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Hellemans R, Bosmans JL, Abramowicz D. Early steroid withdrawal: a niche for anti-interleukin 2 receptor monoclonal antibodies? Nephrol Dial Transplant 2018; 33:1083-1087. [DOI: 10.1093/ndt/gfy053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/13/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rachel Hellemans
- Department of Nephrology and Hypertension, Antwerp University Hospital, Edegem, Belgium
| | - Jean-Louis Bosmans
- Department of Nephrology and Hypertension, Antwerp University Hospital, Edegem, Belgium
| | - Daniel Abramowicz
- Department of Nephrology and Hypertension, Antwerp University Hospital, Edegem, Belgium
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Banham GD, Flint SM, Torpey N, Lyons PA, Shanahan DN, Gibson A, Watson CJE, O'Sullivan AM, Chadwick JA, Foster KE, Jones RB, Devey LR, Richards A, Erwig LP, Savage CO, Smith KGC, Henderson RB, Clatworthy MR. Belimumab in kidney transplantation: an experimental medicine, randomised, placebo-controlled phase 2 trial. Lancet 2018; 391:2619-2630. [PMID: 29910042 DOI: 10.1016/s0140-6736(18)30984-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND B cells produce alloantibodies and activate alloreactive T cells, negatively affecting kidney transplant survival. By contrast, regulatory B cells are associated with transplant tolerance. Immunotherapies are needed that inhibit B-cell effector function, including antibody secretion, while sparing regulators and minimising infection risk. B lymphocyte stimulator (BLyS) is a cytokine that promotes B-cell activation and has not previously been targeted in kidney transplant recipients. We aimed to determine the safety and activity of an anti-BLyS antibody, belimumab, in addition to standard-of-care immunosuppression in adult kidney transplant recipients. We used an experimental medicine study design with multiple secondary and exploratory endpoints to gain further insight into the effect of belimumab on the generation of de-novo IgG and on the regulatory B-cell compartment. METHODS We undertook a double-blind, randomised, placebo-controlled phase 2 trial of belimumab, in addition to standard-of-care immunosuppression (basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone) at two centres, Addenbrooke's Hospital, Cambridge, UK, and Guy's and St Thomas' Hospital, London, UK. Participants were eligible if they were aged 18-75 years and receiving a kidney transplant and were planned to receive standard-of-care immunosuppression. Participants were randomly assigned (1:1) to receive either intravenous belimumab 10 mg per kg bodyweight or placebo, given at day 0, 14, and 28, and then every 4 weeks for a total of seven infusions. The co-primary endpoints were safety and change in the concentration of naive B cells from baseline to week 24, both of which were analysed in all patients who received a transplant and at least one dose of drug or placebo (the modified intention-to-treat [mITT] population). This trial has been completed and is registered with ClinicalTrials.gov, NCT01536379, and EudraCT, 2011-006215-56. FINDINGS Between Sept 13, 2013, and Feb 8, 2015, of 303 patients assessed for eligibility, 28 kidney transplant recipients were randomly assigned to receive belimumab (n=14) or placebo (n=14). 25 patients (12 [86%] patients assigned to the belimumab group and 13 [93%] patients assigned to the placebo group) received a transplant and were included in the mITT population. We observed similar proportions of adverse events in the belimumab and placebo groups, including serious infections (one [8%] of 12 in the belimumab group and five [38%] of 13 in the placebo group during the 6-month on-treatment phase; and none in the belimumab group and two [15%] in the placebo group during the 6-month follow-up). In the on-treatment phase, one patient in the placebo group died because of fatal myocardial infarction and acute cardiac failure. The co-primary endpoint of a reduction in naive B cells from baseline to week 24 was not met. Treatment with belimumab did not significantly reduce the number of naive B cells from baseline to week 24 (adjusted mean difference between the belimumab and placebo treatment groups -34·4 cells per μL, 95% CI -109·5 to 40·7). INTERPRETATION Belimumab might be a useful adjunct to standard-of-care immunosuppression in renal transplantation, with no major increased risk of infection and potential beneficial effects on humoral alloimmunity. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Gemma D Banham
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Shaun M Flint
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Nicholas Torpey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Don N Shanahan
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Adele Gibson
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ann-Marie O'Sullivan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Joseph A Chadwick
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Katie E Foster
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Luke R Devey
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Anna Richards
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Lars-Peter Erwig
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Caroline O Savage
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Menna R Clatworthy
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.
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53
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Querido S, Weigert A, Adragão T, Henriques J, Birne R, Matias P, Jorge C, Nascimento C, Bruges M, Machado D. Intravenous Immunoglobulin and Rituximab in HLA Highly Sensitized Kidney Transplant Recipients. Transplant Proc 2018; 50:723-727. [PMID: 29661424 DOI: 10.1016/j.transproceed.2018.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION HLA-sensitized patients are penalized both in the access to kidney transplantation (KT) and, once transplanted, in the incidence of rejections and long-term allograft survival despite aggressive induction and maintenance therapy. METHODS This study retrospectively evaluates the impact of combining T- and B-cell-depleting agents and intravenous immunoglobulin for induction therapy in 45 highly sensitized KT patients (anti-panel reactive antibodies >60%, positive flow cytometry crossmatch or donor specific antibodies at the time of transplantation). The outcome data included the occurrence of biopsy-proven acute rejection, new-onset proteinuria, development of leukopenia, incidence of poliomavirus infection (BK or JC virus), fungal or bacterial infection after KT, de novo neoplasia, graft function, graft loss, or death with functioning KT. RESULTS The average panel reactive antibody was 62.5%; 41 patients (91.1%) had ≥3 HLA mismatches with the donor and 91.1% of patients had class I or II anti-HLA antibodies. Fourteen patients (31.1%) presented pre-KT donor-specific antibodies and 6 patients (13.3%) had a positive flow cytometry cross-match at the time of transplantation. The incidence of acute rejection in the first 6 months was 24.4% and the cumulative incidence was 37.8%. Two patients were diagnosed with leukopenia in the first 6 months after KT. Two patients (4.5%) had cytomegalovirus disease, 17 patients (37.8%) were diagnosed with bacterial infections. Cutaneous neoplasms were identified in 5 patients (11.1%) and solid tumors in 4 (8.9%). The death-censored graft survival was 100% in the first 6 months and 93.5% at the last evaluation. Patient survival in the same periods was 97.8% and 93.3%, respectively. CONCLUSIONS Induction immunosuppressive therapy with intravenous immunoglobulin and rituximab is effective; outcomes demonstrate an excellent patient and allograft survival and allograft function over the follow-up period.
