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Hanouneh T, Attieh RM, Craver E, Jebrini A, Elrefaei M, Jarmi T. Comparative analysis of Basiliximab and Alemtuzumab induction therapies in blood type A2-to-B kidney transplantation: Impact on kidney function and de novo donor-specific HLA antibodies. Transpl Immunol 2023; 81:101958. [PMID: 37949378 DOI: 10.1016/j.trim.2023.101958] [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: 07/28/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Blood group B kidney transplant candidates have lower transplantation rates and longer waiting times compared to other blood groups. Kidney transplantation from blood group A2-to-B has offered a solution for these patients. This study aimed to investigate the impact of Basiliximab and Alemtuzumab induction therapies on kidney function and de novo donor-specific antibodies (DSA) in blood type A2-to-B kidney transplant recipients within the first 12 months of post-transplant. METHODS A retrospective analysis was conducted on 110 consecutive A2-to-B kidney transplant recipients between January 2015 and December 2022. Of these, 46 (41.8%) received Basiliximab, while 64 (58.2%) received Alemtuzumab as induction therapy. Demographics and comorbidities data were collected and compared between the two groups. Serum samples collected at 4- and 12-month intervals post-transplant were used to assess the presence of de novo DSA. Kidney allograft function was evaluated by monitoring serum creatinine levels and assessing Creatinine Clearance based on 24-h urine collection at various time points. RESULTS During the follow-up period, 20.00% of patients who received Alemtuzumab developed de novo DSA, whereas none of the patients induced with Basiliximab developed de novo DSA (p = 0.038). Recipients who received Basiliximab were older (mean age = 72.00) and received higher Kidney Donor Profile Index (KDPI) kidneys (mean = 75) compared to those induced with Alemtuzumab (mean age = 58.00, mean KDPI = 49) (p < 0.001), with no significant difference observed in the last follow-up creatinine clearance or creatinine levels between the two groups (p = 0.28). CONCLUSION The use of Basiliximab as induction immunosuppression in A2-to-B kidney transplant recipients is associated with a lower incidence of de novo HLA DSA formation without significant differences in overall renal function compared to Alemtuzumab.
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Affiliation(s)
- Tareq Hanouneh
- Department of Transplant, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Rose Mary Attieh
- Department of Transplant, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Emily Craver
- Department of Biostatistics, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Abdullah Jebrini
- Department of Transplant, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States of America.
| | - Tambi Jarmi
- Department of Transplant, Mayo Clinic, Jacksonville, FL, United States of America.
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2
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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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Ramouz A, Nikbakhsh R, Khajeh E, Sadeghi M, Daniel V, Schmitzler P, Morath C, Zeier M, Mehrabi A, Oweira H. Preoperative CD52 Level Predicts Graft Survival following Kidney Transplantation. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8949919. [PMID: 39281063 PMCID: PMC11401654 DOI: 10.1155/2022/8949919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/05/2022] [Indexed: 09/18/2024]
Abstract
Several factors have been reported to affect graft survival following kidney transplantation. CD52 molecules may increase T cell proliferation and activation, which may contribute to acute graft rejection and graft survival. In the current study, we studied the possible value of preoperative CD52 levels in predicting graft survival following renal transplantation. Ninety-six patients with end-stage renal disease who had kidney transplantation were included in the study from our prospective cohort. Blood samples were taken one day before surgery, and plasma CD52 levels were measured using ELISA (Cloud-Clone Corp., Houston, TX, USA). Acute rejection, acute tubular necrosis, delayed graft function, graft loss, BK infection, cytomegalovirus infection, and graft survival were evaluated. The mean age of recipients was 50.08 ± 12.82 years, and 64.6% were male. The incidence of delayed graft function, acute rejection, graft loss (p < 0.01), BK virus infection, and serum creatinine levels were significantly higher in recipients with high preoperative CD52 levels six months after transplantation (p < 0.05). Kaplan-Meier analysis revealed that three-year graft survival was significantly higher in patients with low preoperative CD52 levels (p < 0.0001). Univariate and multivariate Cox regression analyses showed that serum creatinine levels (hazard ratio [HR] = 1.7, p < 0.05), acute rejection (HR = 2.919, p < 0.05), and preoperative CD52 levels (HR = 3.114, p < 0.05) were independent prognostic factors for graft survival after kidney transplantation. We showed that high preoperative CD52 levels are associated with higher rates of acute rejection, delayed graft function, and BK virus infection and lower rates of graft survival after kidney transplantation.
