In pursuit of the ultimate: the initial Ahmedabad journey toward transplantation tolerance

Co-infusion of donor adipose tissue-derived mesenchymal and hematopoietic stem cells helps safe minimization of immunosuppression in renal transplantation - single center experience

BACKGROUND

Stem cell therapy (SCT) is used for immunosuppression minimization in renal transplantation (RT). We carried out a prospective study to evaluate the benefits of co-infusion of donor adipose-derived mesenchymal stem cells (AD-MSC) + hematopoietic stem cells (HSC) in living donor RT (LDRT) under non-myeloablative conditioning.

METHODS

In a demographically balanced three-armed LDRT trial with 95 patients in each arm, group-1 received portal co-infusion of AD-MSC + HSC, group-2 received HSC and group-3 received no SCT. Lymphoid irradiation and anti-thyroglobulin were used for conditioning.

RESULTS

SCT was safe. At 1 and 5 years post-transplant, patient survival was 100% and 94.7% in group-1, 100% and 95.7% in group-2, and 94.7% and 84% in group-3, death-censored graft survival was 100% and 94.6% in group-1, 100% and 91.3% in group-2, and 98.9% and 94.4% in group-3 with mean serum creatinine (mg/dL) of 1.38 and 1.39 in group-1, 1.48 and 1.51 in group-2, and 1.29 and 1.42 and in group-3. Rejection episodes and immunosuppression requirement were lesser in SCT groups versus controls with best results noted in group-1.

CONCLUSION

Coinfusion of donor AD-MSC +HSC in portal circulation pre-transplant under non-myeloablative conditioning is safe and effective for immunosuppression minimization in LDRT.

Effect of co-transplantation of mesenchymal stem cells and hematopoietic stem cells as compared to hematopoietic stem cell transplantation alone in renal transplantation to achieve donor hypo-responsiveness

INTRODUCTION

We evaluated donor hypo-responsiveness in renal allograft recipients to donor adipose tissue-derived mesenchymal stem cell (h-AD-MSC) +hematopoietic stem cell transplantation (HSCT) vs. HSCT alone.

METHODS

Patients were divided into 2 demographically equal groups (n = 100) A and B subjected to equal non-myeloablative conditioning of target-specific irradiation, anti-T + B cell antibodies and cyclophosphamide with HSCT. Group A was administered h-AD-MSC additionally. Transplantation was performed following favorable cross-matching. Cyclosporine, 3 mg/kg BW/day + prednisone, 20 mg/day were immunosuppressants for first 3 months, cyclosporine was replaced by azathioprine subsequently and prednisone lowered to 5-10 mg/day. Peripheral blood chimerism (PBC) was studied using fluorescent in situ hybridization technique at 3/18 months post transplant. Biopsy was performed for graft dysfunction and reported as per Banff criteria,'05.

RESULTS

Mean nucleated HSC counts (n × 10(8)/kgBW) was 7.32 with mean CD34+ yield 0.09% in group A; and 6.98 and 0.40% in group B, respectively; CD45-/90+ was 13.49% in former. Over 18 months post transplant, former had mean serum creatinine (SCr), 1.59 mg%, 12% acute rejection (AR) episodes, 3% patient, 1% patient +graft loss; latter had mean SCr 1.49 mg%, 18% AR episodes, 1% patient, 6% graft and 8% patient +graft losses. PBC was higher (4%) in former than later (1.8%).

CONCLUSION

Combined h-AD-MSC +HSCT under non-myeloablative conditioning was safe, more effective than HSCT alone to achieve donor hypo-responsiveness with adequate stable graft function and reduced rejection episodes.

Significance of pretransplant urinary tract infection in short-term renal allograft function and survival

Renal transplant recipients are susceptible to postoperative infections, among which those in the urinary tract (UTI) are the most common. We examined the effect of pretransplant bacterial UTI on the incidence of posttransplant UTI as well as complications and short-term outcomes.

PATIENTS AND METHODS

We examined the case records of 100 patients who underwent living-related donor renal transplantation at our institute from November 2006 to June 2007.

