Comparison of Intravenous Immunoglobulins. Postgrad Med 2015; 122:176-84. [DOI: 10.3810/pgm.2010.09.2214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Nonspecific Immunoglobulin Replacement in Lung Transplantation Recipients With Hypogammaglobulinemia. Transplantation 2015; 99:444-50. [DOI: 10.1097/tp.0000000000000339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Antibody-Mediated Rejection in Reconstructive Transplantation. THE SCIENCE OF RECONSTRUCTIVE TRANSPLANTATION 2015. [DOI: 10.1007/978-1-4939-2071-6_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Srinivas TR, Schold JD, Meier-Kriesche HU. Mycophenolate mofetil: long-term outcomes in solid organ transplantation. Expert Rev Clin Immunol 2014; 2:495-518. [DOI: 10.1586/1744666x.2.4.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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24
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Liu A, Bernard M. Pharmaceutical costs of desensitization therapy in patients awaiting lung transplantation in France. BioDrugs 2013; 28:55-61. [PMID: 23912421 DOI: 10.1007/s40259-013-0054-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Based on solid experience in renal transplant, new treatments aiming to decrease anti-human leukocyte antigen (HLA) antibodies in patients awaiting lung transplant have recently been developed. The off-label use of high-dose intravenous polyvalent immunoglobulins (IVIg) and/or plasmapheresis changes the economical weight of pharmaceutical cost before lung transplantation. OBJECTIVE Our objective was to assess the budgetary impact of pharmaceutical costs of desensitization therapy. METHODS Two observational studies were conducted in 2009 and 2010 at the Bichat Claude Bernard (BCB) hospital in France. The first assessed the real pharmaceutical costs, and identified cost drivers, of desensitized (D+) patients awaiting lung transplantation. The second compared pharmaceutical and clinical data between D+ and non-treated (D-) patients. RESULTS The major cost drivers were IVIg, representing 89.7 % of pharmaceutical costs. The real cost of drugs was €4,392 ± 647 per hospitalization. Mean hospitalization and annual pharmaceutical costs per patient were significantly higher for D+ than for D- patients (€6,972 vs. 2,925 and €13,074 vs. 399). D+ patients had a significantly higher average number of annual hospitalizations than did D- patients. Total IVIg costs represented 98 % of the pharmaceutical costs for desensitization stays. Pharmaceutical costs represented 40 % of total hospitalization costs for D+ versus only 7 % for D-. CONCLUSION New desensitization protocols can help to manage the immunological hurdle of anti-donor antibodies in lung transplantation. They are expensive and not yet correctly covered by national health insurance, as they are supported by hospital budgets. A medico-economical evaluation of IVIg use in this indication seems necessary.
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Affiliation(s)
- Annaë Liu
- Department of Pharmacy, Bichat Claude Bernard Hospital, AP-HP, 146 rue Henri Huchard, 75877, Paris Cedex 18, France
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25
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Bostock IC, Alberú J, Arvizu A, Hernández-Mendez EA, De-Santiago A, González-Tableros N, López M, Castelán N, Contreras AG, Morales-Buenrostro LE, Gabilondo B, Vilatobá M. Probability of deceased donor kidney transplantation based on % PRA. Transpl Immunol 2013; 28:154-8. [PMID: 23684945 DOI: 10.1016/j.trim.2013.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/26/2013] [Accepted: 05/01/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Sensitization to HLA antigens creates an obstacle for the accessibility and success of kidney transplantation (KT). Highly sensitized patients have longer waiting times and some may never receive a KT. AIM To determine the probability of patients on the deceased donor (DD) waiting list to receive a KT based on the panel reactive antibody percentage (% PRA) in our center. METHODS The DD waiting list from our institution was analyzed from 01/05 to 08/12 documenting the clinical variables from donor and potential recipients (ABO blood group), lymphocyte cross-match [CxM (CDC-AHG)] results, highest % PRA determination, and time on the waiting list. The patients were classified into 4 groups based on the % PRA: 0%, 1-19%, 20-79% and 80-100%. The data was analyzed using odds ratio and logistic regression (significant p<0.05). RESULTS 58 DD (F:M 34:24, ABO group O=35, A=13, B=10) and 179 potential recipients were analyzed (F:M 98:81, ABO group O=127, A=33, B=19, participating 4.2 ± 3.8 times with different donors to receive KT). The mean PRA for the whole group was 22 ± 32%, median [md] 0 (0-98). A total of 100 patients received KT (mean waiting time 2.2 ± 1.7 years, 12 days-7 years) and their mean % PRA was 11.6 ± 24, md 0 (0-94) vs. 31.4 ± 37 md 8.5 (0-98) in those who have not received a KT. An association between the % PRA group and KT (p<0.003) was observed. The probability of receiving KT with a 0% PRA vs. >0% was higher (OR 2.12, 1.17-3.84). There was no difference between the 0% vs. 1-19% group (OR 1); differences were observed between 0% vs. 20-79% (OR 2.5, 1.18-5.3) and 0% vs. 80-100% (OR 5, 1.67-14.9). For every percent increase in the PRA above 20%, the risk of not receiving a KT increased by 5% (1-9, p<0.01). CONCLUSIONS The probability of receiving a DD kidney transplant is inversely related to the % PRA although a higher risk for not receiving a KT becomes evident with a PRA >20%.