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Affiliation(s)
- S Querido
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal.
| | - A Weigert
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - T Adragão
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - J Henriques
- Department of Pathology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - R Birne
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - P Matias
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - C Jorge
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - C Nascimento
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - M Bruges
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - D Machado
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
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54
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Lee J, Huh KH, Park Y, Park BG, Yang J, Jeong JC, Lee J, Park JB, Cho JH, Lee S, Ro H, Han SY, Kim MS, Kim YS, Kim SJ, Kim CD, Chung W, Park SB, Ahn C. The clinicopathological relevance of pretransplant anti-angiotensin II type 1 receptor antibodies in renal transplantation. Nephrol Dial Transplant 2018; 32:1244-1250. [PMID: 26546592 DOI: 10.1093/ndt/gfv375] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022] Open
Abstract
Background Anti-angiotensin II type 1 receptor antibodies (AT1R-Abs) have been suggested as a risk factor for graft failure and acute rejection (AR). However, the prevalence and clinical significance of pretransplant AT1R-Abs have seldom been evaluated in Asia. Methods In this multicenter, observational cohort study, we tested the AT1R-Abs in pretransplant serum samples obtained from 166 kidney transplant recipients. Statistical analysis was used to set a threshold AT1R-Abs level at 9.05 U/mL. Results Pretransplant AT1R-Abs were detected in 98/166 (59.0%) of the analyzed recipients. No graft loss or patient death was reported during the study period. AT1R-Abs (+) patients had a significantly higher incidence of biopsy-proven AR than AT1R-Abs (-) patients (27.6 versus 10.3%, P = 0.007). Recipients with pretransplant AT1R-Abs had a 3.2-fold higher risk of AR within a year of transplantation (P = 0.006). Five study subjects developed microcirculation inflammation (score ≥2). Four of them were presensitized to AT1R-Abs. In particular, three patients had a high titer of anti-AT1R-Abs (>22.7 U/mL). Conclusions Pretransplant AT1R-Abs is an independent risk factor for AR, especially acute cellular rejection, and is possibly associated with the risk of antibody-mediated injury. Pretransplant assessment of AT1R-Abs may be useful for stratifying immunologic risks.
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Affiliation(s)
- Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yongjung Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Laboratory Medicine, NHIC Medical Center, Ilsan Hospital, Goyang, Republic of Korea
| | - Borae G Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong Cheol Jeong
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joongyup Lee
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Berm Park
- Department of Surgery, Sungkyunkwan University, Seoul Samsung Medical Center, Seoul, Republic of Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sik Lee
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Han Ro
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Republic of Korea
| | - Seung-Yeup Han
- Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Joo Kim
- Department of Surgery, Sungkyunkwan University, Seoul Samsung Medical Center, Seoul, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Republic of Korea
| | - Sung-Bae Park
- Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Curie Ahn
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Risk factors associated with the development of histocompatibility leukocyte antigen sensitization. Curr Opin Organ Transplant 2017; 21:447-52. [PMID: 27258577 DOI: 10.1097/mot.0000000000000336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Despite excellent short-term kidney allograft survival rates, long-term outcomes have not improved. For years, the focus on improving these outcomes revolved around minimization or elimination of calcineurin toxicity. Despite our best efforts, approximately 5000 allografts are lost each year in the United States and results in a significant emotional burden for patients and financial burden for the healthcare system. RECENT FINDINGS Advancements in detection of donor-specific histocompatibility leukocyte antigen antibodies (DSAs) and improved assessment of allograft biopsy tissue have shown that the most common cause for graft failures is DSA-related antibody-mediated rejection. Sensitization is directly related to human tissue exposure prior to transplant. We now know that sensitization can occur in patients who are non compliant or poorly compliant with their calcineurin inhibitors. They develop de-novo DSAs, which are responsible for numerous allograft losses around the world. SUMMARY Given the current evidence, it is imperative that all transplant physicians recognize the importance of encouraging medication adherence to prevent the consequences of DSA-induced graft failure. However, little progress has been made in this area. Other potential therapeutic approaches based on B-cell depletion or modulation early posttransplant may help to reduce the risk for de-novo DSA development.
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Okada M, Watarai Y, Iwasaki K, Murotani K, Futamura K, Yamamoto T, Hiramitsu T, Tsujita M, Goto N, Narumi S, Takeda A, Morozumi K, Uchida K, Kobayashi T. Favorable results in ABO-incompatible renal transplantation without B cell-targeted therapy: Advantages and disadvantages of rituximab pretreatment. Clin Transplant 2017; 31. [PMID: 28792635 DOI: 10.1111/ctr.13071] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
The effectiveness of desensitization with rituximab in ABO-incompatible renal transplantation (ABO-I) has been widely reported. However, ABO-I outcomes are still worse than those of ABO-identical or ABO-compatible renal transplantation (ABO-Id/C). We retrospectively examined the outcomes in consecutive living donor ABO-Id/C (n = 412) and ABO-I (n = 205) cases to elucidate the causes of inferiority in ABO-I. ABO-I cases included recipients treated with rituximab (RIT, n = 131), splenectomy (SPX, n = 21), or neither because of low anti-A/B antibody titers (NoR/S, n = 53). Graft survival, infection, and de novo HLA antibody production were compared for ABO-I and ABO-Id/C, followed by stratification into RIT and NoR/S groups. Propensity score-based methods were employed to limit selection bias and potential confounders. Overall graft survival for ABO-I was significantly lower than that for ABO-Id/C (92.8% vs 97.2% after 5 years, P = .0037). Graft loss due to infection with ABO-I was significantly more frequent than that with ABO-Id/C, whereas acute antibody-mediated rejection (AMR) caused no graft failure in ABO-I recipients. Stratified analysis demonstrated significantly higher infection risk with RIT than with NoR/S. Safe reduction or avoidance of rituximab in desensitization protocols might contribute to further improvement of ABO-I outcome.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Iwasaki
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kenta Murotani
- Division of Biostatistics, Clinical Research Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan.,Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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Wehmeier C, Hönger G, Cun H, Amico P, Hirt-Minkowski P, Georgalis A, Hopfer H, Dickenmann M, Steiger J, Schaub S. Donor Specificity but Not Broadness of Sensitization Is Associated With Antibody-Mediated Rejection and Graft Loss in Renal Allograft Recipients. Am J Transplant 2017; 17:2092-2102. [PMID: 28245084 DOI: 10.1111/ajt.14247] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/13/2017] [Accepted: 02/17/2017] [Indexed: 01/25/2023]
Abstract
Panel-reactive antibodies are widely regarded as an important immunological risk factor for rejection and graft loss. The broadness of sensitization against HLA is most appropriately measured by the "calculated population-reactive antibodies" (cPRA) value. In this study, we investigated whether cPRA represent an immunological risk in times of sensitive and accurate determination of pretransplantation donor-specific HLA antibodies (DSA). Five hundred twenty-seven consecutive transplantations were divided into four groups: cPRA 0% (n = 250), cPRA 1-50% (n = 129), cPRA 51-100% (n = 43), and DSA (n = 105). Patients without DSA were considered as normal risk and received standard immunosuppression without T cell-depleting induction. Patients with DSA received an enhanced induction therapy and maintenance immunosuppression. Surveillance biopsies were performed at 3 and 6 months. Median follow-up was 5.7 years. Among the three cPRA groups, there were no differences regarding the 1-year incidence of ABMR (p = 0.16) and TCMR (p = 0.75). The 5-year allograft survival rates were similar and around 87% (p = 0.28). The estimated glomerular filtration rate at last follow-up was 50-53 mL/min (p = 0.45). On multivariable Cox proportional hazard analysis, the strongest independent predictor for ABMR and (death-censored) graft survival was pretransplantation DSA. cPRA were not predictive for ABMR, TCMR, or (death-censored) graft survival. We conclude that with current DSA assignment, the broadness of sensitization measured by cPRA does not imply an immunological risk.
