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Degagné É, Donohoue PD, Roy S, Scherer J, Fowler TW, Davis RT, Reyes GA, Kwong G, Stanaway M, Larroca Vicena V, Mutha D, Guo R, Edwards L, Schilling B, Shaw M, Smith SC, Kohrs B, Kufeldt HJ, Churchward G, Ruan F, Nyer DB, McSweeney K, Irby MJ, Fuller CK, Banh L, Toh MS, Thompson M, Owen AL, An Z, Gradia S, Skoble J, Bryan M, Garner E, Kanner SB. High-Specificity CRISPR-Mediated Genome Engineering in Anti-BCMA Allogeneic CAR T Cells Suppresses Allograft Rejection in Preclinical Models. Cancer Immunol Res 2024; 12:462-477. [PMID: 38345397 PMCID: PMC10985478 DOI: 10.1158/2326-6066.cir-23-0679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/16/2023] [Accepted: 01/31/2024] [Indexed: 04/04/2024]
Abstract
Allogeneic chimeric antigen receptor (CAR) T cell therapies hold the potential to overcome many of the challenges associated with patient-derived (autologous) CAR T cells. Key considerations in the development of allogeneic CAR T cell therapies include prevention of graft-vs-host disease (GvHD) and suppression of allograft rejection. Here, we describe preclinical data supporting the ongoing first-in-human clinical study, the CaMMouflage trial (NCT05722418), evaluating CB-011 in patients with relapsed/refractory multiple myeloma. CB-011 is a hypoimmunogenic, allogeneic anti-B-cell maturation antigen (BCMA) CAR T cell therapy candidate. CB-011 cells feature 4 genomic alterations and were engineered from healthy donor-derived T cells using a Cas12a CRISPR hybrid RNA-DNA (chRDNA) genome-editing technology platform. To address allograft rejection, CAR T cells were engineered to prevent endogenous HLA class I complex expression and overexpress a single-chain polyprotein complex composed of beta-2 microglobulin (B2M) tethered to HLA-E. In addition, T-cell receptor (TCR) expression was disrupted at the TCR alpha constant locus in combination with the site-specific insertion of a humanized BCMA-specific CAR. CB-011 cells exhibited robust plasmablast cytotoxicity in vitro in a mixed lymphocyte reaction in cell cocultures derived from patients with multiple myeloma. In addition, CB-011 cells demonstrated suppressed recognition by and cytotoxicity from HLA-mismatched T cells. CB-011 cells were protected from natural killer cell-mediated cytotoxicity in vitro and in vivo due to endogenous promoter-driven expression of B2M-HLA-E. Potent antitumor efficacy, when combined with an immune-cloaking armoring strategy to dampen allograft rejection, offers optimized therapeutic potential in multiple myeloma. See related Spotlight by Caimi and Melenhorst, p. 385.
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Affiliation(s)
| | | | - Suparna Roy
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | | | | | | | | | | | - Devin Mutha
- Caribou Biosciences, Inc., Berkeley, California
| | - Raymond Guo
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | - McKay Shaw
- Caribou Biosciences, Inc., Berkeley, California
| | | | - Bryan Kohrs
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | - Finey Ruan
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | | | | | - Lynda Banh
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | | | - Zili An
- Caribou Biosciences, Inc., Berkeley, California
| | | | | | - Mara Bryan
- Caribou Biosciences, Inc., Berkeley, California
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2
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [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] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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3
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Jagannath S, Anderson MA, Yee AJ, Hasserjian RP. Case 29-2023: A 34-Year-Old Woman with Abdominal Distention and Acute Kidney Injury. N Engl J Med 2023; 389:1133-1143. [PMID: 37733312 DOI: 10.1056/nejmcpc2027091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Sundar Jagannath
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Mark A Anderson
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Andrew J Yee
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Robert P Hasserjian
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
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4
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Kidney Transplantation in Patients With Monoclonal Gammopathy of Renal Significance. Transplantation 2022; 107:1056-1068. [PMID: 36584374 DOI: 10.1097/tp.0000000000004443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) defines disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin produced by a B-cell or plasma-cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end-stage kidney disease. The current paradigm states that the underlying hematologic condition should be treated and in deep remission before kidney transplantation can be performed because recurrence has been reported for all MGRS-associated kidney diseases. However, we suggest that decisions regarding kidney transplantation in MGRS patients should be individualized considering many factors such as the subtype of MGRS-associated kidney disease, patient age and comorbidity, presence and risk of extrarenal complications, estimated waiting time, the availability of a living kidney donor, and previous hematological treatment and response. Thus, kidney transplantation should be considered even in treatment-naive patients, with hematological treatment initiated after successful kidney transplantation.