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Affiliation(s)
- I C Bostock
- Department of Transplantation, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
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Mainra R, Xu Q, Chibbar R, Hassan A, Shoker A. Severe antibody-mediated rejection following IVIG infusion in a kidney transplant recipient with BK-virus nephropathy. Transpl Immunol 2013; 28:145-7. [PMID: 23685054 DOI: 10.1016/j.trim.2013.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 02/08/2023]
Abstract
Intravenous immune-globulin (IVIG) use in renal transplantation has increased, with common uses including desensitization, treatment of antibody mediated rejection and adjunctive therapy for BK virus nephropathy. Although considered generally safe, potential side effects can occur in up to 23% of patients including acute kidney injury. We present a case of an unexpected cause of acute kidney injury in a renal transplant recipient following IVIG infusion. A 48-year-old nonsensitized female with end stage renal disease secondary to polycystic kidney disease received a deceased donor kidney transplant. The initial post-transplant period was unremarkable however at three years post-transplant the patient develops BK virus nephropathy. Despite a reduction in immunosuppression, graft function worsened and IVIG infusion was commenced. Immediately following the IVIG infusion, the patient develops anuric acute kidney injury necessitating hemodialysis. Renal transplant biopsy performed before and after the IVIG infusion revealed the de novo development of acute antibody mediated rejection and donor specific antibodies in the serum. Anti-HLA and donor-specific antibodies were also confirmed in a diluted sample of the IVIG preparation. We argue that the anti-HLA antibodies present in the IVIG caused an acute antibody mediated rejection in this previously nonsensitized female.
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Affiliation(s)
- R Mainra
- Division of Nephrology, Saskatchewan Transplant Program, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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Abstract
The complement cascade is a major contributor to the innate immune response. It has now been well accepted that complement plays a critical role in hyperacute rejection and acute antibody-mediated rejection of transplanted organ. There is also increasing evidence that complement proteins contribute to the pathogenesis of organ ischemia-reperfusion injury, and even to cell-mediated rejection. Furthermore, the chemoattractants C3a and C5a and the terminal membrane attack complex that are generated by complement activation can directly or indirectly mediate tissue injury and trigger adaptive immune responses. Here, we review recent findings concerning the role of complement in graft ischemia-reperfusion injury, antibody-mediated rejection and accommodation, and cell-mediated rejection. We also discuss the current status of complement intervention therapies in clinical transplantation and describe potential new therapeutic strategies for clinical application.
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Affiliation(s)
- Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Abstract
Many factors limit short- and long-term survival after pediatric heart transplantation. Historically, attention had been directed toward T-cell responses and acute cellular rejection. Presence of pretransplant antibodies against HLA is associated with increased donor wait times and poor post-transplant outcomes. Therapies aimed to mitigate circulating antibodies include plasmapheresis, protein A immunoadsorption columns, intravenous immune globulin, rituximab, and bortezomib. The negative effects of B cells, HLA antibodies, and AMR and potential interventions are the focus of this review article.