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Affiliation(s)
- C Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - G Hönger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.,HLA-Diagnostic and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland.,Transplantation Immunology and Nephrology, Department of Biomedicine, University Basel, Basel, Switzerland
| | - H Cun
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - P Amico
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.,HLA-Diagnostic and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - P Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - A Georgalis
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - H Hopfer
- Institute for Pathology, University Hospital Basel, Basel, Switzerland
| | - M Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - J Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - S Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.,HLA-Diagnostic and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland.,Transplantation Immunology and Nephrology, Department of Biomedicine, University Basel, Basel, Switzerland
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59
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Absence of Intragraft B Cells in Rejection Biopsies After Rituximab Induction Therapy: Consequences for Clinical Outcome. Transplant Direct 2017; 3:e143. [PMID: 28405599 PMCID: PMC5381736 DOI: 10.1097/txd.0000000000000659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 01/19/2023] Open
Abstract
Background The pathophysiological role of intragraft B cells during renal allograft rejection is unclear. Methods We studied B-cell infiltration during acute rejection in 53 patients who participated in a clinical trial in which adult renal transplant patients were randomized between a single intraoperative dose of rituximab (375 mg/m2) or placebo as induction therapy. Two independent pathologists scored all biopsies in a blinded fashion according to the Banff classification and scored for the presence of B cells and plasma cells using CD79a and CD138 as markers. Results The majority of acute rejections were T cell–mediated. The proportion of acute rejections with an antibody-mediated component tended to be lower in rituximab-treated patients (4/23, 17.4%) than in placebo-treated patients (11/30, 36.7%; P = 0.14). Biopsies of rituximab-treated patients had significantly lower scores for B cells (0.00; range, 0.00-0.50 vs 1.70; range, 0.60-3.30; P < 0.0001) and plasma cells (0.10; range, 0.00-1.90 vs 0.40; range, 0.00-7.50; P = 0.006). During acute rejection, intragraft clusters of B cells were not observed after rituximab induction therapy. However, the depletion of intragraft B cells during acute rejection did not affect steroid resistance, proteinuria, graft function at 2 years follow-up, or patient and graft survival at a median follow-up of 4.1 years (range, 2.0-6.2 years). Conclusions These data do not support a harmful influence of intragraft B cells present during acute allograft rejection on the clinical course within the first few years after renal transplantation.
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60
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Firl DJ, Benichou G, Kim JI, Yeh H. A Paradigm Shift on the Question of B Cells in Transplantation? Recent Insights on Regulating the Alloresponse. Front Immunol 2017; 8:80. [PMID: 28210263 PMCID: PMC5288351 DOI: 10.3389/fimmu.2017.00080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
B lymphocytes contribute to acute and chronic allograft rejection through their production of donor-specific antibodies (DSAs). In addition, B cells present allopeptides bound to self-MHC class II molecules and provide costimulation signals to T cells, which are essential to their activation and differentiation into memory T cells. On the other hand, both in laboratory rodents and patients, the concept of effector T cell regulation by B cells is gaining traction in the field of transplantation. Specifically, clinical trials using anti-CD20 monoclonal antibodies to deplete B cells and reverse DSA had a deleterious effect on rates of acute cellular rejection; a peculiar finding that calls into question a central paradigm in transplantation. Additional work in humans has characterized IL-10-producing B cells (IgM memory and transitional B cells), which suppress the proliferation and inflammatory cytokine productions of effector T cells in vitro. Understanding the mechanisms of regulating the alloresponse is critical if we are to achieve operational tolerance across transplantation. This review will focus on recent evidence in murine and human transplantation with respect to non-traditional roles for B cells in determining clinical outcomes.
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Affiliation(s)
- Daniel J Firl
- Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Howard Hughes Medical Institute, Chevy Chase, MD, USA
| | - Gilles Benichou
- Transplant Center, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - James I Kim
- Transplant Center, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Heidi Yeh
- Transplant Center, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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61
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Yeung MY, Gabardi S, Sayegh MH. Use of polyclonal/monoclonal antibody therapies in transplantation. Expert Opin Biol Ther 2017; 17:339-352. [PMID: 28092486 DOI: 10.1080/14712598.2017.1283400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION For over thirty years, antibody (mAb)-based therapies have been a standard component of transplant immunosuppression, and yet much remains to be learned in order for us to truly harness their therapeutic capabilities. Current mAbs used in transplant directly target and destroy graft-destructive immune cells, interrupt cytokine and costimulation-dependent T and B cell activation, and prevent down-stream complement activation. Areas covered: This review summarizes our current approaches to using antibody-based therapies to prevent and treat allograft rejection. It also provides examples of promising novel mAb therapies, and discusses the potential for future mAb development in transplantation. Expert opinion: The broad capability of antibodies, in parallel with our growing ability to synthetically modulate them, offers exciting opportunities to develop better biologic therapeutics. In order to do so, we must further our understanding about the basic biology underlying allograft rejection, and gain better appreciation of how characteristics of therapeutic antibodies affect their efficacy.
