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Mupfudze TG, Martinez A, Noreen SM, Stewart DE, Schold JD, Cartwright L. Individual-level social determinants of health and disparities in access to kidney transplant and waitlist mortality. PLoS One 2024; 19:e0308407. [PMID: 39167588 PMCID: PMC11338441 DOI: 10.1371/journal.pone.0308407] [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: 02/21/2024] [Accepted: 07/23/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Comprehensive, individual-level social determinants of health (SDOH) are not collected in national transplant registries, limiting research aimed at understanding the relationship between SDOH and waitlist outcomes among kidney transplant candidates. METHODS We merged Organ Procurement and Transplantation Network data with individual-level SDOH data from LexisNexis, a commercial data vendor, and conducted a competing risk analysis to determine the association between individual-level SDOH and the cumulative incidence of living donor kidney transplant (LDKT), deceased donor kidney transplant (DDKT), and waitlist mortality. We included adult kidney transplant candidates placed on the waiting list in 2020, followed through December 2023. RESULTS In multivariable analysis, having public insurance (Medicare or Medicaid), less than a college degree, and any type of derogatory record (liens, history of eviction, bankruptcy and/ felonies) were associated with lower likelihood of LDKT. Compared with patients with estimated individual annual incomes ≤ $30,000, patients with incomes ≥ $120,000 were more likely to receive a LDKT (sub distribution hazard ratio (sHR), 2.52; 95% confidence interval (CI), 2.03-3.12). Being on Medicare (sHR, 1.49; 95% CI, 1.42-1.57), having some college or technical school, or at most a high school diploma were associated with a higher likelihood of DDKT. Compared with patients with incomes ≤ $30,000, patients with incomes ≥ $120,000 were less likely to receive a DDKT (sHR, 0.60; 95% CI, 0.51-0.71). Lower individual annual income, having public insurance, at most a high school diploma, and a record of liens or eviction were associated with higher waitlist mortality. CONCLUSIONS Patients with adverse individual-level SDOH were less likely to receive LDKT, more likely to receive DDKT, and had higher risk of waitlist mortality. Differential relationships between SDOH, access to LDKT, DDKT, and waitlist mortality suggest the need for targeted interventions aimed at decreasing waitlist mortality and increasing access to LDKT among patients with adverse SDOH.
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Affiliation(s)
- Tatenda G. Mupfudze
- Research Department, United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - Alina Martinez
- Research Department, United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - Samantha M. Noreen
- Research Department, United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - Darren E. Stewart
- Departments of Surgery, NYU Langone Health, New York, New York, United States of America
| | - Jesse D. Schold
- Departments of Surgery and Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Laura Cartwright
- Research Department, United Network for Organ Sharing, Richmond, Virginia, United States of America
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Wu M, Ma Z, Xu X, Lu B, Gu Y, Yoon J, Xia J, Ma Z, Upreti N, Anwar IJ, Knechtle SJ, T Chambers E, Kwun J, Lee LP, Huang TJ. Acoustofluidic-based therapeutic apheresis system. Nat Commun 2024; 15:6854. [PMID: 39127732 DOI: 10.1038/s41467-024-50053-1] [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: 02/17/2024] [Accepted: 06/26/2024] [Indexed: 08/12/2024] Open
Abstract
Therapeutic apheresis aims to selectively remove pathogenic substances, such as antibodies that trigger various symptoms and diseases. Unfortunately, current apheresis devices cannot handle small blood volumes in infants or small animals, hindering the testing of animal model advancements. This limitation restricts our ability to provide treatment options for particularly susceptible infants and children with limited therapeutic alternatives. Here, we report our solution to these challenges through an acoustofluidic-based therapeutic apheresis system designed for processing small blood volumes. Our design integrates an acoustofluidic device with a fluidic stabilizer array on a chip, separating blood components from minimal extracorporeal volumes. We carried out plasma apheresis in mouse models, each with a blood volume of just 280 μL. Additionally, we achieved successful plasmapheresis in a sensitized mouse, significantly lowering preformed donor-specific antibodies and enabling desensitization in a transplantation model. Our system offers a new solution for small-sized subjects, filling a critical gap in existing technologies and providing potential benefits for a wide range of patients.
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Affiliation(s)
- Mengxi Wu
- School of Mechanical Engineering, Dalian University of Technology, Dalian, Liaoning, P.R. China
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA
| | - Zhiteng Ma
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA
| | - Xianchen Xu
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA
| | - Brandon Lu
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Yuyang Gu
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA
| | - Janghoon Yoon
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, 27708, USA
| | - Jianping Xia
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA
| | - Zhehan Ma
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Neil Upreti
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Imran J Anwar
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, 27708, USA
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, 27708, USA
| | - Eileen T Chambers
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, 27708, USA
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, 27708, USA.
| | - Luke P Lee
- Renal Division and Division of Engineering in Medicine, Department of Medicine, Harvard Medical School, Harvard University, Brigham and Women's Hospital, Boston, MA, 02115, USA.
- Department of Bioengineering, University of California, Berkeley, Berkeley, CA, 94720, USA.
- Department of Electrical Engineering and Computer Science, University of California, Berkeley, Berkeley, CA, 94720, USA.
- Department of Biophysics, Institute of Quantum Biophysics, Sungkyunkwan University, Suwon, Korea.
- Department of Chemistry and Nanoscience, Ewha Womans University, Seoul, Korea.
| | - Tony Jun Huang
- Thomas Lord Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, 27708, USA.
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3
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Orandi BJ, Li Y, Seckin T, Bae S, Lonze BE, Ren-Fielding CJ, Lofton H, Gujral A, Segev DL, McAdams-DeMarco M. Obesogenic Medication Use in End-Stage Kidney Disease and Association With Transplant Listing. Clin Transplant 2024; 38:e15414. [PMID: 39166467 DOI: 10.1111/ctr.15414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES Obesogenic medications are a putative contributor to the obesity epidemic. While 20% of adults take ≥1 obesogenic medication, the proportion in the end-stage kidney disease (ESKD) population-a group enriched for cardiometabolic complications-is unknown. Obesogenic medications may contribute to obesity and hamper weight loss efforts to achieve transplant listing. METHODS Using 2017-2020 USRDS and Medicare claims, patients were identified as taking obesogenic medications if prescribed anticonvulsants, antidepressants, antidiabetics, anti-inflammatories, antipsychotics, and/or antihypertensives known to cause weight gain for ≥30 days in their first hemodialysis year. Ordinal logistic and Cox regression with inverse probability of treatment weighting were used to quantify obesogenic medications' association with body mass index (BMI) and listing, respectively. RESULTS Among 271 401 hemodialysis initiates, 63.5% took ≥1 obesogenic medication. For those in underweight, normal weight, overweight, and class I, II, and III categories, 54.3%, 58.4%, 63.1%, 66.5%, 68.6%, and 68.8% took ≥1, respectively. Number of obesogenic medications was associated with increased BMI; use of one was associated with 13% increased odds of higher BMI (aOR [adjusted odds ratio] 1.14; 95%CI: 1.13-1.16; p < 0.001), use of three was associated with a 55% increase (aOR 1.55; 95%CI: 1.53-1.57; p < 0.001). Any use was associated with 6% lower odds of transplant listing (aHR [adjusted hazard ratio] 0.94; 95%CI: 0.92-0.96; p < 0.001). Within each BMI category, obesogenic medication use was associated with lower listing likelihood. CONCLUSIONS Obesogenic medication use is common in ESKD patients-particularly those with obesity-and is associated with lower listing likelihood. Whenever possible, non-obesogenic alternatives should be chosen for ESKD patients attempting weight loss to achieve transplant listing.
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Affiliation(s)
- Babak J Orandi
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Yiting Li
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Timur Seckin
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Sunjae Bae
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Bonnie E Lonze
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | | | - Holly Lofton
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Akash Gujral
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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4
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Santos E, Lucisano G, Dor FJMF, Willicombe M. Comparative outcomes of DSA positive, crossmatch negative living donor kidney transplants versus remaining on the waitlist for an HLA compatible deceased donor. Transpl Immunol 2024; 86:102098. [PMID: 39074764 DOI: 10.1016/j.trim.2024.102098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION The clinical relevance of preformed donor specific antibodies in the setting of a negative crossmatch (DSA + XM-) remains controversial. In this study we investigate the outcomes of patients with a DSA + XM- living donor (LDi) who proceeded with an HLA-incompatible (HLAi) transplant compared with those who waited for an HLA-compatible deceased donor (DDc). MATERIALS AND METHODS We investigated 359 patients on the transplant waiting list who had at least one potential HLAi living donor, from which 203 DSA + XM- pairs were identified and outcomes analysed. RESULTS Out of 203 patients, 96 (47.3%) received a LD transplant: 52/96 (54.2%) a LDi, and 44/96 (45.8%) an alternative compatible LD. In addition, 107 patients out of 203(52.7%) waited for a DDc, of which 47(43.9%) were subsequently transplanted. Our adjusted analysis showed that the LDi transplantation did not offer a superior patient survival over waiting for a DDc transplant. For those transplanted, there was no difference in patient (p = 0.065) or death censored allograft survival (p = 0.37) between DDc and LDi recipients. However, there was a higher incidence of acute allograft rejection (p = 0.043) and antibody-mediated rejection (p = 0.005) in the LDi group. Having a high pre-transplant calculated reaction frequency and preformed DSA to both class I and class II antigens were associated with inferior outcomes in the LDi transplants. CONCLUSIONS Given the lack of difference in allograft survival between LDi and DDc transplants, in the absence of an alternative compatible living donor, proceeding with a LDi should be supported despite a higher rejection risk, providing individual risk assessment and shared decision making is undertaken.
