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Montero N, Rodrigo E, Crespo M, Cruzado JM, Gutierrez-Dalmau A, Mazuecos A, Sancho A, Belmar L, Calatayud E, Mora P, Oliveras L, Solà E, Villanego F, Pascual J. The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100795. [PMID: 37774445 DOI: 10.1016/j.trre.2023.100795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups. METHODS We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias. RESULTS Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group. CONCLUSIONS Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.
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Affiliation(s)
- Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Lara Belmar
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Emma Calatayud
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Paula Mora
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eulalia Solà
- Nephrology Department, Consorci Sanitari del Garraf, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Selection of More Vulnerable Patients for Cytomegalovirus Infection in Renal Transplant Recipients With Antithymocyte Globulin Induction Therapy: An Analysis of Risk Factors and Cell-Mediated Immunity. Transplant Proc 2021; 53:2252-2260. [PMID: 34452738 DOI: 10.1016/j.transproceed.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is an important complication after kidney transplantation (KT). Antithymocyte globulin (ATG) increases the risk for CMV infection, and universal prophylaxis is recommended during the first 3 to 6 months after ATG induction in CMV-seropositive recipients. However, following this recommendation is not easy because the cost is high. The aim of this study was to determine who, among high-risk KT recipients, are more vulnerable to CMV infections. METHODS We retrospectively analyzed the medical records of patients who underwent KT with ATG induction therapy at a single institute from April 2014 to June 2019. We assessed pretransplant recipient characteristics to determine the CMV infection risk factors. Cell-mediated immunity was evaluated with a lymphocyte subset test before transplantation and at the time of discharge. We included 227 patients in the study. RESULTS CMV-DNAemia was associated with donor type (deceased donor), the duration of renal replacement therapy, and the ATG dose. Multivariable analysis revealed that donor type is the primary risk factor for CMV-DNAemia. We also found that CD4+ cell counts were significantly lower in CMV-DNAemia recipients at the time of discharge. CONCLUSION The risk for CMV infection in CMV-seropositive KT recipients with ATG induction therapy increases when a graft is received from a deceased donor with renal impairment and when insufficient CD4+ cells are present during recovery.
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Ashoor IF, Beyl RA, Gupta C, Jain A, Kiessling SG, Moudgil A, Patel HP, Sherbotie J, Weaver DJ, Zahr RS, Dharnidharka VR. Low-Dose Antithymocyte Globulin Has No Disadvantages to Standard Higher Dose in Pediatric Kidney Transplant Recipients: Report From the Pediatric Nephrology Research Consortium. Kidney Int Rep 2021; 6:995-1002. [PMID: 33912749 PMCID: PMC8071617 DOI: 10.1016/j.ekir.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/14/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Rabbit antithymocyte globulin (rATG) dosing strategies for induction in pediatric kidney transplantation vary between centers. It is not known whether a lower rATG induction dose provides safe and effective immunosuppression compared with a "standard" higher dose. METHODS We performed a retrospective multicenter study of all isolated first-time kidney transplant recipients <21 years old who received rATG induction between 1 January 2010 and 31 December 2014 at 9 pediatric centers. An a priori cutoff of a 4.5-mg/kg cumulative rATG dose was used to identify low (≤ 4.5 mg/kg) and standard (> 4.5 mg/kg) exposure groups. Outcomes examined included 12 months posttransplant graft function (estimated glomerular filtration rate [eGFR]); the occurrence of acute rejection, donor-specific antibody (DSA), neutropenia, and viral infection (cytomegalovirus [CMV], Epstein-Barr virus [EBV], and BK virus); and 24-month outcomes of posttransplant lymphoproliferative disorder (PTLD) occurrence and patient and graft survival. RESULTS Two hundred thirty-five patients were included. Baseline features of the low and standard rATG dose groups were similar. By 12 months, the rATG dose group had no significant impact on the occurrence of neutropenia, positive DSA, or viral polymerase chain reaction (PCR). Graft function was similar. Acute rejection rates were similar at 17% (low dose) versus 19% (standard dose) (P = 0.13). By 24 months, graft survival (96.4% vs. 94.6%) and patient survival (100% vs. 99.3%) were similar between the low- and standard-dose groups (P = 0.54 and 0.46), whereas the occurrence of PTLD trended higher in the standard-dose group (0% vs. 2.6%, P = 0.07). CONCLUSION A low rATG induction dose ≤ 4.5 mg/kg provided safe and effective outcomes in this multicenter low immunologic risk pediatric cohort. Prospective studies are warranted to define the optimal rATG induction dose in pediatric kidney transplantation.
