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Song T, Jiang Y, Liu J, Wang Z, Zeng J, Huang Z, Fan Y, Wang X, Lin T. Steroid withdrawal or avoidance is safe in high‐risk kidney transplants: A systematic review and meta‐analysis. Kaohsiung J Med Sci 2019; 35:350-357. [PMID: 30942560 DOI: 10.1002/kjm2.12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/03/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Tu‐Run Song
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Ya‐Mei Jiang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jin‐Peng Liu
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhi‐Ling Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jun Zeng
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhong‐Li Huang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Yu Fan
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Xian‐Ding Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Tao Lin
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
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Skledar SJ, Corman SL, Smitherman T. Addressing innovative off-label medication use at an academic medical center. Am J Health Syst Pharm 2015; 72:469-77. [DOI: 10.2146/ajhp140306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Susan J. Skledar
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
| | - Shelby L. Corman
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
| | - Thomas Smitherman
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
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Riquelme P, Geissler EK, Hutchinson JA. Alternative approaches to myeloid suppressor cell therapy in transplantation: comparing regulatory macrophages to tolerogenic DCs and MDSCs. Transplant Res 2012; 1:17. [PMID: 23369628 PMCID: PMC3561050 DOI: 10.1186/2047-1440-1-17] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 09/18/2012] [Indexed: 01/08/2023] Open
Abstract
Several types of myeloid suppressor cell are currently being developed as cell-based immunosuppressive agents. Despite detailed knowledge about the molecular and cellular functions of these cell types, expert opinions differ on how to best implement such therapies in solid organ transplantation. Efforts in our laboratory to develop a cell-based medicinal product for promoting tolerance in renal transplant patients have focused on a type of suppressor macrophage, which we call the regulatory macrophage (M reg). Our favoured clinical strategy is to administer donor-derived M regs to recipients one week prior to transplantation. In contrast, many groups working with tolerogenic dendritic cells (DCs) advocate post-transplant administration of recipient-derived cells. A third alternative, using myeloid-derived suppressor cells, presumably demands that cells are given around the time of transplantation, so that they can infiltrate the graft to create a suppressive environment. On present evidence, it is not possible to say which cell type and treatment strategy might be clinically superior. This review seeks to position our basic scientific and early-stage clinical studies of human regulatory macrophages within the broader context of myeloid suppressor cell therapy in transplantation.
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Affiliation(s)
- Paloma Riquelme
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, 93053, Germany.
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Nainani N, Patel N, Tahir N, Kumar R, Weber-Shrikant E, Gundroo AA, Murray BM, Tornatore KM, Blessios GA, Venuto RC. Effect of steroid-free low concentration calcineurin inhibitor maintenance immunosuppression regimen on renal allograft histopathology and function. Nephrol Dial Transplant 2012; 27:2077-2083. [DOI: 10.1093/ndt/gfr608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
The last two decades have witnessed a pandemic in antibody development, with over 600 entering clinical studies and a total of 28 approved by the FDA and European Union. The incorporation of biologics in transplantation has made a significant impact on allograft survival. Herein, we review the armamentarium of clinical and preclinical biologics used for organ transplantation--with the exception of belatacept--from depleting and IL-2R targeting induction agents to costimulation blockade, B-cell therapeutics, BAFF and complement inhibition, anti-adhesion, and anti-cytokine approaches. While individual agents may be insufficient for tolerance induction, they provide possibilities for reduction of steroid or calcineurin inhibitor use, alternatives to rejection episodes refractory to conventional therapies, and specialized immunosuppression for highly sensitized patients.
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Affiliation(s)
- Eugenia K Page
- Department of Surgery, Emory University Hospital, Atlanta, GA, USA
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Focosi D, Maggi F, Pistello M, Boggi U, Scatena F. Immunosuppressive monoclonal antibodies: current and next generation. Clin Microbiol Infect 2011; 17:1759-68. [PMID: 21995285 DOI: 10.1111/j.1469-0691.2011.03677.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Monoclonal antibodies (mAbs) are well-established therapeutics, as evidenced by the large number of Food and Drug Administration-approved mAbs for the treatment of cancers, and inflammatory or autoimmune diseases, and for the prevention and treatment of solid organ transplant rejection. Although, in many cases, mAbs have improved patient survival, they are also associated with an increased incidence of opportunistic infections. We review here the current and next generation of mAbs and the risks that infectious disease specialists should be aware of.