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Affiliation(s)
- Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Song YH, Huh KH, Kim YS, Lee HS, Kim MS, Kim SJ, Kim HJ, Kim SI, Joo DJ. Impact of pretransplant rituximab induction on highly sensitized kidney recipients: comparison with non-rituximab group. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 82:335-9. [PMID: 22708094 PMCID: PMC3373982 DOI: 10.4174/jkss.2012.82.6.335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 04/05/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Highly sensitized patients with a high level of panel reactive antibody (PRA) experience more episodes of antibody-mediated rejection (AMR) and poorer graft survival than non-sensitized patients. Rituximab is a well-known monoclonal anti-CD20 antibody that causes the depletion of B lymphocytes. The aim of this study was to compare a rituximab-administered and a non-administered group of highly sensitized recipients. METHODS Forty-three kidney recipients with a PRA level of ≥50% were included. Sixteen (group R) received one dose of rituximab at 2 days prior to transplantation and 27 patients (group NR) did not. RESULTS Patients' demographics, such as age, sex, dialysis duration, and type of immunosuppressive agent were not different in the two groups. No side effects due to rituximab administration were observed in group R. Class I PRA of group R (75.6 ± 37.7%) was higher than that of group NR (45.7 ± 35.8%, P = 0.013). More acute rejection episodes occurred within 1 year after transplantation in group NR but the difference between the groups was not significant (18.8% in group R vs. 29.6% in group NR, P = 0.631). However, two AMR episodes occurred only in group NR. Renal functions were not different in the two groups. In group R, CD19 and CD20 rapidly decreased 2 days after rituximab infusion. Furthermore, the administration of rituximab was not linked to acute rejection. CONCLUSION To confirm the long-term anti-rejection and beneficial effects of rituximab, further studies should be performed with a larger cohort. In conclusion, rituximab administration 2 days prior to transplantation is both effective and safe.
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Affiliation(s)
- Young Hae Song
- Department of Surgery, Yonsei University Health System, Seoul, Korea
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Fu Q, Wang C, Zeng W, Liu L. The correlation of HLA allele frequencies and HLA antibodies in sensitized kidney transplantation candidates. Transplant Proc 2012; 44:217-21. [PMID: 22310618 DOI: 10.1016/j.transproceed.2011.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The clinical importance of the HLA system is as a transplant antigen. However, correlations between the development and strength of the immune response and HLA genes or specific foreign antigens are not clear. OBJECTIVES The objectives of this study were to detect HLA-A, -B, and -DRB1 allele frequencies and HLA antibodies in sensitized patients, and to investigate the correlation between the HLA alleles and HLA sensitization. METHODS This study included 383 sensitized patients and 1000 unsensitized patients awaiting kidney transplantation from 2001-2010. HLA -A, -B, and -DRB1 typing was performed using sequence-specific primer-polymerase chain reactions (SSP-PCR). Arlequin statistical analysis software was used to calculate the HLA allele frequencies among the 2 groups. The anti-HLA-specific antibodies of sensitized patients were identified and analyzed using enzyme-linked immunosorbent assay (ELISA). RESULTS The numbers of identified HLA -A, -B, and -DRB1 alleles were 20, 43, and 14, respectively. The 5 most frequent HLA alleles in the 2 groups were not different: A-02, 11, 24, 33, 26; B-46, 60, 13, 75, 58; and DR-9, 15, 12, 4, 14. Among the sensitized group, the most frequent HLA-specific antibodies were as follows: A-2, 24, 68, 23, 32; B-27, 56, 57, 7, 60; and DR-7, 4, 9, 13, 17. CONCLUSIONS There was little correlation between HLA sensitization and HLA alleles of oneself. High frequency alleles and the specificity of high-frequency HLA antibodies were not consistent.
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Affiliation(s)
- Q Fu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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31
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Chen Song S, Zhong S, Xiang Y, Li JH, Guo H, Wang WY, Xiong YL, Li XC, Chen Shi S, Chen XP, Chen G. Complement inhibition enables renal allograft accommodation and long-term engraftment in presensitized nonhuman primates. Am J Transplant 2011; 11:2057-66. [PMID: 21831160 DOI: 10.1111/j.1600-6143.2011.03646.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Protection against humoral injury mediated by donor-specific antibodies (DSA), also known as accommodation, may allow for long-term allograft survival in presensitized recipients. In the present study, we determined the role of complement in renal allograft accommodation in donor skin-presensitized nonhuman primates under conventional immunosuppression. Donor skin allografts were transplanted to presensitized recipients 14 days prior to renal transplantation. Renal allografts not receiving any immunosuppressive treatment developed accelerated rejection with predominantly humoral injury, which was not prevented using conventional cyclosporine (CsA) triple therapy. Inhibition of complement activation with the Yunnan-cobra venom factor (Y-CVF) successfully prevented accelerated antibody-mediated rejection and resulted in successful accommodation and long-term renal allograft survival in most presensitized recipients. Accommodation in this model was associated with the prevention of the early antibody responses induced against donor antigens by complement inhibition. Some antiapoptotic proteins and complement regulatory proteins, including Bcl-2, CD59, CD46 and clusterin, were upregulated in the surviving renal allografts. These results suggest that the complement inhibition-based strategy may be valuable alternative in future clinical cross-match positive or ABO-incompatible transplantation.
