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Torres Crigna A, Daniele C, Gamez C, Medina Balbuena S, Pastene DO, Nardozi D, Brenna C, Yard B, Gretz N, Bieback K. Stem/Stromal Cells for Treatment of Kidney Injuries With Focus on Preclinical Models. Front Med (Lausanne) 2018; 5:179. [PMID: 29963554 PMCID: PMC6013716 DOI: 10.3389/fmed.2018.00179] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
Within the last years, the use of stem cells (embryonic, induced pluripotent stem cells, or hematopoietic stem cells), Progenitor cells (e.g., endothelial progenitor cells), and most intensely mesenchymal stromal cells (MSC) has emerged as a promising cell-based therapy for several diseases including nephropathy. For patients with end-stage renal disease (ESRD), dialysis or finally organ transplantation are the only therapeutic modalities available. Since ESRD is associated with a high healthcare expenditure, MSC therapy represents an innovative approach. In a variety of preclinical and clinical studies, MSC have shown to exert renoprotective properties, mediated mainly by paracrine effects, immunomodulation, regulation of inflammation, secretion of several trophic factors, and possibly differentiation to renal precursors. However, studies are highly diverse; thus, knowledge is still limited regarding the exact mode of action, source of MSC in comparison to other stem cell types, administration route and dose, tracking of cells and documentation of therapeutic efficacy by new imaging techniques and tissue visualization. The aim of this review is to provide a summary of published studies of stem cell therapy in acute and chronic kidney injury, diabetic nephropathy, polycystic kidney disease, and kidney transplantation. Preclinical studies with allogeneic or xenogeneic cell therapy were first addressed, followed by a summary of clinical trials carried out with autologous or allogeneic hMSC. Studies were analyzed with respect to source of cell type, mechanism of action etc.
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Affiliation(s)
- Adriana Torres Crigna
- Medical Faculty Mannheim, Institute of Transfusion Medicine and Immunology, University of Heidelberg, German Red Cross Blood Service Baden-Württemberg-Hessen, Mannheim, Germany
| | - Cristina Daniele
- Medical Faculty Mannheim, Medical Research Centre, University of Heidelberg, Mannheim, Germany
| | - Carolina Gamez
- Department for Experimental Orthopaedics and Trauma Surgery, Medical Faculty Mannheim, Orthopaedic and Trauma Surgery Centre (OUZ), Heidelberg University, Mannheim, Germany
| | - Sara Medina Balbuena
- Department of Medicine (Nephrology/Endrocrinology/Rheumathology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Diego O. Pastene
- Department of Medicine (Nephrology/Endrocrinology/Rheumathology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Daniela Nardozi
- Medical Faculty Mannheim, Medical Research Centre, University of Heidelberg, Mannheim, Germany
| | - Cinzia Brenna
- Medical Faculty Mannheim, Medical Research Centre, University of Heidelberg, Mannheim, Germany
| | - Benito Yard
- Department of Medicine (Nephrology/Endrocrinology/Rheumathology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Norbert Gretz
- Medical Faculty Mannheim, Medical Research Centre, University of Heidelberg, Mannheim, Germany
| | - Karen Bieback
- Medical Faculty Mannheim, Institute of Transfusion Medicine and Immunology, University of Heidelberg, German Red Cross Blood Service Baden-Württemberg-Hessen, Mannheim, Germany
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Li DL, Fang J, Zheng Z, Wu W, Wu Z. Successful treatment of fibrosing cholestatic hepatitis following kidney transplantation with allogeneic hematopoietic stem cell transplantation: a case report. Medicine (Baltimore) 2015; 94:e480. [PMID: 25654389 PMCID: PMC4602713 DOI: 10.1097/md.0000000000000480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Fibrosing cholestatic hepatitis (FCH) is an uncommon complication of renal transplantation and usually associated with hepatitis B and C viral infection. Without treatment, the prognosis is usually fatal within weeks of onset. There was rarely report with successful treatment intervention. This case report describes a uremic patient with HCV infection who developed a fatal form of FCH after kidney transplantation. This is the first reported successful case with allogeneic hematopoietic stem cell transplantation (AHSCT) without ablative conditioning. A dramatic virologic and clinical improvement was observed in this post-transplantation patient. But no adverse events related to AHSCT were observed. The patient returned to work full-time at 10 months of hospitalization and is still in good health by now. Serum HCV RNA gradually decreased from 2.5 × 10 (6) Copies/mL at day 1 to 3.2 × 10 (4) Copies/mL at day 98 and became negative (<400 Copies/mL) at day 126 of hospitalization and remains negative at the last available assessment. Our report suggests that allogeneic HSCT may have a therapeutic role in FCH.