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Affiliation(s)
- Melissa Y Yeung
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States
| | - Steven Gabardi
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States
| | - Mohamed H Sayegh
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States.,b Faculty of Medicine, Professor of Medicine and Immunology , American University of Beirut , Beirut , Lebanon
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Hill P, Cross NB, Barnett ANR, Palmer SC, Webster AC. Polyclonal and monoclonal antibodies for induction therapy in kidney transplant recipients. Cochrane Database Syst Rev 2017; 1:CD004759. [PMID: 28073178 PMCID: PMC6464766 DOI: 10.1002/14651858.cd004759.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prolonging kidney transplant survival is an important clinical priority. Induction immunosuppression with antibody therapy is recommended at transplantation and non-depleting interleukin-2 receptor monoclonal antibodies (IL2Ra) are considered first line. It is suggested that recipients at high risk of rejection should receive lymphocyte-depleting antibodies but the relative benefits and harms of the available agents are uncertain. OBJECTIVES We aimed to: evaluate the relative and absolute effects of different antibody preparations (except IL2Ra) when used as induction therapy in kidney transplant recipients; determine how the benefits and adverse events vary for each antibody preparation; determine how the benefits and harms vary for different formulations of antibody preparation; and determine whether the benefits and harms vary in specific subgroups of recipients (e.g. children and sensitised recipients). SEARCH METHODS Randomised controlled trials (RCTs) comparing monoclonal or polyclonal antibodies with placebo, no treatment, or other antibody therapy in adults and children who had received a kidney transplant. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing monoclonal or polyclonal antibodies with placebo, no treatment, or other antibody therapy in adults and children who had received a kidney transplant. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) together with their 95% confidence intervals (CI). MAIN RESULTS We included 99 studies (269 records; 8956 participants; 33 with contemporary agents). Methodology was incompletely reported in most studies leading to lower confidence in the treatment estimates.Antithymocyte globulin (ATG) prevented acute graft rejection (17 studies: RR 0.63, 95% CI 0.51 to 0.78). The benefits of ATG on graft rejection were similar when used with (12 studies: RR 0.61, 0.49 to 0.76) or without (5 studies: RR 0.65, 0.43 to 0.98) calcineurin inhibitor (CNI) treatment. ATG (with CNI therapy) had uncertain effects on death (3 to 6 months, 3 studies: RR 0.41, 0.13 to 1.22; 1 to 2 years, 5 studies: RR 0.75, 0.27 to 2.06; 5 years, 2 studies: RR 0.94, 0.11 to 7.81) and graft loss (3 to 6 months, 4 studies: RR 0.60, 0.34 to 1.05; 1 to 2 years, 3 studies: RR 0.65, 0.36 to 1.19). The effect of ATG on death-censored graft loss was uncertain at 1 to 2 years and 5 years. In non-CNI studies, ATG had uncertain effects on death but reduced death-censored graft loss (6 studies: RR 0.55, 0.38 to 0.78). When CNI and older non-CNI studies were combined, a benefit was seen with ATG at 1 to 2 years for both all-cause graft loss (7 studies: RR 0.71, 0.53 to 0.95) and death-censored graft loss (8 studies: RR 0.55, 0.39 to 0.77) but not sustained longer term. ATG increased cytomegalovirus (CMV) infection (6 studies: RR 1.55, 1.24 to 1.95), leucopenia (4 studies: RR 3.86, 2.79 to 5.34) and thrombocytopenia (4 studies: RR 2.41, 1.61 to 3.61) but had uncertain effects on delayed graft function, malignancy, post-transplant lymphoproliferative disorder (PTLD), and new onset diabetes after transplantation (NODAT).Alemtuzumab was compared to ATG in six studies (446 patients) with early steroid withdrawal (ESW) or steroid minimisation. Alemtuzumab plus steroid minimisation reduced acute rejection compared to ATG at one year (4 studies: RR 0.57, 0.35 to 0.93). In the two studies with ESW only in the alemtuzumab arm, the effect of alemtuzumab on acute rejection at 1 year was uncertain compared to ATG (RR 1.27, 0.50 to 3.19). Alemtuzumab had uncertain effects on death (1 year, 2 studies: RR 0.39, 0.06 to 2.42; 2 to 3 years, 3 studies: RR 0.67, 95% CI 0.15 to 2.95), graft loss (1 year, 2 studies: RR 0.39, 0.13 to 1.30; 2 to 3 years, 3 studies: RR 0.98, 95% CI 0.47 to 2.06), and death-censored graft loss (1 year, 2 studies: RR 0.38, 0.08 to 1.81; 2 to 3 years, 3 studies: RR 2.45, 95% CI 0.67 to 8.97) compared to ATG. Creatinine clearance was lower with alemtuzumab plus ESW at 6 months (2 studies: MD -13.35 mL/min, -23.91 to -2.80) and 2 years (2 studies: MD -12.86 mL/min, -23.73 to -2.00) compared to ATG plus triple maintenance. Across all 6 studies, the effect of alemtuzumab versus ATG was uncertain on all-cause infection, CMV infection, BK virus infection, malignancy, and PTLD. The effect of alemtuzumab with steroid minimisation on NODAT was uncertain, compared to ATG with steroid maintenance.Alemtuzumab plus ESW compared with triple maintenance without induction therapy had uncertain effects on death and all-cause graft loss at 1 year, acute rejection at 6 months and 1 year. CMV infection was increased (2 studies: RR 2.28, 1.18 to 4.40). Treatment effects were uncertain for NODAT, thrombocytopenia, and malignancy or PTLD.Rituximab had uncertain effects on death, graft loss, acute rejection and all other adverse outcomes compared to placebo. AUTHORS' CONCLUSIONS ATG reduces acute rejection but has uncertain effects on death, graft survival, malignancy and NODAT, and increases CMV infection, thrombocytopenia and leucopenia. Given a 45% acute rejection risk without ATG induction, seven patients would need treatment to prevent one having rejection, while incurring an additional patient experiencing CMV disease for every 12 treated. Excluding non-CNI studies, the risk of rejection was 37% without induction with six patients needing treatment to prevent one having rejection.In the context of steroid minimisation, alemtuzumab prevents acute rejection at 1 year compared to ATG. Eleven patients would require treatment with alemtuzumab to prevent 1 having rejection, assuming a 21% rejection risk with ATG.Triple maintenance without induction therapy compared to alemtuzumab combined with ESW had similar rates of acute rejection but adverse effects including NODAT were poorly documented. Alemtuzumab plus steroid withdrawal would cause one additional patient experiencing CMV disease for every six patients treated compared to no induction and triple maintenance, in the absence of any clinical benefit. Overall, ATG and alemtuzumab decrease acute rejection at a cost of increased CMV disease while patient-centred outcomes (reduced death or lower toxicity) do not appear to be improved.
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Affiliation(s)
- Penny Hill
- Christchurch Public HospitalDepartment of NephrologyChristchurchNew Zealand
| | - Nicholas B Cross
- Christchurch Public HospitalDepartment of NephrologyChristchurchNew Zealand
| | | | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Progress in Desensitization of the Highly HLA Sensitized Patient. Transplant Proc 2017; 48:802-5. [PMID: 27234740 DOI: 10.1016/j.transproceed.2015.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/11/2015] [Indexed: 01/15/2023]
Abstract
The presence of HLA antibodies remains a significant and often impenetrable barrier to kidney transplantation, leading to increased morbidity and mortality for patients remaining on long-term dialysis. In recent years, a number of new approaches have been developed to overcome these barriers. Intravenous immunoglobulin (IVIG) remains the lynchpin of HLA desensitization therapy and has been shown in a prospective, randomized, placebo-controlled trial to improve transplantation rates. In addition, IVIG used in low doses with plasma exchange is a reliable protocol for desensitization. Another significant advancement was the addition of rituximab (anti-B-cell therapy) to IVIG and plasma exchange-based desensitization. This approach has significantly improved rates of transplantation and outcomes. There is limited experience with bortezomib (anti-plasma cell therapy) and eculizumab (complement inhibition) for desensitization. However, recent data from a completed trial of eculizumab failed to show a significant benefit for prevention of antibody-mediated rejection compared with standard therapy plus placebo, and bortezomib produced inconsistent results. There is a growing interest in developing new therapeutic agents for desensitization. Newer approaches that address antibody reduction with B-cell depletion are discussed.