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Ng JH, Izard S, Murakami N, Jhaveri KD, Sharma A, Nair V. Outcomes of kidney transplantation in patients with myeloma and amyloidosis in the USA. Nephrol Dial Transplant 2022; 37:2569-2580. [PMID: 35687020 PMCID: PMC9681913 DOI: 10.1093/ndt/gfac196] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Recent improvement in treatment and patient survival has opened the eligibility of kidney transplantation to patients who developed end-stage kidney disease (ESKD) from plasma cell dyscrasias (PCDs). Data on clinical outcomes in this population are lacking. METHODS We conducted a retrospective study of United Network for Organ Sharing/Organ Procurement and Transplantation Network dataset (2006-2018) to compare patient and graft outcomes of kidney transplant recipients with ESKD due to PCD versus other causes. RESULTS Among 168 369 adult first kidney transplant recipients, 0.22-0.43% per year had PCD as the cause of ESKD. The PCD group had worse survival than the non-PCD group for both living and deceased donor types {adjusted hazard ratio [aHR] 2.24 [95% confidence interval (CI) 1.67-2.99] and aHR 1.40 [95% CI 1.08-1.83], respectively}. The PCD group had worse survival than the diabetes group, but only among living donors [aHR 1.87 (95% CI 1.37-2.53) versus aHR 1.16 (95% CI 0.89-1.2)]. Graft survival in patients with PCD were worse than non-PCD in both living and deceased donors [aHR 1.72 (95% CI 1.91-2.56) and aHR 1.30 (95% CI 1.03-1.66)]. Patient and graft survival were worse in amyloidosis but not statistically different in multiple myeloma compared with the non-PCD group. CONCLUSION The study data are crucial when determining kidney transplant eligibility and when discussing transplant risks in patients with PCD.
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Affiliation(s)
- Jia H Ng
- Correspondence to: Jia H. Ng; E-mail:
| | - Stephanie Izard
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Amy Sharma
- Northwell Cancer Institute, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA,New affiliation as of June 2022. Montefiore Medical Center, Department of Hematology and Oncology, NY, USA
| | - Vinay Nair
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
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6
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Murakami N, Webber AB, Nair V. Transplant Onconephrology in Patients With Kidney Transplants. Adv Chronic Kidney Dis 2022; 29:188-200.e1. [PMID: 35817526 PMCID: PMC9326185 DOI: 10.1053/j.ackd.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
Cancer is a leading cause of death in patients with kidney transplantation. Patients with kidney transplants are 10- to 200-times more likely to develop cancers after transplant than the general population, depending on the cancer type. Recent advances in cancer therapies have dramatically improved survival outcomes; however, patients with kidney transplants face unique challenges of immunosuppression management, cancer screening, and recurrence of cancer after transplant. Patients with a history of cancer tend to be excluded from transplant candidacy or are required to have long cancer-free wait time before wait-listing. The strategy of pretransplant wait time management may need to be revisited as cancer therapies improve, which is most applicable to patients with a history of multiple myeloma. In this review, we discuss several important topics in transplant onconephrology: the current recommendations for pretransplant wait times for transplant candidates with cancer histories, cancer screening post-transplant, post-transplant lymphoproliferative disorder, strategies for transplant patients with a history of multiple myeloma, and novel therapies for patients with post-transplant malignancies. With emerging novel cancer treatments, it is critical to have multidisciplinary discussions involving patients, caregivers, transplant nephrologists, and oncologists to achieve patient-oriented goals.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Allison B. Webber
- Divisino of Nephrology, Kidney Transplant Service, University of California San Francisco, San Francisco, CA
| | - Vinay Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Abstract
Cancer remains a significant cause of morbidity and mortality in kidney transplant recipients, due to long-term immunosuppression. Salient issues to consider in decreasing the burden of malignancy among kidney transplant recipients include pretransplant recipient evaluation, post-transplant screening and monitoring, and optimal treatment strategies for the kidney transplant recipients with cancer. In this review, we address cancer incidence and outcomes, approaches to cancer screening and monitoring pretransplant and post-transplant, as well as treatment strategies, immunosuppressive management, and multidisciplinary approaches in the kidney transplant recipients with cancer.