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Affiliation(s)
- Dong Liang Li
- From the Department of Hepatobiliary Disease, Fuzhou General Hospital (Dongfang Hospital), Xiamen University, Fuzhou 350025, China (DLL, JF, ZW); Department of Pathology, Fuzhou General Hospital (Dongfang Hospital), Xiamen University, Fuzhou 350025, China (ZZ); Department of Urology, Fuzhou General Hospital (Dongfang Hospital), Xiamen University, Fuzhou 350025, China (WW)
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Ballet C, Giral M, Ashton-Chess J, Renaudin K, Brouard S, Soulillou JP. Chronic rejection of human kidney allografts. Expert Rev Clin Immunol 2014; 2:393-402. [DOI: 10.1586/1744666x.2.3.393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Operational Tolerance in Living-Related Renal Transplantation: A Single-Center Experience. Transplant Proc 2011; 43:1551-8. [DOI: 10.1016/j.transproceed.2011.01.161] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 01/12/2011] [Accepted: 01/19/2011] [Indexed: 11/30/2022]
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Clinical operational tolerance after renal transplantation: current status and future challenges. Ann Surg 2010; 252:915-28. [PMID: 21107102 DOI: 10.1097/sla.0b013e3181f3efb0] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In solid organ transplantation, the achievement of an immunosuppression (IS)-free state [also referred to as clinical operational tolerance (COT)] represents the ultimate goal. Although COT is feasible and safe in selected cases after liver transplantation, it is an exceptional finding after other types of solid organ transplantation. In the field of renal transplantation (RT), approximately 100 cases of COT have been reported to date, mainly in patients who were not compliant with their immunosuppressive regimens or in individuals who had previously received a bone marrow transplant for hematological disorders. On the basis of promising results obtained in animal models, several tolerogenic protocols have been attempted in humans, but most have failed to achieve robust and stable COT after RT. Molecule-based regimens have been largely ineffective, whereas cell-based regimens have provided some encouraging results. In these latter regimens, apart from standard IS, patients usually receive perioperative infusion of donor bone marrow-derived stem cells, which are able to interact with the immune cells of the host and mitigate their response to engraftment. Unfortunately, most renal transplant patients who developed acute rejection-occurring either during the weaning protocol or after complete withdrawal of IS-eventually lost their grafts. Currently, the immune monitoring necessary for predicting the presence and persistence of donor-specific unresponsiveness is not available. Overall, the present review will provide a conceptual framework for COT and conclude that stable and robust COT after RT remains an elusive goal and that the different strategies attempted to date are not yet reproducibly safe or effective.