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Desensitization: Overcoming the Immunologic Barriers to Transplantation. J Immunol Res 2017; 2017:6804678. [PMID: 28127571 PMCID: PMC5239985 DOI: 10.1155/2017/6804678] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/14/2016] [Indexed: 12/17/2022] Open
Abstract
HLA (Human Leucocyte Antigen) sensitization is a significant barrier to successful kidney transplantation. It often translates into difficult crossmatch before transplant and increased risk of acute and chronic antibody mediated rejection after transplant. Over the last decade, several immunomodulatory therapies have emerged allowing for increased access to kidney transplantation for the immunologically disadvantaged group of HLA sensitized end stage kidney disease patients. These include IgG inactivating agents, anti-cytokine antibodies, costimulatory molecule blockers, complement inhibitors, and agents targeting plasma cells. In this review, we discuss currently available agents for desensitization and provide a brief analysis of data on novel biologics, which will likely improve desensitization outcomes, and have potential implications in treatment of antibody mediated rejection.
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Trivin C, Tran A, Moulin B, Choukroun G, Gatault P, Courivaud C, Augusto JF, Ficheux M, Vigneau C, Thervet E, Karras A. Infectious complications of a rituximab-based immunosuppressive regimen in patients with glomerular disease. Clin Kidney J 2016; 10:461-469. [PMID: 28852482 PMCID: PMC5570029 DOI: 10.1093/ckj/sfw101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/24/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent years have seen increasing use of rituximab (RTX) for various types of primary and secondary glomerulopathies. However, there are no studies that specifically address the risk of infection related to this agent in patients with these conditions. METHODS We reviewed the outcomes of all patients who received RTX therapy for glomerular disease between June 2000 and October 2011 in eight French nephrology departments. Each case was analysed for survival, cause of death if a non-survivor and/or the presence of infectious complications, including severe or opportunistic infection occurring within the 12 months following RTX infusion. RESULTS Among 98 patients treated with RTX, 25 presented with at least one infection. We report an infection rate of 21.6 per 100 patient-years. Five patients died within 12 months following an RTX infusion, of whom four also presented with an infection. The median interval between the last RTX infusion and the first infectious episode was 2.1 months (interquartile range 0.5-5.1). Most infections were bacterial (79%) and pneumonia was the most frequent infection reported (27%). The presence of diabetes mellitus (P = 0.006), the cumulative RTX dose (P = 0.01) and the concomitant use of azathioprine (P = 0.03) were identified as independent risk factors. Renal failure was significantly associated with an increased infection risk by bivariate analysis (P = 0.03) and was almost significant by multivariate analysis (P = 0.05). Nephrotic syndrome did not further increase the risk of infection and/or death. CONCLUSION The risk of infection after RTX-based immunosuppression among patients with glomerulopathy must be considered and patients should receive close monitoring and appropriate infection prophylaxis, especially in those with diabetes and high-dose RTX regimens.
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Affiliation(s)
- Claire Trivin
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Antoine Tran
- Pediatric Emergency, Hopitaux pediatrique CHU Nice Lenval, France
| | - Bruno Moulin
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, France
| | | | | | - Cécile Courivaud
- Nephrology, Dialysis and Renal Transplantation, CHU Saint Jacques, Besançon, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, France.,University of Angers, INSERM, U892-CRCNA, France
| | | | - Cécile Vigneau
- Service de Néphrologie, CHU Rennes, France.,Université Rennes 1, CNRS UMR 6290 equipe Kyca, France
| | - Eric Thervet
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
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Laws LH, Parker CE, Cherala G, Koguchi Y, Waisman A, Slifka MK, Oberbarnscheidt MH, Obhrai JS, Yeung MY, Riella LV. Inflammation Causes Resistance to Anti-CD20-Mediated B Cell Depletion. Am J Transplant 2016; 16:3139-3149. [PMID: 27265023 PMCID: PMC5334788 DOI: 10.1111/ajt.13902] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 05/11/2016] [Accepted: 05/23/2016] [Indexed: 01/25/2023]
Abstract
B cells play a central role in antibody-mediated rejection and certain autoimmune diseases. However, B cell-targeted therapy such as anti-CD20 B cell-depleting antibody (aCD20) has yielded mixed results in improving outcomes. In this study, we investigated whether an accelerated B cell reconstitution leading to aCD20 depletion resistance could account for these discrepancies. Using a transplantation model, we found that antigen-independent inflammation, likely through toll-like receptor (TLR) signaling, was sufficient to mitigate B cell depletion. Secondary lymphoid organs had a quicker recovery of B cells when compared to peripheral blood. Inflammation altered the pharmacokinetics (PK) and pharmacodynamics (PD) of aCD20 therapy by shortening drug half-life and accelerating the reconstitution of the peripheral B cell pool by bone marrow-derived B cell precursors. IVIG (intravenous immunoglobulin) coadministration also shortened aCD20 drug half-life and led to accelerated B cell recovery. Repeated aCD20 dosing restored B cell depletion and delayed allograft rejection, especially B cell-dependent, antibody-independent allograft rejection. These data demonstrate the importance of further clinical studies of the PK/PD of monoclonal antibody treatment in inflammatory conditions. The data also highlight the disconnect between B cell depletion on peripheral blood compared to secondary lymphoid organs, the deleterious effect of IVIG when given with aCD20 and the relevance of redosing of aCD20 for effective B cell depletion in alloimmunity.
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Affiliation(s)
| | | | - Ganesh Cherala
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University
| | - Yoshinobu Koguchi
- Molecular Microbiology & Immunology, Oregon Health & Science University
| | - Ari Waisman
- Institute for Molecular Medicine, Johannes Gutenberg University Mainz
| | - Mark K. Slifka
- Oregon National Primate Research Center, Oregon Health & Science University
| | | | | | - Melissa Y. Yeung
- Schuster Transplant Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School
| | - Leonardo V. Riella
- Schuster Transplant Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School
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Uchida J, Iwai T, Kabei K, Nishide S, Yamasaki T, Kuwabara N, Naganuma T, Kumada N, Takemoto Y, Nakatanti T. ABO-Incompatible Living Kidney Transplant Recipients from Spousal Donors Receiving Rituximab. Urol Int 2016; 97:457-465. [PMID: 27732972 DOI: 10.1159/000449014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/08/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We summarized our experience with ABO-incompatible living kidney transplant recipients from spousal donors receiving rituximab. PATIENTS AND METHODS Between June 2006 and December 2014, 82 patients with end-stage renal disease underwent living donor kidney transplantation at Osaka City University Hospital, of which 23 cases were ABO-incompatible transplantation between spouses with rituximab induction. We analyzed these recipients, focusing on their immunosuppressive protocols, frequency of acute rejections, and patient/graft survivals. RESULTS Patient and graft survival rates were 100%. The incidence of acute cellular rejection (ACR) was 30.4%. One patient experienced antibody-mediated rejection (AMR) and intractable ACR, 2 had AMR, and 2 had intractable ACR episodes that were treated using thymoglobulin. CONCLUSIONS This study demonstrated that ABO-incompatible kidney transplantation between spouses using rituximab is a radical but effective treatment for end-stage renal disease. However, this procedure could be immunologically high risk due to ABO-incompatibility and poor histocompatibility.