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Affiliation(s)
- Eva Santos
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.
| | - Gaetano Lucisano
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Frank J M F Dor
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Michelle Willicombe
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK; Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK; Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, UK
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5
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Krishnan N, Briggs D. Imlifidase: Is it the Magic Wand in Renal Transplantation? Indian J Nephrol 2024; 34:291-296. [PMID: 39156835 PMCID: PMC11326793 DOI: 10.25259/ijn_325_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/15/2023] [Indexed: 08/20/2024] Open
Abstract
Potential kidney transplant patients with HLA-specific antibodies have reduced access to transplantation. Their harmful effects are mediated by the Fc portion of IgG, including activation of the complement system and Fc receptor-initiated cytotoxic processes by circulating leucocytes. Avoiding antibody incompatibility is the conventional approach, but for some patients this can mean extended waiting times, or even no chance of a transplant if there are no alternative, compatible donors. For these cases, pretransplant antibody removal may provide access to transplantation. Plasmapheresis is currently used to achieve this, with acceptable outcome results, but the process can take days to reduce the antibody levels to a safe level, so has limited use for deceased donors. There is now an alternative, in the form of an IgG-digesting enzyme, Imlifidase, which can be administered for in vivo IgG inactivation. Imlifidase cleaves human IgG, separating the antigen-binding part, F(ab')2 from Fc. Typically, within six hours of dosing, most, if not all, of the circulating IgG has been inactivated, allowing safe transplantation from a previously incompatible donor. For deceased donor transplantation, where minimizing cold ischaemia is critical, this six-hour delay before implantation should be manageable, with the compatibility testing processes adjusted to accommodate the treatment. This agent has been used successfully in phase 2 clinical trials, with good short to medium term outcomes. While a donation rate that matches demand may be one essential answer to providing universal access to kidney transplantation, this is currently unrealistic. IgG inactivation, using Imlifidase, is, however, a realistic and proven alternative.
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Affiliation(s)
- Nithya Krishnan
- Department of Renal and Transplant Medicine, Institute of Cardiometabolic Medicine, University of Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute of Community and Health Care, Coventry University, Coventry, United Kingdom
| | - David Briggs
- Histocompatibility and Immunogenetics Lab, NHS Blood and Transplant, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Coventry, United Kingdom
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6
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Manook M, Olaso D, Anwar I, DeLaura I, Yoon J, Bae Y, Barbas A, Shaw B, Moris D, Song M, Farris AB, Stiede K, Youd M, Knechtle S, Kwun J. Prolonged xenokidney graft survival in sensitized NHP recipients by expression of multiple human transgenes in a triple knockout pig. Sci Transl Med 2024; 16:eadk6152. [PMID: 38865482 PMCID: PMC11328991 DOI: 10.1126/scitranslmed.adk6152] [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: 09/01/2023] [Accepted: 05/07/2024] [Indexed: 06/14/2024]
Abstract
Genetic modification of porcine donors, combined with optimized immunosuppression, has been shown to improve outcomes of experimental xenotransplant. However, little is known about outcomes in sensitized recipients, a population that could potentially benefit the most from the clinical implementation of xenotransplantation. Here, five highly allosensitized rhesus macaques received a porcine kidney from GGTA1 (α1,3-galactosyltransferase) knockout pigs expressing the human CD55 transgene (1KO.1TG) and were maintained on an anti-CD154 monoclonal antibody (mAb)-based immunosuppressive regimen. These recipients developed de novo xenoreactive antibodies and experienced xenograft rejection with evidence of thrombotic microangiopathy and antibody-mediated rejection (AMR). In comparison, three highly allosensitized rhesus macaques receiving a kidney from GGTA1, CMAH (cytidine monophospho-N-acetylneuraminic acid hydroxylase), and b4GNT2/b4GALNT2 (β-1,4-N-acetyl-galactosaminyltransferase 2) knockout pigs expressing seven human transgenes including human CD46, CD55, CD47, THBD (thrombomodulin), PROCR (protein C receptor), TNFAIP3 (tumor necrosis factor-α-induced protein 3), and HMOX1 (heme oxygenase 1) (3KO.7TG) experienced significantly prolonged graft survival and reduced AMR, associated with dampened post-transplant humoral responses, early monocyte and neutrophil activation, and T cell repopulation. After withdrawal of all immunosuppression, recipients who received kidneys from 3KO.7TG pigs rejected the xenografts via AMR. These data suggest that allosensitized recipients may be suitable candidates for xenografts from genetically modified porcine donors and could benefit from an optimized immunosuppression regimen designed to target the post-transplant humoral response, thereby avoiding AMR.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Imran Anwar
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Isabel DeLaura
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Andrew Barbas
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | | - Stuart Knechtle
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
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García-Jiménez S, Paz-Artal E, Trujillo H, Polanco N, Castro MJ, Del Rey MJ, Alfocea Á, Morales E, González E, Andrés A, Mancebo E. A personalised delisting strategy enables successful kidney transplantation in highly sensitised patients with preformed donor-specific anti HLA antibodies. HLA 2024; 103:e15572. [PMID: 38923242 DOI: 10.1111/tan.15572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/13/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
This study investigates kidney transplant outcomes in highly sensitised patients after implementing a delisting strategy aimed at enabling transplantation despite preformed donor-specific antibodies (preDSA), with the goal of reducing acute antibody-mediated rejection (aAMR) risk. Fifty-three sensitised recipients underwent kidney transplant after delisting prohibited HLA antigens, focusing initially in low MFI antibodies (<5000), except for anti-HLA-DQ. If insufficient, higher MFI antibodies were permitted, especially for those without an immunogenic eplet pattern assigned. Delisting of Complement-fixing antibodies (C1q+) was consistently avoided. Comparison cohorts included 53 sensitised recipients without DSA (SwoDSA) and 53 non-sensitised (NS). The average waiting time prior to delisting was 4.4 ± 1.8 years, with a reduction in cPRA from 99.7 ± 0.5 to 98.1 ± 0.7, followed by transplantation within 7.2 ± 8.0 months (analysed in 34 patients). Rejection rates were similar among preDSA, SwoDSA, and NS groups (16%, 8%, and 11%, respectively; p = 0.46). However, aAMR was higher in the preDSA group (12%, 4%, and 2%, respectively; p = 0.073), only presented in recipients with DSA of MFI >5000. The highest MFI DSA were against HLA-DP (Median: 10796 MFI), with 50% of preDSA aAMR cases due to anti-DP antibodies (n = 3). Graft survival rates at 1 and 5 years in preDSA group were 94%, and 67%, comparable to SwoDSA (94%, and 70%; p = 0.69), being significantly higher in the NS group (p = 0.002). The five-year recipient survival rate was 89%, comparable to SwoDSA and NS groups (p = 0.79). A delisting strategy enables safe kidney transplant in highly sensitised patients with preDSA, with a slight increase in aAMR and comparable graft and patient survivals to non-DSA cohorts.
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Affiliation(s)
- Sandra García-Jiménez
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Estela Paz-Artal
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Natalia Polanco
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - María J Castro
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Manuel J Del Rey
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Ángel Alfocea
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Enrique Morales
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Esther González
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Amado Andrés
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Nephrology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Esther Mancebo
- Immunology Department, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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8
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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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9
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Furian L, Bestard O, Budde K, Cozzi E, Diekmann F, Mamode N, Naesens M, Pengel LHM, Schwartz Sorensen S, Vistoli F, Thaunat O. European Consensus on the Management of Sensitized Kidney Transplant Recipients: A Delphi Study. Transpl Int 2024; 37:12475. [PMID: 38665475 PMCID: PMC11043529 DOI: 10.3389/ti.2024.12475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
An increasing number of sensitized patients awaiting transplantation face limited options, leading to fatalities during dialysis and higher costs. The absence of established evidence highlights the need for collaborative consensus. Donor-specific antibodies (DSA)-triggered antibody-mediated rejection (AMR) significantly contributes to kidney graft failure, especially in sensitized patients. The European Society for Organ Transplantation (ESOT) launched the ENGAGE initiative, categorizing sensitized candidates by AMR risk to improve patient care. A systematic review assessed induction and maintenance regimens as well as antibody removal strategies, with statements subjected to the Delphi methodology. A Likert-scale survey was distributed to 53 European experts (Nephrologists, Transplant surgeons and Immunologists) with experience in kidney transplant recipient care. A rate ≥75% with the same answer was considered consensus. Consensus was achieved in 95.3% of statements. While most recommendations aligned, two statements related to complement inhibitors for AMR prophylaxis lacked consensus. The ENGAGE consensus presents contemporary recommendations for desensitization and immunomodulation strategies, grounded in predefined risk categories. The adoption of tailored, patient-specific measures is anticipated to streamline the care of sensitized recipients undergoing renal allografts. While this approach holds the promise of enhancing transplant accessibility and fostering long-term success in transplantation outcomes, its efficacy will need to be assessed through dedicated studies.
