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Pawar N, Tiwari V, Gupta A, Divyaveer S, Rather I, Chadha S, Bhargava V, Malik M, Gupta A, Bhalla AK, Rana D, Gupta P. ABO-Incompatible Renal Transplant: A Single-Center Experience from India. Indian J Nephrol 2024; 34:24-30. [PMID: 38645921 PMCID: PMC11003606 DOI: 10.4103/ijn.ijn_247_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/31/2023] [Indexed: 04/23/2024] Open
Abstract
Introduction In view of ever-increasing end-stage renal disease (ESRD) population but inadequate availability of suitable donors, ABO-incompatible (ABOi) transplantation can be an important void filler. However, at present, ABOi transplantation is limited to a few centers in India and there is a lack of adequate experience and expertise to guide this program to other centers in the country. Methods Data of all the ABOi transplants performed from 2012 to 2021 in a tertiary care hospital was retrospectively analyzed. The anti-ABO antibody (IgG) titers (≤1:4) were considered safe before transplantation. Desensitization included rituximab, plasma exchange, or selective immunoadsorption column. Tacrolimus and mycophenolate mofetil were initiated at day -7. Induction agents included ATG, ATLG, basiliximab, or no induction. Postoperatively, anti-ABO titers were done daily for 2 weeks. Results A total of 202 patients underwent transplantation; of these, 195 patients whose data were for available for 12 months were included in the study. Mean duration of follow-up was 28.9 ± 21.7 months. UTI was the most common source of infection, occurring in almost half (46.1%) of the patients. Antibody-mediated rejection (ABMR; 15%) was common in the first year. Patient survival was 86.6% (169/195) at 1 year. Sepsis was the most common of death in more than two-thirds of the population, including coronavirus disease 2019 (COVID-19)-associated mortality in nine patients (4.6%). Death-censored graft survival was 89.3% (174/195). AMR was the leading cause of graft loss in almost half of the patients. Conclusion ABOi should be considered in ESRD patients for whom suitable ABO-compatible donor is not available. Higher rate of rejection and infection are still a major concern.
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Affiliation(s)
- Nikita Pawar
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Vaibhav Tiwari
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Anurag Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Smita Divyaveer
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Imran Rather
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Chadha
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Anil Kumar Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - D.S. Rana
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Pallav Gupta
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
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Hou YB, Chang S, Chen S, Zhang WJ. Intravenous immunoglobulin in kidney transplantation: Mechanisms of action, clinical applications, adverse effects, and hyperimmune globulin. Clin Immunol 2023; 256:109782. [PMID: 37742791 DOI: 10.1016/j.clim.2023.109782] [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: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
Intravenous immunoglobulin (IVIG) has been developed for over 40 years. The mechanisms of action of IVIG are complex and diverse, and there may be multiple mechanisms that combine to influence it. IVIG has been used in kidney transplantation for desensitization, treatment of antibody-mediated rejection, and ABO-incompatible transplantation. and treatment or prevention of some infectious diseases. Hyperimmune globulins such as cytomegalovirus hyperimmune globulin (CMV-IG) and hepatitis B hyperimmune globulin (HBIG) have also been used to protect against cytomegalovirus and hepatitis B virus, respectively. However, IVIG is also associated with some rare but serious adverse effects and some application risks, and clinicians need to weigh the pros and cons and develop individualized treatment programs to benefit more patients. This review will provide an overview of the multiple mechanisms of action, clinical applications, adverse effects, and prophylactic measures of IVIG, and hyperimmune globulin will also be introduced in it.
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Affiliation(s)
- Yi-Bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Wei-Jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China.