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Affiliation(s)
- Isa F. Ashoor
- Division of Nephrology, Department of Pediatrics, LSU Health New Orleans, New Orleans, Louisiana, USA
| | - Robbie A. Beyl
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Charu Gupta
- Children’s National Hospital, Washington, DC, USA
| | - Amrish Jain
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | | | - Asha Moudgil
- Children’s National Hospital, Washington, DC, USA
| | | | - Joseph Sherbotie
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Rima S. Zahr
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University and St. Louis Children’s Hospital, St. Louis, Missouri, USA
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Reassessing Rabbit Antithymocyte Globulin Induction in Kidney Transplantation (RETHINK): An Analysis of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Registry. Transplant Direct 2020; 6:e598. [PMID: 32903852 PMCID: PMC7447457 DOI: 10.1097/txd.0000000000001042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 01/29/2023] Open
Abstract
Supplemental Digital Content is available in the text. Background. There is no consensus on rabbit antithymocyte globulin (rATG) dose used for induction immunosuppression in pediatric kidney transplants. We aimed to identify whether a lower rATG dose provides safe and effective immunosuppression compared with a higher dose. Methods. We retrospectively analyzed all first-time kidney transplant recipients (aged <21 y) in the North American Pediatric Renal Trials and Collaborative Studies registry since 1998 on mycophenolate mofetil– and tacrolimus-based immunosuppression with rATG induction. An a priori cutoff of 7.5 mg/kg cumulative rATG dose was used to identify low (<7.5 mg/kg) and high (≥7.5 mg/kg) exposure groups. Primary outcome was time to first-acute rejection episode. Secondary outcomes included graft function, patient survival, hospitalizations due to infections, and time to first-posttransplant lymphoproliferative disorder episode. Results. Four hundred fifty-five patients met inclusion criteria (59% male, 49% whites, 26% blacks, 38% living donor source). Median cumulative rATG dose was 6.8 mg/kg with a median of 5 doses and a median 1.5 mg/kg/dose introduced at a median of postoperative 0 days. Sixty-four percent received <7.5 mg/kg total rATG. There was no difference in age at transplant, gender, race, end-stage renal disease causes, or HLA mismatch among groups. Time to first-acute rejection was similar (P = 0.07). There was no significant difference in graft or patient survival or time to posttransplant lymphoproliferative disorder. Hospitalization for infection rates was similar. Conclusions. These data demonstrate a wide variation in cumulative rATG induction dose. A smaller rATG dose <7.5 mg/kg may provide effective and safe immunosuppression compared with a higher dose.