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8
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Dinh AR, Wong SW, Martin TG, Wolf JL, Webber AB. Outcomes of kidney transplant recipients with ESKD due to plasma cell dyscrasia: A case series. Clin Transplant 2021; 36:e14541. [PMID: 34797567 DOI: 10.1111/ctr.14541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
Transplant centers have historically been reluctant to proceed with kidney transplantation in individuals with plasma cell dyscrasias (PCDs) due to concern for high rates of PCD recurrence and PCD-related mortality. As novel therapies for PCDs have improved hematologic outcomes, strategies to optimize kidney transplantation in individuals with PCD-mediated kidney disease are needed. In this single-center case series we discuss our protocol for the transplantation of individuals with ESKD attributed to PCD as well as the hematologic and allograft outcomes of 12 kidney transplant recipients with ESKD attributed to PCD. Median follow-up time after kidney transplantation was 44 months (IQR 36, 84). All patients had a functioning allograft 1 year after kidney transplantation. 9/12 patients were alive and had a functioning allograft 5 years after kidney transplantation. Five patients experienced relapse of PCD (of whom three responded well to subsequent therapies) and four patients developed secondary malignancies, including three patients with urologic malignancies. This case series demonstrates that patients with kidney disease attributed to PCD have favorable outcomes with kidney transplantation. Transplant evaluation in patients with PCDs should involve a multidisciplinary team of transplant nephrologists and oncologists to select appropriate candidates. Providers should consider screening for urologic malignancies pre- and post-transplantation.
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Affiliation(s)
- Alex R Dinh
- Department of Medicine, Division of Nephrology, University of California, San Francisco, California, USA.,Department of Medicine, Kidney Transplant Service, University of California, San Francisco, California, USA
| | - Sandy W Wong
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Thomas G Martin
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Jeffrey L Wolf
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Allison B Webber
- Department of Medicine, Division of Nephrology, University of California, San Francisco, California, USA.,Department of Medicine, Kidney Transplant Service, University of California, San Francisco, California, USA
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9
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Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent Glomerular Disease after Kidney Transplantation: Diagnostic and Management Dilemmas. Clin J Am Soc Nephrol 2021; 16:1730-1742. [PMID: 34686531 PMCID: PMC8729409 DOI: 10.2215/cjn.00280121] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recurrent glomerular disease after kidney transplant remains an important cause of allograft failure. Many of the different entities post-transplant still suffer from incomplete knowledge on pathophysiology, and therefore lack targeted and effective therapies. In this review, we focus on specific clinical dilemmas encountered by physicians in managing recurrent glomerular disease by highlighting new insights into the understanding and treatment of post-transplant focal segmental glomerulosclerosis, membranous nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, amyloid light-chain (AL) amyloidosis, and IgA nephropathy.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Hullekes
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J. Hogan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, Mandelbrot D, Verna E, Locke J, D'Cunha J, Farr M, Sawinski D, Agarwal PK, Plichta J, Pruthi S, Farr D, Carvajal R, Walker J, Zwald F, Habermann T, Gertz M, Bierman P, Dizon DS, Langstraat C, Al-Qaoud T, Eggener S, Richgels JP, Chang GJ, Geltzeiler C, Sapisochin G, Ricciardi R, Krupnick AS, Kennedy C, Mohindra N, Foley DP, Watt KD. Preexisting melanoma and hematological malignancies, prognosis, and timing to solid organ transplantation: A consensus expert opinion statement. Am J Transplant 2021; 21:475-483. [PMID: 32976703 PMCID: PMC8555431 DOI: 10.1111/ajt.16324] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
Patients undergoing evaluation for solid organ transplantation (SOT) frequently have a history of malignancy. Only patients with treated cancer are considered for SOT but the benefits of transplantation need to be balanced against the risk of tumor recurrence, taking into consideration the potential effects of immunosuppression. Prior guidelines on timing to transplant in patients with a prior treated malignancy do not account for current staging, disease biology, or advances in cancer treatments. To update these recommendations, the American Society of Transplantation (AST) facilitated a consensus workshop to comprehensively review contemporary literature regarding cancer therapies, cancer stage specific prognosis, the kinetics of cancer recurrence, as well as the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis, treatment, and transplant recommendations for melanoma and hematological malignancies. Given the limited data regarding the risk of cancer recurrence in transplant recipients, the goal of the AST-sponsored conference and the consensus documents produced are to provide expert opinion recommendations that help in the evaluation of patients with a history of a pretransplant malignancy for transplant candidacy.
