Limited-dose Daclizumab versus Basiliximab: a comparison of cost and efficacy in preventing acute rejection

Efficacy and Safety of Induction Therapy in Kidney Transplantation: A Network Meta-Analysis

BACKGROUND

Rejection and infection can occur after kidney transplantation and are important factors in preserving graft kidney function. The use of immunosuppressant agents in transplantation is therefore important, and the question of which induction therapy should be used as an immunosuppressant is controversial.

OBJECTIVE

The goal of this study was to assess the comparative benefits and harms of various maintenance immunosuppressive induction agents in adults undergoing kidney transplantation by using a network meta-analysis and to generate rankings of the different immunosuppressive regimens according to their safety and efficacy.

METHODS

CENTRAL, MEDLINE, EMBASE, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trial registers were searched until May 2017 to identify randomized controlled trials on immunosuppression for kidney transplantation.

RESULTS

Twenty-seven studies involving 4484 participants were eligible for analysis. Induction and maintenance treatments were administered for 12 months. There was no evidence of differences in outcomes between therapies on all-cause mortality, graft loss, cytomegalovirus, BK virus, neutropenia, thrombocytopenia, and biopsy-proven acute rejection. However, compared with intravenous basiliximab (an interleukin-2 receptor antagonist [IL-2RA]), the most effective treatments to decrease biopsy-proven acute rejection were intravenous alemtuzumab and rabbit antithymocyte globulin (rATG). The odds ratios were 0.45 (95% confidence interval [CI], 0.29-40.78) and 0.63 (95% CI, 0.42-0.95), respectively. As a side effect, rATG was accompanied by more bacterial infection than the IL-2RA (OR, 1.8 [95% CI, 1.01-2.8]).

CONCLUSIONS

The determination of induction in kidney transplantation is important for future prognosis of the graft kidney. Alemtuzumab and rATG exhibited lower biopsy-proven acute rejection than the IL-2RA. As a side effect, rATG produced frequent bacterial infections.

Genetic barriers in transplantation medicine

The successful of transplantation is determined by the shared human leukocyte antigens (HLAs) and ABO blood group antigens between donor and recipient. In recent years, killer cell receptor [i.e., killer cell immunoglobulin-like receptor (KIR)] and major histocompatibility complex (MHC) class I chain-related gene molecule (i.e., MICA) were also reported as important determinants of transplant compatibility. At present, several different genotyping techniques (e.g., sequence specific primer and sequence based typing) can be used to characterize blood group, HLA, MICA and KIR and loci. These molecular techniques have several advantages because they do not depend on the availability of anti-sera, cellular expression and have greater specificity and accuracy compared with the antibody-antigen based typing. Nonetheless, these molecular techniques have limited capability to capture increasing number of markers which have been demonstrated to determine donor and recipient compatibility. It is now possible to genotype multiple markers and to the extent of a complete sequencing of the human genome using next generation sequencer (NGS). This high throughput genotyping platform has been tested for HLA, and it is expected that NGS will be used to simultaneously genotype a large number of clinically relevant transplantation genes in near future. This is not far from reality due to the bioinformatics support given by the immunogenetics community and the rigorous improvement in NGS methodology. In addition, new developments in immune tolerance based therapy, donor recruitment strategies and bioengineering are expected to provide significant advances in the field of transplantation medicine.

Outcome and cost analysis of induction immunosuppression with IL2Mab or ATG in DCD kidney transplants

BACKGROUND

Kidney transplantation from DCD now represents a significant part of the overall transplant activity in the UK. Outcome of different induction immunosuppression regimes and related cost benefit analysis has been reported by very few studies.This is a single centre study on frequency-matched patients who received a DCD kidney transplant between August 2007 and August 2009.

METHODS

Data on 45 patients divided in 2 groups were collected prospectively and analyzed retrospectively. Group A (24 patients) received IL2Mab and Group B (21 patients) ATG as induction immunosuppression. Patient and graft survival were similar in both groups.

RESULTS

In the ATG-induced group, there was a significant lower rate of DGF, BPAR, and infections requiring readmission.A cost analysis was performed including all immunosuppression-related costs, and it has shown remarkable savings in the ATG-induced group.

CONCLUSION

Considering that the number of DCD kidney transplants is destined to rise in the UK, we believe that ATG is a valid option to continue optimizing outcomes of DCD kidney transplant. In our experience, ATG proved to be safe, effective, and contributed to significant cost savings.

Risk of serious opportunistic infections after solid organ transplantation: interleukin-2 receptor antagonists versus polyclonal antibodies. A meta-analysis

BACKGROUND

We aimed to evaluate and quantify the risk of serious opportunistic infections after induction with polyclonal antibodies versus IL-2 receptor antagonists (IL-2RAs) in randomized clinical trials.

METHODS

PRISMA guidelines were followed and random-effects models were performed.

RESULTS

70 randomized clinical trials (10,106 patients) were selected: 36 polyclonal antibodies (n = 3377), and 34 IL-2RAs (n = 6729). Compared to controls, polyclonal antibodies showed higher risk of serious opportunistic infections (OR: 1.93, 95% CI: 1.34-2.80; p < 0.0001); IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.80, 95% CI: 0.68-0.94; p = 0.009). Polyclonal antibodies were associated with higher risk of bacterial (OR: 1.58, 95% CI: 1.00-2.50; p = 0.049) and viral infections (OR: 2.37, 95% CI: 1.60-3.49; p < 0.0001), while IL-2RAs were associated with lower risk of cytomegalovirus (CMV) disease (OR: 0.73, 95% CI: 0.56-0.97; p = 0.032). Adjusted indirect comparison: compared to polyclonal antibodies, IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.41, 95% CI: 0.34-0.49; p < 0.0001), bacterial infections (OR: 0.51, 95% CI: 0.39-0.67; p < 0.0001) and CMV disease (OR: 0.58, 95% CI: 0.34-0.98; p = 0.043). Results remained consistent across allografts.