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Affiliation(s)
- Ali Ramouz
- Department of General Visceral, and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Rajan Nikbakhsh
- Department of General Visceral, and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Elias Khajeh
- Department of General Visceral, and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Mahmoud Sadeghi
- Transplantation Immunology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Volker Daniel
- Transplantation Immunology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Paul Schmitzler
- Center for Infectious Disease Virology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christian Morath
- Division of Nephrology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General Visceral, and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Hani Oweira
- Department of Surgery Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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Regulatory B cells: the cutting edge of immune tolerance in kidney transplantation. Cell Death Dis 2018; 9:109. [PMID: 29371592 PMCID: PMC5833552 DOI: 10.1038/s41419-017-0152-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 12/20/2022]
Abstract
Kidney transplantation is the optimal treatment for end-stage renal diseases. Although great improvement has been achieved, immune tolerance is still the Holy Grail that every organ transplant practitioner pursues. The role of B cells in transplantation has long been considered simply to serve as precursors of plasma cells, which produce alloantibodies and induce antibody-mediated rejection. Recent research indicates that a specialized subset of B cells plays an important role in immune regulation, which has been well demonstrated in autoimmune diseases, infections, and cancers. This category of regulatory B cells (Bregs) differs from conventional B cells, and they may help develop a novel immunomodulatory therapeutic strategy to achieve immune tolerance in transplantation. Here, we review the latest evidence regarding phenotypes, functions, and effectors of Bregs and discuss their diverse effects on kidney transplantation.
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6
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Comparative efficacy and safety of antibody induction therapy for the treatment of kidney: a network meta-analysis. Oncotarget 2017; 8:66426-66437. [PMID: 29029524 PMCID: PMC5630424 DOI: 10.18632/oncotarget.19815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/12/2017] [Indexed: 12/22/2022] Open
Abstract
To evaluate the efficacy and safety of antibody induction therapies in kidney transplantation. Systematic literature searches were undertaken using MEDLINE, Embase, and Cochrane Library database from 1980 to 2016. Randomized controlled trials (RCTs) comparing three antibody induction therapies (alemtuzumab, interleukin-2 receptor antibodies and antithymocyte globulin) between each other were identified. Bayesian network meta-analysis was used to combine both the direct and indirect evidence on treatment efficacy and its safety. Antibody induction therapy studies, comprising of 18 RCTs (3444 kidney transplant recipients), were included. Overall, alemtuzumab treatment was superior to the ATG group (OR: 0.49, 95% CI: 0.32 to 0.71) and IL-2RAs group (OR: 0.36, 95% CI: 0.25 to 0.52) for reducing the 1-year acute rejection in kidney transplant recipients. Although alemtuzumab treatment was nearly same with ATG group and IL-2RAs group in improving patient survival and renal function, it can reduce the adverse effects of cytomegalovirus infection more efficiently than ATG group (OR: 0.59, 95% CI: 0.32 to 0.95) and IL-2RAs group (OR: 1.08, 95% CI: 0.61 to 1.73). Alemtuzumab was not associated with increased other adverse effects. Alemtuzumab treatment is safe and effective for kidney transplant recipients. No serious adverse effects were observed in trials or in general populations.