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Isoagglutinin Titers in ABO-Incompatible Kidney Transplant. Transplant Proc 2021; 53:2675-2677. [PMID: 34610865 DOI: 10.1016/j.transproceed.2021.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND A decrease in the isoagglutinin titer <1:8 is usually required for ABO-incompatible (ABOi) transplantation and the presence of high predesensitization titers may condition future transplantation. The aim of the study was to analyze the prognosis of ABOi patients undergoing desensitization and to compare the results according to the baseline isoagglutinin titer. METHODS ABOi patients transplanted in our center after desensitization with rituximab, apheresis (plasmapheresis, immunoadsorption with Glycosorb, or both) and immunoglobulins were studied. Survival, renal function, and complications were analyzed and the results were compared according to the presence of a baseline isoagglutinin titer higher or lower than 1:128. We analyzed 48 patients (34 male) with a mean age of 50.9 ± 11 years and a mean follow-up of 44.6 ± 30 months. Thirty-eight patients had a basal isoagglutinin titer ≤1:128 and 10 had a titer >1:128. We did not observe differences in patient survival: 96% vs 100% at 5 years (P = .64) and renal survival: 91% vs 100% at 5 years (P = .39), incidence of acute rejection: 13.2% vs 0% (P = .22), infectious complications (cytomegalovirus; 16% vs 30%, P = 0.30; Polyomavirus BK virus: 13% vs 0%, P = .22), or surgical (hematoma): 47% vs 60% (P = .47) between the 2 groups. A higher number of apheresis sessions was observed (4.8 ± 1.9 vs 10.9 ± 3.9; P = .001); use of both techniques (0% vs 100%, P < .001) and higher processed volume (1 ± 0.1 vs 1.4 ± 0.5; P = .049) in patients with titer >128 was observed. Creatinine and proteinuria were similar and not significant. CONCLUSIONS Baseline isoagglutinin titer does not influence the prognosis of ABOi patients after desensitization. The number of sessions required to achieve baseline titer <1:8 is higher but does not influence the number of days of hospital admission.
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Inducing Transient Mixed Chimerism for Allograft Survival Without Maintenance Immunosuppression With Combined Kidney and Bone Marrow Transplantation: Protocol Optimization. Transplantation 2020; 104:1472-1482. [PMID: 31634324 DOI: 10.1097/tp.0000000000003006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tolerance induction is an important goal in the field of organ transplantation. We have sequentially modified our conditioning regimen for induction of donor-specific tolerance in recipients of major histocompatibility complex-mismatched combined kidney and bone marrow transplantation (CKBMT). METHODS From December 2011 to May 2017, 8 major histocompatibility complex-mismatched patients received CKBMT. The initial conditioning regimen (protocol 1) consisted of cyclophosphamide (CP), rituximab, rabbit antithymocyte globulin, and thymic irradiation. Tacrolimus and steroids were used for the maintenance of immunosuppression (IS). RESULTS This regimen was complicated by transient acute kidney injury, which has been the major clinical feature of engraftment syndrome and side effects of CP, although one of 2 subjects successfully discontinued his IS for 14 months. The conditioning regimen was modified by reducing the CP dose and adding fludarabine (protocol 2). The final modification was reducing the fludarabine and rabbit antithymocyte globulin doses (protocol 3). Mixed chimerism, detected by the short tandem repeat method, was achieved transiently in all subjects for 3-20 weeks. Among the 3 subjects treated with protocol 2, IS was successfully discontinued for >35 months in one subject, but the other 2 subjects suffered from severe BK virus-associated nephritis. All 3 subjects treated with protocol 3 tolerated the protocol well and have successfully discontinued IS for >4-41 months. Interestingly, de novo donor-specific antibody was not detected in any subject during all the follow-up periods. CONCLUSIONS Our clinical trial has shown that long-term renal allograft survival without maintenance IS can be achieved by induction of mixed chimerism following CKBMT.
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Cao J, Chen C, Liu L, Zhang Y, Zhou H, Xiao J, Wang Y. Identification of an activation-related protein in B cells in the ABO incompatible condition. Exp Ther Med 2020; 19:741-747. [PMID: 31897108 DOI: 10.3892/etm.2019.8234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/22/2019] [Indexed: 11/05/2022] Open
Abstract
In ABO-incompatible (ABOi) kidney transplantation (KT), antibodies can mediate immunological accommodation or immune rejection, but the mechanism by which B cells are induced to produce antibodies with different functions is still unclear. Previous research established an ABOi kidney cell model and identified that haptoglobin (HP) is associated with the activation of lymphocytes. In the present study, the results of a flow cytometric assay demonstrated that HP was expressed by B cells. Moreover, dot-ELISA and ELISA analyses showed that the concentrations of total IgG, blood group B antibody, IgG1, IgG2 and IgG4 were all significantly increased in the cell model. In addition, dot-ELISA and haptoglobin level analyses showed that HP protein expression was significantly increased, while RT-qPCR assay indicated that HP was significantly reduced at the mRNA level. Furthermore, bioinformatics analysis showed that HP could interact with Smad3, and the HP-Smad3 complex was detected in a peripheral blood mononuclear cell (PBMC) protein extract by a dot-ELISA method. This research revealed that HP was involved in the process of B-cell activation by interacting with Smad3, and the results will be helpful to reveal the mechanism of B-cell activation in ABOi-KT.