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Affiliation(s)
- Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Oriol Bestard
- Kidney Transplant Unit, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Emanuele Cozzi
- Transplant Immunology Unit, Department of Cardiac, Thoracic and Vascular Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Fritz Diekmann
- Experimental Nephrology and Transplant Laboratory, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Liset H. M. Pengel
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Soren Schwartz Sorensen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Fabio Vistoli
- University of Pisa, Pisa, Italy
- Department of Biothecnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Olivier Thaunat
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hospices Civils de Lyon, Lyon, France
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10
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Vo A, Ammerman N, Jordan SC. Advances in desensitization for human leukocyte antigen incompatible kidney transplantation. Curr Opin Organ Transplant 2024; 29:104-120. [PMID: 38088373 DOI: 10.1097/mot.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
PURPOSE OF REVIEW Human leukocyte antigen (HLA) sensitization is a major barrier to kidney transplantation induced by exposure to alloantigens through pregnancy, blood product exposure and previous transplantations. Desensitization strategies are undertaken to improve the chances of finding compatible organ offers. Standard approaches to desensitization include the use of plasmapheresis/low dose intravenous immunoglobulin (IVIG) or high dose IVIG plus anti-CD20. However, current methods to reduce HLA antibodies are not always successful, especially in those with calculated panel reactive antibody 99-100%. RECENT FINDINGS Newer desensitization strategies such as imlifidase [immunoglobulin G (IgG) endopeptidase] rapidly inactivates IgG molecules and creates an "antibody-free zone", representing an important advancement in desensitization. However, pathogenic antibodies rebound, increasing allograft injury that is not addressed by imlifidase. Here, use of anti-IL-6R (tocilizumab) or anti-interleukin-6 (clazakizumab) could offer long-term control of B-memory and plasma cell DSA responses to limit graft injury. Agents aimed at long-lived plasma cells (anti-CD38 and anti-BCMAxCD3) could reduce or eliminate HLA-producing plasma cells from marrow niches. Other agents such as complement inhibitors and novel agents inhibiting the Fc neonatal receptor (FcRn) mediated IgG recycling will likely find important roles in desensitization. SUMMARY Use of these agents alone or in combination will likely improve the efficacy and durability of desensitization therapies, improving access to kidney transplantation for immunologically disadvantaged patients.
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Affiliation(s)
- Ashley Vo
- Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California, USA
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11
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Perry J, McLeod MC, Reed RD, Baker GA, Stanford LA, Allen J, Jones B, Robinson T, MacLennan PA, Kumar V, Locke JE. Patient-Level and Center-Level Factors Associated with Required Predonation Weight Loss among Obese Living Kidney Donors. KIDNEY360 2024; 5:437-444. [PMID: 38319632 PMCID: PMC11000741 DOI: 10.34067/kid.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
Key Points Among obese living kidney donors, year of donation, preoperative body mass index, hypertension, and center percent of living kidney donor transplants were associated with required predonation weight loss. There were no significant differences in the likelihood of predonation weight loss requirement by race, sex, or age or by markers of preoperative metabolic dysfunction. Background The proportion of overweight/mildly obese living kidney donors (OLKDs) has increased in the past few decades, with significant center variation in the body mass index (BMI) of LKDs. The purpose of this study was to examine factors associated with required predonation weight loss among OLKDs (BMI, ≥30 kg/m2). Methods This retrospective cohort study surveyed 1097 OLKDs (1979–2020) (mean BMI, 33 kg/m2) about their donation experience. Bivariate analyses compared donor demographic and center characteristics by whether the donor reported predonation weight loss requirement. Generalized estimating equations with logit link were used to estimate marginal effects of patient-level and center-level factors. Multiple imputation using chained equations was implemented to account for missing values. Results Of 1097 OLKDs surveyed, 340 (31.0%) reported predonation weight loss requirement. Donors with a predonation weight loss requirement had slightly higher predonation BMIs and donated in more recent years at centers performing a lower percentage of living donor nephrectomies and with a lower median BMI. In multivariable logistic regression analysis, we observed transplant year (odds ratio [OR], 1.04 per year donation; 95% confidence interval [CI], 1.01 to 1.07; P = 0.005), preoperative BMI (OR, 1.16; 95% CI, 1.05 to 1.28; P < 0.01), preoperative hypertension (OR, 1.61; 95% CI, 1.08 to 2.40; P = 0.02), and center percentage of living donor kidney transplants (OR, 0.99; 95% CI, 0.98 to 1.00; P = 0.02) as significantly associated with a predonation weight loss requirement. The study found no differences in the likelihood of predonation weight loss requirement by race, sex, age, preoperative creatinine, preoperative metabolic dysfunction, or center-level median BMI of living donors. Conclusions These results suggest that both center-level and patient-level factors influence whether OLKDs are required to lose weight before donation. Future study is needed to determine whether predonation weight loss is associated with improved long-term postdonation outcomes.
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Affiliation(s)
- Jackson Perry
- University of Alabama Comprehensive Transplant Institute, Birmingham, Alabama
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12
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Kanbay M, Copur S, Guldan M, Topcu AU, Ozbek L, Hasbal B, Süsal C, Kocak B, Callemeyn J, Segelmark M. Imlifidase in kidney transplantation. Clin Kidney J 2024; 17:sfae033. [PMID: 38504664 PMCID: PMC10949912 DOI: 10.1093/ckj/sfae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Indexed: 03/21/2024] Open
Abstract
Kidney transplantation, the gold-standard therapeutic approach for patients with end-stage kidney disease, offers improvement in patient survival and quality of life. However, broad sensitization against human leukocyte antigens often resulting in a positive crossmatch against the patient's living donor or the majority of potential deceased donors in the allocation system represents a major obstacle due to a high risk for antibody-mediated rejection, delayed graft function and allograft loss. Kidney-paired donation and desensitization protocols have been established to overcome this obstacle, with limited success. Imlifidase, a novel immunoglobulin G (IgG)-degrading enzyme derived from Streptococcus pyogenes and recombinantly produced in Escherichia coli, is a promising agent for recipients with a positive crossmatch against their organ donor with high specificity towards IgG, rapid action and high efficacy in early pre-clinical and clinical studies. However, the rebound of IgG after a few days can lead to antibody-mediated rejection, making the administration of potent immunosuppressive regimens in the early post-transplant phase necessary. There is currently no comparative study evaluating the efficiency of imlifidase therapy compared with conventional desensitization protocols along with the lack of randomized control trials, indicating the clear need for future large-scale clinical studies in this field. Besides providing a practical framework for the clinical use of the agent, our aim in this article is to evaluate the underlying mechanism of action, efficiency and safety of imlifidase therapy in immunologically high-risk kidney transplant recipients.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mustafa Guldan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmet U Topcu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Lasin Ozbek
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Hasbal
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Süsal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Jasper Callemeyn
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Endocrinology, Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
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13
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de Weerd AE, Roelen DL, van de Wetering J, Betjes MGH, Heidt S, Reinders MEJ. Imlifidase Desensitization in HLA-incompatible Kidney Transplantation: Finding the Sweet Spot. Transplantation 2024; 108:335-345. [PMID: 37340532 DOI: 10.1097/tp.0000000000004689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Imlifidase, derived from a Streptococcus pyogenes enzyme, cleaves the entire immunoglobulin G pool within hours after administration in fully cleaved antigen-binding and crystallizable fragments. These cleaved fragments can no longer exert their antibody-dependent cytotoxic functions, thereby creating a window to permit HLA-incompatible kidney transplantation. Imlifidase is labeled, in Europe only, for deceased donor kidney transplantation in highly sensitized patients, whose chances for an HLA-compatible transplant are negligible. This review discusses outcomes of preclinical and clinical studies on imlifidase and describes the phase III desensitization trials that are currently enrolling patients. A comparison is made with other desensitization methods. The review discusses the immunological work-up of imlifidase candidates and especially the "delisting strategy" of antigens that shift from unacceptable to acceptable with imlifidase desensitization. Other considerations for clinical implementation, such as adaptation of induction protocols, are also discussed. Imlifidase cleaves most of the currently used induction agents except for horse antithymocyte globulin, and rebound of donor-specific antibodies should be managed. Another consideration is the timing and interpretation of (virtual) crossmatches when bringing this novel desensitization agent into the clinic.
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Affiliation(s)
- Annelies E de Weerd
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
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14
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DeLaura I, Zikos J, Anwar IJ, Yoon J, Ladowski J, Jackson A, Van Rompay K, Magnani D, Knechtle SJ, Kwun J. The impact of IdeS (imlifidase) on allo-specific, xeno-reactive, and protective antibodies in a sensitized rhesus macaque model. Xenotransplantation 2024; 31:e12833. [PMID: 37864433 PMCID: PMC10999173 DOI: 10.1111/xen.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Highly sensitized patients face many barriers to kidney transplantation, including higher rates of antibody-mediated rejection after HLA-incompatible transplant. IdeS, an endopeptidase that cleaves IgG nonspecifically, has been trialed as desensitization prior to kidney transplant, and successfully cleaves donor-specific antibody (DSA), albeit with rebound. METHODS IdeS was generated and tested (2 mg/kg, IV) in two naïve and four allosensitized nonhuman primates (NHP). Peripheral blood samples were collected at regular intervals following IdeS administration. Total IgG, total IgM, and anti-CMV antibodies were quantified with ELISA, and donor-specific antibody (DSA) and anti-pig antibodies were evaluated using flow cytometric crossmatch. B cell populations were assessed using flow cytometry. RESULTS IdeS successfully cleaved rhesus IgG in vitro. In allosensitized NHP, robust reduction of total, DSA, anti-pig, and anti-CMV IgG was observed within one day following IdeS administration. Rapid rebound of all IgG antibody populations was observed, with antibody levels returning to baseline around day 14 post-infusion. Total IgM level was not affected by IdeS. Interestingly, a comparable reduction in antibody populations was observed after the second dose of IdeS. However, we have not observed any significant modulation of B cell subpopulations after IdeS. CONCLUSIONS This study evaluated efficacy of IdeS in the allosensitized NHP in IgG with various specificities, mirroring antibody kinetics in human patients. The efficacy of IdeS on preexisting anti-pig antibodies may be useful in clinical xenotransplantation. However, given the limitation of IdeS on its durability as a monotherapy, optimization of IdeS with other agents targeting the humoral response is further needed.