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Mohamed M, Ghonim MA, Abouzeid MM, Salas MAP. Does rabbit anti-thymocyte globulin dose and antiviral prophylaxis alter the risk of the development of PTLD in renal transplant population? Ren Fail 2020; 42:673-674. [PMID: 32662315 PMCID: PMC7470055 DOI: 10.1080/0886022x.2020.1792927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Mahmoud Mohamed
- Nephrology Division, Department of Medicine.,University of Tennessee Health Science Center.,Memphis, TN, USA
| | - Mohamed A Ghonim
- St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Immunology, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Mai M Abouzeid
- Louisiana State University Health Sciences Center.,New Orleans, LA, USA
| | - Maria Aurora Posadas Salas
- Division of Nephrology and Hypertension, Department of Medicine.,Medical University of South Carolina.,Charleston, SC, USA
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Outcome Comparison between Low-Dose Rabbit Anti-Thymocyte Globulin and Basiliximab in Low-Risk Living Donor Kidney Transplantation. J Clin Med 2020; 9:jcm9051320. [PMID: 32370265 PMCID: PMC7290680 DOI: 10.3390/jcm9051320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/09/2023] Open
Abstract
The objective of this study was to compare outcomes between basiliximab and low-dose r-ATG in living donor kidney transplantation recipients with low immunological risk. Patients in the low-dose r-ATG group received 1.5 mg/kg of r-ATG for 3 days (total 4.5 mg/kg). Graft survival, patient survival, acute rejection, de novo donor specific antibody (DSA), estimated glomerular filtration rate (e-GFR) changes, and infection status were compared. Among 268 patients, 37 received r-ATG, and 231 received basiliximab. There was no noticeable difference in the graft failure rate (r-ATG vs. basiliximab: 2.7% vs. 4.8%) or rejection (51.4% vs. 45.9%). de novo DSA was more frequent in the r-ATG group (11.4% vs. 2.4%, p = 0.017). e-GFR changes did not differ noticeably between groups. Although most infections showed no noticeable differences between groups, more patients in the r-ATG group had cytomegalovirus (CMV) antigenemia and serum polyomavirus (BK virus) (73.0% vs. 51.9%, p = 0.032 in CMV; 37.8% vs. 15.6%, p = 0.002 in BK), which did not aggravate graft failure. Living donor kidney transplantation patients who received low-dose r-ATG and patients who received basiliximab showed comparable outcomes in terms of graft survival, function, and overall infections. Although CMV antigenemia, BK viremia were more frequent in the r-ATG group, those factors didn’t change the graft outcomes.
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Martinez-Mier G, Moreno-Ley PI, Budar-Fernández LF, Méndez-López MT, Allende-Castellanos CA, Jiménez-López LA, Barrera-Amoros DA, Aguilar-Sandoval E, De la Paz-Román M, Soto-Miranda E, Rivera-Sanchez Y, Martínez-Maldonado M. Low-dose Thymoglobulin vs Basiliximab Induction Therapy in Low-Risk Living Related Kidney Transplant Recipients: A Prospective Randomized Trial. Transplant Proc 2020; 53:1005-1009. [PMID: 32178925 DOI: 10.1016/j.transproceed.2020.01.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/10/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Thymoglobulin is used effectively as induction agent in kidney transplantation but the optimal dose is not well established. OBJECTIVE Demonstrate that low-dose thymoglobulin (3 mg/kg) has similar efficacy and safety compared to basiliximab induction in low-risk kidney transplantation under standard maintenance immunosuppression DESIGN, SETTING, PARTICIPANTS: Prospective randomized study in kidney transplant patients (12/2016-05/2018). INCLUSION CRITERIA Recipients > 18 years, first living donor transplant. EXCLUSION CRITERIA Second and multiorgan transplant, ABO incompatibility, positive cross-match, panel reactive antibodies (PRA) > 30%, positive donor-specific antibody, human immunodeficiency virus, hepatitis B surface antigen, hepatitis C virus positive, white blood cells < 2000 cells/mm3, platelets < 75,000 cells/mm3 and malignancy. INTERVENTION Group A: basiliximab (20 mg D0 and D4). Group B: thymoglobulin (3 mg/kg total). Maintenance immunosuppression: tacrolimus, mycophenolate mofetil, and steroids. MAIN OUTCOME MEASURES Biopsy-proven acute rejection (BPAR), delayed graft function, slow graft function, leukopenia, infections, adverse events, graft loss, estimated glomerular filtration rate, and death within 12 months. RESULTS 100 patients (basiliximab, n = 53) (thymoglobulin, n = 47) were included. Donor and recipient characteristics were similar except for longer dialysis (basiliximab), PRA class I (1.2% basiliximab, 4.5% thymoglobulin), HLA match (basiliximab 2.8, thymoglobulin 2.2), and cytomegalovirus status. BPAR rate was basiliximab 3.8% and thymoglobulin 6.4% (P = ns). Delayed graft function (basiliximab 3.8%; thymoglobulin 4.3%), slow graft function, and 12-month leukopenia (basiliximab 11.3%, thymoglobulin 21.3%) were similar between groups (P = ns). There was no difference in infections and adverse events between groups. Patient and graft survival were as follows: basiliximab 98.1% and 92.5%, thymoglobulin 100% and 93.6% (P = ns). CONCLUSION Low-dose thymoglobulin induction (3 mg/kg) can be used effectively and safely in low-risk kidney transplantation with good results during the first year post-transplant.