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Affiliation(s)
- S Chen Song
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Levine MH, Abt PL. Treatment options and strategies for antibody mediated rejection after renal transplantation. Semin Immunol 2011; 24:136-42. [PMID: 21940179 DOI: 10.1016/j.smim.2011.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 08/24/2011] [Indexed: 12/17/2022]
Abstract
Antibody mediated rejection is a significant clinical problem encountered in a subset of renal transplant recipients. This type of rejection has a variable pathogenesis from the presence of donor specific antibodies with no overt disease to immediate hyperacute rejection and many variations between. Antibody mediated rejection is more common in human leukocyte antigen sensitized patients. In general, transplant graft survival after antibody mediated rejection is jeopardized, with less than 50% graft survival 5 years after this diagnosis. A variety of agents have been utilized singly and in combinations to treat antibody mediated rejection with differing results and significant research efforts are being placed on developing new targets for intervention. These same agents have been used in desensitization protocols with some success. In this review, we describe the biology of antibody mediated rejection, review the available agents to treat this form of rejection, and highlight areas of ongoing and future research into this difficult clinical problem.
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Affiliation(s)
- Matthew H Levine
- University of Pennsylvania, Transplant Surgery, Philadelphia, PA 19104, USA.
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Mark SM. Comparison of Intravenous Immunoglobulin Formulations: Product Formulary, and Cost Considerations. Hosp Pharm 2011. [DOI: 10.1310/hpj4609-668] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose A review of the different formulations of intravenous immunoglobulin (IVIG) replacement therapy for primary immunodeficiency and other severe diseases, focusing on the comparative efficacy, safety, and tolerability of these formulations. This review discusses the manufacturing processes, physicochemical properties, and other attributes of IVIG therapy that affect its clinical utility. Summary IVIG therapy is a preferred treatment for patients with certain types of primary immunodeficiency, neuroimmunologic, and autoimmune hematologic disorders, as well as for immunomodulation in bone marrow and some solid organ transplants. The IVIG products available in the United States include lyophilized, 5% liquid, and 10% ready-to-use liquid formulations. Differences among these formulations in their manufacturing processes, excipients, pH, and physicochemical properties may be reflected as differences in clinical efficacy, safety, and tolerability. For example, compared with lyophilized and 5% liquid IVIG formulations, 10% ready-to-use IVIG liquid formulations may be associated with better tolerability because of lower IgA concentrations, optimal pH, use of glycine or proline stabilizers, low sodium content, and less osmolality. Liquid formulations (both 5% and 10%) may provide greater convenience than lyophilized formulations for both patients and health care providers, because they do not require further dilution before administration and have shorter infusion times. Conclusion Before selecting an IVIG product for a hospital formulary, pharmacists should be knowledgeable about the product's concentration to ensure delivery of the proper dosage, the staff training needed for proper administration, the potential benefits and problems of brand substitution, the safety and efficacy of each formulation, the hospital's policies on off-label use of IVIG, and the impact of reimbursement.
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Affiliation(s)
- Scott M. Mark
- West Penn Allegheny Health System, One Allegheny Center, 6th Floor, Pittsburgh, PA 15212
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Immunologic parameters and viral infections in patients desensitized with intravenous immunoglobulin and rituximab. Transpl Immunol 2011; 24:142-8. [DOI: 10.1016/j.trim.2010.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 12/20/2022]
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Marfo K, Lu A, Ling M, Akalin E. Desensitization protocols and their outcome. Clin J Am Soc Nephrol 2011; 6:922-36. [PMID: 21441131 DOI: 10.2215/cjn.08140910] [Citation(s) in RCA: 197] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the last decade, transplantation across previously incompatible barriers has increasingly become popular because of organ donor shortage, availability of better methods of detecting and characterizing anti-HLA antibodies, ease of diagnosis, better understanding of antibody-mediated rejection, and the availability of effective regimens. This review summarizes all manuscripts published since the first publication in 2000 on desensitized patients and discusses clinical outcomes including acute and chronic antibody-mediated rejection rate, the new agents available, kidney paired exchange programs, and the future directions in sensitized patients. There were 21 studies published between 2000 and 2010, involving 725 patients with donor-specific anti-HLA antibodies (DSAs) who underwent kidney transplantation with different desensitization protocols. All studies were single center and retrospective. The patient and graft survival were 95% and 86%, respectively, at a 2-year median follow-up. Despite acceptable short-term patient and graft survivals, acute rejection rate was 36% and acute antibody-mediated rejection rate was 28%, which is significantly higher than in nonsensitized patients. Recent studies with longer follow-up of those patients raised concerns about long-term success of desensitization protocols. The studies utilizing protocol biopsies in desensitized patients also reported higher subclinical and chronic antibody-mediated rejection. An association between the strength of DSAs determined by median fluorescence intensity values of Luminex single-antigen beads and risk of rejection was observed. Two new agents, bortezomib, a proteasome inhibitor, and eculizumab, an anti-complement C5 antibody, were recently introduced to desensitization protocols. An alternative intervention is kidney paired exchange, which should be considered first for sensitized patients.