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Effect of co-transplantation of mesenchymal stem cells and hematopoietic stem cells as compared to hematopoietic stem cell transplantation alone in renal transplantation to achieve donor hypo-responsiveness. Int Urol Nephrol 2010; 43:225-32. [PMID: 20084457 DOI: 10.1007/s11255-009-9659-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 09/29/2009] [Indexed: 01/11/2023]
Abstract
INTRODUCTION We evaluated donor hypo-responsiveness in renal allograft recipients to donor adipose tissue-derived mesenchymal stem cell (h-AD-MSC) +hematopoietic stem cell transplantation (HSCT) vs. HSCT alone. METHODS Patients were divided into 2 demographically equal groups (n = 100) A and B subjected to equal non-myeloablative conditioning of target-specific irradiation, anti-T + B cell antibodies and cyclophosphamide with HSCT. Group A was administered h-AD-MSC additionally. Transplantation was performed following favorable cross-matching. Cyclosporine, 3 mg/kg BW/day + prednisone, 20 mg/day were immunosuppressants for first 3 months, cyclosporine was replaced by azathioprine subsequently and prednisone lowered to 5-10 mg/day. Peripheral blood chimerism (PBC) was studied using fluorescent in situ hybridization technique at 3/18 months post transplant. Biopsy was performed for graft dysfunction and reported as per Banff criteria,'05. RESULTS Mean nucleated HSC counts (n × 10(8)/kgBW) was 7.32 with mean CD34+ yield 0.09% in group A; and 6.98 and 0.40% in group B, respectively; CD45-/90+ was 13.49% in former. Over 18 months post transplant, former had mean serum creatinine (SCr), 1.59 mg%, 12% acute rejection (AR) episodes, 3% patient, 1% patient +graft loss; latter had mean SCr 1.49 mg%, 18% AR episodes, 1% patient, 6% graft and 8% patient +graft losses. PBC was higher (4%) in former than later (1.8%). CONCLUSION Combined h-AD-MSC +HSCT under non-myeloablative conditioning was safe, more effective than HSCT alone to achieve donor hypo-responsiveness with adequate stable graft function and reduced rejection episodes.
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Dhanireddy KK, Bruno DA, Weaver TA, Xu H, Zhang X, Leopardi FV, Hale DA, Kirk AD. Portal venous donor-specific transfusion in conjunction with sirolimus prolongs renal allograft survival in nonhuman primates. Am J Transplant 2009; 9:124-31. [PMID: 18976300 PMCID: PMC2756429 DOI: 10.1111/j.1600-6143.2008.02448.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pretransplant exposure to donor antigen is known to modulate recipient alloimmunity, and frequently results in sensitization. However, donor-specific transfusion (DST) can have a protolerant effect that is dependent on route, dose and coadministered immunosuppression. Rodent studies have shown in some strain combinations that portal venous (PV) DST alone can induce tolerance, and uncontrolled clinical use of PVDST has been reported. In order to determine if pretransplant PVDST has a clinically relevant salutary effect, we studied it and the influence of concomitant immunosuppression in rhesus monkeys undergoing renal allotransplantation. Animals received PVDST with unfractionated bone marrow and/or tacrolimus or sirolimus 1 week prior to transplantation. Graft survival was assessed without any posttransplant immunosuppression. PVDST alone or in combination with tacrolimus was ineffective. However, PVDST in combination with sirolimus significantly prolonged renal allograft survival to a mean of 24 days. Preoperative sirolimus alone had no effect, and peripheral DST with sirolimus prolonged graft survival in 2/4 animals, but resulted in accelerated rejection in 2/4 animals. These data demonstrate that PVDST in combination with sirolimus delays rejection in a modest but measurable way in a rigorous model. It may thus be a preferable method for donor antigen administration.