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Affiliation(s)
- Gustavo Martinez-Mier
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico.
| | - Pedro I Moreno-Ley
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Luis F Budar-Fernández
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Marco T Méndez-López
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Carlos A Allende-Castellanos
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Luis A Jiménez-López
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Daniel A Barrera-Amoros
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Edgar Aguilar-Sandoval
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Maritza De la Paz-Román
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Ernesto Soto-Miranda
- Department of Organ Transplantation, IMSS UMAE Hospital de Especialidades 14 Adolfo Ruiz Cortines, Veracruz, Mexico
| | - Yamilli Rivera-Sanchez
- School of Medicine, Universidad del Valle de México-Universidad Villa Rica, Veracruz, México
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Lasmar MF, Dutra RS, Nogueira-Machado JA, Fabreti-Oliveira RA, Siqueira RG, Nascimento E. Effects of immunotherapy induction on outcome and graft survival of kidney-transplanted patients with different immunological risk of rejection. BMC Nephrol 2019; 20:314. [PMID: 31409321 PMCID: PMC6693276 DOI: 10.1186/s12882-019-1497-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 07/26/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In kidney transplantation, immunotherapy with thymoglobulin (rATG) has been used to down-regulate the patient immune system. rATG is a powerful immunobiologic drug used to deplete lymphocytes to prevent early acute rejection. The aim of this research was to evaluate the effects of immunotherapy by rATG on graft suvival during a 9-year period in kidney-transplanted patients with different immunological profiles. METHODS A sample of 469 patients were allocated into four groups (G) based on immunological risk of rejection: G1, low risk, not sensitized recipients, solid-phase immunoassay with single antigen beads (SPI-SAB) < 10%; G2, medium risk I, sensitized recipients, SPI-SAB ≥ 10 < 50%; G3, medium risk II sensitized (SPI-SAB ≥50%); and G4, high risk, sensitized recipients, SPI-SAB- donor-specific antibody positive (DSA+). Only patients from G3 and G4 received immunotherapy. RESULTS Of 255 patients who received a kidney from a living donor (LD), 42 (16.47%) from all groups (G) had T-cell-mediated rejection (TCMR) and four (G1) lost their grafts, 8 (3.14%) had antibody-mediated rejection (AMR), and two lost their graft in G1 and G4. Of 214 patients who received a kidney from deceased donors (DD), 37 (17.29%) had TCMR with one lost graft in G1. AMR was shown in 13 (6.07%) patients, with three losses observed in G2. Statistical differences between the groups in the 9-year graft survival rate were found only in the comparison of G1 versus G2 (P = 0.005) and G2 versus G4 (P = 0.047) for DD. For LD, no statistical differences were found. CONCLUSION This clinical retrospective study shows that immunotherapy induction was associated with improvement of outcomes, graft function, and survival in patients treated with immunotherapy in comparison with patients who did not received induction therapy. These findings strongly suggest that immunotherapy should be used for all patients transplanted with kidneys from deceased donors.