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Affiliation(s)
- David P Al-Adra
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Hammel
- Department of Anesthesiology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - John Roberts
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - E Steve Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Levine
- Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth Verna
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Jayme Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Maryjane Farr
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer Plichta
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Sandhya Pruthi
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Richard Carvajal
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - John Walker
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fiona Zwald
- Piedmont Transplant Institute, Piedmont Atlanta Hospital, Atlanta, Georgia
| | | | - Morie Gertz
- Hematology Division, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip Bierman
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, Rhode Island
| | - Carrie Langstraat
- Departments of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Talal Al-Qaoud
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Scott Eggener
- Department of Urology, University of Chicago, Chicago, Illinois
| | - John P Richgels
- Department of Urology, University of Chicago, Chicago, Illinois
| | - George J Chang
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Cristina Geltzeiler
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | | | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Cassie Kennedy
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nisha Mohindra
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - David P Foley
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
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11
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Acute Liver Rejection in a Multiple Myeloma Patient Treated with Lenalidomide. Case Rep Transplant 2020; 2020:8894922. [PMID: 33381347 PMCID: PMC7749773 DOI: 10.1155/2020/8894922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 01/13/2023] Open
Abstract
Herein we present a patient that underwent a liver transplant due to primary biliary cholangitis (PBC) and after 9 years developed multiple myeloma. Following the cessation of mycophenolate mofetil and 2 weeks after lenalidomide treatment was started, the patient experienced acute cellular rejection. The patient recovered after treatment with corticosteroids, resumption of mycophenolate mofetil, and cessation of lenalidomide. Lenalidomide-associated allograft rejection has been reported in other organs. However, this is the first case report of liver rejection induced by lenalidomide.
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12
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Chitty DW, Hartley-Brown MA, Abate M, Thakur R, Wanchoo R, Jhaveri KD, Nair V. Kidney transplantation in patients with multiple myeloma: narrative analysis and review of the last 2 decades. Nephrol Dial Transplant 2020; 37:1616-1626. [PMID: 33295615 DOI: 10.1093/ndt/gfaa361] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 12/17/2022] Open
Abstract
There have been significant advances in the treatment of multiple myeloma in the last 2 decades. Approximately 25% of patients with newly diagnosed myeloma have some degree of kidney impairment. During the course of illness, nearly 50% of myeloma patients will develop kidney disease. Moreover, approximately 10% of myeloma patients have advanced kidney disease requiring dialysis at presentation. Hemodialysis is associated with a significantly reduced overall survival. In the setting of prolonged long-term overall survival due to the use of newer immunotherapeutic agents in the treatment of myeloma, patients with myeloma and advanced kidney disease may benefit from more aggressive management with kidney transplantation. Unfortunately, most data regarding outcomes of kidney transplantation in patients with myeloma come from single center case series. With the advent of novel treatment choices, it remains unclear if outcomes of kidney transplant recipients with myeloma have improved in recent years. In this descriptive systematic review, we coalesced published patient data over the last 20 years to help inform clinicians and patients on expected hematologic and kidney transplant outcomes in this complex population. We further discuss the future of kidney transplantation in patients with paraproteinemia.