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Affiliation(s)
- Jingsong Cao
- Clinical Research Center, Institute of Pathogenic Biology, Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, Hunan 421001, P.R. China.,The Second Hospital, University of South China, Hengyang, Hunan 421001, P.R. China.,The First Affiliated Hospital of University of South China, Hengyang, Hunan 421001, P.R. China
| | - Cong Chen
- Clinical Research Center, Institute of Pathogenic Biology, Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, Hunan 421001, P.R. China
| | - Luogen Liu
- The Second Hospital, University of South China, Hengyang, Hunan 421001, P.R. China
| | - Yunsheng Zhang
- The Second Hospital, University of South China, Hengyang, Hunan 421001, P.R. China
| | - Hong Zhou
- The First Affiliated Hospital of University of South China, Hengyang, Hunan 421001, P.R. China
| | - Jianhua Xiao
- Clinical Research Center, Institute of Pathogenic Biology, Medical College, Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, Hunan 421001, P.R. China
| | - Yi Wang
- The Second Hospital, University of South China, Hengyang, Hunan 421001, P.R. China.,The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570102, P.R. China
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Fernández Rivera C, Calvo Rodríguez M, López Muñíz A, Ferreiro Hermida T, Seijo Bestilleiro R, Andón Saavedra C, Galego García A, Alonso Hernández A. Trasplante renal de donante vivo ABO incompatible. Estudio de 48 pacientes tras desensibilización. Nefrologia 2019; 39:612-622. [DOI: 10.1016/j.nefro.2019.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 12/26/2022] Open
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Chauhan K, Mehta AA. Rituximab in kidney disease and transplant. Animal Model Exp Med 2019; 2:76-82. [PMID: 31392300 PMCID: PMC6600632 DOI: 10.1002/ame2.12064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
Rituximab is a chimeric monoclonal antibody that binds to CD20 antigen of B-cells. It depletes the level of mature B-cells by various mechanisms such as mediation of antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity, and B-cell apoptosis. Rituximab is a USFDA approved drug for clinical use in non-Hodgkin's B-cell lymphoma (NHL), rheumatoid arthritis, chronic lymphocytic leukemia (CLL), granulomatosis with polyangiitis and pemphigus vulgaris. It is also known for its "off label" use in renal disease and renal transplant worldwide. However, the exact mechanisms by which it exerts its effect in the aforementioned condition remain unclear but may be related to its long-term effects on plasma cell development and the impact on B-cell modulation of T cell responses. This review discusses the current use of rituximab in renal disease and renal transplantation, and its potential role in novel therapeutic protocols.
