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Lee BK, Han HS, Adler JT. Minimization of Transplant Immunosuppression: An Elusive Goal. Transplantation 2024; 108:18-19. [PMID: 37525368 PMCID: PMC10830878 DOI: 10.1097/tp.0000000000004737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Brian K Lee
- Division of Nephrology, Department of Medicine, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Hwarang S Han
- Division of Nephrology, Department of Medicine, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
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Viklicky O, Zahradka I, Bold G, Bestard O, Hruba P, Otto NM, Stein M, Sefrin A, Modos I, Meneghini M, Crespo E, Grinyo J, Volk HD, Christakoudi S, Reinke P. Tacrolimus After rATG and Infliximab Induction Immunosuppression-RIMINI Trial. Transplantation 2024; 108:242-251. [PMID: 37525369 DOI: 10.1097/tp.0000000000004736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Infliximab selectively targets recently activated effector cells and, as an induction agent, might enable the safe elimination of mycophenolate from maintenance immunosuppression in kidney transplantation. METHODS This is a phase II international multicenter open-label single-arm confidence interval (CI)-based clinical trial of the BIO-DrIM EU consortium aimed at assessing the efficacy and safety of rabbit antithymocyte globulin and infliximab induction in kidney transplantation. Sixty-seven primary kidney transplant recipients at low risk (panel-reactive antibodies <20%, no donor-specific antibodies [DSA]) received rabbit antithymocyte globulin (2 × 1.5 mg/kg, postoperative days 0 and 1) and infliximab (5 mg/kg, postoperative day 2), followed by mycophenolate-free tacrolimus-based immunosuppression for 12 mo. The primary endpoint was efficacy failure, defined as a composite of acute rejection, graft loss, or poor graft function (estimated glomerular filtration rate <40 mL/min) at 12 mo and was based on the endpoint of the comparator study. Additionally, a historical propensity-matched control cohort was established. RESULTS Primary endpoint occurred in 22 of 67 patients (32.84%), with upper bound of an exact 1-sided 95% CI of 43.47%, which met the predefined criteria (efficacy failure of <40% and upper-bound 95% CI of <50%) and was similar in the historical matched cohort. By 12 mo, 79.1% of patients remained on the study protocol. Lower rates of BK replication (6% versus 22.4%; P = 0.013) but higher rates of de novo DSAs (11.9% versus 1.5%; P = 0.039) were observed in the study cohort. CONCLUSIONS A similar efficacy of the study immunosuppression regimen to the comparator study and the historical matched cohort was found. However, a higher de novo DSA emergence points to an increased risk of antibody-mediated rejection (NCT04114188).
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Affiliation(s)
- Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Zahradka
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Gantuja Bold
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d'Hebron University Hospital, Barcelona Hospital Campus, Barcelona, Spain
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Natalie M Otto
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Maik Stein
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Anett Sefrin
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Istvan Modos
- Information Technology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Maria Meneghini
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Elena Crespo
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Josep Grinyo
- Department of Medicine, Barcelona University, Barcelona, Spain
| | - Hans-Dieter Volk
- Berlin Center for Advanced Therapies (BeCAT) and Institute of Medical Immunology, Charité Universitätsmedizin Berlin, Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Sofia Christakoudi
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St. Mary's Campus, Norfolk Place, London, United Kingdom
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
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Hickey MJ, Singh G, Lum EL. Continuation of immunosuppression vs. immunosuppression weaning in potential repeat kidney transplant candidates: a care management perspective. FRONTIERS IN NEPHROLOGY 2023; 3:1163581. [PMID: 37746029 PMCID: PMC10513023 DOI: 10.3389/fneph.2023.1163581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/17/2023] [Indexed: 09/26/2023]
Abstract
Management of immunosuppression in patients with a failing or failed kidney transplant requires a complete assessment of their clinical condition. One of the major considerations in determining immunosuppression is whether or not such an individual is considered a candidate for re-transplantation. Withdrawal of immunosuppression in a re-transplant candidate can result in allosensitization and markedly reduce the chances of a repeat transplant. In this review, we summarize the effects of immunosuppression reduction on HLA sensitization, discuss the impacts of allosensitization in these patients, and explore reduction protocols and future directions. Risks of chronic immunosuppression, medical management of the failing allograft, and the effect of nephrectomy are covered elsewhere in this issue.