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7
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Zheng J, Song W. Alemtuzumab versus antithymocyte globulin induction therapies in kidney transplantation patients: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e7151. [PMID: 28700465 PMCID: PMC5515737 DOI: 10.1097/md.0000000000007151] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Alemtuzumab (ALEM) is widely used as an induction therapy for organ transplantation, and numerous randomized controlled trials (RCTs) have been published to evaluate its efficacy and safety in kidney transplantation as compared with antithymocyte globulin (ATG). The purpose of this study was to compare the benefits and safety of ALEM with those of ATG for induction therapy.A systematic literature search in three electronic databases, including PubMed, EmBase, and Cochrane Library, since inception through October 2016, was conducted to identify potential RCTs for inclusion. Trials that investigated the risk of biopsy-proven acute rejection (BPAR), mortality, graft failure, delayed graft function (DGF), chronic allograft nephropathy (CAN), infections, cytomegalovirus (CMV) infections, new-onset diabetes mellitus after transplant (NODAT), and granulocyte colony stimulation factor (GCSF) use in kidney transplant recipients who received ALEM or ATG as an induction therapy were included. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model.Six RCTs involving 446 kidney transplantation patients were included in this meta-analysis. The effects of ALEM therapy were not significantly different from those of ATG therapy, including the incidence of BPAR (RR: 0.77; 95% CI: 0.51-1.18; P = .229), mortality (RR: 0.64; 95% CI: 0.30-1.39; P = .263), graft failure (RR: 0.81; 95% CI: 0.49-1.33; P = .411), DGF (RR: 1.00; 95% CI: 0.60-1.67; P = .999), CAN (RR: 1.42; 95% CI: 0.44-4.57; P = .556), infections (RR: 1.00; 95% CI: 0.74-1.35; P = .989), CMV infections (RR: 0.70; 95% CI: 0.38-1.30; P = .263), NODAT (RR: 0.50; 95% CI: 0.18-1.36; P = .174), and GCSF use (RR: 1.16; 95% CI: 0.81-1.66; P = .413). Sensitivity analyses were consistent with the overall analysis for all effects except CAN, suggesting that the risk of CAN might be higher with ALEM therapy than ATG therapy (RR: 2.45; 95% CI: 1.02-5.94; P = .046).The findings of this study suggest that the beneficial effects of ALEM therapy are greater than those of ATG therapy in kidney transplantation patients; however, the effects were not statistically significant because of the limited number of trials. Further large-scale RCTs are needed to verify the treatment effects of ALEM.
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Daloul R, Gupta S, Brennan DC. Biologics in Transplantation (Anti-thymocyte Globulin, Belatacept, Alemtuzumab): How Should We Use Them? CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Toyoda M, Shin BH, Ge S, Mirocha J, Thomas D, Chu M, Rodriguez E, Chao C, Petrosyan A, Galera OA, Vo A, Choi J, Peng A, Kahwaji J, Jordan SC. Impact of Desensitization on Antiviral Immunity in HLA-Sensitized Kidney Transplant Recipients. J Immunol Res 2017; 2017:5672523. [PMID: 28265581 PMCID: PMC5317146 DOI: 10.1155/2017/5672523] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/15/2016] [Indexed: 12/15/2022] Open
Abstract
Viral infections represent significant morbidity and mortality factors in kidney transplant recipients, with CMV, EBV, and BKV infections being most common. Desensitization (DES) with IVIg and rituximab with/without plasma exchange followed by kidney transplantation with alemtuzumab induction increased successful transplant rates in HLA-sensitized patients but may represent an increased risk for viral infections due to severe lymphocyte depletion. Here, we report on the posttransplant viral infection status in 372 DES versus 538 non-DES patients. CMV and EBV viremia were significantly lower in DES patients, while BKV viremia was similar. This trend was observed primarily in CMV sero(-), EBV sero(+), and sero(-) patients. No patient developed PTLD. The incidence of BKAN, allograft, and patient survival was similar in both groups. These viral infections were not associated with subsequent allograft rejection which occurred within 6 months after the infection. Conclusions. The IVIg + rituximab desensitization combined with alemtuzumab induction with triple immunosuppression maintenance does not increase the risk for CMV, EBV, and BKV infections. Possible factors include, in addition to posttransplant antiviral prophylaxis and PCR monitoring, presence of memory T cells and antibodies specific to CMV and likely EBV, NK cell-mediated ADCC despite lymphocyte depletion, elimination of EBV and CMV reservoirs by rituximab and alemtuzumab, and use of IVIg with antiviral properties.