CONCLUSION

The risk of serious opportunistic infections, bacterial infections and CMV disease were all significantly decreased with IL-2RAs compared to polyclonal antibodies.

Interleukin-2 receptor blockade with humanized monoclonal antibody for solid organ transplantation

IMPORTANCE OF THE FIELD

Induction therapy has reduced the incidence of acute rejection compared with historical standards. The potency of currently available induction immunosuppression is not without risk and should be carefully considered. Induction with daclizumab, an IL-2 receptor antagonist, has been used safely and effectively for over 10 years across different transplant types. As a result of daclizumab use, transplant centers are able to implement steroid-sparing or calcineurin minimization protocols. Unfortunately, the manufacturing costs have resulted in withdrawal of this agent from the market reducing the options for patients undergoing transplantation.

AREAS COVERED IN THIS REVIEW

This review will update the reader on recently published daclizumab studies in adult solid organ transplant recipients, focusing on comparative studies with other induction agents.

WHAT THE READER WILL GAIN

This paper will provide a summary of comparative studies between daclizumab and other induction therapies focusing on their efficacy and safety.

TAKE HOME MESSAGE

Novel applications, such as long-term use in combination with calcineurin-inhibitor dose reduction and its value in the treatment of acute or chronic rejection have yet to be explored. Since daclizumab has been withdrawn from the market, future IL-2 receptor blockade will have to be achieved with basiliximab, which is a chimeric, monoclonal antibody directed against the same epitope.

Daclizumab

Daclizumab is a humanized monoclonal antibody which binds to the IL-2 receptor on activated lymphocytes and blocks the production of IL-2. Its use is well established in solid organ transplantation as induction therapy, especially in high-risk patients where reduction or delayed dose of standard immunosuppression would be beneficial. It has been used effectively in both 2-dose and 5-dose regimens in conjunction with other standard immunosuppressive agents. The incidence of acute rejection appears reduced without increasing the rates of infection or post-transplant lympho-proliferative disorders. The agent is generally well tolerated in adults and children and there is no need for additional monitoring. Daclizumab has also been used outside the transplant arena in a variety of immune-mediated diseases with limited success.

Update on Pharmacoeconomics in Transplantation

Purpose

To provide current information on pharmacoeconomic outcomes in transplantation for the past 6 years.

Methods

An extensive literature search was undertaken using PubMed and other authenticated Internet sources. Key words used to elicit pertinent studies were “pharmacoeconomics,” “transplantation,” “cost-effectiveness,” “cost-benefit,” “cost-minimization” and “cost-utility” analyses. Studies included in the review contain updated pharmacoeconomic data generated during the past 6 years on economic, clinical, and humanistic outcomes. These data are used to describe and analyze the cost of drug therapy used in transplantation.

Results

Background information is included in the review to provide a context from which to evaluate new study material. Data extracted from the studies include significant findings and study limitations. Data were stratified into understanding pharmacoeconomic methods and their application to transplantation, maintenance and induction therapies, and management of and costs associated with adverse events and quality-of-life issues.

Conclusions

Continued evolution of pharmacoeconomic analysis is needed so that optimal care can be provided in the most cost-effective manner. Pharmacoeconomic study, done rationally and logically, is an indispensable tool in determining optimal transplantation regimens.

The economics and ethics of kidney transplantation: perspectives in 2006

PURPOSE OF REVIEW

The field of kidney transplantation has made impressive progress, which has led to marked improvements in both patient and allograft survival. The economic and ethical consequences of these advances have recently garnered increasing attention in the medical literature. This review highlights key articles published in 2005 and 2006.

RECENT FINDINGS

Major areas of focus in the health economics literature pertaining to kidney transplantation include the most cost-effective strategies for immunosuppressive therapies, the management of posttransplant complications, and the optimal utilization of the current pool of deceased-donor kidneys. Ethical challenges include various aspects of living donation, strategies to expand the donor pool, and the impact of financial policies for immunosuppressive agents on long-term patient and allograft survival.

SUMMARY

Given the rising demand for kidney transplantation within a setting of scarce resources, the economic and ethical dimensions of transplant medicine are of increasing interest to patients, providers, and payers. Research in these areas will help uncover ways to utilize this important medical technology in the most ethical and cost-effective manner.

Immunosuppressive preconditioning or induction regimens : evidence to date

The success of solid organ transplantation has been directly related to the development of immunosuppressive drug therapies. Preconditioning or induction therapy was developed to reduce early immunological and nonimmunological renal injury, with the goal of increasing long-term graft survival. However, the routine induction of immunological tolerance to solid organ allograft is currently not achievable because of the morbidity and mortality related to the immunosuppressive regimens themselves. The different therapeutic preconditioning or induction agents and their associated effects on cellular rejection, graft survival outcomes and the need for multiagent post-transplant maintenance therapy are reviewed.

Interleukin-2 receptor antagonist induction in modern immunosuppression regimens for renal transplant recipients

Addition of interleukin-2 receptor antagonist (IL-2RA) induction to calcineurin inhibitor (CNI)-based regimens reduces biopsy-proven acute rejection by 30-40%. IL-2RA induction facilitates early withdrawal of steroids, and supports the safe use of reduced-exposure CNI or delayed CNI introduction. IL-2RAs and rabbit antithymocyte globulin (Thymoglobulin) show comparable efficacy in patients at standard or low immunologic risk, but the adverse event profiles of lymphocyte-depleting agents are less favorable. IL-2RAs, uniquely, provide effective immunosuppression with similar tolerability to placebo.