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Affiliation(s)
- D Focosi
- U.O. Immuoematologia SSN, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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Hutchinson JA, Riquelme P, Sawitzki B, Tomiuk S, Miqueu P, Zuhayra M, Oberg HH, Pascher A, Lützen U, Janssen U, Broichhausen C, Renders L, Thaiss F, Scheuermann E, Henze E, Volk HD, Chatenoud L, Lechler RI, Wood KJ, Kabelitz D, Schlitt HJ, Geissler EK, Fändrich F. Cutting Edge: Immunological consequences and trafficking of human regulatory macrophages administered to renal transplant recipients. THE JOURNAL OF IMMUNOLOGY 2011; 187:2072-8. [PMID: 21804023 DOI: 10.4049/jimmunol.1100762] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Regulatory macrophages (M regs) were administered to two living-donor renal transplant recipients. Both patients were minimized to low-dose tacrolimus monotherapy within 24 wk of transplantation and subsequently maintained excellent graft function. After central venous administration, most M regs remained viable and were seen to traffic from the pulmonary vasculature via the blood to liver, spleen, and bone marrow. By 1 y posttransplantation, both patients displayed patterns of peripheral blood gene expression converging upon the IOT-RISET signature. Furthermore, both patients maintained levels of peripheral blood FOXP3 and TOAG-1 mRNA expression within the range consistent with nonrejection. It is concluded that M regs warrant further study as a potential immune-conditioning therapy for use in solid-organ transplantation. The results of this work are being used to inform the design of The ONE Study, a multinational clinical trial of immunomodulatory cell therapy in renal transplantation.
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Affiliation(s)
- James A Hutchinson
- Laboratory for Transplantation Research, Department of Surgery, University Hospital Regensburg, Regensburg 93053, Germany.
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Mahmud N, Klipa D, Ahsan N. Antibody immunosuppressive therapy in solid-organ transplant: Part I. MAbs 2011; 2:148-56. [PMID: 20150766 DOI: 10.4161/mabs.2.2.11159] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Currently, a wide variety of both polyclonal and monoclonal antibodies are being routinely utilized to prevent and treat solid organ rejection. More commonly, these agents are also administered in order to delay introduction of calcineurin inhibitors, especially in patients with already compromised renal function. While these antibody therapies dramatically reduced the incidence of acute rejection episodes and improved both short and long-term graft survival, they are also associated with an increased incidence of opportunistic infections and neoplastic complications. Therefore, effective patient management must necessarily balance these risks against the potential benefits of the therapy.
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Mujtaba MA, Taber TE, Goggins WC, Yaqub MS, Mishler DP, Milgrom ML, Fridell JA, Lobashevsky A, Powelson JA, Sharfuddin AA. Early steroid withdrawal in repeat kidney transplantation. Clin J Am Soc Nephrol 2010; 6:404-11. [PMID: 21051751 DOI: 10.2215/cjn.05110610] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidney re-transplantation (KRT) candidates are considered at high risk for graft failure. Most of these patients are kept on a chronic steroid maintenance (CSM) regimen. The safety of early steroid withdrawal (ESW) remains unanswered in KRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study was aimed at comparing the outcomes of ESW and CSM in KRT. Retrospective analysis of 113 KRT patients (ESW, n=59; CSM, n=54) was performed. All patients received rabbit anti-thymocyte globulin/steroid induction and were maintained on mycophenolate/tacrolimus (±steroids). RESULTS One- and 5-year patient survival for the ESW and the CSM group were not significantly different (98 versus 96% and 91 versus 88%, respectively; P=0.991). No significant difference was seen in the graft survival for both groups at 1 and 5 years (98 versus 93% and 80 versus 74%, respectively; P=0.779). Mean 1- and 5-year estimated GFR was not statistically different between the groups (P=0.773 and 0.790, respectively). The incidence of acute rejection at 1 year was 17 and 22% in ESW and CSM patients, respectively (P=0.635). Compared with the ESW group, patients in the CSM group were more likely to be hyperlipidemic (P=0.044), osteoporotic (P=0.010), post-transplant diabetics (P=0.051) and required more medications to control BP (P=0.004). CONCLUSIONS ESW seems to be a reasonable approach in KRT recipients because the short and intermediate patient survival, graft survival, and graft function is comparable to CSM immunosuppression.