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Affiliation(s)
- David W Chitty
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Monique A Hartley-Brown
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Mersema Abate
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Richa Thakur
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Rimda Wanchoo
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Kenar D Jhaveri
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Vinay Nair
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
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13
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Małyszko J, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Porta C. KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation. Kidney Int 2020; 98:1407-1418. [PMID: 33276867 DOI: 10.1016/j.kint.2020.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023]
Abstract
The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.
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Affiliation(s)
- Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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Venetoclax in a Patient With Light Chain Deposition Disease Secondary to MGRS That Progressed After Kidney Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e488-e491. [DOI: 10.1016/j.clml.2020.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/20/2022]
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15
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Current opinions in nephrology and hypertension: kidney transplantation in patients with plasma cell dyscrasias. Curr Opin Nephrol Hypertens 2020; 28:573-580. [PMID: 31403474 DOI: 10.1097/mnh.0000000000000544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Plasma cell dyscrasias encompass a group of hematological disorders characterized by increased production of immunoglobulins by clonal B cells. Kidney involvement is common. Significant advances in the treatment of plasma cell dyscrasias have resulted in improved survival and may permit kidney transplantation in candidates previously denied transplantation. Treatments may also have effects on kidney transplant recipients who develop plasma cell dyscrasias post transplantation. RECENT FINDING The available evidence suggests that transplantation of candidates with nonmultiple myeloma plasma cell dyscrasias provides good outcome with low recurrence rates, so long as the disease has been treated with a complete or good partial response prior to transplantation. Candidates with a history untreated MGRS or a history of multiple myeloma have a high rate of recurrence posttransplant. Kidney transplant recipients who develop plasma cell dyscrasias post transplantation have an increased risk of death and thalidomide-based regimens may increase the risk of rejection. SUMMARY Transplant candidates with a history of plasma cell dyscrasia who are in remission should not be excluded from transplantation. Individuals with multiple myeloma have a high rate of recurrence and myeloma post kidney transplant must be managed carefully.
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16
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17
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Qualls DA, Lewis GD, Sanchorawala V, Staron A. Orthotopic heart transplant rejection in association with immunomodulatory therapy for AL amyloidosis: A case series and review of the literature. Am J Transplant 2019; 19:3185-3190. [PMID: 31207062 DOI: 10.1111/ajt.15499] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 01/25/2023]
Abstract
Although end-organ damage caused by AL amyloidosis historically portends a poor prognosis, advances in therapy in combination with solid organ transplantation can lead to significant improvements in survival. Immunomodulatory agents (IMiDs), such as lenalidomide and pomalidomide, are an effective class of drugs in the treatment of AL amyloidosis. However, there is growing concern that these agents may precipitate acute transplant rejection via upregulation of interleukin-2 and inhibition of immune tolerance. This case series describes three patients who underwent orthotopic heart transplantation for AL amyloidosis and later had progression of their underlying plasma cell dyscrasia, leading to treatment with IMiD therapy. Two patients subsequently developed acute allograft rejection, including the first reported case of pomalidomide-associated allograft rejection. The third patient tolerated long-term therapy without signs of rejection: the first reported case of IMiD tolerability after heart transplant. These cases, together with a review of the literature, demonstrate variable outcomes and elucidate the potential risk of organ rejection associated with the use of IMiDs. When treatment with IMiDs is necessary, close surveillance and modification of immunosuppression may mitigate risks of rejection and complications.