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Affiliation(s)
- Kwaku Marfo
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA
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Lucas JG, Co JP, Nwaogwugwu UT, Dosani I, Sureshkumar KK. Antibody-mediated rejection in kidney transplantation: an update. Expert Opin Pharmacother 2011; 12:579-92. [PMID: 21294653 DOI: 10.1517/14656566.2011.525219] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Acute antibody-mediated rejection (AMR) in renal-transplant recipients is generally less responsive to conventional antirejection therapy and has a worse prognosis than acute cellular rejection. AREAS COVERED This review provides a broad understanding of the pathogenesis of AMR, recent advances in its therapy, and future directions. Conventional therapeutic approaches to AMR have minimal impact on mature plasma cells, the major source of antibody production. Emerging therapies include bortezomib, a proteasome inhibitor, and eculizumab, an anti-C5 antibody. In several reports, bortezomib therapy resulted in prompt reversal of rejection, decreased titers of donor-specific antibodies (DSA), and improved renal allograft function. Eculizumab also reversed AMR and prevented its development in patients with high post-transplantation DSA levels. EXPERT OPINION Despite the small sample size and lack of controls, these studies are encouraging, and although larger studies and long-term follow-up are needed, bortezomib and eculizumab may play a major future role in AMR therapy.
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Affiliation(s)
- Jessica G Lucas
- Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
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Barnett N, Dorling A, Mamode N. B cells in renal transplantation: pathological aspects and therapeutic interventions. Nephrol Dial Transplant 2010; 26:767-74. [PMID: 21139038 DOI: 10.1093/ndt/gfq716] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
B cells are vital in renal transplantation. B2 cells are part of the adaptive immune system. Activated B cells mature into plasma cells or memory B cells: their life spans can be prolonged by niches. B cells have a wide variety of functions: antibody production, antigen presentation, cytokine production and shaping of the splenic architecture. These functions play a vital role in graft rejection, both T cell-mediated rejection and antibody-mediated rejection. Markers of B cell activity include intragraft B cell infiltration, C4d deposition and circulating donor-specific antibodies. Many therapeutic options target B cells or plasma cells. As greater understanding is gained of their appropriate use, and new agents are developed, we should see prolonged graft survival and reduced graft rejection.
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Affiliation(s)
- Nicholas Barnett
- Renal, Urology and Transplantation Directorate, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, London SE1 9RT, UK
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Tanabe M, Kawachi S, Obara H, Shinoda M, Hibi T, Kitagawa Y, Wakabayashi G, Shimazu M, Kitajima M. Current progress in ABO-incompatible liver transplantation. Eur J Clin Invest 2010; 40:943-9. [PMID: 20636381 DOI: 10.1111/j.1365-2362.2010.02339.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND ABO-incompatible (ABOi) living donor liver transplantation (LDLT) in adult patients has been controversial because of the high risk of antibody-mediated rejection (AMR) mediated by preformed anti-ABO antibodies. However, outcomes have recently improved owing to various treatment advances. MATERIALS AND METHODS This review article describes the history and current progress in ABOi liver transplantation, mainly from the viewpoint of the Japanese experience. RESULTS The typical clinical manifestations of AMR are hepatic necrosis and intrahepatic biliary complication. The outcomes of early ABOi LDLT were poor, especially in older children and adult cases. Since we first introduced portal vein infusion therapy into adult ABOi LDLT in 1998, local graft infusion therapy has emerged in Japan as a crucial breakthrough to overcome the ABO blood group barrier. From 2003, rituximab prophylaxis has been widely used with local graft infusion, and has resulted in markedly improved patient survival. The novel approach of intravenous immunoglobulin induction may become another option to suppress AMR. Continued patient enrollment and controlled trials will allow further validation of these treatments. CONCLUSIONS The outcome of ABOi LDLT is now similar to that of blood-type-matched transplantation in Japan. However, infection is the major cause of morbidity and mortality after ABOi LDLT. Thus, evaluation of the patients' immune status and adjustment of immunosuppression will be the way forward in the future.