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Affiliation(s)
- K. K. Dhanireddy
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,Department of Surgery, Georgetown University Hospital, Washington, DC
| | - D. A. Bruno
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,Department of Surgery, Georgetown University Hospital, Washington, DC
| | - T. A. Weaver
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,Emory Transplant Center, Emory University, Atlanta, GA
| | - H. Xu
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - X. Zhang
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - F. V. Leopardi
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,Emory Transplant Center, Emory University, Atlanta, GA
| | - D. A. Hale
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - A. D. Kirk
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,Emory Transplant Center, Emory University, Atlanta, GA,Corresponding author: Allan D. Kirk,
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Trivedi HL, Vanikar AV, Modi PR, Shah PR, Shah VR, Trivedi VB. In pursuit of the ultimate: the initial Ahmedabad journey toward transplantation tolerance. Transplant Proc 2007; 39:653-7. [PMID: 17445566 DOI: 10.1016/j.transproceed.2007.01.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
We designed a prospective clinical trial of 357 patients divided in two groups--treated (n = 201) and controls (n = 156)--to evaluate effects of donor hematopoietic stem cell transplantation (HSCT) with minimal nonmyeloablative conditioning for tolerance induction in living related donor renal allograft recipients. Conditioning included donor leukocyte infusions, target-specific irradiation, anti-T-cell antibody, cyclophosphamide, cyclosporine (CsA), followed by bone marrow (BM)-derived and peripheral blood stem cell (PBSC) infusion into thymus, liver, BM, and periphery, with mean total dose of 20 x 10(8) nucleated cells/kg body weight (BW) (mean CD34(+) count: 0.9%) pretransplantation. CsA (3 mg/kg BW/d) and prednisolone (10 mg/d) were used for immunosuppression. Azathioprine/mycophenolate mofetil were added in the event of an acute rejection episode. The controls underwent transplantation with three drug immunosuppression. With a mean follow-up of 21.5 months, the treated cohort showed better allograft function with mean serum creatinine (SCr), 1.42 +/- 0.31 mg% in contrast with the controls mean SCr, 1.61 +/- 0.52 mg% (P < .0001) at 23.9 months follow-up. One-year allograft/patient survival was 95%/96.7% versus 89%/93.4%, respectively. Peripheral blood chimerism by fluorescent in situ hybridization was 0.8% +/- 0.2% in the subset of treated patients with gender-mismatched donors. No graft-versus-host disease was noted. Nine patients with donor-specific cytotoxic alloantibodies pretransplantation showed a decrease in positivity to <15% post-HSCT and were transplanted safely. A transient rise in donor-specific cytotoxic alloantibodies was noted in 19 treated patients post-HSCT, 14 of whom returned to the transplantable range within 2 weeks and five required a desensitization protocol. "Prope" tolerance may be induced in living related donor renal transplantation across major histocompatability complex barriers using HSCT with minimal nonmyeloablative conditioning.
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Affiliation(s)
- H L Trivedi
- Department of Nephrology and Transplantation Medicine, Institute of Transplantation Sciences, Gulabben Rasiklal Doshi and Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India.
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Trivedi HL, Mishra VV, Vanikar AV, Modi PR, Shah VR, Shah PR, Firoz A. Embryonic stem cell derived and adult hematopoietic stem cell transplantation for tolerance induction in a renal allograft recipient:--a case report. Transplant Proc 2007; 38:3103-8. [PMID: 17112910 DOI: 10.1016/j.transproceed.2006.08.173] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Indexed: 11/30/2022]
Abstract
UNLABELLED We generated an human embryonic stem cell (hESC) line to augment chimerism-associated tolerance. A 40-year-old African with chronic glomerulonephritis-chronic renal failure with 100% G6PD enzyme deficiency presented for renal transplantation with a 27-year-old, 6/6 HLA-matched sister as a willing donor. METHOD We generated an hESC line from the donor's oocytes using long ovarian stimulation protocol simultaneously with tolerance induction protocol. A nuclear transfer (NT)-hESC line was derived by transferring a donor cumulus cell into an enucleated oocyte, subjected to electrical fusion, and cultured for 5 days. ESCs hatched from the blastocyst on day 6 were cocultured with her unmodified bone marrow for 2 days and suspended in Ringer's lactate. Five milliliters of suspension were collected for cell counting, viability, pluripotency, flow cytometry, and karyotyping. The remaining suspension was infused into the periphery of the recipient. Transplantation was performed 1 week later following a negative lymphocytotoxicity cross-match test using no immunosuppression. Peripheral blood chimerism (PBC) was studied using fluorescent in situ hybridization technique. Allograft biopsy was performed on day 7. RESULTS NT-hESC CD34+ count was 7.6%, viability 100%, karyotyping normal, pluripotency markers: SSEA-1, SSEA-4, OCT-3/4, TRA-1/60:positive; 12% PBC was noted at 1 week after transplantation. Serum creatinine was 1.2 mg%, graft biopsy was unremarkable, and G6PD enzyme deficiency was corrected to 0% at 100 days posttransplant. Liver function tests and hematology profile were unremarkable for graft-versus-host disease. CONCLUSION This is the first report of tolerance induction using NT-hESC-induced hematopoietic chimerism with synergistic use of adult bone marrow. It was safe and effective.