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Affiliation(s)
- David A Qualls
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Andrew Staron
- Amyloidosis Center, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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18
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Dinh A, Palmer MB, Svoboda J, Hogan JJ. Lenalidomide-induced tubulointerstitial nephritis in Hodgkin lymphoma. Leuk Lymphoma 2019; 60:3084-3086. [PMID: 31125280 DOI: 10.1080/10428194.2019.1616187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Alex Dinh
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Matthew B Palmer
- Department of Medicine and Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jakub Svoboda
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jonathan J Hogan
- Division of Nephrology, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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19
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Shah S, Ibrahim M, Delaney M, Schey S, Bygrave C, Streetly M, Benjamin R. Risk of relapse of multiple myeloma following kidney transplantation. Clin Kidney J 2019; 12:216-223. [PMID: 30976399 PMCID: PMC6452174 DOI: 10.1093/ckj/sfy137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) and novel therapies have improved the prognosis for patients with multiple myeloma (MM). For those who undergo ASCT while on dialysis, a similar survival compared with the overall MM population has been reported. Therefore, for patients achieving remission following ASCT, kidney transplantation is an attractive option, offering an improved quality of life and significant economic advantage. Method This case series investigates the outcome of five patients who underwent an ASCT for MM with subsequent kidney transplantation between 2006 and 2012. Results Four patients presented with end-stage renal disease (ESRD) and one progressed to ESRD shortly after diagnosis. Induction chemotherapy regimens with novel agents including thalidomide and bortezomib were utilized. Following attainment of very good partial remission or complete remission, high-dose melphalan ASCTs were performed after a median of 10 months. Kidney transplantation (living donor n = 3, deceased donor n = 2) with tacrolimus-based immunosuppression regimens was completed at a median of 27 months after ASCT. Patients 1 and 3 experienced relapse of myeloma at 6 and 16 months after kidney transplantation. Patients 2, 4 and 5 remain alive at 55 months (median) after kidney transplantation with no evidence of relapse. Conclusion Forty percent of our cohort experienced a relapse in MM within 2 years of kidney transplantation. Death-censored graft survival and patient survival were 80% at 4 years. Our study adds to the growing literature supporting kidney transplantation following successful ASCT for MM and is useful when counselling patients regarding renal and haematological outcomes.
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Affiliation(s)
| | | | - Michael Delaney
- East Kent Hospital University NHS Foundation Trust, Kent, UK
| | - Steve Schey
- King's College Hospital NHS Trust, London, UK
| | - Ceri Bygrave
- Cardiff and Vale University Health Board, Cardiff, UK
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20
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Van den bosch I, Sprangers B, Gertz M. Multiple myeloma and kidney transplantation: the beginning of a new era. Clin Kidney J 2019; 12:213-215. [PMID: 30976398 PMCID: PMC6452187 DOI: 10.1093/ckj/sfz003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Indexed: 11/13/2022] Open
Abstract
The introduction of several novel therapeutic agents has improved the outcome in multiple myeloma (MM) patients including those with chronic kidney disease, and it is predicted that MM will become a curable disease in a substantial subset of MM patients. While in the past-because of inferior posttransplant outcomes-renal transplantation was not offered to MM patients, recent data suggest that renal transplantation is a viable treatment option in patients treated with modern anti-myeloma induction therapy followed by autologous stem cell transplantation achieving durable complete responses. The article of Shah, Ibrahim, Delaney et al. [Risk of relapse of multiple myeloma following kidney transplantation: a case series report. Clin Kidney J 2018 (in this issue)] in the current issue of Clinical Kidney Journal adds to this evidence and highlights the limitations and outstanding questions concerning renal transplantation in MM patients.