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Affiliation(s)
- Muhammad A Mujtaba
- Indiana University School of Medicine/Clarian Transplant Institute, Department of Medicine, Division of Nephrology, 550 N. University Boulevard, Suite UH4601, Indianapolis, IN 46202, USA.
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Tan HP, Donaldson J, Basu A, Unruh M, Randhawa P, Sharma V, Morgan C, McCauley J, Wu C, Shah N, Zeevi A, Shapiro R. Two hundred living donor kidney transplantations under alemtuzumab induction and tacrolimus monotherapy: 3-year follow-up. Am J Transplant 2009; 9:355-66. [PMID: 19120078 DOI: 10.1111/j.1600-6143.2008.02492.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Alemtuzumab has been used in off-label studies of solid organ transplantation. We extend our report of the first 200 consecutive living donor solitary kidney transplantations under alemtuzumab pretreatment with tacrolimus monotherapy and subsequent spaced weaning to 3 years of follow-up. We focused especially on the causes of recipient death and graft loss, and the characteristics of rejection. The actuarial 1-, 2- and 3-year patient and graft survivals were 99.0% and 98.0%, 96.4% and 90.8% and 93.3% and 86.3%, respectively. The cumulative incidence of acute cellular rejection (ACR) at the following months was 2%</=6, 9.0%</=12, 16.5%</=18, 19.5%</=24, 23.5%</=30, 24.0%</=36 and 25%</=42. The mean serum creatinine (mg/dL) and glomerular filtration rate (mL/min/1.73 m(2)) at 1 and 3 years were 1.4 +/- 0.6 and 58.7 +/- 21.6 and 1.5 +/- 0.7 and 54.9 +/- 20.9, respectively. Fifty (25%) recipients had a total of 89 episodes of ACR. About 88.7% of ACR episodes were Banff 1, and of those, 82% were steroid-sensitive. Nine (4.5%) recipients had antibody-mediated rejection (AMR). About 76.5% were weaned but only 46% are currently on spaced dose (qod or less) tacrolimus monotherapy, and 94.4% remained steroid-free from the time of transplantation. Infectious complications were uncommon. This experience suggests the 3-year efficacy of this approach.