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Affiliation(s)
- Marcus Faria Lasmar
- University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais state Brazil
- Institute of Research and Education of the Hospital Santa Casa, Belo Horizonte, Minas Gerais state Brazil
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State Brazil
| | - Rodrigo Santana Dutra
- University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais state Brazil
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State Brazil
| | | | - Raquel A. Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State Brazil
- IMUNOLAB – Laboratory of Histocompatibility, Minas Gerais state, Belo Horizonte, Brazil
| | | | - Evaldo Nascimento
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais State Brazil
- IMUNOLAB – Laboratory of Histocompatibility, Minas Gerais state, Belo Horizonte, Brazil
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Ducloux D, Bamoulid J, Daguindau E, Rebibou JM, Courivaud C, Saas P. Antithymocytes globulins: Time to revisit its use in kidney transplantation? Int Rev Immunol 2018; 37:183-191. [DOI: 10.1080/08830185.2018.1455194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- D. Ducloux
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - J. Bamoulid
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - E. Daguindau
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- Department of Hematology, CHU Besançon, Besançon, France
| | - J. M. Rebibou
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Dijon, Dijon, France
| | - C. Courivaud
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - P. Saas
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, Interactions hôte-greffon-tumeur, Federation hospitalo-universitaire INCREASE, LabEX LipSTIC, Besançon, France
- INSERM, CHU Besançon, Besançon, France
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Lee H, Lee S, Jeon J, Kwon S, Noh H, Han D, Yun S, Song D. Thymoglobulin Versus Basiliximab Induction Therapy in Low-Risk Kidney Transplant Recipients: A Single-Center Experience. Transplant Proc 2018; 50:1285-1288. [DOI: 10.1016/j.transproceed.2018.02.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/17/2018] [Indexed: 10/14/2022]
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Abstract
Liver transplantation outcomes have significantly improved over the past few decades owing largely to the introduction of effective immunosuppression medications. Further comprehension of the unique immune microenvironment of the liver has led to the development of newer molecular targeted therapeutics. Understanding the mechanism of action and adverse effect profiles of these medications is crucial for appropriate management of posttransplant patients. In this review, the author describes the immunologic response elicited by liver transplantation, chronicles the various immunosuppressant drug classes, discusses the evidence behind their use, and evaluates the management of special subpopulations of posttransplantation patients.
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Affiliation(s)
- Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Stanford University, 750 Welch Road, Suite 210, Palo Alto, CA 94304, USA.
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Pereira M, Guerra J, Neves M, Gonçalves J, Santana A, Nascimento C, da Costa AG. Predictive Factors of Acute Rejection in Low Immunologic Risk Kidney Transplant Recipients Receiving Basiliximab. Transplant Proc 2017; 48:2280-2283. [PMID: 27742279 DOI: 10.1016/j.transproceed.2016.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The optimal immunosuppressive induction therapy in kidney transplant recipients with low immunologic risk of acute rejection (AR) is still controversial. The use of basiliximab (BSX) has led to a significant decrease of AR with a low side effect profile. OBJECTIVE This study sought to evaluate predictive risk factors for AR in low immunologic risk patients subjected to immunosuppressive induction therapy with BSX. METHODS We reviewed all low immunologic risk patients (panel reactive antibody [PRA] level <50%, who had undergone a first deceased-donor transplant) subjected to immunosuppressive induction therapy with BSX, calcineurin inhibitor, mycophenolate mofetil, and prednisolone (n = 346). AR was defined as any rejection occurring until 12 months posttransplantation. Predictive risk factors for AR were evaluated by logistic regression and, to find the best cut-off of PRA related to a higher incidence of AR, receiver-operator characteristic (ROC) curve analysis was performed. RESULTS The rate of AR was 7.8%. Multivariate logistic regression analysis identified age at the time of transplantation (P = .040) and PRA level (P = .001) as independent risk factors for AR. ROC curve analysis confirmed that PRA >10% was related to an increased incidence of AR (19.2% vs 6.0%, P = .005). CONCLUSIONS A higher incidence of AR was observed in low immunologic risk kidney transplant patients with a PRA level >10%. These data support the use of more intensive immunosuppressive induction therapy in patients with low immunologic risk and a PRA level >10%.
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Affiliation(s)
- M Pereira
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.