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Affiliation(s)
- Michelle J. Hickey
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Immunogenetics Center, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Gurbir Singh
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
| | - Erik L. Lum
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
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Immune Response to COVID-19 mRNA Vaccination in Previous Nonresponder Kidney Transplant Recipients After Short-term Withdrawal of Mycophenolic Acid 1 and 3 Months After an Additional Vaccine Dose. Transplantation 2023; 107:1139-1150. [PMID: 36617671 PMCID: PMC10125015 DOI: 10.1097/tp.0000000000004516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The impaired immune response to coronavirus disease 2019 (COVID-19) vaccination in kidney transplant recipients (KTRs) leads to an urgent need for adapted immunization strategies. METHODS Sixty-nine KTRs without seroconversion after ≥3 COVID-19 vaccinations were enrolled, and humoral response was determined after an additional full-dose mRNA-1273 vaccination by measuring severe acute respiratory syndrome coronavirus 2-specific antibodies and neutralizing antibody activity against the Delta and Omicron variants 1 and 3 mo postvaccination. T-cell response was analyzed 3 mo postvaccination by assessing interferon-γ release. Mycophenolic acid (MPA) was withdrawn in 41 KTRs 1 wk before until 4 wk after vaccination to evaluate effects on immunogenicity. Graft function, changes in donor-specific anti-HLA antibodies, and donor-derived cell-free DNA were monitored in KTRs undergoing MPA withdrawal. RESULTS Humoral response to vaccination was significantly stronger in KTRs undergoing MPA withdrawal 1 mo postvaccination; however, overall waning humoral immunity was noted in all KTRs 3 mo after vaccination. Higher anti-S1 immunoglobulin G levels correlated with better neutralizing antibody activity against the Delta and Omicron variants, whereas no significant association was detected between T-cell response and neutralizing antibody activity. No rejection occurred during study, and graft function remained stable in KTRs undergoing MPA withdrawal. In 22 KTRs with Omicron variant breakthrough infections, neutralizing antibody activity was better against severe acute respiratory syndrome coronavirus 2 wild-type and the Delta variants than against the Omicron variant. CONCLUSIONS MPA withdrawal to improve vaccine responsiveness should be critically evaluated because withdrawing MPA may be associated with enhanced alloimmune response, and the initial effect of enhanced seroconversion rates in KTRs with MPA withdrawal disappears 3 mo after vaccination.
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Miura M, Fukumoto M, Komatsu N, Shuto R, Harada H, Sasaki H. Temporary reduction of immunosuppression enhances production of anti-S antibody against severe acute respiratory syndrome coronavirus 2 after vaccination in kidney transplant recipients. Int J Urol 2022; 29:1505-1510. [PMID: 36070502 PMCID: PMC9538803 DOI: 10.1111/iju.15027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/07/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES The study identified factors affecting anti-S immunoglobulin G production after vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in kidney transplant recipients. METHODS Serum samples were prospectively collected from kidney transplant recipients, live kidney donors, and healthy volunteers 1 month after receiving the second dose of SARS-CoV-2 vaccine, and anti-S immunoglobulin G titers were measured. The mycophenolate mofetil dose was reduced before vaccination in some immunologically low-risk recipients. RESULTS A total of 151 kidney transplant recipients, 74 live kidney donors, and 50 healthy volunteers were included. Kidney transplant recipients had significantly lower titers of anti-S immunoglobulin G than donors and healthy volunteers (1377 ± 246, 8310 ± 932, and 9908 ± 1040 AU/ml, respectively). Only 67.3% of kidney transplant recipients, compared to 100% of donors and healthy volunteers, were positive for anti-S immunoglobulin G. Among the kidney transplant recipients, the anti-S titer was higher in younger recipients, those with higher peripheral blood lymphocyte counts and glomerular filtration rates, those without a history of antithymocyte globulin use, and those who had discontinued or received a reduced dose of mycophenolate mofetil. Younger age, higher lymphocyte count, glomerular filtration rate, and mycophenolate reduction were significantly associated with anti-S immunoglobulin G > 1000 AU/ml in nominal logistic regression analysis. There were no rejection episodes after mycophenolate modification in kidney transplant recipients. CONCLUSIONS Anti-S immunoglobulin G production after vaccination was attenuated in kidney transplant recipients. Mycophenolate mofetil cessation or reduction is a modifiable means to enhance anti-S immunoglobulin G production in immunosuppressed kidney transplant recipients.
