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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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Mehta RB, Shimko K, Zhang X, Puttarajappa C, Wu C, Sharma A, Molinari M, Tevar AD, Hariharan S, Sood P. Rabbit antithymocyte globulin dose and early subclinical and clinical rejections in kidney transplantation. Clin Transplant 2022; 36:e14582. [PMID: 35000234 DOI: 10.1111/ctr.14582] [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: 11/11/2021] [Revised: 12/12/2021] [Accepted: 12/30/2021] [Indexed: 11/28/2022]
Abstract
Antithymocyte globulin (ATG) is a commonly used induction agent in kidney transplant recipients. However, the optimal dosing has not been well defined. Our protocol aims for a 5-6 mg/kg cumulative dose. It is unclear if a dose lower than 5 mg/kg is associated with more rejection. We performed a retrospective cohort study of patients who received a kidney transplant at our center between January 1, 2013 and December 31, 2016. Primary outcome was biopsy proven acute rejection (clinical and subclinical) in the first six months after kidney transplant. CMV viremia in high risk(D+/R-) recipients and BK viremia was compared as a secondary endpoint. Of the 543 patients, the Low Dose (LD) group (n = 56) received <5 mg/kg ATG and Regular Dose (RD) group (n = 487) received ≧5 mg/kg. Patients in RD were more sensitized (higher PRA and CPRA). LD received a dose of 4 ± 1.1 mg/kg ATG whereas RD received 5.6 ± 0.3 mg/kg ATG (p < 0.001). TCMR(Banff 1A or greater) was present in 34% of patients in LD vs. 22% in RD (p = 0.04) (OR 2.1;95%CI 1.12-3.81;p = 0.019). There was no difference in the incidence of CMV or BK viremia. ATG doses lower than 5 mg/kg may be associated with a heightened risk of rejection despite a low degree of sensitization. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Rajil B Mehta
- University of Pittsburgh Medical Center, Division of Transplant Nephrology.,University of Pittsburgh, Division of Transplant Surgery
| | - Kristen Shimko
- University of Pittsburgh Medical Center, Department of Pharmacy
| | - Xingyu Zhang
- University of Pittsburgh, Division of Transplant Surgery
| | | | - Christine Wu
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | - Akhil Sharma
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | | | - Amit D Tevar
- University of Pittsburgh, Division of Transplant Surgery
| | - Sundaram Hariharan
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
| | - Puneet Sood
- University of Pittsburgh Medical Center, Division of Transplant Nephrology
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Outcomes Following ATG Therapy for Chronic Lung Allograft Dysfunction. Transplant Direct 2021; 7:e681. [PMID: 33748410 PMCID: PMC7969305 DOI: 10.1097/txd.0000000000001134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/08/2020] [Accepted: 12/29/2020] [Indexed: 12/19/2022] Open
Abstract
Chronic lung allograft dysfunction (CLAD) is the major factor limiting survival post lung transplantation (LTx) with limited effective therapeutic options. We report our 12-y experience of antithymocyte globulin (ATG) as second-line CLAD therapy.
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Good-Weber M, Roos M, Mueller TF, Rüsi B, Fehr T. Tailored immunosuppression after kidney transplantation - a single center real-life experience. BMC Nephrol 2020; 21:501. [PMID: 33228545 PMCID: PMC7686677 DOI: 10.1186/s12882-020-02137-5] [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: 03/04/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
Background Kidney allograft survival continuously improved with introduction of novel immunosuppressants. However, also immunologically challenging transplants (blood group incompatibility and sensitized recipients) increase. Between 2006 and 2008, a new tailored immunosuppression scheme for kidney transplantation was implemented at the University Hospital in Zurich, together with an ABO-incompatible transplant program and systematic pre- and posttransplant anti-human leukocyte antigen (HLA) antibody screening by Luminex technology. This study retrospectively evaluated the results of this tailored immunosuppression approach with a particular focus on immunologically higher risk transplants. Methods A total of 204 consecutive kidney transplantations were analyzed, of whom 14 were ABO-incompatible and 35 recipients were donor-specific anti-HLA antibodies (DSA) positive, but complement-dependent cytotoxicity crossmatch (CDC-XM) negative. We analyzed patient and graft survival, acute rejection rates and infectious complications in ABO-compatible versus -incompatible and in DSA positive versus negative patients and compared those with a historical control group. Results Overall patient, death-censored allograft survival and non-death-censored allograft survival at 4 years were 92, 91 and 87%, respectively. We found that (1) there were no differences between ABO-compatible and -incompatible and between DSA positive and DSA negative patients concerning acute rejection rate and graft survival; (2) compared with the historical control group there was a significant decrease of acute rejection rates in sensitized patients who received an induction with thymoglobulin; (3) there was no increased rate of infection among the patients who received induction with thymoglobulin compared to no induction therapy. Conclusions We observed excellent overall mid-term patient and graft survival rates with our tailored immunosuppression approach. Induction with thymoglobulin was efficient and safe in keeping rejection rates low in DSA positive patients with a negative CDC-XM. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02137-5.
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Affiliation(s)
- Miriam Good-Weber
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Malgorzata Roos
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University Zurich, Zurich, Switzerland
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Barbara Rüsi
- HLA Typing Laboratory, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Fehr
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland. .,Department of Internal Medicine, Cantonal Hospital Graubünden, Loestrasse 170, 7000, Chur, Switzerland.
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