| | - J Guerra
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - M Neves
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - J Gonçalves
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - A Santana
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - C Nascimento
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - A G da Costa
- Nephrology and Kidney Transplantation Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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13
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Impact of Rabbit Antithymocyte Globulin Dose on Long-term Outcomes in Heart Transplant Patients. Transplantation 2016; 100:685-93. [PMID: 26457604 DOI: 10.1097/tp.0000000000000950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal dosing strategies have not been established for rabbit antithymocyte globulin (rATG) after heart transplantation, and there is currently wide variability in rATG regimens with respect to both dose and duration. METHODS In a retrospective, single-center analysis, 523 patients undergoing heart transplantation during 1996 to 2009 were stratified by cumulative rATG dose: less than 4.5 mg/kg (group A), 4.5 to 7.5 mg/kg (group B) or greater than 7.5 mg/kg (group C). RESULTS Survival at 1 year after transplantation was 80% in group A, 90% in group B, and 88% in group C (P = 0.062). Incidence of acute rejection per 1000 patient-years was significantly higher in group A (hazards ratio [HR], 54.8; 95% confidence interval [95% CI], 33.9-83.8) compared to groups B (19.6; 95% CI, 11.4-31.4) and C (23.6; 95% CI, 17.5-31.3). Incidence of severe infection 10 years after transplantation was higher in group C (45%) than groups A (37%) or B (23%) (P < 0.001); cytomegalovirus infection rates were 35%, 20% and 23%, respectively (P = 0.009). Multivariable Cox regression showed an HR of 0.51 (95% CI, 0.25-1.02) for acute rejection with group B versus group A, and 0.54 (95% CI, 0.33-0.88; P = 0.013) for severe infection. The rate of malignancy per 1000 patient-years was higher in groups B (13.85) and C (14.95) than group A (7.83). CONCLUSIONS These retrospective data suggest that a cumulative rATG dose of 4.5 to 7.5 mg/kg may offer a better risk-benefit ratio than lower or higher doses, with acceptable rates of infection and posttransplant malignancy. Prospective trials are needed.
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14
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Thymoglobulin Induction Therapy in Deceased Donor Kidney Transplantation: Single-Center Experience in Mexico. Transplant Proc 2016; 48:596-9. [PMID: 27110010 DOI: 10.1016/j.transproceed.2016.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Induction therapy is used to reduce the incidence of graft rejection and delayed graft function. Thymoglobulin is the most used inductor agent in deceased donor kidney transplantation due to its lower rejection and delayed graft function rates. METHODS Retrospective study of patients who underwent deceased donor kidney transplantation from 2011 to 2014. Efficacy and safety outcomes evaluated were primary graft nonfunction, delayed graft function, acute rejection episodes, the lowest leukocyte count during the induction, adverse effects, eGFR, and patient and graft survival. P < .05 was considered statistically significant. RESULTS A total of 42 patients were registered. Of these, 51.7% were female, with a mean age of 36.4 ± 11.1 years. Mean dialysis time was 112.4 ± 365 months. Mean donor age was 33.7 ± 13.1 years. Of the registered patients, 14.3% were extended criteria donors and 23.8% high-risk. Mean thymoglobulin dose was 4.4 ± 0.8 mg/kg. Primary graft nonfunction was 2.4%. Nineteen percent presented with delayed graft function and 19% with acute rejection. Mean lowest leukocyte count was of 4.6 ± 1.5 × 10(3) cells/mm(3). Mean hospital stay was 11.3 ± 6.3 days. Adverse effects were seen in 59.5% of registered patients, whereas graft survival 1 year and 3 years after transplantation was 85.3% and 56.9%, respectively. Patient survival 1 year and 3 years after transplantation was 85.3% and 53.8%, respectively. Patients who received a higher dose (>4.4 mg/kg) had a shorter hospital stay (9.4 ± 4.6 and 8.1 ± 2.3) than those who received lower dose (13.6 ± 7.9 and 12.8 ± 7.4; P < .05). CONCLUSION Thymoglobulin induction at doses near 5 mg/kg in deceased donor kidney transplant is efficient and secure at our center.
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Kim Y, Kang SS, Park WY, Jin K, Park SB, Park UJ, Kim HT, Han S. Optimal Dose of Thymoglobulin for Induction Therapy in High Risk Kidney Transplant Recipients. ACTA ACUST UNITED AC 2016. [DOI: 10.4285/jkstn.2016.30.2.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
| | - Seong Sik Kang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
| | - Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
| | - Sung Bae Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
| | - Ui Jun Park
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
- Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Hyoung Tae Kim
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
- Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Department of Internal Medicine, Keimyung University Kidney Institute, Daegu, Korea
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16
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Malvezzi P, Jouve T, Rostaing L. Induction by anti-thymocyte globulins in kidney transplantation: a review of the literature and current usage. J Nephropathol 2015; 4:110-5. [PMID: 26457257 PMCID: PMC4596294 DOI: 10.12860/jnp.2015.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 07/25/2015] [Indexed: 01/28/2023] Open
Abstract
Context: Preventing acute rejection (AR) after kidney transplantation is of utmost importance because an AR can have a negative impact on long-term allograft survival.