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Affiliation(s)
- Minoru Tanabe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
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Raghavan R, Jeroudi A, Achkar K, Gaber AO, Patel SJ, Abdellatif A. Bortezomib in kidney transplantation. J Transplant 2010; 2010:698594. [PMID: 20953363 PMCID: PMC2952895 DOI: 10.1155/2010/698594] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 09/09/2010] [Indexed: 12/12/2022] Open
Abstract
Although current therapies for pretransplant desensitization and treatment of antibody-mediated rejection (AMR) have had some success, they do not specifically deplete plasma cells that produce antihuman leukocyte antigen (HLA) antibodies. Bortezomib, a proteasome inhibitor approved for the treatment of multiple myeloma (a plasma cell neoplasm), induces plasma cell apoptosis. In this paper we review the current body of literature regarding the use of this biological agent in the field of transplantation. Although limited experience with bortezomib may seem to show promise in the realm of transplant recipients desensitization and treatment of AMR, there is also experience that may suggest otherwise. Bortezomib's role in desensitization protocols and treatment of AMR will be defined better as more clinical data and trials become available.
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Affiliation(s)
- Rajeev Raghavan
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Division of Nephrology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Abdallah Jeroudi
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Katafan Achkar
- Department of Medicine, The Kidney Institute and The Methodist Hospital, Houston, TX 77030, USA
- Division of Nephrology, The Kidney Institute and The Methodist Hospital, Houston, TX 77030, USA
| | - A. Osama Gaber
- Department of Surgery, The Methodist Hospital, Weill Cornell University, Houston, TX 77030, USA
| | - Samir J. Patel
- Department of Pharmacy, The Methodist Hospital, Weill Cornell University, Houston, TX 77030, USA
| | - Abdul Abdellatif
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Division of Nephrology, Baylor College of Medicine, Houston, TX 77030, USA
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Sharma KG, Radha R, Pao A, Amet N, Baden L, Jordan SC, Toyoda M. Mycophenolic acid and intravenous immunoglobulin exert an additive effect on cell proliferation and apoptosis in the mixed lymphocyte reaction. Transpl Immunol 2010; 23:117-20. [PMID: 20450974 DOI: 10.1016/j.trim.2010.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 04/20/2010] [Accepted: 04/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) has known immunomodulatory effects in autoimmune diseases and transplantation and is commonly used in desensitization protocols and for treatment of antibody-mediated rejection (AMR). IVIG inhibits the MLR and induces apoptosis in immune cells. Mycophenolate mofetil inhibits immune cell proliferation and is an effective immunsuppressive agent. Here, we examined the possible synergistic effects of combined MMF and IVIG on cell proliferation and apoptosis induction in the MLR. METHODS Two-way MLRs were performed with mycophenolic acid (MPA), IVIG and both in combination. Cell proliferation and apoptosis were detected by 3H-thymidine incorporation and Annexin flow cytometry, respectively. RESULTS IVIG (1-10mg/ml) or MPA (0.01-0.25 microg/ml) alone inhibited cell proliferation in the MLR in a dose-dependent manner. MPA at 0.01-0.03 microg/ml showed minimal inhibition, but the addition of 5 and 10mg/ml IVIG increased inhibition significantly (p<0.05) to 43% and 64%, respectively. Annexin V positive cell number was significantly higher in IVIG (5mg/ml) treated CD19+ cells (68+/-13% vs. 43+/-12%, p=0.001) compared to untreated cells and to a lesser degree in CD3+ cells (29+/-7% vs. 25+/-10 %, p=0.02). MPA (0.25-10 microg/ml) alone neither induced nor inhibited apoptosis. Addition of MPA had no effect on apoptosis induced by IVIG. CONCLUSION 1) Combining low concentrations of IVIG (5-10 mg/ml) and MPA (0.01-0.03 microg/ml)has an additive effect on inhibition of cell proliferation in the MLR. 2) MPA alone neither induces nor inhibits apoptosis in T or B cells in the MLR, and has no effect on apoptosis induced by IVIG. These in vitro observations may have implications for modification of therapeutic approaches to protocols utilizing IVIG for desensitization and immune modulation.