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Affiliation(s)
- Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Joanna Zikos
- MassBiologics of University of Massachusetts Medical School, Boston, MA, 02126, USA
| | - Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Joseph Ladowski
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Annette Jackson
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Koen Van Rompay
- California National Primate Research Center, University of California, Davis, CA 95616, USA
| | - Diogo Magnani
- MassBiologics of University of Massachusetts Medical School, Boston, MA, 02126, USA
| | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
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15
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Scurt FG, Fischer-Fröhlich CL, Wassermann T, Ernst A, Schwarz A, Becker JU, Chatzikyrkou C. Histological and clinical evaluation of discarded kidneys in a European cohort of deceased brain death donor kidneys of marginal quality. J Nephrol 2023; 36:2587-2600. [PMID: 37856068 DOI: 10.1007/s40620-023-01785-8] [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] [Accepted: 09/04/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Despite organ shortages, the discard rate of deceased donor kidneys is high. Risk factors for this trend warrant further study. METHODS We investigated reasons for discard in a cohort of brain death donors with marginal kidneys and procurement biopsies. Paraffin embedded procurement biopsies were systematically reevaluated and graded for the purpose of the study. Assessment included percentage of global glomerulosclerosis, Banff Lesion scores and tubular epithelial damage. Donor-, transplant process-, perfusion quality-, histopathology-, and recipient-related parameters were compared between discarded and transplanted organs. RESULTS Although most clinical characteristics were similar between donors whose kidneys were transplanted and those whose kidneys were procured but discarded, discarded kidneys were more likely to be from donors with hepatitis C, to have undergone wedge biopsies, to show changes of acute and chronic injury and to be deemed poor quality. Except for obvious anatomic abnormalities, kidneys were often discarded due to the findings of procurement biopsies. Donors of kidneys discarded for histologic reasons more often had hypertension, coronary artery disease, stroke, and increased serum creatinine. The reason for discard was unknown in 20% of cases. Discarded kidneys came from donors who appeared to be clinically similar to donors whose kidneys were utilized for transplant. CONCLUSION A considerable proportion of discarded kidneys were of acceptable quality. The analysis of the outcome of every recovered organ could help to overcome this problem. Procurement biopsies more often lead to discard than to transplantation of recovered organs. Proper handling during allocation has to be determined.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Otto-von Guericke University, Magdeburg, Germany
| | | | - Tamara Wassermann
- Otto-von Guericke University, Magdeburg, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Anke Schwarz
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany.
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany.
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16
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Betriu S, Rovira J, Arana C, García-Busquets A, Matilla-Martinez M, Ramirez-Bajo MJ, Bañon-Maneus E, Lazo-Rodriguez M, Bartoló-Ibars A, Claas FHJ, Mulder A, Heidt S, Juan M, Bayés-Genís B, Campistol JM, Palou E, Diekmann F. Chimeric HLA antibody receptor T cells for targeted therapy of antibody-mediated rejection in transplantation. HLA 2023; 102:449-463. [PMID: 37503860 DOI: 10.1111/tan.15156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/29/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023]
Abstract
The presence of donor-specific antibodies (DSA), mainly against HLA, increases the risk of allograft rejection. Moreover, antibody-mediated rejection (ABMR) remains an important barrier to optimal long-term outcomes after solid organ transplantation. The development of chimeric autoantibody receptor T lymphocytes has been postulated for targeted therapy of autoimmune diseases. We aimed to develop a targeted therapy for DSA desensitization and ABMR, generating T cells with a chimeric HLA antibody receptor (CHAR) that specifically eliminates DSA-producing B cells. We have genetically engineered an HLA-A2-specific CHAR (A2-CHAR) and transduced it into human T cells. Then, we have performed in vitro experiments such as cytokine measurement, effector cell activation, and cytotoxicity against anti-HLA-A2 antibody-expressing target cells. In addition, we have performed A2-CHAR-Tc cytotoxic assays in an immunodeficient mouse model. A2-CHAR expressing T cells could selectively eliminate HLA-A2 antibody-producing B cells in vitro. The cytotoxic capacity of A2-CHAR expressing T cells mainly depended on Granzyme B release. In the NSG mouse model, A2-CHAR-T cells could identify and eradicate HLA-A2 antibody-producing B cells even when those cells are localized in the bone marrow. This ability is effector:target ratio dependent. CHAR technology generates potent and functional human cytotoxic T cells to target alloreactive HLA class I antibody-producing B cells. Thus, we consider that CHAR technology may be used as a selective desensitization protocol or an ABMR therapy in transplantation.
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Affiliation(s)
- Sergi Betriu
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Carolt Arana
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Ainhoa García-Busquets
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Marina Matilla-Martinez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | - Maria J Ramirez-Bajo
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Lazo-Rodriguez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
| | | | - Frans H J Claas
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arend Mulder
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Manel Juan
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Beatriu Bayés-Genís
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
| | - Eduard Palou
- Department of Immunology, Clinic Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació de Recerca Clinic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
- Department of Nephrology and Kidney Transplantation, Institut Clínic de Nefrologia i Urologia (ICNU), Clínic Barcelona, Barcelona, Spain
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17
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Malhotra D, Jethwani P. Preventing Rejection of the Kidney Transplant. J Clin Med 2023; 12:5938. [PMID: 37762879 PMCID: PMC10532029 DOI: 10.3390/jcm12185938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
With increasing knowledge of immunologic factors and with the advent of potent immunosuppressive agents, the last several decades have seen significantly improved kidney allograft survival. However, despite overall improved short to medium-term allograft survival, long-term allograft outcomes remain unsatisfactory. A large body of literature implicates acute and chronic rejection as independent risk factors for graft loss. In this article, we review measures taken at various stages in the kidney transplant process to minimize the risk of rejection. In the pre-transplant phase, it is imperative to minimize the risk of sensitization, aim for better HLA matching including eplet matching and use desensitization in carefully selected high-risk patients. The peri-transplant phase involves strategies to minimize cold ischemia times, individualize induction immunosuppression and make all efforts for better HLA matching. In the post-transplant phase, the focus should move towards individualizing maintenance immunosuppression and using innovative strategies to increase compliance. Acute rejection episodes are risk factors for significant graft injury and development of chronic rejection thus one should strive for early detection and aggressive treatment. Monitoring for DSA development, especially in high-risk populations, should be made part of transplant follow-up protocols. A host of new biomarkers are now commercially available, and these should be used for early detection of rejection, immunosuppression modulation, prevention of unnecessary biopsies and monitoring response to rejection treatment. There is a strong push needed for the development of new drugs, especially for the management of chronic or resistant rejections, to prolong graft survival. Prevention of rejection is key for the longevity of kidney allografts. This requires a multipronged approach and significant effort on the part of the recipients and transplant centers.
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Affiliation(s)
- Divyanshu Malhotra
- Johns Hopkins Medicine, Johns Hopkins Comprehensive Transplant Center, Baltimore, MD 21287, USA
| | - Priyanka Jethwani
- Methodist Transplant Institute, University of Tennessee Health Science Center, Knoxville, TN 37996, USA;
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18
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Kim DG, Cho DH, Kim K, Kim SH, Lee J, Huh KH, Kim MS, Kang DR, Yang JW, Han BG, Lee JY. Survival Benefit of Kidney Transplantation in Patients With End-Stage Kidney Disease and Prior Acute Myocardial Infarction. Transpl Int 2023; 36:11491. [PMID: 37692454 PMCID: PMC10483068 DOI: 10.3389/ti.2023.11491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/04/2023] [Indexed: 09/12/2023]
Abstract
Patients with end stage kidney disease (ESKD) and a previous acute myocardial infarction (AMI) have less access to KT. Data on ESKD patients with an AMI history who underwent first KT or dialysis between January 2007 and December 2018 were extracted from the Korean National Health Insurance Service. Patients who underwent KT (n = 423) were chronologically matched in a 1:3 ratio with those maintained on dialysis (n = 1,269) at the corresponding dates, based on time-conditional propensity scores. The 1, 5, and 10 years cumulative incidences for all-cause mortality were 12.6%, 39.1%, and 60.1% in the dialysis group and 3.1%, 7.2%, and 14.5% in the KT group. Adjusted hazard ratios (HRs) of KT versus dialysis were 0.17 (95% confidence interval [CI], 0.12-0.24; p < 0.001) for mortality and 0.38 (95% CI, 0.23-0.51; p < 0.001) for major adverse cardiovascular events (MACE). Of the MACE components, KT was most protective against cardiovascular death (HR, 0.23; 95% CI, 0.12-0.42; p < 0.001). Protective effects of KT for all-cause mortality and MACE were consistent across various subgroups, including patients at higher risk (e.g., age >65 years, recent AMI [<6 months], congestive heart failure). KT is associated with lower all-cause mortality and MACE than maintenance dialysis patients with a prior AMI.
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Affiliation(s)
- Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Department of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Kihyun Kim
- Department of Cardiology, Gangneung Dong-in Hospital, Gangneung, Republic of Korea
| | - Sung Hwa Kim
- National Health Big Data Clinical Research Institute, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Ryong Kang
- National Health Big Data Clinical Research Institute, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byoung Geun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jun Young Lee
- National Health Big Data Clinical Research Institute, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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19
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Bureau C, Rafat C, Taupin JL, Malard S, Mesnard L, François H, Petit-Hoang C, Ouali N, Hertig A, Jamme M, Buob D, Rondeau E, Galichon P, Luque Y. Immunoadsorption-Based HLA Desensitization in Patients Awaiting Deceased Donor Kidney Transplantation: An Interventional, Non-Randomised, Single Cohort Study. Transpl Int 2023; 36:11212. [PMID: 37680645 PMCID: PMC10481532 DOI: 10.3389/ti.2023.11212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
Abstract
Whether immunoadsorption (IADS) as part of desensitization protocols could facilitate deceased donor kidney transplantation (KT) in highly sensitized (HS) patients remains to be proven. We retrospectively analyzed our IADS based desensitization protocol for deceased donor KTs between 2013 and 2018. Fifteen HS patients (age 52 years [40-56]) were included. Waiting time before IADS was 6 years [5-10] and the interval between IADS initiation and KT was 5 months [1-12] for the 14 transplanted patients. Nine patients had prior KT. Calculated panel reactive antibody decreased significantly during the protocol (99.3% [92.5-99.9] vs. 79.4% [56.7-81.9]; p = 0.004). Death-censored graft survival was 85.7% at 1 and 2 years post-transplantation. One-year median plasma creatinine level was 135 µmol/L [111-202]. Six developed active antibody mediated rejection (ABMR) at 1 year, with a median delay of 13 days [11-26]. Eight patients developed severe infections, including two fatal outcomes. Finally, compared to 93% of patients who received desensitization receiving a KT, only 43% of a control with similar characteristics underwent transplantation. However, no difference was found in overall probability of being alive with a functioning graft at the end of follow-up. The results indicate that our IADS-based desensitization strategy was not effective due to a high rate of ABMR and severe infectious complications which pose a challenge to its universalization.