Evidence Acquisition: Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO, and Web of Science have been searched.
Results: At the moment this can be done by using rabbit anti-thymocyte globulins (rATGs) as an induction therapy. However, because rATGs are associated with some deleterious side-effects, such as the opportunistic infections cytomegalovirus (CMV) and
de novo
post-transplant cancer, it is very important they are used optimally, i.e., at minimal doses that avoid many side-effects but still retain optimal treatment efficacy. Recent data show that the risk of CMV infection can be minimized using tacrolimus plus everolimus, and not tacrolimus plus mycophenolic acid, as the maintenance immunosuppression. The use of rATG is particularly valuable in; (a) sensitized patients;
(b)
in recipients from an expanded-criteria donor, thus enabling the introduction of calcineurin inhibitors at reduced doses; and
(c)
for patients where steroid avoidance is contemplated. However, we also need to consider that rATG may increase the risk of
de novo
cancer, even though recent data indicate this is unlikely and that any risk can be reduced by using mammalian target of rapamycin (mTOR) inhibitors instead of mycophenolic acid combined with low-dose calcineurin inhibitors.
Conclusions: Even though rATGs do not improve long-term kidney-allograft survival, they may help reduce calcineurin-inhibitor dosage during the early post-transplant period and minimize the risk of AR.
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Affiliation(s)
- Paolo Malvezzi
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Thomas Jouve
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Lionel Rostaing
- Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France ; Université Paul Sabatier, Toulouse, France
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Cheon SU, Moon JI, Choi IS, Yoon SH, Hwang WM, Yun SR. Comparison of the Clinical Outcomes between Anti-thymocyte Globulin and Basiliximab Induction Therapy in Deceased Donor Kidney Transplantation: Single Center Experience. KOREAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.4285/jkstn.2015.29.2.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seong Uk Cheon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Ju Ik Moon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - In Seok Choi
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Se Hee Yoon
- Department of Internal Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Won Min Hwang
- Department of Internal Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Sung Ro Yun
- Department of Internal Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Outcome and cost analysis of induction immunosuppression with IL2Mab or ATG in DCD kidney transplants. Transplantation 2014; 97:1161-5. [PMID: 24573113 DOI: 10.1097/01.tp.0000442505.10490.20] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Nair N, Gongora E, Mehra MR. Long-term immunosuppression and malignancy in thoracic transplantation: Where is the balance? J Heart Lung Transplant 2014; 33:461-7. [DOI: 10.1016/j.healun.2014.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/01/2014] [Accepted: 03/04/2014] [Indexed: 12/20/2022] Open
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20
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Hardinger KL, Brennan DC, Klein CL. Selection of induction therapy in kidney transplantation. Transpl Int 2012; 26:662-72. [PMID: 23279211 DOI: 10.1111/tri.12043] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/03/2012] [Accepted: 11/23/2012] [Indexed: 01/28/2023]
Abstract
Currently available immunosuppressive agents can be classified into three categories: induction agents, maintenance therapy, and treatment for rejection. This review article will focus on induction immunosuppression. There are three antibodies which are used for induction therapy: the lymphocyte-depleting agents - anti-thymocyte globulin and alemtuzumab, and basiliximab which is nondepleting. Historically, immunosuppressant selection was solely based on efficacy for prevention of rejection. In the current era of transplantation, it is now common practice in the transplant community to select induction therapy on the basis of risk-benefit considerations for each patient. This article will focus on the efficacy of available induction agents and the selection of induction agent based on donor and recipient risk factors.
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Affiliation(s)
- Karen L Hardinger
- Department of Pharmacy Practice, University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, USA
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