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Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Kleinclauss F, Frontczak A, Terrier N, Thuret R, Timsit MO. [Immunology and immunosuppression in kidney transplantation. ABO and HLA incompatible kidney transplantation]. Prog Urol 2016; 26:977-992. [PMID: 27670824 DOI: 10.1016/j.purol.2016.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To perform a state of the art about immunological features in renal transplantation, immunosuppressive drugs and their mechanisms of action and immunologically high risk transplantations such as ABO and HLA-incompatible transplantation. MATERIAL AND METHODS An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "allogenic response; allograft; immunosuppression; ABO incompatible transplantation; donor specific antibodies; HLA incompatible; desensitization; kidney transplantation". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 4717 articles. After reading titles and abstracts, 141 were included in the text, based on their relevance. RESULTS The considerable step in comprehension and knowledge allogeneic response this last few years allowed a better used of immunosuppression and the discover of news immunosuppressive drugs. In the first part of this article, the allogeneic response will be described. The different classes of immunosuppressive drugs will be presented and the actual management of immunosuppression will be discussed. Eventually, the modalities and results of immunologically high-risk transplantations such as ABO and HLA incompatible transplantations will be reported. CONCLUSIONS The knowledge and the control of allogeneic response to allogeneic graft allowed the development of renal transplantation.
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Affiliation(s)
- F Kleinclauss
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France.
| | - A Frontczak
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France
| | - N Terrier
- Service d'urologie et transplantation rénale, CHU de Grenoble, 38700 Grenoble, France
| | - R Thuret
- Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34000 Montpellier, France
| | - M-O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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Safa K, Chandran S, Wojciechowski D. Pharmacologic targeting of regulatory T cells for solid organ transplantation: current and future prospects. Drugs 2016; 75:1843-52. [PMID: 26493288 DOI: 10.1007/s40265-015-0487-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The last three decades have witnessed significant advances in the development of immunosuppressive medications used in kidney transplantation leading to a remarkable gain in short-term graft function and outcomes. Despite these major breakthroughs, improvements in long-term outcomes lag behind due to a stalemate between drug-related nephrotoxicity and chronic rejection typically due to donor-specific antibodies. Regulatory T cells (Tregs) have been shown to modulate the alloimmune response and can exert suppressive activity preventing allograft rejection in kidney transplantation. Currently available immunosuppressive agents impact Tregs in the alloimmune milieu with some of these interactions being deleterious to the allograft while others may be beneficial. Variable effects are seen with common antibody induction agents such that basiliximab, an IL-2 receptor blocker, decreases Tregs while lymphocyte depleting agents such as antithymocyte globulin increase Tregs. Calcineurin inhibitors, a mainstay of maintenance immunosuppression since the mid-1980s, seem to suppress Tregs while mammalian targets of rapamycin (less commonly used in maintenance regimens) expand Tregs. The purpose of this review is to provide an overview of Treg biology in transplantation, identify in more detail the interactions between commonly used immunosuppressive agents and Tregs in kidney transplantation and lastly describe future directions in the use of Tregs themselves as therapy for tolerance induction.
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Affiliation(s)
- Kassem Safa
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Sindhu Chandran
- Division of Nephrology, Department of Medicine, University of California San Francisco Medical center, San Francisco, CA, USA
| | - David Wojciechowski
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
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Novel immunotherapeutic strategies to target alloantibody-producing B and plasma cells in transplantation. Curr Opin Organ Transplant 2016; 21:419-26. [DOI: 10.1097/mot.0000000000000338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Preemptive CD20+ B cell Depletion Attenuates Cardiac Allograft Vasculopathy in CD154-Treated Monkeys. Transplantation 2016; 101:63-73. [PMID: 27362307 DOI: 10.1097/tp.0000000000001258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Anti-CD154 monotherapy is associated with antidonor allo-antibody (Ab) elaboration, cardiac allograft vasculopathy (CAV), and allograft failure in preclinical primate cell and organ transplant models. In the context of calcineurin inhibitors (CNI), these pathogenic phenomena are delayed by preemptive "induction" B cell depletion. METHODS αCD154 (IDEC-131)-treated cynomolgus monkey heart allograft recipients were given peritransplant rituximab (αCD20) alone or with rabbit antihuman thymocyte globulin. RESULTS Relative to previously reported reference groups, αCD20 significantly prolonged survival, delayed Ab detection, and attenuated CAV within 3 months in αCD154-treated recipients (αCD154 + αCD20 graft median survival time > 90 days, n = 7, vs 28 days for αCD154 alone (IDEC-131), n = 21; P = 0.05). Addition of rabbit antihuman thymocyte globulin to αCD154 (n = 6) or αCD154 + αCD20 (n = 10) improved graft protection from graft rejection and failure during treatment but was associated with significant morbidity in 8 of 16 recipients (6 infections, 2 drug-related complications). In αCD20-treated animals, detection of antidonor Ab and relatively severe CAV were anticipated by appearance of CD20 cells (>1% of lymphocytes) in peripheral blood and were associated with low αCD154 trough levels (below 100 μg/mL). CONCLUSIONS These observations support the hypothesis that efficient preemptive "induction" CD20 B cell depletion consistently modulates pathogenic alloimmunity and attenuates CAV in this translational model, extending our prior findings with calcineurin inhibitors to the context of CD154 blockade.