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Affiliation(s)
- H L Trivedi
- Institute of Transplantation Sciences, Department of Nephrology and Transplantation Medicine, Civil Hospital, Gujarat, India.
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Trivedi HL, Vanikar AV, Modi PR, Shah VR, Vakil JM, Trivedi VB, Khemchandani SI. Allogeneic hematopoietic stem-cell transplantation, mixed chimerism, and tolerance in living related donor renal allograft recipients. Transplant Proc 2005; 37:737-42. [PMID: 15848518 DOI: 10.1016/j.transproceed.2005.01.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We designed a prospective, randomized, and controlled clinical trial to evaluate the efficacy and safety of achieving a mixed chimerism-associated tolerance protocol for recipients of living related donor (LRD) renal allografts. PATIENTS AND METHODS Sixty-six consecutive patients were divided into two equal groups of 33 patients with end-stage renal disease. They were enrolled for transplantation after negative lymphocytotoxicity cross-matching (LCM). Both groups (treated [Tn] and control [Cn]) showed similar clinical and laboratory parameters and donor HLA match profiles. The Tn group underwent thymic transplantation of donor renal tissue, two donor-specific transfusions, low-intensity conditioning, and high-dose hematopoietic stem-cell transplantation (HSCT) before renal transplantation. The conditioning regimen included low-dose, target-specific irradiation (to abdominal and inguinal lymph nodes, bone marrow [BM] from thoracolumbar vertebrae and part of the pelvis on alternate days, 100 rad x 4), anti-T-cell antibodies (1.5 mg/kg body weight [BW]), cyclophosphamide (10 mg/kg BW x 2 consecutive days), and cyclosporine (CyA; >3 mg/kg BW/d). Unfractionated HSCT procured from the donor marrow was administered into the BM, portal and peripheral circulations, within 24 hours of achieving CD 4+/CD 8+ T-cell count less than 10% of normal. This infusion was supplemented with a dose of peripherally mobilized stem cells (mean total dose of 20 x 10(8) cells/kg recipient BW) administered peripherally. Renal transplantation was performed after negative LCM. Donor-specific cytotoxic antibodies were eliminated with intravenous immunoglobulins and plasmapheresis before renal transplantation. Mixed chimerism was evaluated before and after transplantation at monthly intervals in patients with donors of opposite gender by the FISH technique. Both groups received CyA and prednisolone for immunosuppression; Cn subjects also received mycophenolate mofetil/azathioprine. Rejection was treated with standard treatment. Immunosuppression was withdrawn 6 months after renal transplantation for patients with consistently positive chimerism. Clinical tolerance was defined as stable allograft function for more than 100 days without immunosuppression and confirmed by allograft biopsy. RESULTS Over a mean follow-up of 210 days, all Tn patients showed stable allograft function with mean serum creatinines (SCr) of 1.20 mg/dL, no rejection/CMV infections/graft or patient loss. A low-level donor-specific cytotoxic antibody was observed in all Tn patients. The CyA toxicity was noted in 10 (30.3%) patients. Persistent mixed hematopoietic chimerism was seen in all 21 patients irrespective of donor-recipient HLA matching (mean 0.5% before and 1 +/- 0.3% after transplantation). All four patients on drug withdrawal have shown donor-specific tolerance at a mean follow-up of 129.8 days. Other Tn patients are in the process of being weaned off immunosuppression. Mean SCr of controls was 1.45 mg/dL over a mean follow-up of 216 days. Acute rejection was observed in 17 (51.5%) patients; no CMV infection/patient loss was noted and one (3.03%) graft was lost in controls. No patient was lost in controls. No graft-versus-host disease was observed in Tn patients. CONCLUSION We have achieved mixed hematopoietic chimerism-associated tolerance with high-dose HSCT, intrathymic donor renal tissue transplantation, and minimal conditioning without any adverse effects.