RESULTS

Nineteen patients had positive pretransplant bacterial urine cultures and four required native nephrectomy for control of persistent bacterial UTI. All patients were transplanted under a tolerance induction protocol using low-dose immunosuppression after negative suprapubic culture reports. There was no urinary leak/obstruction or vascular complication. The incidence of postoperative bacterial UTI was 31.6% (6 of 19) compared with 6.2% (6 of 81) among patients without pretransplant UTI. E. coli was the most common isolated organism. All patients were doing well with 100% graft survival at 3 months and a mean serum creatinine of 1.27 mg%.

CONCLUSION

Preoperative UTI predicted an increased likelihood of postoperative UTI without a significant effect on graft/patient survival and graft function.

Human adipose tissue-derived mesenchymal stem cells combined with hematopoietic stem cell transplantation synthesize insulin

BACKGROUND

Type 1 diabetes mellitus (DM) is an autoimmune disorder with disturbed glucose/insulin metabolism, which has no medical treatment other than life-long insulin therapy, despite which 30% of subjects develop organ failure. Herein we have reported the use of human adipose-tissue-derived, insulin-making mesenchymal stem cells (h-AD-MSC) transfused with unfractionated cultured bone marrow (CBM) in 5 insulinopenic DM patients.

PATIENTS AND METHODS

Five (M:F, 2:3) insulinopenic DM patients of 0.6 to 10 years' duration, ages 14 to 28 years under treatment insulin (Human with 14-70 U/d) showed postprandial blood sugars between 156 to 470 mg%, glycosylated hemoglobin 6.8% to 9.9% and c-peptide levels of 0.02 to 0.2 ng/mL. They underwent intraportal administration of xenogeneic-free h-AD-MSC (mean dose = 1.5 mL; cell counts, 2.1 x 10(3)/muL). The CD45-/90+/73(+) cells (29.8/16.8%) showed c-peptide levels of 3.08 ng/mL, insulin level of 1578 micro IU/mL. The aliquot was supplemented with CBM (mean dose 94 mL with cell counts: 18.7 x 10(3)/microL) containing CD45-/34+ elements of 0.93%. The Institutional Review Board approved the study protocol and consent forms.

RESULTS

All patients were successfully infused CBM plus h-AD-MSC without any untoward effects and showed 30% to 50% decreased insulin requirements with 4- to 26-fold increased serum c-peptide levels, with a mean follow-up of 2.9 months.

CONCLUSION

This report describes safe and effective treatment of insulinopenic diabetics using insulin-producing h-AD-MSC plus CBM without xenogeneic materials.

Study of acute antibody-mediated rejection in renal allograft biopsies

INTRODUCTION

Acute B-cell-mediated rejection (AMR) was ill-defined until the 6(th) Banff meeting establishing the criteria. We performed a retrospective analysis of renal allograft biopsies to evaluate immune injury with reference to the Ahmedabad Tolerance Induction Protocols (ATIP).

METHODS

We evaluated renal allograft biopsies belonging to 3 groups: group A patients (n = 120) underwent a modified ATIP with addition of mesenchymal stem cells, anti-B-cell antibodies, and higher target-specific irradiation; group B patients (n = 351) belong to the old ATIP; and group C (n = 142) were controls who opted out of ATIP. The majority were biopsied 2 or 3 times. Biopsies were subdivided: <or=60 days, 61 to 180 days, or 181 to 365 days' posttransplant. We compared demographics and diagnoses per the modified Banff criteria.

RESULTS

At <or=60 days' posttransplantation, acute T-cell-mediated rejection (ATIR) was noted in 1.7% of group A patients; 5.98% of B; 33.8% of C with AMR in 11.7% of A; 10.8% of B; and 24.6% of C. At 61 to 180 days' posttransplant, ATIR was absent in group A, 1.99% in group B, and 21.83% in controls, whereas AMR was absent in group A; 1.7% in group B; and 39.4% of controls. At 181 to 365 days, ATIR and AMR were absent in group A; ATIR was 0.56% in group B and 14.1% in controls; AMR was 0.85% in group B and 21.1% in controls. The immunosuppression included cyclosporine (mg/kgBW/day) was 1.5 +/- 0.1 in group A; 2 +/- 0.5 in group B; and prednisone (mg/kgBW/day), 0.15 in group A, 0.2 in group B. The controls received standard doses.

CONCLUSION

The modified ATIP has reduced immunosuppressive drug dose requirements and lessened ATIR; however, AMR, although significantly less than controls, needs to be addressed.