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The Influence of Immunosuppressive Agents on the Risk of De Novo Donor-Specific HLA Antibody Production in Solid Organ Transplant Recipients. Transplantation 2016; 100:39-53. [PMID: 26680372 PMCID: PMC4683034 DOI: 10.1097/tp.0000000000000869] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Production of de novo donor-specific antibodies (dnDSA) is a major risk factor for acute and chronic antibody-mediated rejection and graft loss after all solid organ transplantation. In this article, we review the data available on the risk of individual immunosuppressive agents and their ability to prevent dnDSA production. Induction therapy with rabbit antithymocyte globulin may achieve a short-term decrease in dnDSA production in moderately sensitized patients. Rituximab induction may be beneficial in sensitized patients, and in abrogating rebound antibody response in patients undergoing desensitization or treatment for antibody-mediated rejection. Use of bortezomib for induction therapy in at-risk patients is of interest, but the benefits are unproven. In maintenance regimens, nonadherent and previously sensitized patients are not suitable for aggressive weaning protocols, particularly early calcineurin inhibitor withdrawal without lymphocyte-depleting induction. Early conversion to mammalian target of rapamycin inhibitor monotherapy has been reported to increase the risk of dnDSA formation, but a combination of mammalian target of rapamycin inhibitor and reduced-exposure calcineurin inhibitor does not appear to alter the risk. Early steroid therapy withdrawal in standard-risk patients after induction has no known dnDSA penalty. The available data do not demonstrate a consistent effect of mycophenolic acid on dnDSA production. Risk minimization for dnDSA requires monitoring of adherence, appropriate risk stratification, risk-based immunosuppression intensity, and prospective DSA surveillance.
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Umber A, Killackey M, Paramesh A, Liu Y, Qin H, Atiq M, Lee B, Alper AB, Simon E, Buell J, Zhang R. A comparison of three induction therapies on patients with delayed graft function after kidney transplantation. J Nephrol 2016; 30:289-295. [PMID: 27062485 DOI: 10.1007/s40620-016-0304-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/25/2016] [Indexed: 01/16/2023]
Abstract
We compare the outcomes of induction therapies with either methylprednisolone (group 1, n = 58), basiliximab (group 2, n = 56) or alemtuzumab (group 3, n = 98) in primary deceased donor kidney transplants with delayed graft function (DGF). Protocol biopsies were performed. Maintenance was tacrolimus and mycophenolate with steroid (group 1 and 2) or without steroid (group 3). One-year biopsy-confirmed acute rejection (AR) rates were 27.6, 19.6 and 10.2 % in group 1, 2 and 3 (p = 0.007). AR was significantly lower in group 3 (p = 0.002) and group 2 (p = 0.03) than in group 1. One-year graft survival rates were 90, 96 and 100 % in group 1, 2 and 3 (log rank p = 0.006). Group 1 had inferior graft survival than group 2 (p = 0.03) and group 3 (p = 0.002). The patient survival rates were not different (96.6, 98.2 and 100 %, log rank p = 0.81). Multivariable analysis using methylprednisolone induction as control indicated that alemtuzumab (OR 0.31, 95 % CI 0.11-0.82; p = 0.03) and basiliximab (OR 0.60, 95 % CI 0.23-0.98; p = 0.018) were associated with lower risk of AR. Therefore, alemtuzumab or basiliximab induction decreases AR and improves graft survival than methylprednisolone alone in patients with DGF. Alemtuzumab induction might also allow patients with DGF to be maintained with contemporary steroid-withdrawal protocol.
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Affiliation(s)
- Afia Umber
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA
| | - Mary Killackey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Anil Paramesh
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Yongjun Liu
- Department of Biostatistics, Tulane University School of Public Health and Tropic Medicine, New Orleans, LA, USA
| | - Huaizhen Qin
- Department of Biostatistics, Tulane University School of Public Health and Tropic Medicine, New Orleans, LA, USA
| | - Muhammad Atiq
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA
| | - Belinda Lee
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA
| | - Arnold Brent Alper
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA
| | - Eric Simon
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA
| | - Joseph Buell
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Rubin Zhang
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, USA.
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75
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Lee J, Lee JG, Kim S, Song SH, Kim BS, Kim HO, Kim MS, Kim SI, Kim YS, Huh KH. The effect of rituximab dose on infectious complications in ABO-incompatible kidney transplantation. Nephrol Dial Transplant 2016; 31:1013-21. [DOI: 10.1093/ndt/gfw017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
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Okumi M, Toki D, Nozaki T, Shimizu T, Shirakawa H, Omoto K, Inui M, Ishida H, Tanabe K. ABO-Incompatible Living Kidney Transplants: Evolution of Outcomes and Immunosuppressive Management. Am J Transplant 2016; 16:886-96. [PMID: 26555133 DOI: 10.1111/ajt.13502] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 08/23/2015] [Accepted: 08/23/2015] [Indexed: 01/25/2023]
Abstract
ABO-incompatible living kidney transplantation (ABO-ILKT) has steadily become more widespread. However, the optimal immunosuppressive regimen for ABO-ILKT remains uncertain. We aimed to determine the longitudinal changes in the outcomes from ABO-ILKT compared with those from ABO-compatible living kidney transplantation (ABO-CLKT) over the last 25 years. Of 1195 patients who underwent living kidney transplantations (LKT) at our institute between 1989 and 2013, 1032-including 247 ABO-ILKT and 785 ABO-CLKT cases-were evaluated for graft survival, patient survival, infectious adverse events, and renal function. The patients were divided into four groups according to the transplantation era and ABO-compatibility. In the past decade, ABO-ILKT and ABO-CLKT recipients yielded almost equivalent outcomes with respect to the 9-year graft survival rates, which were 86.9% and 92.0%, respectively (hazard ratio [HR] 1.38, 95% confidence interval [CI] 0.59-3.22, p = 0.455). The graft survival rate for ABO-ILKT conducted between 2005 and 2013 was better than that for ABO-ILKT conducted between 1998 and 2004 (HR 0.30, 95% CI 0.13-0.72, p = 0.007). ABO-ILKT recipients showed substantial improvements in the graft survival rate over time. Graft survival was almost identical over the past decade, regardless of ABO-incompatibility. Currently, ABO-ILKT is an acceptable treatment for patients with end-stage renal disease.
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Affiliation(s)
- M Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - D Toki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Nozaki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Shimizu
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Shirakawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - M Inui
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - K Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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77
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Abstract
PURPOSE OF REVIEW There are several monoclonal and polyclonal antibodies used in renal transplantation today, this article will discuss several agents, their updates and newer agents. RECENT FINDINGS Antithymocyte globulin and interleukin-2 (IL-2) receptor blocker continue to be used as induction agents. The risk of acute rejection was higher in IL-2 receptor blockers mainly in the first year, but graft survivals were similar in both groups long term. Belatacept is the only approved intravenous maintenance immunosuppressive therapy which provides the benefit of glomerular filtration rate preservation, but it was associated with a higher risk of acute rejection and post-transplant lymphoproliferative disorder. Bortezomib may help decrease donor-specific antibody levels, but there are limited data to support its use for desensitization or rejection. Eculizumab may help in antibody-mediated rejection in some cases but has not shown promising long-term effects in high-risk individuals. Newer agents have been continuously tested for improved efficacy and safety. SUMMARY Transplantation is the standard of care for end-stage renal disease patients, but we still have a long way to go, as we need to improve long-term outcomes. The manipulation of the immune system is a delicate undertaking, with risks of adverse events; therefore, risk versus benefit needs to be carefully evaluated and treatment needs to be individualized.