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Affiliation(s)
- Côme Bureau
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Cédric Rafat
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Jean Luc Taupin
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d’Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Stéphanie Malard
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d’Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Laurent Mesnard
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Hélène François
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Camille Petit-Hoang
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Nacera Ouali
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Alexandre Hertig
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Matthieu Jamme
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - David Buob
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service d’Anatomie et Cytologie Pathologiques, Hôpital Tenon, Paris, France
| | - Eric Rondeau
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Pierre Galichon
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Yosu Luque
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
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20
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Motter JD, Massie AB, Garonzik-Wang JM, Pfeiffer RM, Yu KJ, Segev DL, Engels EA. Cancer Risk Following HLA-Incompatible Living Donor Kidney Transplantation. Transplant Direct 2023; 9:e1505. [PMID: 37492080 PMCID: PMC10365202 DOI: 10.1097/txd.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 07/27/2023] Open
Abstract
Incompatible living donor kidney transplant recipients (ILDKTr) require desensitization to facilitate transplantation, and this substantial upfront immunosuppression may result in serious complications, including cancer. Methods To characterize cancer risk in ILDKTr, we evaluated 858 ILDKTr and 12 239 compatible living donor kidney transplant recipients (CLDKTr) from a multicenter cohort with linkage to the US transplant registry and 33 cancer registries (1997-2016). Cancer incidence was compared using weighted Cox regression. Results Among ILDKTr, the median follow-up time was 6.7 y (maximum 16.1 y) for invasive cancers (ascertained via cancer registry linkage) and 5.0 y (maximum 16.1 y) for basal and squamous cell carcinomas (ascertained via the transplant registry and censored for transplant center loss to follow-up). Invasive cancers occurred in 53 ILDKTr (6.2%) and 811 CLDKTr (6.6%; weighted hazard ratio [wHR] 1.01; 95% confidence interval [CI], 0.76-1.35). Basal and squamous cell carcinomas occurred in 41 ILDKTr (4.8%) and 737 CLDKTr (6.0%) (wHR 0.99; 95% CI, 0.69-1.40). Cancer risk did not vary according to donor-specific antibody strength, and in an exploratory analysis, was similar between CLDKTr and ILDKTr for most cancer types and according to cancer stage, except ILDKTr had a suggestively increased risk of colorectal cancer (wHR 3.27; 95% CI, 1.23-8.71); however, this elevation was not significant after correction for multiple comparisons. Conclusions These findings indicate that the risk of cancer is not increased for ILDKTr compared with CLDKTr. The possible elevation in colorectal cancer risk is unexplained and might suggest a need for tailored screening or prevention.
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Affiliation(s)
- Jennifer D. Motter
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Allan B. Massie
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | | | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Kelly J. Yu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
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21
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Betjes MGH, De Weerd A. Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and clinical dots. Front Med (Lausanne) 2023; 10:1215167. [PMID: 37502354 PMCID: PMC10368955 DOI: 10.3389/fmed.2023.1215167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
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22
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Couzi L, Malvezzi P, Amrouche L, Anglicheau D, Blancho G, Caillard S, Freist M, Guidicelli GL, Kamar N, Lefaucheur C, Mariat C, Koenig A, Noble J, Thaunat O, Thierry A, Taupin JL, Bertrand D. Imlifidase for Kidney Transplantation of Highly Sensitized Patients With a Positive Crossmatch: The French Consensus Guidelines. Transpl Int 2023; 36:11244. [PMID: 37448448 PMCID: PMC10336835 DOI: 10.3389/ti.2023.11244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023]
Abstract
Imlifidase recently received early access authorization for highly sensitized adult kidney transplant candidates with a positive crossmatch against an ABO-compatible deceased donor. These French consensus guidelines have been generated by an expert working group, in order to homogenize patient selection, associated treatments and follow-up. This initiative is part of an international effort to analyze properly the benefits and tolerance of this new costly treatment in real-life. Eligible patients must meet the following screening criteria: cPRA ≥ 98%, ≤ 65-year of age, ≥ 3 years on the waiting list, and a low risk of biopsy-related complications. The final decision to use Imlifidase will be based on the two following criteria. First, the results of a virtual crossmatch on recent serum, which shall show a MFI for the immunodominant donor-specific antibodies (DSA) > 6,000 but the value of which does not exceed 5,000 after 1:10 dilution. Second, the post-Imlifidase complement-dependent cytotoxicity crossmatch must be negative. Patients treated with Imlifidase will receive an immunosuppressive regimen based on steroids, rATG, high dose IVIg, rituximab, tacrolimus and mycophenolic acid. Frequent post-transplant testing for DSA and systematic surveillance kidney biopsies are highly recommended to monitor post-transplant DSA rebound and subclinical rejection.
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Affiliation(s)
- Lionel Couzi
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- CNRS-UMR 5164 Immuno ConcEpT, Université de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | | | - Gilles Blancho
- Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | | | - Marine Freist
- Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | | | - Nassim Kamar
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Christophe Mariat
- Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Saint-Etienne, France
| | | | - Johan Noble
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | - Antoine Thierry
- Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
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23
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de Klerk M, Kal-van Gestel JA, Roelen D, Betjes MGH, de Weerd AE, Reinders MEJ, van de Wetering J, Kho MML, Glorie K, Roodnat JI. Increasing Kidney-Exchange Options Within the Existing Living Donor Pool With CIAT: A Pilot Implementation Study. Transpl Int 2023; 36:11112. [PMID: 37342179 PMCID: PMC10278123 DOI: 10.3389/ti.2023.11112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/16/2023] [Indexed: 06/22/2023]
Abstract
Computerized integration of alternative transplantation programs (CIAT) is a kidney-exchange program that allows AB0- and/or HLA-incompatible allocation to difficult-to-match patients, thereby increasing their chances. Altruistic donors make this available for waiting list patients as well. Strict criteria were defined for selected highly-immunized (sHI) and long waiting (LW) candidates. For LW patients AB0i allocation was allowed. sHI patients were given priority and AB0i and/or CDC cross-match negative HLAi allocations were allowed. A local pilot was established between 2017 and 2022. CIAT results were assessed against all other transplant programs available. In the period studied there were 131 incompatible couples; CIAT transplanted the highest number of couples (35%), compared to the other programs. There were 55 sHI patients; CIAT transplanted as many sHI patients as the Acceptable Mismatch program (18%); Other programs contributed less. There were 69 LW patients; 53% received deceased donor transplantations, 20% were transplanted via CIAT. In total, 72 CIAT transplants were performed: 66 compatible, 5 AB0i and 1 both AB0i and HLAi. CIAT increased opportunities for difficult-to-match patients, not by increasing pool size, but through prioritization and allowing AB0i and "low risk" HLAi allocation. CIAT is a powerful addition to the limited number of programs available for difficult-to-match patients.
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Affiliation(s)
- Marry de Klerk
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Judith A. Kal-van Gestel
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Dave Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Michiel G. H. Betjes
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Annelies E. de Weerd
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Marlies E. J. Reinders
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Marcia M. L. Kho
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Joke I. Roodnat
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
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24
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Wilson N, Reese S, Ptak L, Aziz F, Parajuli S, Jucaud V, Denham S, Mishra A, Cascalho M, Platt JL, Hematti P, Djamali A. Ixazomib for Desensitization (IXADES) in Highly Sensitized Kidney Transplant Candidates: A Phase II Clinical Trial. KIDNEY360 2023; 4:e796-e808. [PMID: 36951387 PMCID: PMC10371382 DOI: 10.34067/kid.0000000000000113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Key Points Ixazomib treatment resulted in decreases in B-cell subsets and bone marrow lymphocytes. Ixazomib treatment resulted in modest decreases in certain anti-HLA antibody specificities. Ixazomib treatment was tolerated, with modest adverse events. Background Ixazomib is a second-generation oral proteasome inhibitor approved for treatment of refractory multiple myeloma. We conducted an open-label phase II trial, IXAzomib for DESensitization (IXADES), testing the safety of ixazomib treatment as an approach to decreasing the level and diversity of specificities of anti-HLA antibodies in subjects awaiting kidney transplantation. The trial (NCT03213158 ) enrolled highly sensitized kidney transplant candidates, defined as subjects with calculated panel reactive antibodies (cPRA) >80%, awaiting kidney transplantation >24 months. The subjects were treated with 12 monthly cycles of ixazomib 3 mg+dexamethasone 20 mg. Efficacy was defined as a decrease of cPRA >20% or kidney transplantation. The safety end point was tolerability. Methods In ten enrolled subjects, no grade IV, five grade III, 11 grade II, and 43 grade I adverse events were noted. The adverse events included infection, transient paresthesia, nausea, vomiting, and diarrhea. The IXADES regimen was not associated with significant change in levels or diversity of anti-HLA antibodies (cPRA). Results Although the IXADES regimen did not exhibit a clear impact on levels and diversity of anti-HLA antibodies in this small cohort, the prolonged half-life of IgG could necessitate a longer duration of treatment for accurate evaluation of efficacy. Conclusions In conclusion, treatment with ixazomib/dexamethasone engendered mild-to-moderate toxicity. The impact on anti-HLA was modest and paradoxical in the case of anti-HLA-DR. Clinical trials combining ixazomib with other immunosuppressive agents may be more effective in addressing antibody-mediated processes in kidney transplantation.