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Affiliation(s)
- H L Trivedi
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases & Research Centre and Institute of Transplantation Sciences, Gujarat, India.
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Abstract
Allogenic skin has had a major role in acute burns care for over 100 years. The principle source of allogenic skin is from cadavers. Allogenic skin provides the gold standard for temporary skin substitutes. The main drawbacks to its wider use are availability and disease transmission. The major obstacle to prolonged use is its immunogenicity. As more effective means are developed to ensure the supply and safety of allogenic skin and novel ways of circumventing the immunologic problems are developed, it is possible that allogenic skin may find a new role as a permanent skin replacement in future burns care.
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Affiliation(s)
- Andrew Burd
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.
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Abstract
By definition, tolerance will eliminate the problem of adolescent medication non-adherence. Although adolescents' propensity toward non-adherence makes them at first glance to be particularly attractive candidates for tolerance trials, there are also immunologic, psychosocial and ethical barriers that temper enthusiasm for their inclusion at present. Limits in emotional and cognitive maturity are combined during the teenage years with adult-like immunologic maturity to lessen the potential for successful implementation of tolerance and near tolerance strategies. Alternatively, an interval step to tolerance in adolescents is to eliminate the medications most likely contributing to non-adherence through harsh side effects such as steroids and calcineurin inhibitors. This manuscript will review the general topic of transplantation tolerance with specific attention given to the application of pro-tolerant therapies in adolescent recipients.
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Affiliation(s)
- Kiran K Dhanireddy
- Transplantation Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD 20892, USA
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Vanikar AV, Trivedi HL, Patel RD, Kanodia KV, Vakil JM. Effects of a Tolerance Induction Protocol in Renal Allograft Recipients — the Ahmedabad Experience. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1561-5413(09)60176-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Classical Tolerance Induction in Renal Transplantation — A Study of 11 Patients. Int J Organ Transplant Med 2005. [DOI: 10.1016/s1561-5413(09)60177-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Delis S, Ciancio G, Burke GW, Garcia-Morales R, Miller J. Donor bone marrow transplantation: chimerism and tolerance. Transpl Immunol 2005; 13:105-15. [PMID: 15380541 DOI: 10.1016/j.trim.2004.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2004] [Indexed: 11/23/2022]
Abstract
Infusion of donor bone marrow (DBM)-derived cells continue to be tested in clinical protocols intended to induce specific immunologic tolerance. Central clonal deletion of donor-specific alloreactive cells associated with mixed chimerism reliably produced long-term graft tolerance. In this setting, depletion of recipient T cells by antilymphocyte antibodies and subsequent repopulation by donor hematopoietic cells after donor bone marrow infusion (DBMI) are prerequisites for tolerance induction. Major advances have been made in animal models and in pilot clinical trials and the key questions with the future perspectives are presented in this article.
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Affiliation(s)
- Spiros Delis
- Department of Surgery, Division of Kidney, Kidney/Pancreas Transplant, University of Miami School of Medicine, Miami, FL, USA
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Abstract
Clinical transplantation tolerance has remained an elusive goal in the 50 yr since it was first described in experimental animals. Greater understanding of the molecular mechanisms responsible for allorecognition have allowed for the development of promising immunosuppressive strategies that may bring us closer to reproducible induction of tolerance; consideration of past successes and failures from both clinical and basic science is required to define future challenges facing this field. This article reviews mechanisms of self and transplantation tolerance, translation of basic science research to clinical protocols in animals and human beings, the changing role of immunosuppression, complications following tolerance induction and controversies surrounding the choice of patients for tolerance trials with a focus on issues relevant to pediatric patients. The role of the Immune Tolerance Network is discussed along with realistic goals for tolerance induction in human beings over the next decade.