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78
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Cheungpasitporn W, Thongprayoon C, Edmonds PJ, Bruminhent J, Tangdhanakanond K. The effectiveness and safety of rituximab as induction therapy in ABO-compatible non-sensitized renal transplantation: a systematic review and meta-analysis of randomized controlled trials. Ren Fail 2015; 37:1522-6. [PMID: 26337918 DOI: 10.3109/0886022x.2015.1077310] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The objective of this systematic review and meta-analysis was to evaluate the effectiveness and safety of rituximab as induction therapy in ABO-compatible, non-sensitized renal transplantation. METHODS A literature search for randomized controlled trials (RCTs) was performed from inception through February 2015. Studies that reported relative risks or hazard ratios comparing the risks of biopsy-proven acute rejection (BPAR), graft loss, leukopenia, infection or mortality in ABO-compatible, non-sensitized renal transplant recipients who received rituximab as induction therapy versus controls were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method. RESULTS Four RCTs with 480 patients were included in the meta-analysis. Pooled RR of BPAR in recipients with rituximab induction was 0.90 (95% CI 0.50-1.60). Compared to placebo, the risk of BPAR in rituximab group was 0.76 (95% CI 0.51-1.14, I(2) = 0). The risk of leukopenia was increased in rituximab group with the pooled RR of 8.22 (95% CI 2.08-32.47). There were no statistical differences in the risks of infection, graft loss and mortality at 3-6 months after transplantation with pool RRs of 1.02 (95% CI 0.85-1.21), 0.55 (95% CI 0.21-1.48) and 0.58 (95% CI 0.17-1.99), respectively. CONCLUSION This meta-analysis demonstrated insignificant reduced risks of BPAR, graft loss or mortality among in ABO-compatible, non-sensitized renal transplant recipients with rituximab induction. Although rituximab induction significantly increases risk of leukopenia, it appears to be safe with no significant risk of infection.
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Affiliation(s)
| | - Charat Thongprayoon
- a Division of Nephrology and Hypertension , Mayo Clinic , Rochester , MN , USA
| | | | - Jackrapong Bruminhent
- c Department of Medicine , Faculty of Medicine Ramathibodi Hospital, Mahidol University , Bangkok , Thailand , and
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79
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Abstract
Kidney transplantation across the ABO blood group barrier was long considered a contraindication for transplantation, but in an effort to increase donor pools, specific regimens for ABO-incompatible (ABOi) transplantation have been developed. These regimens are now widely used as an integral part of the available treatment options. Various desensitization protocols, commonly based on transient depletion of preformed anti-A and/or anti-B antibodies and modulation of B-cell immunity, enable excellent transplant outcomes, even in the long-term. Nevertheless, the molecular mechanisms behind transplant acceptance facilitated by a short course of anti-humoral treatment are still incompletely understood. With the evolution of efficient clinical programmes, tailoring of recipient preconditioning based on individual donor-recipient blood type combinations and the levels of pretransplant anti-A/B antibodies has become possible. In the context of low antibody titres and/or donor A2 phenotype, immunomodulation and/or apheresis might be dispensable. A concern still exists, however, that ABOi kidney transplantation is associated with an increased risk of surgical and infectious complications, partly owing to the effects of extracorporeal treatment and intensified immunosuppression. Nevertheless, a continuous improvement in desensitization strategies, with the aim of minimizing the immunosuppressive burden, might pave the way to clinical outcomes that are comparable to those achieved in ABO-compatible transplantation.
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80
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Abstract
PURPOSE OF REVIEW B cells are known to play a central role in humoral immunity and to boost cellular immunity, however, in a variety of experimental models, B-cell subsets ameliorate inflammation and autoimmune disease, indicating that they can also play a regulatory role. Here, we highlight the advances in regulatory B-cell (Breg) biology of the past year with an emphasis on findings pertinent to transplantation. Several recent observations highlight the relevance to clinical transplantation. Data from at least three independent groups demonstrated that spontaneously tolerant renal transplant recipients exhibit a peripheral blood B-cell signature although the significance of these data remains unclear. Moreover, new data suggest that regulatory B cells may serve as a biomarker for long-term allograft outcomes. Finally, recent evidence suggesting that plasma cells may be an essential component of Bregs raises new concerns about targeting antibody producing cells. RECENT FINDINGS We describe new information on Breg mechanisms of action to suppress the alloresponse, signals to expand Bregs in vitro, and more functional evidence of Breg involvement in operationally tolerant kidney patients and in maintaining stable allograft function. SUMMARY Although lymphocyte depletion remains central to tolerance induction therapy, the sparing or expansion of regulatory B cells may be an additional strategy to preempt graft rejection.
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Affiliation(s)
- James I. Kim
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Thier 8, Boston, MA 02114
| | - David M. Rothstein
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical School, 200 Lothrop Street, E1555 Biomedical Science Tower, Pittsburgh, PA 15261
| | - James F. Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Thier 8, Boston, MA 02114
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81
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Smolewski P, Robak T. The preclinical discovery of rituximab for the treatment of non-Hodgkin’s lymphoma. Expert Opin Drug Discov 2015; 10:791-808. [DOI: 10.1517/17460441.2015.1045295] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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82
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Abstract
BACKGROUND Desensitization, a term loosely referring to a collection of antibody reduction and B-cell depletional therapies aimed at improving rates of transplantation in highly HLA and ABO-incompatible transplant recipients, has seen significant growth in the last decade. Advancements relate to an increasing unmet medical need for FDA-approved therapies, advancements in antibody detection methodologies and improved renal pathological assessments of antibody-mediated rejection (ABMR). SOURCES OF DATA, AREAS OF AGREEMENT AND CONTROVERSY Data reviewed include collective summaries of experience with high-dose intravenous immunoglobulin (IVIG), B-cell depletion with rituximab and the use of plasma exchange with low-dose IVIG. Consensus suggests that these protocols are the most commonly used while experiences with other agents (i.e. bortezomib) are evolving. Controversy exists as to the extent of resources required, expense and outcomes of desensitization protocols. GROWING POINTS OR AREAS TIMELY FOR DEVELOPING RESEARCH Here we review and synthesize data from evolving protocols and summarize developments of novel biologics aimed at modification of B-cells, antibodies and complement activation which will likely improve desensitization and treatment of ABMR.
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Affiliation(s)
- Stanley C Jordan
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jua Choi
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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83
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Clatworthy MR. B cell depletion at induction--making bad immunological memory fade? Am J Transplant 2015; 15:297-8. [PMID: 25612482 DOI: 10.1111/ajt.13054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 09/22/2014] [Accepted: 10/07/2014] [Indexed: 01/25/2023]
Affiliation(s)
- M R Clatworthy
- Department of Medicine, University of Cambridge, Cambridge, UK
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