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Affiliation(s)
- Nancy Wilson
- Department of Pathology and Laboratory Medicine, AVRL, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shannon Reese
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lucy Ptak
- Department of Administration, Division of Clinical Trials, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Fahad Aziz
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | | | | | - Ameet Mishra
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Marilia Cascalho
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey L. Platt
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Peiman Hematti
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, Maine
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25
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Manook M, Olaso D, Anwar IJ, Yoon J, Delaura I, Bae Y, Moris D, Shaw B, Song M, Farris AB, Jackson A, Kwun J, Knechtle S. Desensitization and belatacept-based maintenance therapy in pregnancy-sensitized monkeys receiving a kidney transplant. SCIENCE ADVANCES 2023; 9:eadg1448. [PMID: 37205758 PMCID: PMC10198638 DOI: 10.1126/sciadv.adg1448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
Among sensitized patients awaiting a transplant, females are disproportionately represented, partly because of pregnancy-induced sensitization. Using female NHPs sensitized by pregnancy alone, we examined the efficacy of costimulation blockade and proteasome inhibition for desensitization. Three animals received no desensitization (control), and seven animals received weekly carfilzomib (27 mg/m2) and belatacept (20 mg/kg) before kidney transplantation. All animals received renal allografts from crossmatch-positive/maximally MHC-mismatched donors. Controls and three desensitized animals received tacrolimus-based immunosuppression. Four desensitized animals received additional belatacept with tacrolimus-based immunosuppression. Multiparous females had less circulating donor-specific antibody when compared to skin-sensitized males before transplantation. While females receiving desensitization showed only a marginal survival benefit over control females (MST = 11 days versus 63 days), additional belatacept to posttransplant maintenance significantly prolonged graft survival (MST > 164 days) and suppressed posttransplant DSA and circulating follicular helper T-like cells. This combination of therapies demonstrates great potential to reduce antibody-mediated rejection in sensitized recipients.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Isabel Delaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Annette Jackson
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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26
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Mohamadou I, Matignon M, Malard S, Lombardi Y, Buob D, Moktefi A, Jamme M, Ouali N, Rafat C, François H, Petit-Hoang C, Rondeau E, Mesnard L, Grimbert P, Taupin JL, Luque Y. Additional Benefits of Rituximab and Plasma Exchange on Top of Standard Induction Therapy in Kidney Transplant Recipients With a Negative CDC Crossmatch but High Preformed Donor Specific Antibody Titer. Transpl Int 2023; 36:10844. [PMID: 37056357 PMCID: PMC10088221 DOI: 10.3389/ti.2023.10844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
Optimal induction strategy in highly sensitized kidney transplant recipients (KTRs) is still a matter of debate. The place of therapies, such as plasma exchange and rituximab, with potential side effects and high cost, is not clearly established. We compared two induction strategies with (intensive) or without (standard) rituximab and plasma exchange in KTRs with high levels of preformed DSA transplanted between 2012 and 2019. Sixty KTRs with a mean age of 52.2 ± 12.2 years were included, 36 receiving standard and 24 intensive induction. Mean fluorescence intensity of immunodominant DSA in the cohort was 8,903 ± 5,469 pre-transplantation and similar in both groups. DSA level decrease was similar at 3 and 12 months after transplantation in the two groups. An intensive induction strategy was not associated with better graft or patient survival, nor more infectious complications. The proportion of patients with rejection during the first year was similar (33% in each group), but rejection occurred later in the intensive group (211 ± 188 days, vs. 79 ± 158 days in the standard group, p < 0.01). Our study suggests that an intensive induction therapy including rituximab and plasma exchanges in highly sensitized kidney recipients is not associated with better graft survival but may delay biopsy-proven rejection.
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Affiliation(s)
- Inna Mohamadou
- Service de Transplantation Rénale, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris, Paris, France
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- *Correspondence: Inna Mohamadou,
| | - Marie Matignon
- Service de Néphrologie, Hôpitaux Universitaires Henri Mondor, Créteil, France
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Stéphanie Malard
- Laboratoire d’Immunologie et d’Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | - Yannis Lombardi
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - David Buob
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Anatomie Pathologique, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Pairs, France
| | - Anissa Moktefi
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
- Département de Pathologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique – Hôpitaux de Paris, Créteil, France
| | - Matthieu Jamme
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Nacera Ouali
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Cedric Rafat
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Hélène François
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Camille Petit-Hoang
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Laurent Mesnard
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Philippe Grimbert
- Service de Néphrologie, Hôpitaux Universitaires Henri Mondor, Créteil, France
- INSERM U955 Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Jean-Luc Taupin
- Laboratoire d’Immunologie et d’Histocompatibilité, Hôpital Saint-Louis, Paris, France
| | - Yosu Luque
- Sorbonne Université, Paris, France
- INSERM U1155 Des Maladies Rénales Rares Aux Maladies Fréquentes, Remodelage Et Réparation, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
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Kim I, Maggiore U, Knight SR, Rana Magar R, Pengel LHM, Dor FJMF. Pre-emptive living donor kidney transplantation: A public health justification to change the default. Front Public Health 2023; 11:1124453. [PMID: 37006536 PMCID: PMC10063978 DOI: 10.3389/fpubh.2023.1124453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/28/2023] [Indexed: 03/19/2023] Open
Affiliation(s)
- Isaac Kim
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, Unità Operativa Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Simon R. Knight
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Reshma Rana Magar
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Liset H. M. Pengel
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- *Correspondence: Frank J. M. F. Dor
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Karydis N, Maroulis I. Changing landscape in living kidney donation in Greece. World J Transplant 2023; 13:28-35. [PMID: 36908308 PMCID: PMC9993187 DOI: 10.5500/wjt.v13.i2.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/05/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
Patients with end-stage renal disease in Greece are facing long waiting times to receive a kidney transplant from a deceased donor. Living kidney donation offers a valuable alternative that provides optimal outcomes and significantly expands the donor pool but still remains relatively underutilised. Developments around the world in the field of kidney transplantation mandate a change in current practice to include additional options for living donation through paired exchange, antibody-incompatible transplantation and other strategies, following careful consideration of the cultural and ethical factors involved in these complex clinical decisions. An increase in living donation rates may be achieved in several ways, including targeted campaigning to overcome potential barriers. Educating clinicians on transplantation will prove as equally important as informing patients and prospective donors but requires training and resources. Adoption of established practices and implementation of new strategies must be tailored to the needs of the Greek donor and recipient population. Local beliefs about donation, perception of associated risk and other social characteristics must be considered in the design of future strategies. Facilitating living donation in a safe environment with appropriate donor and recipient education will form the solid foundation of a new era of kidney transplantation in Greece.
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Affiliation(s)
- Nikolaos Karydis
- Department of General Surgery and Transplantation, University of Patras, Patras 26504, Greece
| | - Ioannis Maroulis
- Department of General Surgery, University of Patras, Patras 26504, Greece
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Rostaing L, Noble J, Malvezzi P, Jouve T. Imlifidase therapy: exploring its clinical uses. Expert Opin Pharmacother 2023; 24:259-265. [PMID: 36404277 DOI: 10.1080/14656566.2022.2150965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Imlifidase, the IgG-degrading enzyme derived from Streptococcus pyogenes, can cleave all four human IgG subclasses with precise specificity. All IgG molecules can be inactivated for ~1-to-2 weeks, until new IgG synthesis is detected. AREAS COVERED Imlifidase was first studied for the desensitization of highly HLA-sensitized patients to enable kidney transplantation. It is currently being evaluated for kidney transplant recipients who have antibody-mediated rejection (AMR), those with acute kidney injury in the setting of anti-glomerular basement membrane disease, and those with Guillain-Barré syndrome. In 2020, imlifidase received conditional approval from the European Medicines Agency for use to desensitize deceased-donor kidney transplant recipients with a positive crossmatch. Literature search through PubMed revealed that so far, 39 crossmatched-positive patients, i.e. in the presence of donor-specific alloantibodies (DSA) on the transplantation day, have received imlifidase prior to kidney transplantation in four single-arm, open-label, phase II studies. Results at 3-year follow-up are good, i.e. allograft survival is 84%, despite 38% of patients presenting with acute AMR. Mean estimated glomerular filtration rate at 3 years was 55 mL/min/1.73 m2. EXPERT OPINION The major hurdle now is how to prevent/avoid DSA rebound within days 5-15 post-transplantation. Thus, imlifidase represents a major breakthrough for highly HLA-sensitized kidney transplant candidates, particularly those that have calculated panel-reactive alloantibodies of ≥90%.
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Affiliation(s)
- Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France.,School of Medicine, University Grenoble Alpes, Grenoble, France.,Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France.,School of Medicine, University Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France.,School of Medicine, University Grenoble Alpes, Grenoble, France
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Tramper T, Roelen DL, Brand-Schaaf SH, Kal-van Gestel JA, Kho MML, Reinders MEJ, Roodnat JI, van de Wetering J, Betjes MGH, de Weerd AE. The detrimental effect of donor-specific antibodies is irrespective of its level in highly-immunized living donor kidney transplant recipients: A case-control series. Front Immunol 2023; 13:1093359. [PMID: 36703958 PMCID: PMC9873371 DOI: 10.3389/fimmu.2022.1093359] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background The impact of donor-specific antibodies (DSA) in (highly-) immunized living donor kidney transplant recipients is reported differentially in various patient cohorts. Methods We have performed a retrospective analysis of all consecutive HLA-incompatible living donor kidney transplant recipients in our center between 2010-2019. Recipients who underwent plasmafiltration for a positive CDC-crossmatch were excluded. For each DSA+ recipient (DSA+), one immunized recipient without DSA (pPRA+) and two non-immunized recipients (pPRA-) were included. Patient and graft survival were analyzed and a subgroup analysis of DSA+ recipients was performed. Results For 63 DSA+ recipients, 63 PRA+ and 126 PRA- recipients were included. 26 (41%) had class I, 24 (38%) class II and 13 (21%) combined HLA class I and II DSA. Death-censored graft survival was inferior in DSA+ recipients compared to pPRA+ (HR 2.38 [95% CI 1.00-5.70]) as well as to pPRA- (HR 3.91 [1.86-8.22]). In multivariate analysis, DSA remained of negative influence on death-censored graft survival. Flowcytometric crossmatch, MFI value, HLA class and origin of DSA were not of significant impact. Conclusion In our cohort of (highly-) immunized recipients, pretransplant DSA led to inferior death-censored graft survival. There were no "safe" DSA characteristics since only DSA per se impacted death-censored graft survival.