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Affiliation(s)
- Mieko Toyoda
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bong-Ha Shin
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shili Ge
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Mirocha
- Biostatistics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Thomas
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maggie Chu
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edgar Rodriguez
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christine Chao
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anna Petrosyan
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Odette A. Galera
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Kahwaji
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stanley C. Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Nashan B, Abbud-Filho M, Citterio F. Prediction, prevention, and management of delayed graft function: where are we now? Clin Transplant 2016; 30:1198-1208. [PMID: 27543840 DOI: 10.1111/ctr.12832] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2016] [Indexed: 12/28/2022]
Abstract
Delayed graft function (DGF) remains a major barrier to improved outcomes after kidney transplantation. High-risk transplant recipients can be identified, but no definitive prediction model exists. Novel biomarkers to predict DGF in the first hours post-transplant, such as neutrophil gelatinase-associated lipocalin (NGAL), are under investigation. Donor management to minimize the profound physiological consequences of brain death is highly complex. A hormonal resuscitation package to manage the catecholamine "storm" that follows brain death is recommended. Donor pretreatment with dopamine prior to procurement lowers the rate of DGF. Hypothermic machine perfusion may offer a significant reduction in the rate of DGF vs simple cold storage, but costs need to be evaluated. Surgically, reducing warm ischemia time may be advantageous. Research into recipient preconditioning options has so far not generated clinically helpful interventions. Diagnostic criteria for DGF vary, but requirement for dialysis and/or persistent high serum creatinine is likely to remain key to diagnosis until current work on early biomarkers has progressed further. Management centers on close monitoring of graft (non)function and physiological parameters. With so many unanswered questions, substantial reductions in the toll of DGF in the near future seem unlikely but concentrated research on many levels offers long-term promise.
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Affiliation(s)
- Björn Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Mario Abbud-Filho
- Department of Nephrology, Medical School FAMERP, Director Organ Transplantation Center Foundation FUNFARME, São José do Rio Preto, SP, Brazil
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome, Italy
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Clinical Outcomes Associated With Induction Regimens Among Retransplant Kidney Recipients in the United States. Transplantation 2015; 99:1165-71. [DOI: 10.1097/tp.0000000000000507] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Recent trials in immunosuppression and their consequences for current therapy. Curr Opin Organ Transplant 2015; 19:387-94. [PMID: 24905020 DOI: 10.1097/mot.0000000000000093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Although the scarcity of clinical trials with de-novo immunosuppression has been typical over the last 2 years, several attempts have been made in drug conversion, dosing optimization, and bioequivalence. On the basis of recent clinical and animal studies, future directions of management and treatment are outlined. RECENT FINDINGS Studies with new tacrolimus formulations showed better bioavailability and lower doses, which might translate into less toxicity. The long-term results of studies with costimulation blockade confirmed their safety and efficacy. Calcineurin inhibitor (CNI)-free regimens based on mTOR inhibitors were shown to be associated with increased risk of the humoral response. Therefore, ongoing trials are predominantly designed to minimize calcineurin inhibitor dose only. Biologics, such as B-cell-specific agents (bortezomib and rituximab) and complement inhibitors (eculizumab) used to treat antibody-mediated rejection, recurrence of glomerulonephritis, are shifted to more preventive applications. The pretransplant quantification of alloreactive memory/effector T cell response may help to better stratify a patient's immunologic risk and allow for drug minimization. SUMMARY Despite clinical trials with innovative protocols with already established agents, tacrolimus-based and induction-based protocols have been shown to be the mainstay of immunosuppressive regimens. In the future, research aims to focus on biomarker-driven immunosuppression and cell therapy approaches.