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Affiliation(s)
- Masayoshi Miura
- Department of Renal Transplant Surgery and UrologySapporo Hokuyu HospitalSapporoJapan
| | - Maiko Fukumoto
- Transplant Supporting OfficeSapporo Hokuyu HospitalSapporoJapan
| | - Natsumi Komatsu
- Transplant Supporting OfficeSapporo Hokuyu HospitalSapporoJapan
| | - Reimi Shuto
- Transplant Supporting OfficeSapporo Hokuyu HospitalSapporoJapan
| | | | - Hajime Sasaki
- Department of Kidney Transplant SurgerySapporo City General HospitalSapporoJapan
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Myint TM, Chong CHY, Wyld M, Nankivell B, Kable K, Wong G. Polyoma BK Virus in Kidney Transplant Recipients: Screening, Monitoring, and Management. Transplantation 2022; 106:e76-e89. [PMID: 33908382 DOI: 10.1097/tp.0000000000003801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polyomavirus BK virus (BKPyV) infection is an important complication of kidney transplantation and allograft failure. The prevalence of viremia is 10%-15%, compared with BK-associated nephropathy (BKPyVAN) at 3%-5%. Given that there are no effective antiviral prophylaxis or treatment strategies for BKPyVAN, active screening to detect BKPyV viremia is recommended, particularly during the early posttransplant period. Immunosuppression reduction to allow viral clearance may avoid progression to severe and irreversible allograft damage. The frequency and duration of screening are highly variable between transplant centers because the evidence is reliant largely on observational data. While the primary treatment goals center on achieving viral clearance through immunosuppression reduction, prevention of subsequent acute rejection, premature graft loss, and return to dialysis remain as major challenges. Treatment strategies for BKPyV infection should be individualized to the recipient's underlying immunological risk and severity of the allograft infection. Efficacy data for adjuvant therapies including intravenous immunoglobulin and cidofovir are sparse. Future well-powered and high-quality randomized controlled trials are needed to inform evidence-based clinical practice for the management of BKPy infection.
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Affiliation(s)
- Thida Maung Myint
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, NSW, Australia
| | - Chanel H Y Chong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Brian Nankivell
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Kathy Kable
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Li J, Thomson AW, Rogers NM. Myeloid and Mesenchymal Stem Cell Therapies for Solid Organ Transplant Tolerance. Transplantation 2021; 105:e303-e321. [PMID: 33756544 PMCID: PMC8455706 DOI: 10.1097/tp.0000000000003765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Transplantation is now performed globally as a routine procedure. However, the increased demand for donor organs and consequent expansion of donor criteria has created an imperative to maximize the quality of these gains. The goal is to balance preservation of allograft function against patient quality-of-life, despite exposure to long-term immunosuppression. Elimination of immunosuppressive therapy to avoid drug toxicity, with concurrent acceptance of the allograft-so-called operational tolerance-has proven elusive. The lack of recent advances in immunomodulatory drug development, together with advances in immunotherapy in oncology, has prompted interest in cell-based therapies to control the alloimmune response. Extensive experimental work in animals has characterized regulatory immune cell populations that can induce and maintain tolerance, demonstrating that their adoptive transfer can promote donor-specific tolerance. An extension of this large body of work has resulted in protocols for manufacture, as well as early-phase safety and feasibility trials for many regulatory cell types. Despite the excitement generated by early clinical trials in autoimmune diseases and organ transplantation, there is as yet no clinically validated, approved regulatory cell therapy for transplantation. In this review, we summarize recent advances in this field, with a focus on myeloid and mesenchymal cell therapies, including current understanding of the mechanisms of action of regulatory immune cells, and clinical trials in organ transplantation using these cells as therapeutics.
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Affiliation(s)
- Jennifer Li
- Center of Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, Australia
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Angus W Thomson
- Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Natasha M Rogers
- Center of Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, Australia
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, Australia
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