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Affiliation(s)
- H P Tan
- The Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Hutchinson JA, Gövert F, Riquelme P, Bräsen JH, Brem-Exner BG, Matthäi M, Schulze M, Renders L, Kunzendorf U, Geissler EK, Fändrich F. Administration of donor-derivedtransplant acceptance-inducing cellsto the recipients of renal transplants from deceased donors is technically feasible. Clin Transplant 2009; 23:140-5. [DOI: 10.1111/j.1399-0012.2008.00953.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Pediatric Living Donor Kidney Transplantation Under Alemtuzumab Pretreatment and Tacrolimus Monotherapy: 4-Year Experience. Transplantation 2008; 86:1725-31. [DOI: 10.1097/tp.0b013e3181903da7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Agarwal A, Shen LY, Kirk AD. The role of alemtuzumab in facilitating maintenance immunosuppression minimization following solid organ transplantation. Transpl Immunol 2008; 20:6-11. [DOI: 10.1016/j.trim.2008.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 09/10/2008] [Indexed: 01/08/2023]
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Hutchinson JA, Riquelme P, Brem-Exner BG, Schulze M, Matthi M, Renders L, Kunzendorf U, Geissler EK, Fndrich F. Transplant acceptance-inducing cells as an immune-conditioning therapy in renal transplantation. Transpl Int 2008; 21:728-41. [DOI: 10.1111/j.1432-2277.2008.00680.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hutchinson JA, Brem-Exner BG, Riquelme P, Roelen D, Schulze M, Ivens K, Grabensee B, Witzke O, Philipp T, Renders L, Humpe A, Sotnikova A, Matthäi M, Heumann A, Gövert F, Schulte T, Kabelitz D, Claas FHJ, Geissler EK, Kunzendorf U, Fändrich F. A cell-based approach to the minimization of immunosuppression in renal transplantation. Transpl Int 2008; 21:742-54. [PMID: 18573141 DOI: 10.1111/j.1432-2277.2008.00692.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Five renal transplant recipients were preoperatively treated with transplant acceptance-inducing cells (TAICs) in a Phase-I safety study of TAICs as an adjunct immune-conditioning therapy in living-donor kidney transplantation. Initially, patients received anti-thymocyte globulin induction therapy in combination with tacrolimus and steroid immunosuppression. Over the course of 12 weeks, steroids were withdrawn and tacrolimus therapy was minimized. Three of the five patients were able to tolerate low-dose tacrolimus monotherapy and one patient was withdrawn from all immunosuppression for over 8 months. No acute or delayed adverse events were associated with the infusion of TAICs. Monitoring of the recipient anti-donor reactivity of TAIC-treated patients in mixed lymphocyte cultures demonstrated that, during periods of clinically stable graft function, recipient T-cell proliferation and cytokine secretion in response to stimulation with donor alloantigen was relatively suppressed. Therefore, although the TAIC-II trial did not provide conclusive evidence of a beneficial effect of preoperative TAIC treatment, the results were encouraging because they suggest that TAICs promote a state of alloantigen-specific unresponsiveness, which might allow safe minimization of pharmacological immunosuppression.
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Affiliation(s)
- James A Hutchinson
- Laboratory of Transplantation Research of the Clinic of General and Thoracic Surgery, University of Schleswig-Holstein, Kiel, Germany.
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Tan HP, Shapiro R, Tom K, Thai N, Marsh W, Basu A, Marcos A. Alemtuzumab pretreatment and tacrolimus monotherapy in living-donor liver and kidney transplantation. Expert Rev Pharmacoecon Outcomes Res 2007; 7:113-118. [DOI: 10.1586/14737167.7.2.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Abstract
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.
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Affiliation(s)
- Henkie P Tan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Abstract
Living donor kidney transplantation has increased in frequency in pediatric patients, accounting for 43% of cases performed between 1987 and 1991, and 52% of cases performed between 1987 and 2004 in North America. Patient survival has remained excellent over the years, and is currently over 96% at five years. Graft survival has improved over the years, and is currently over 95% at one year. Rejection rates have fallen over the years, and are currently <25% overall, with selected centers having very low rejection rates. The reasons for these improved outcomes are likely related to improvements in maintenance immunosuppression, which include a transition from cyclosporine to tacrolimus-based regimens, and from azathioprine to mycophenolate mofetil or sirolimus as adjunctive agents. Steroid withdrawal and steroid avoidance are beginning to be utilized by several centers, with excellent early outcomes. Finally, while there may be center effect/learning curve issues involved, the type of donor nephrectomy has recently been shown to influence early outcomes, particularly in very young recipients.