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Laftavi MR, Sharma R, Feng L, Said M, Pankewycz O. Induction Therapy in Renal Transplant Recipients: A Review. Immunol Invest 2014; 43:790-806. [DOI: 10.3109/08820139.2014.914326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW To provide an overview of recent advances and future possibilities for therapeutic tolerance. RECENT FINDINGS Allograft survival despite complete immunosuppressant withdrawal has been demonstrated in selected renal-transplant recipients with haematopoietic chimerism. Early clinical trials of mesenchymal stromal cell therapy have shown promising results in several autoimmune diseases. Regulatory T cells show potential benefit in graft versus host disease, although challenges to ex-vivo expansion remain. Targeted modulation of T-cell function in vivo with monoclonal antibodies has shown beneficial effects in phase II/III trials of multiple sclerosis (alemtuzumab) and type I diabetes mellitus (teplizumab, otelixizumab). Emerging data from animal models suggest an important role for the commensal microbiome in the maintenance and disruption of immune tolerance with parallels in human studies. SUMMARY After years of slow progress, recent research has reduced the translational gap between animal models and clinical therapeutic tolerance. Early detection of autoimmunity, potentially at preclinical stages, offers a window of opportunity for tolerogenic therapy. Reliable biomarkers of tolerance are urgently needed to provide objective measurements of the effectiveness of tolerogenic therapies, and to allow intelligent immunosuppressant withdrawal in patients whose autoimmune disease is stable. VIDEO ABSTRACT AVAILABLE See the Video Supplementary Digital Content 1 (http://links.lww.com/COR/A8).
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Affiliation(s)
- Kenneth F Baker
- The National Institute for Health Research Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, UK
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15
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Zaza G, Tomei P, Granata S, Boschiero L, Lupo A. Monoclonal antibody therapy and renal transplantation: focus on adverse effects. Toxins (Basel) 2014; 6:869-91. [PMID: 24590384 PMCID: PMC3968366 DOI: 10.3390/toxins6030869] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/07/2014] [Accepted: 02/21/2014] [Indexed: 02/06/2023] Open
Abstract
A series of monoclonal antibodies (mAbs) are commonly utilized in renal transplantation as induction therapy (a period of intense immunosuppression immediately before and following the implant of the allograft), to treat steroid-resistant acute rejections, to decrease the incidence and mitigate effects of delayed graft function, and to allow immunosuppressive minimization. Additionally, in the last few years, their use has been proposed for the treatment of chronic antibody-mediated rejection, a major cause of late renal allograft loss. Although the exact mechanism of immunosuppression and allograft tolerance with any of the currently used induction agents is not completely defined, the majority of these medications are targeted against specific CD proteins on the T or B cells surface (e.g., CD3, CD25, CD52). Moreover, some of them have different mechanisms of action. In particular, eculizumab, interrupting the complement pathway, is a new promising treatment tool for acute graft complications and for post-transplant hemolytic uremic syndrome. While it is clear their utility in renal transplantation, it is also unquestionable that by using these highly potent immunosuppressive agents, the body loses much of its innate ability to mount an adequate immune response, thereby increasing the risk of severe adverse effects (e.g., infections, malignancies, haematological complications). Therefore, it is extremely important for clinicians involved in renal transplantation to know the potential side effects of monoclonal antibodies in order to plan a correct therapeutic strategy minimizing/avoiding the onset and development of severe clinical complications.
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Affiliation(s)
- Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Luigino Boschiero
- First Surgical Clinic, Kidney Transplantation Center, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
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O'Callaghan JM, Morgan RD, Knight SR, Morris PJ. Systematic reviews of alemtuzumab in renal transplantation. Transpl Immunol 2013; 28:71. [PMID: 23352935 DOI: 10.1016/j.trim.2013.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 01/13/2013] [Indexed: 10/27/2022]
Affiliation(s)
- John M O'Callaghan
- Centre for Evidence in Transplantation, Royal College of Surgeons of England/London School of Hygiene and Tropical Medicine, London, UK.
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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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