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Affiliation(s)
- T. Tramper
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - D. L. Roelen
- HLA Laboratory, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - S. H. Brand-Schaaf
- HLA Laboratory, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - J. A. Kal-van Gestel
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. M. L. Kho
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. E. J. Reinders
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - J. I. Roodnat
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - J. van de Wetering
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M. G. H. Betjes
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A. E. de Weerd
- Erasmus Medical Center Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands,*Correspondence: A. E. de Weerd,
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Chang H, Veith FJ, Laskowski I, Maldonado TS, Butler JR, Jacobowitz GR, Rockman CB, Zeeshan M, Ventarola DJ, Cayne NS, Lui A, Mateo R, Babu S, Goyal A, Garg K. Renal transplant recipients undergoing endovascular abdominal aortic aneurysm repair have increased risk of perioperative acute kidney injury but no difference in late mortality. J Vasc Surg 2023; 77:1396-1404.e3. [PMID: 36626957 DOI: 10.1016/j.jvs.2022.12.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR. METHODS The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes. RESULTS Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235). CONCLUSIONS Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.
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Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Igor Laskowski
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Jonathan R Butler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Muhammad Zeeshan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Daniel J Ventarola
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Aiden Lui
- New York Medical College, Valhalla, NY
| | - Romeo Mateo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sateesh Babu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Arun Goyal
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
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Jouve T, Daligault M, Noble J, Terrec F, Imerzoukene F, Dard C, Bardy B, Malvezzi P, Rostaing L. Tocilizumab Evaluation in HLA-Desensitization before Kidney Transplantation as an Add-On Therapy to Apheresis: The TETRA Study. J Clin Med 2023; 12:jcm12020424. [PMID: 36675353 PMCID: PMC9866000 DOI: 10.3390/jcm12020424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Desensitization strategies improve access to transplantation in highly sensitized kidney transplant candidates. Tocilizumab could be a valuable addition to more traditional desensitization regimens. We investigated the effect of tocilizumab as an add-on therapy to our standard of care (SoC) desensitization strategy based on rituximab and apheresis. METHODS In this study, we prospectively included highly sensitized patients to receive monthly tocilizumab infusions for 6 months before our SoC regimen (Toci + SoC group). We compared the reductions in the mean fluorescent intensity (MFI) rebound at post-transplantation and kidney function at 1-year post-transplantation to patients treated by SoC (based on apheresis and two doses of rituximab). RESULTS Twenty-six patients were included in the SoC group; seven in the Toci + SoC group. Reductions in pre-transplantation MFI were similar between groups. At 1-year post-transplantation, there was no absolute difference in overall MFI rebounds, including donor-specific antibodies. Toci + SoC helped lower the rebound of antibodies with more elevated baseline MFIs. Graft function and survival rates were similar at one-year post-transplantation (median eGFR 62.8 vs. 65.6 mL/min/1.73 m2 for SoC and Toci + SoC, respectively). CONCLUSIONS Tocilizumab as an add-on to SoC desensitization may help control the post-transplantation rebound of antibodies with elevated baseline MFIs. However, reductions in pre-transplantation MFIs were similar with or without tocilizumab. Further studies are needed to validate this pilot study.
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Affiliation(s)
- Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38400 Grenoble, France
- Faculty of Health, Université Grenoble Alpes, 38400 Saint-Martin-d’Hères, France
- Correspondence:
| | - Mélanie Daligault
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38400 Grenoble, France
| | - Florian Terrec
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - Farida Imerzoukene
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - Céline Dard
- Etablissement Français du Sang (EFS) Rhône Alpes, 38700 La Tronche, France
| | - Béatrice Bardy
- Etablissement Français du Sang (EFS) Rhône Alpes, 38700 La Tronche, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, 38043 Grenoble, France
- Faculty of Health, Université Grenoble Alpes, 38400 Saint-Martin-d’Hères, France
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Llinàs-Mallol L, Raïch-Regué D, Pascual J, Crespo M. Alloimmune risk assessment for antibody-mediated rejection in kidney transplantation: A practical proposal. Transplant Rev (Orlando) 2023; 37:100745. [PMID: 36572001 DOI: 10.1016/j.trre.2022.100745] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
Kidney transplantation is the treatment of choice for patients with end-stage renal disease. Although an improvement in graft survival has been observed in the last decades with the use of different immunosuppressive drugs, this is still limited in time with antibody-mediated rejection being a main cause of graft-loss. Immune monitoring and risk assessment of antibody-mediated rejection before and after kidney transplantation with useful biomarkers is key to tailoring treatments to achieve the best outcomes. Here, we provide a review of the rationale and several accessible tools for immune monitoring, from the most classic to the modern ones. Finally, we end up discussing a practical proposal for alloimmune risk assessment in kidney transplantation, including histocompatibility leukocyte antigen (HLA) and non-HLA antibodies, HLA molecular mismatch analysis and characterization of peripheral blood immune cells.
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Affiliation(s)
- Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Dàlia Raïch-Regué
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Julio Pascual
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Updated management for antibody-mediated rejection: opportunity to prolong kidney allograft survival. Curr Opin Nephrol Hypertens 2023; 32:13-19. [PMID: 36250450 DOI: 10.1097/mnh.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (ABMR) is an important barrier to achieve long-term kidney allograft survival. Human leukocyte antibody (HLA)-incompatibility and ABO-incompatibility are the two main mechanisms of ABMR. Nevertheless, the advances in managing ABMR have changed the paradigm for kidney transplantation. This review aimed to emphasize the HLA-incompatibility and ABO-incompatibility kidney transplant and update the management of ABMR. RECENT FINDINGS HLA-incompatibility kidney transplantation is a strong risk factor for ABMR. Donor-specific antibody (DSA) is a surrogate biomarker that prevents long-term allograft survival. The standard treatment for ABMR has unfavorable results. New drugs that target the B cell are a promising approach to treat ABMR. In the past, ABO-incompatibility kidney donor was an absolute contraindication but now, it is widely accepted as an alternative organ resource. The advancement of ABO antibody removal and B-cell depletion therapy has been successfully developed. ABO isoagglutination remains the main biomarker for monitoring ABMR during the transplantation process. C4d staining without inflammation of the kidney allograft is the marker for the accommodation process. SUMMARY With the shortage of organ donors, transplant experts have expanded the organ resources and learned how to overcome the immunological barriers by using novel biomarkers and developing new treatments that support long-term graft survival.
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Anwar IJ, Ezekian B, DeLaura I, Manook M, Schroder P, Yoon J, Curfman V, Branum E, Messina J, Harnois M, Permar SR, Farris AB, Kwun J, Knechtle SJ. Addition of interleukin-6 receptor blockade to carfilzomib-based desensitization in a highly sensitized nonhuman primate model. Am J Transplant 2022; 22 Suppl 4:1-11. [PMID: 36239200 PMCID: PMC9722597 DOI: 10.1111/ajt.17208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Sensitized patients, those who had prior exposure to foreign human leukocyte antigens, are transplanted at lower rates due to challenges in finding suitable organs. Desensitization strategies have permitted highly sensitized patients to undergo kidney transplantation, albeit with higher rates of rejection. This study assesses targeting plasma cell and interleukin (IL)-6 receptor for desensitization in a sensitized nonhuman primate kidney transplantation model. All animals were sensitized using two sequential skin transplants from maximally major histocompatibility complex-mismatched donors. Carfilzomib (CFZ)/tocilizumab (TCZ) desensitization (N = 6) successfully decreased donor-specific antibody (DSA) titers and prevented the expansion of B cells compared to CFZ monotherapy (N = 3). Dual desensitization further delayed, but did not prevent humoral rebound, as evidenced by a delayed increase in post-kidney transplant DSA titers. Accordingly, CFZ/TCZ desensitization conferred a significant survival advantage over CFZ monotherapy. A trend toward increased T follicular helper cells was also observed in the dual therapy group along the same timeline as an increase in DSA and subsequent graft loss. Cytomegalovirus reactivation also occurred in the CFZ/TCZ group but was prevented with ganciclovir prophylaxis. In accordance with prior studies of CFZ-based dual desensitization strategies, the addition of IL-6 receptor blockade resulted in desensitization with further suppression of posttransplant humoral response compared to CFZ monotherapy.