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Affiliation(s)
- Ron Shapiro
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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Tan HP, Kaczorowski DJ, Basu A, Unruh M, McCauley J, Wu C, Donaldson J, Dvorchik I, Kayler L, Marcos A, Randhawa P, Smetanka C, Starzl TE, Shapiro R. Living donor renal transplantation using alemtuzumab induction and tacrolimus monotherapy. Am J Transplant 2006; 6:2409-17. [PMID: 16889606 PMCID: PMC3154761 DOI: 10.1111/j.1600-6143.2006.01495.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Alemtuzumab was used as an induction agent in 205 renal transplant recipients undergoing 207 living donor renal transplants. All donor kidneys were recovered laparoscopically. Postoperatively, patients were treated with tacrolimus monotherapy, and immunosuppression was weaned when possible. Forty-seven recipients of living donor renal transplants prior to the induction era who received conventional triple drug immunosuppression without antibody induction served as historic controls. The mean follow-up was 493 days in the alemtuzumab group and 2101 days in the historic control group. Actuarial 1-year patient and graft survival were 98.6% and 98.1% in the alemtuzumab group, compared to 93.6% and 91.5% in the control group, respectively. The incidence of acute cellular rejection (ACR) at 1 year was 6.8% in the alemtuzumab group and 17.0% (p < 0.05) in the historic control group. Most (81.3%) episodes of ACR in the alemtuzumab group were Banff 1 (a or b) and were sensitive to steroid pulses for the treatment of rejection. There was no cytomegalovirus disease or infection. The incidence of delayed graft function was 0%, and the incidence of posttransplant insulin-dependent diabetes mellitus was 0.5%. This study represents the largest series to date of live donor renal transplant recipients undergoing alemtuzumab induction, and confirms the short-term safety and efficacy of this approach.
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Affiliation(s)
- H P Tan
- The Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Tolerogenic immunosuppression in pediatric abdominal transplantation. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000244652.90414.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Augustine JJ, Hricik DE. Steroid Sparing in Kidney Transplantation: Changing Paradigms, Improving Outcomes, and Remaining Questions. Clin J Am Soc Nephrol 2006; 1:1080-9. [PMID: 17699329 DOI: 10.2215/cjn.01800506] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The widely known adverse effects of long-term therapy with corticosteroids have motivated increasing interest in steroid-free immunosuppression for kidney transplant recipients. Results from recent trials that used newer immunosuppressants to facilitate elimination of steroids suggest better short-term results than were achieved in an earlier era. However, the best results have been reported in uncontrolled trials of low-risk patients or in randomized trials with relatively short periods of follow-up. Increasingly, the therapeutic paradigm has shifted from late withdrawal of steroids to very early withdrawal after transplantation or even complete avoidance. Induction antibody therapy has been used routinely in the most successful trials that involved early steroid withdrawal or avoidance. Although the outcomes of kidney transplant recipients who are treated with steroid-free immunosuppression are improving steadily, there still is room for concern in recommending this strategy as a standard of practice.
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Affiliation(s)
- Joshua J Augustine
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Abstract
Alemtuzumab (Campath-1H) is a powerful antilymphocyte antibody that produces profound and long-lasting lymphopenia. It is being used with increasing frequency for induction in organ transplantation, with the aim of allowing steroid-free and/or calcineurin-free/sparing maintenance immunosuppressive protocols. Despite a considerable experience with this agent, mostly in kidney transplantation, there are only two relatively small randomized controlled trials available, and therefore the level of evidence for its role in transplantation is limited. Nevertheless, it does appear that the incidence of acute rejection is low after induction with alemtuzumab, perhaps if used with a calcineurin inhibitor, and that steroid-free and calcineurin-sparing protocols are possible. Although there is a profound and long-lasting T cell lymphopenia after administration of alemtuzumab, there is no apparent increase in infection, posttransplantation lymphoproliferative disease, or other side effects, other than perhaps autoimmune disease. Whether alemtuzumab is more effective than Thymoglobulin or anti-interleukin 2 receptor antibodies cannot be answered at this time. However from a cost aspect, the use of alemtuzumab for induction compares more than favorably with other lymphocyte-depleting agents. Alemtuzumab is an attractive agent for induction in organ transplantation, but there is a need for more and larger randomized trials with long-term follow-up before its true role can be established, particularly with respect to safety.
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Affiliation(s)
- Peter J Morris
- Centre for Evidence in Transplantation, Royal College of Surgeons of England and London School of Hygiene & Tropical Medicine, University of London, UK.
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