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Affiliation(s)
- Kathryn J Tinckam
- Transplantation Research Center, Brigham and Women's Hospital and Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Verholen F, Stalder M, Helg C, Chalandon Y. Resistant pure red cell aplasia after allogeneic stem cell transplantation with major ABO mismatch treated by escalating dose donor leukocyte infusion. Eur J Haematol 2004; 73:441-6. [PMID: 15522068 DOI: 10.1111/j.1600-0609.2004.00320.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of pure red cell aplasia (PRCA) following allogeneic stem cell transplantation (SCT) with major ABO mismatch which proved resistant to all standard treatment options such as change in immunosuppressive treatment, high-dose erythropoietin (EPO) or plasma exchange. We therefore proceeded to administer five cycles of Rituximab therapy, without success. Finally, escalating doses of donor-derived leukocyte infusion (DLI) resolved the PRCA of our patient 415 d after bone-marrow transplantation (BMT) and 140 d after the first infusion of donor leukocytes. A review of the literature shows the efficacy of various treatments; the role of DLI and other treatment options are discussed. Furthermore, the underlying pathophysiological mechanisms especially with regard to the role of NK cells in alloreactivity after allogeneic SCT are explained.
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MESH Headings
- ABO Blood-Group System/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Blood Group Incompatibility/complications
- Blood Transfusion
- Combined Modality Therapy
- Cytarabine/administration & dosage
- Drug Resistance
- Erythropoietin/therapeutic use
- Hematopoietic Stem Cell Transplantation/adverse effects
- Humans
- Idarubicin/administration & dosage
- Immunosuppressive Agents/therapeutic use
- Killer Cells, Natural/immunology
- Leukemia, Myelomonocytic, Acute/drug therapy
- Leukemia, Myelomonocytic, Acute/therapy
- Leukocyte Transfusion
- Male
- Middle Aged
- Plasmapheresis
- Red-Cell Aplasia, Pure/etiology
- Red-Cell Aplasia, Pure/immunology
- Red-Cell Aplasia, Pure/physiopathology
- Red-Cell Aplasia, Pure/therapy
- Remission Induction
- Rituximab
- Transplantation, Homologous/adverse effects
- Transplantation, Homologous/immunology
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Affiliation(s)
- F Verholen
- Service d'Hématologie, Hôpital Cantonal Universitaire de Genève, Geneva, Switzerland.
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Hematopoietic stem cells as inducers of tolerance to solid organ transplants. Curr Opin Organ Transplant 2004. [DOI: 10.1097/01.mot.0000134871.02707.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Donor hematopoietic cells: central versus peripheral tolerance. Curr Opin Organ Transplant 2004. [DOI: 10.1097/01.mot.0000134872.10331.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Elster EA, Hale DA, Mannon RB, Cendales LC, Swanson SJ, Kirk AD. The road to tolerance: renal transplant tolerance induction in nonhuman primate studies and clinical trials. Transpl Immunol 2004; 13:87-99. [PMID: 15380539 DOI: 10.1016/j.trim.2004.05.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2004] [Indexed: 02/06/2023]
Abstract
Organ transplantation has become a standard life-saving therapy for many causes of end stage organ failure. Although valuable, it remains hampered by the requirement for, and complications of, immunosuppression to prevent immune rejection of the transplanted organ. It is now clear that rejection can be avoided in some experimental systems without a requirement of immunosuppressive medication, and these experimental concepts are now making their way into the clinic in the form of early transplantation tolerance trials. This manuscript will discuss the most promising techniques for tolerance induction, namely, costimulation blockade, lymphocyte depletion, and mixed chimerism. Seminal preclinical studies will be cited and the results of initial clinical trials will be reviewed. The data to date indicate that while tolerance remains elusive, immunosuppression minimization is a feasible near-term alternative.
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Affiliation(s)
- Eric A Elster
- Department of Health and Human Services, Transplantation Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Abstract
Significant advances have been made in the understanding of allograft rejection. There is growing awareness that allograft acceptance, or tolerance, is also an active process rather than a passive absence of rejection. Mechanistic awareness of this process has spawned many preclinical strategies for the prevention of allograft rejection without the need for chronic immunosuppression. These therapies are currently entering clinical trials. This article reviews the prevailing therapies that hold promise for future clinical application. In particular, their application in children is discussed, as are biologic aspects of childhood immunity that may play a role in the success or failure of these strategies.