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Affiliation(s)
- Kajal Chauhan
- Medical ServicesTorrent PharmaceuticalsAhmedabadIndia
| | - Anita A. Mehta
- Department of PharmacologyL. M. College of PharmacyAhmedabadGujaratIndia
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Lee KW, Kim KS, Lee JS, Yoo H, Kim K, Park JB, Kwon GY, Kim SJ. Impact of Induction Immunosuppression on the Recurrence of Primary IgA Nephropathy. Transplant Proc 2019; 51:1491-1495. [PMID: 31010698 DOI: 10.1016/j.transproceed.2019.01.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the impact of induction immunosuppression on the incidence of recurrent IgA nephropathy (IgAN). METHODS We conducted recurrence-free survival analysis of recipients of a first kidney transplant for IgAN who received a graft between 1995 and 2015. Kaplan-Meier and Cox regression analyses were used to sort the significant risk factors for recurrence. A total of 226 recipients with biopsy-proven IgAN received a kidney transplant, and 218 recipients were enrolled. RESULTS Among the recipients, 29 cases of IgAN recurrence were observed. The recipients were categorized into 3 groups according to induction immunosuppression: no induction (group 1, n = 72), anti-CD25 (group 2, n = 86), and antithymocyte globulin (ATG, group 3, n = 60). The 5- and 10-year cumulative IgAN recurrence rates were 9.7% and 21.0%, respectively. Recipients receiving ATG (group 3) exhibited significantly higher 4- and 5-year recurrence-free graft survival rates (both 96.4%) than recipients who received anti-CD25 (group 2, both 85.1%, P = .03). However, the induction therapy used (ATG or basiliximab) was not the risk factor for IgAN recurrence. CONCLUSIONS Therefore, we concluded that ATG induction seems to postpone IgAN recurrence. These findings should be evaluated with well-designed prospective studies.
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Affiliation(s)
- Kyo Won Lee
- Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Kyeong Sik Kim
- Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Ji Soo Lee
- Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Heejin Yoo
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Korea
| | - Kyunga Kim
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea.
| | - Ghee Young Kwon
- Department of Pathology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
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Increased but stable isoagglutinin titers in hemodialysis patients. J Nephrol 2018; 32:121-127. [DOI: 10.1007/s40620-018-0512-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/04/2018] [Indexed: 12/18/2022]
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Ray DS, Thukral S. ABO-Incompatible Renal Transplantation with High Antibody Titer: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1073-1076. [PMID: 28983073 PMCID: PMC5642648 DOI: 10.12659/ajcr.905633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Even though renal transplantation across blood groups is not uncommonly practiced nowadays, there is still hesitation regarding ABO-incompatible transplantation with very high baseline antibody titer. In this case report, the outcome of an ABO-incompatible kidney transplant recipient with a high baseline isoagglutinin titer is reported. CASE REPORT The patient was a non-diabetic, 33-year-old man with end-stage renal disease secondary to chronic glomerulonephritis. The only kidney donor available was his mother, who was blood-group incompatible. The patient's blood group was O positive, whereas his mother was B positive. We evaluated him for an ABO-incompatible renal transplant. The baseline anti-B isoagglutinin titer was >1:8196. With a desensitization protocol of low-dose Rituximab, plasmapheresis, and IVIG, this titer was brought down to 1:32 before transplantation. He successfully underwent renal transplantation across the ABO barrier, and maintains good graft function after 1 year of follow-up. CONCLUSIONS In the present era, a high baseline isoagglutinin titer is no longer a contraindication for successful kidney transplantation in ABO-incompatible recipient-donor pairs.
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Affiliation(s)
- Deepak Shankar Ray
- Department of Renal Sciences, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health Multispecialty Hospitals, Kolkata, India
| | - Sharmila Thukral
- Department of Renal Sciences, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health Multispecialty Hospitals, Kolkata, India
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Cozzi E, Colpo A, De Silvestro G. The mechanisms of rejection in solid organ transplantation. Transfus Apher Sci 2017; 56:498-505. [PMID: 28916402 DOI: 10.1016/j.transci.2017.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Organ transplantation represents the preferred treatment option for many patients in terminal organ failure. The half-life of transplanted organs, however, is still far from being satisfactory with the vast majority of the organs failing within the first two decades following transplantation. At this stage, it has become apparent that rejection (prevalently mediated by humoral events) remains the primary cause of graft loss after the first year. In this light, studies are underway to better comprehend the immune events underlying graft rejection and novel immunosuppressive strategies are being explored. In this context, therapeutic apheresis techniques, that include therapeutic plasma exchange (TPE), immunoadsorption (IA) and extracorporeal photochemotherapy (ECP), represent an important adjunct in the current immunosuppressive armamentarium. This article briefly reviews our current understanding of the immune process underlying rejection of a solid organ transplant and describes the principal areas of application of therapeutic apheresis techniques in transplantation.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences, Transplant Immunology Unit, Padua University Hospital, Padova, Italy; CORIT (Consortium for Research in Organ Transplantation), Padova, Italy.
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Padova, Italy
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