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Affiliation(s)
- Kavita G Sharma
- Transplant Immunology Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center/UCLA School of Medicine, 8700 Beverly Blvd., Los Angeles, CA 90048, USA
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Sensitized renal transplant recipients: current protocols and future directions. Nat Rev Nephrol 2010; 6:297-306. [DOI: 10.1038/nrneph.2010.34] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Jacqueline Pefaur P, Susana Elgueta M. Inmunidad humoral y trasplante renal posibilidades terapéuticas. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Hartung HP, Mouthon L, Ahmed R, Jordan S, Laupland KB, Jolles S. Clinical applications of intravenous immunoglobulins (IVIg)--beyond immunodeficiencies and neurology. Clin Exp Immunol 2010; 158 Suppl 1:23-33. [PMID: 19883421 DOI: 10.1111/j.1365-2249.2009.04024.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The clinical use of intravenous immunoglobulin (IVIg) has expanded beyond its traditional place in the treatment of patients with primary immunodeficiencies. Due to its multiple anti-inflammatory and immunomodulatory properties, IVIg is used successfully in a wide range of autoimmune and inflammatory conditions. Recognized autoimmune indications include idiopathic thrombocytopenic purpura (ITP), Kawasaki disease, Guillain-Barré syndrome and other autoimmune neuropathies, myasthenia gravis, dermatomyositis and several rare diseases. Several other indications are currently under investigation and require additional studies to establish firmly the benefit of IVIg treatment. Increasing attention is being turned to the use of IVIg in combination with other agents, such as immunosuppressive agents or monoclonal antibodies. For example, recent studies suggest that combination therapy with IVIg and rituximab (an anti-CD20 monoclonal antibody) may be effective for treatment of autoimmune mucocutaneous blistering diseases (AMBDs), with sustained clinical remission. The combination of IVIg and rituximab has also been used in the setting of organ transplantation. Firstly, IVIg +/- rituximab has been administered to highly human leucocyte antigen (HLA)-sensitized patients to reduce anti-HLA antibody levels, thereby allowing transplantation in these patients. Secondly, IVIg in combination with rituximab is effective in the treatment of antibody-mediated rejection following transplantation. Treatment with polyclonal IVIg is a promising adjunctive therapy for severe sepsis and septic shock, but its use remains controversial and further study is needed before it can be recommended routinely. This review covers new developments in these fields and highlights the broad range of potential therapeutic areas in which IVIg may have a clinical impact.
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Affiliation(s)
- H-P Hartung
- Department of Neurology, Heinrich-Heine University, Düsseldorf, Germany.
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Rituximab, IVIG, and plasma exchange without graft local infusion treatment: a new protocol in ABO incompatible living donor liver transplantation. Transplantation 2009; 88:303-7. [PMID: 19667930 DOI: 10.1097/tp.0b013e3181adcae6] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although graft local infusion (GLI) treatment via the portal vein or the hepatic artery has been the pivotal strategy in ABO incompatible (ABOi) living donor liver transplantation (LDLT) in Japan, the procedure is associated with a high rate of catheter-associated complications. METHODS A new ABOi-LDLT protocol has been implemented using rituximab, intravenous immune globulin (IVIG), plasma exchange (PE), and splenectomy, without using GLI, on four patients, since 2007. Three other patients, treated before 2007, received GLI. RESULTS Three of the four patients with liver cirrhosis received rituximab over 3 weeks before LDLT, followed by PEs and post-LDLT IVIG, resulting in no rebound elevation of the isoagglutinin titers. The remaining patient, with fulminant hepatitis, received rituximab 3 days before the LDLT, resulting in antibody-mediated rejection, successfully treated by IVIG and PE. All four patients that were treated with the new protocol are alive, 26, 8, 6, and 5 months after ABOi-LDLT with normal liver function. Two of the three other patients with GLI, before 2007, had catheter-associated complications, including one graft loss. CONCLUSION The new ABOi-LDLT protocol using rituximab, IVIG, and PE, without the use of GLI, therefore seems to be a safe and an effective treatment modality.