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Affiliation(s)
- Jonathan P Pearl
- Department of Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889-5600, USA
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Mathew JM, Garcia-Morales RO, Carreno M, Jin Y, Fuller L, Blomberg B, Cirocco R, Burke GW, Ciancio G, Ricordi C, Esquenazi V, Tzakis AG, Miller J. Immune responses and their regulation by donor bone marrow cells in clinical organ transplantation. Transpl Immunol 2003; 11:307-21. [PMID: 12967784 DOI: 10.1016/s0966-3274(03)00056-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Infusions of donor bone marrow derived cells (DBMC) continue to be tested in clinical protocols intended to induce specific immunologic tolerance of solid organ transplants based on the observations that donor-specific tolerance is induced this way in animal models. We studied the immunological effects of human DBMC infusions in renal transplantation using modifications in lymphoproliferation (MLR) and cytotoxicity (CML) assays. The salient observations and tentative conclusions are summarized in this review. Among many types of organs transplanted using DBMC at this center, it was found that the cadaver renal recipients (CAD) had significantly decreased chronic rejection and higher graft survival when compared to equivalent non-infused controls. DBMC infusion was also associated with a marginal and non-specific immune depression. It was also observed that the number of chimeric donor cells gradually increased in the iliac crest bone marrow compartment with a concomitant decrease in the peripheral blood and that the increase was more rapid in living-related donor (LRD)-kidney/DBMC recipients in spite of a lower number of DBMC infused (<25%) than in the CAD-kidney/DBMC group. In the LRD recipients with residual anti-donor responses, purified chimeric cells of either donor or recipient inhibited recipient immune responses to the donor significantly more strongly than the freshly obtained bone marrow from the specific donor or volunteer suggesting an active regulatory role for chimeric cells. A number of (non-chimeric) subpopulations of bone marrow cells including CD34(+) stem cells and the CD34(-) early progeny like CD38(+), CD2(+), CD5(+) and CD1(+) lymphoid cells as well as CD33(+) (but CD15(-)) myeloid cells down-regulated the MLR and CML responses of allogeneic PBMC stimulated with (autologous) donor spleen cells. These regulatory effects appeared to be refractory to the action of commonly used immunosuppressive drugs and occurred during the early phase of the immune response through cell-cell interactions. Most of these DBMC sub-populations had stimulatory capabilities, albeit markedly lower than donor spleen cells, but only through the indirect antigen presentation pathway. When co-cultured with allogeneic stimulators, purified CD34(+) cells were found to give rise both to CD3(-) TCRalphabeta(+), as well as CD3(+) TCRalphabeta(+) cells and, thereby, responded in MLR to allogeneic stimulation (but did not generate cytotoxic effector cells). Also, a number of DBMC subpopulations inhibited the CML and to a lesser extent the MLR, of autologous post-thymic responding T cells stimulated with allogeneic irradiated cells, mediated through soluble factors. Finally, non-chimeric DBMC also inhibited the proliferative and cytotoxic responses of autologous T cells to EBV antigens, inducing T suppressor cells, which in turn could inhibit autologous anti-EBV CTL generation and B cell anti-CMV antibody production. These studies all suggested a strong inhibitory property of a number of DBMC sub-populations in vitro and in vivo with the notion that they promote unresponsiveness.
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Affiliation(s)
- James M Mathew
- Department of Surgery, Division of Transplantation (R-440), University of Miami School of Medicine, 1600 N.W. 10th Ave., Miami, FL 33136, USA.
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Trivedi H, Vanikar A, Shah V, Mehta A, Shah S, Shah T, Visana K, Modi P, Sinha P, Trivedi V. Mega dose unfractionated donor bone marrow-derived cell infusion in thymus and periphery-an integrated clinical approach for tolerance in living related renal allografts. Transplant Proc 2003; 35:203-6. [PMID: 12591366 DOI: 10.1016/s0041-1345(02)03901-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- H Trivedi
- Institute of Kidney Diseases & Research Centre, Institute of Transplantation Sciences, Civil Hospital Campus, 16, Gujarat, Ahmedabad, India
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