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Affiliation(s)
- Ines Van den bosch
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
- Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
- Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Morie Gertz
- Division of Hematology, Department of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
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22
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Walavalkar V, Adey DB, Laszik ZG, Jen KY. Severe Renal Allograft Rejection Resulting from Lenalidomide Therapy for Multiple Myeloma: Case Report. Transplant Proc 2018; 50:873-876. [PMID: 29661456 DOI: 10.1016/j.transproceed.2018.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 01/19/2018] [Indexed: 12/27/2022]
Abstract
Lenalidomide, a thalidomide analogue, is an immunomodulatory drug currently used as a chemotherapeutic agent in treating certain hematologic malignancies, including multiple myeloma. The antineoplastic effect of lenalidomide may be due to its ability to modulate different components of the immune system as well as its antiangiogenic, antiproliferative, and direct cytotoxic activity. Given its immunomodulatory effects, lenalidomide may potentially elicit unintended immune activity against allografts in solid organ transplant recipients. Here, we present a case of a renal transplant recipient who developed multiple myeloma after transplantation and was treated with the use of lenalidomide, which precipitated severe acute T-cell-mediated rejection. Lenalidomide was thought to be causative, and after cessation of the drug her renal function stabilized.
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Affiliation(s)
- V Walavalkar
- Department of Pathology, University of California, San Francisco, California
| | - D B Adey
- Division of Nephrology, University of California, San Francisco, California
| | - Z G Laszik
- Department of Pathology, University of California, San Francisco, California
| | - K-Y Jen
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, California.
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23
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Goldman JW, Abdalla B, Mendenhall MA, Sisk A, Hunt J, Danovitch GM, Lum EL. PD 1 checkpoint inhibition in solid organ transplants: 2 sides of a coin - case report. BMC Nephrol 2018; 19:210. [PMID: 30126374 PMCID: PMC6102916 DOI: 10.1186/s12882-018-1003-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/06/2018] [Indexed: 11/21/2022] Open
Abstract
Background The management of malignancy post kidney transplantation includes reduction in immunosuppression and referral to an oncologist management of their malignancy. Recent advances in oncology have resulted in the approval of several classes of drugs with immune-modulatory activity. However, activation of the immune system against malignant cells may precipitate allograft rejection in solid organ transplant recipients. Case presentation Herein we present a case of acute kidney allograft rejection in a 50 year old man following administration of the novel immune-modulatory agent nivolumab for the treatment of metastatic squamous cell carcinoma. Conclusion The management of malignancy in solid organ transplant recipients requires a heightened awareness of the potential for allograft rejection in this new era of cancer therapeutics.
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Affiliation(s)
- Jonathan W Goldman
- Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine rat UCLA, 2020 Santa Monica Blvd, Suite 600, Santa Monica, CA, 90404, USA
| | - Basmah Abdalla
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Connie Frank Kidney Transplant Center, 200 Medical Plaza, Ste 565, Los Angeles, CA, 90095, USA
| | - Melody A Mendenhall
- Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine rat UCLA, 2020 Santa Monica Blvd, Suite 600, Santa Monica, CA, 90404, USA
| | - Anthony Sisk
- Department of Pathology, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Jaime Hunt
- Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine rat UCLA, 2020 Santa Monica Blvd, Suite 600, Santa Monica, CA, 90404, USA
| | - Gabriel M Danovitch
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Connie Frank Kidney Transplant Center, 200 Medical Plaza, Ste 565, Los Angeles, CA, 90095, USA
| | - Erik L Lum
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine at UCLA, Connie Frank Kidney Transplant Center, 200 Medical Plaza, Ste 565, Los Angeles, CA, 90095, USA.
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24
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Kidney Transplantation in Patients With Active Multiple Myeloma: Case Reports. Transplant Direct 2017; 3:e200. [PMID: 28795151 PMCID: PMC5540638 DOI: 10.1097/txd.0000000000000716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/23/2017] [Indexed: 01/29/2023] Open
Abstract
Kidney disease is a common complication in patients with multiple myeloma. Traditionally, patients with active multiple myeloma and end-stage renal disease have been excluded from kidney transplantation due to the risk of malignancy progression. The introduction of bortezomib-based therapy for patients with multiple myeloma and renal impairment has significantly improved survival in this population. In this report, we present 2 cases of patients with active and controlled multiple myeloma who underwent successful kidney transplantation without progression of their underlying malignancy. In patients with active multiple myeloma controlled with bortezomib, kidney transplantation should be considered a valid option for patients with end-stage kidney disease.
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