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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Lobashevsky A, Manwaring J, Travis M, Nord B, Higgins N, Serov Y, Arnoff T, Hommel-Berrey G, Goggins W, Taber T, Carter C, Smith D, Wozniak T, O'Donnell J, Turrentine M. Effect of desensitization in solid organ transplant recipients depends on some cytokines genes polymorphism. Transpl Immunol 2009; 21:169-78. [DOI: 10.1016/j.trim.2009.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/12/2009] [Accepted: 03/16/2009] [Indexed: 10/20/2022]
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Tait BD, Hudson F, Cantwell L, Brewin G, Holdsworth R, Bennett G, Jose M. Review article: Luminex technology for HLA antibody detection in organ transplantation. Nephrology (Carlton) 2009; 14:247-54. [PMID: 19207861 DOI: 10.1111/j.1440-1797.2008.01074.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Since its inception in the early 1960s, the serologically based complement-dependent cytotoxicity (CDC) assay has been the cornerstone technique for the detection of human leucocyte antigen (HLA) antibodies, not only in pre-transplant renal patients, but also in other forms of organ transplantation. Recently, solid phase assays have been developed and introduced for this purpose, and in particular the Flow-based bead assays such as the Luminex system. This latter assay has proved to be far more sensitive than the CDC assay and has revealed pre-sensitization in potential transplant recipients not detected by other methods of HLA antibody detection. However, the clinical implications of this increased sensitivity have not been convincingly demonstrated until recently. This technology for HLA antibody detection permits the evaluation of the clinical importance of antibodies directed at, for example, HLA-DPB1 and HLA-DQA1, which has not been possible to date. There are Luminex issues, however, requiring resolution such as the ability to distinguish between complement fixing and non-complement fixing antibodies and determination of their relative clinical significance. Luminex technology will permit a re-evaluation of the role of HLA antibodies in both early and late antibody-mediated rejection.
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Affiliation(s)
- Brian D Tait
- Victorian Transplantation and Immunogenetic Service, Australian Red Cross Blood Service, Parkville, Victoria, Australia.
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Danziger-Isakov L, Mark Baillie G. Hematologic complications of anti-CMV therapy in solid organ transplant recipients. Clin Transplant 2009; 23:295-304. [DOI: 10.1111/j.1399-0012.2008.00942.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Burns AM, Ma L, Li Y, Yin D, Shen J, Xu J, Chong AS. Memory alloreactive B cells and alloantibodies prevent anti-CD154-mediated allograft acceptance. THE JOURNAL OF IMMUNOLOGY 2009; 182:1314-24. [PMID: 19155477 DOI: 10.4049/jimmunol.182.3.1314] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The impact of memory B cells and alloantibodies on the ability to induce transplantation tolerance has not been elucidated. We have developed a murine heart transplant model that isolates the contributions of functional memory B cells from memory T cells in allograft rejection. Memory 3-83 B cells with dual specificity for H-2K(k) and H-2K(b) were generated in 3-83 Igi BCR knockin (BALB/c background) mice by the transplantation of C3H (H-2K(k)) hearts in the absence of immunosuppression. To test the effect of functional memory 3-83 B cells, C3H-primed 3-83 Igi recipients were challenged with C57BL/6 hearts (H-2K(b)) at 60-90 days post-C3H heart transplant and treated with anti-CD154 mAbs. Despite immunosuppression, the C57BL/6 hearts were acutely rejected within 10-13 days and graft rejection was associated with increased frequencies of C57BL/6-specific IFN-gamma-producing T cells. Histology revealed significant numbers of infiltrating T cells, consistent with acute T cell-mediated rejection. The resistance to tolerance induction was dependent on the synergistic effects of memory 3-83 B cells and alloantibodies, whereas memory T cells are not necessary. We conclude that the combined effects of functional memory B cells and alloantibodies prevent anti-CD154-mediated graft acceptance by facilitating the CD40-CD154-independent activation of alloreactive T cells. This study provides insight into the potential ability of memory B cells and alloantibodies to prevent anti-CD154-mediated graft acceptance.
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Affiliation(s)
- Audrea M Burns
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL 60637, USA
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Slatinska J, Honsova E, Burgelova M, Slavcev A, Viklicky O. Plasmapheresis and Intravenous Immunoglobulin in Early Antibody-Mediated Rejection of the Renal Allograft: A Single-Center Experience. Ther Apher Dial 2009; 13:108-12. [DOI: 10.1111/j.1744-9987.2009.00664.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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