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Affiliation(s)
- Imran J Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Brian Ezekian
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Paul Schroder
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Verna Curfman
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Evelyn Branum
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Julia Messina
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Melissa Harnois
- Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710
| | - Sallie R. Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
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Weinhard J, Noble J, Jouve T, Malvezzi P, Rostaing L. [Improving access to kidney transplantation for highly sensitized patients: What place for IL-6 pathway blockade in desensitization protocols?]. Nephrol Ther 2022; 18:577-583. [PMID: 36328901 DOI: 10.1016/j.nephro.2022.07.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 05/19/2022] [Accepted: 07/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Desensitization allows kidney transplantation for HLA highly sensitized subjects. Due to the central role of IL-6 in immunological response, tocilizumab (monoclonal antibody directed against IL-6 receptor) could probably improve desensitization efficacy. METHODS Pubmed systematic review by using MeSH terms: tocilizumab, clazakizumab, interleukin-6 blockade, kidney transplantation, kidney graft and desensitization. STUDIES IL-6 plays a role in humoral response (plasmocyte differentiation induced by lymphocyte T, IL-21 secretion) as well as in cellular response (differentiation of LT Th17 rather than T reg). In desensitization field, tocilizumab was first studied as second-line treatment after failing of standard-of-care (apheresis, rituximab ± IgIV). Recent study showed that tocilizumab as a monotherapy attenuated anti-HLA antibodies rates but was not sufficient to allow transplantation. However, lymphocyte immunophenotyping showed that tocilizumab hindered B cells maturation. Thereby, tocilizumab could improve long-term efficacy of desensitization, by limiting the anti-HLA rebound and so avoiding antibody-mediated rejection. This hypothesis is supported by a recent study which used clazakizumab (monoclonal antibody directed against IL-6) in association with standard-of-care. In that study, clazakizumab was continued after kidney transplantation. Results were encouraging because 9/10 patients were transplanted and there was no donor-specific antibody at 6 months post-transplantation. CONCLUSION IL-6 pathway blockade as a monotherapy fails to desensitize HLA highly sensitized kidney transplant candidates. In association with standard-of-care, it does not seem to significatively improve kidney allograft access (short-term efficacy) vs. standard-of-care only. However, it could improve long-term prognosis of HLA incompatible transplantation by orienting the response towards a tolerogenic profile, by hindering B-cell maturation and, thereby, avoiding DSA rebounds after transplantation. This hypothesis needs to be proven by further studies.
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Affiliation(s)
- Jules Weinhard
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Johan Noble
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Thomas Jouve
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France; Université Grenoble-Alpes, GrenobleFrance
| | - Paolo Malvezzi
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de néphrologie, hémodialyse, aphérèses et transplantation rénale, CHU de Grenoble-Alpes, Grenoble, France; Université Grenoble-Alpes, GrenobleFrance.
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Killian AC, Reed RD, McLeod MC, MacLennan PA, Kumar V, Pittman SE, Maynor AG, Stanford LA, Baker GA, Schinstock CA, Silkensen JR, Roll GR, Segev DL, Orandi BJ, Lewis CE, Locke JE. Diabetes-free survival among living kidney donors and non-donors with obesity: A longitudinal cohort study. PLoS One 2022; 17:e0276882. [PMID: 36399462 PMCID: PMC9674148 DOI: 10.1371/journal.pone.0276882] [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: 06/02/2022] [Accepted: 10/13/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Approval of living kidney donors (LKD) with end-stage kidney disease (ESKD) risk factors, such as obesity, has increased. While lifetime ESKD development data are lacking, the study of intermediate outcomes such as diabetes is critical for LKD safety. Donation-attributable diabetes risk among persons with obesity remains unknown. The purpose of this study was to evaluate 10-year diabetes-free survival among LKDs and non-donors with obesity. METHODS This longitudinal cohort study identified adult, LKDs (1976-2020) from 42 US transplant centers and non-donors from the Coronary Artery Risk Development in Young Adults (1985-1986) and the Atherosclerosis Risk in Communities (1987-1989) studies with body mass index ≥30 kg/m2. LKDs were matched to non-donors on baseline characteristics (age, sex, race, body mass index, systolic and diastolic blood pressure) plus diabetes-specific risk factors (family history of diabetes, impaired fasting glucose, smoking history). Accelerated failure time models were utilized to evaluate 10-year diabetes-free survival. FINDINGS Among 3464 participants, 1119 (32%) were LKDs and 2345 (68%) were non-donors. After matching on baseline characteristics plus diabetes-specific risk factors, 4% (7/165) LKDs and 9% (15/165) non-donors developed diabetes (median follow-up time 8.5 (IQR: 5.6-10.0) and 9.1 (IQR: 5.9-10.0) years, respectively). While not significant, LKDs were estimated to live diabetes-free 2 times longer than non-donors (estimate 1.91; 95% CI: 0.79-4.64, p = 0.15). CONCLUSIONS LKDs with obesity trended toward living longer diabetes-free than non-donors with obesity, suggesting within the decade following donation there was no increased diabetes risk among LKDs. Further work is needed to evaluate donation-attributable diabetes risk long-term.
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Affiliation(s)
- A. Cozette Killian
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - M. Chandler McLeod
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Paul A. MacLennan
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Sydney E. Pittman
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Andrew G. Maynor
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Luke A. Stanford
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Gavin A. Baker
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
| | - John R. Silkensen
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, United States of America
| | - Garrett R. Roll
- Division of Transplant, Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Babak J. Orandi
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Cora E. Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
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40
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Butani L, Tancredi D. Outcomes of living unrelated donor kidney transplants in children: An Organ Procurement and Transplant Network database analysis. Pediatr Transplant 2022; 26:e14368. [PMID: 35869899 DOI: 10.1111/petr.14368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are conflicting data on long-term outcomes of pediatric LURD renal Txs compared to Txs of kidneys from other donor sources. METHODS An analysis of the OPTN database was conducted in children (<18 years) who had received their 1st kidney-only Tx between January 1, 2000, and September 30, 2021. The primary outcome measure was time to graft failure or death. Cox event history regression model for time to primary outcome, categorized by donor source and adjusting for confounders was performed. RESULTS Of the 12 089 subjects, 327 (2.7%) received kidneys from LURDs, 4349 (36%) from LRDs and 7413 (61%) from DD. One year graft failure rate was 3.56%. On regression analyses, compared to LRD kidney recipients, LURD recipients had comparable graft survival (graft failure AHR 1.15, 95th percentile confidence interval 0.87-1.51; p .31) and DD recipients had lower graft survival (graft failure hazard ratio 1.26, 95th percentile confidence interval 1.10-1.43; p < .001). When using living unrelated kidney recipients as the reference group, DD kidney recipients had comparable graft survival, with a wide confidence interval (hazard ratio for graft failure 1.09; 0.83-1.43, p .53). CONCLUSIONS Pediatric LURD kidney recipients have comparable graft survival to LRD kidney recipients; DD kidney recipients had the poorest survival. Our study, the largest to date, should encourage centers to embrace non-commercial living-unrelated transplantation as a viable option for children, preferable to DD kidneys.
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Affiliation(s)
- Lavjay Butani
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California, USA
| | - Daniel Tancredi
- Department of Pediatrics and the Center for Healthcare Policy and Research, University of California Davis Medical Center, Sacramento, California, USA
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41
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Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:jcm11195753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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42
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Killian AC, Carter AJ, Reed RD, Shelton BA, Qu H, McLeod MC, Orandi BJ, Cannon RM, Anderson D, MacLennan PA, Kumar V, Hanaway M, Locke JE. Greater community vulnerability is associated with poor living donor navigator program fidelity. Surgery 2022; 172:997-1004. [PMID: 35831221 PMCID: PMC9633042 DOI: 10.1016/j.surg.2022.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Community-level factors contribute to living donor kidney transplantation disparities but may also influence the interventions aimed to mitigate these disparities. The Living Donor Navigator Program was designed to separate the advocacy role from the patient in need of transplantation-friends/family are encouraged to participate as the patients' advocates to identify living donors, though some of the patients participate alone as self-advocates. Self-advocates have a lower living donor kidney transplantation likelihood compared to the patients with an advocate. We sought to evaluate the relationship between the patients' community-level vulnerability and living donor navigator self-advocacy as a surrogate for program fidelity. METHODS This single-center, retrospective study included 110 Living Donor Navigator participants (April 2017-June 2019). Program fidelity was assessed using the participants' advocacy status. Measures of community vulnerability were obtained from the Centers for Disease Control and Prevention Social Vulnerability Index. Modified Poisson regression was used to evaluate the association between community-level vulnerability and living donor navigator self-advocacy. RESULTS Of the 110 participants, 19% (n = 21) were self-advocates. For every 10% increase in community-level vulnerability, patients had 17% higher risk of self-advocacy (adjusted relative risk 1.17, 95% confidence interval: 1.03-1.32, P = .01). Living in areas with greater unemployment (adjusted relative risk: 1.18, 95% confidence interval: 1.04-1.33, P = .01), single-parent households (adjusted relative risk: 1.23, 95% confidence interval: 1.06-1.42, P = .006), minority population (adjusted relative risk: 1.30, 95% confidence interval: 1.04-1.55, P = .02), or no-vehicle households (adjusted relative risk: 1.17, 95% confidence interval: 1.02-1.35, P = .02) were associated with increased risk of self-advocacy. CONCLUSION Having a greater community-level vulnerability was associated with poor Living Donor Navigator Program fidelity. The potential barriers identified using the Social Vulnerability Index may direct resource allocation and program refinement to optimize program fidelity and efficacy for all participants.
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Affiliation(s)
- A Cozette Killian
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/CozetteKale
| | - Alexis J Carter
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/carteraj21
| | - Rhiannon D Reed
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/rhiruns
| | - Brittany A Shelton
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Haiyan Qu
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - M Chandler McLeod
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Babak J Orandi
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Robert M Cannon
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Douglas Anderson
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Paul A MacLennan
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Vineeta Kumar
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Michael Hanaway
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Jayme E Locke
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL.
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Heo EJ, Hong S, Chun Y. Efficient use of immunosuppressants for kidney transplants. JOURNAL OF HEALTH ECONOMICS 2022; 85:102650. [PMID: 35810567 DOI: 10.1016/j.jhealeco.2022.102650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 06/15/2023]
Abstract
A recent development of immunosuppressive protocols (or simply, suppressants) offers a new option to patients suffering from end-stage renal disease: transplants from biologically incompatible donors. Suppressants are currently being used for direct transplants within patient-donor pairs, but they can be utilized more efficiently when combined with kidney exchanges. To assess the welfare gains from doing so, we introduce the "minimum chains algorithms" for different sizes of feasible exchanges. Using these algorithms, we calculate the minimal number of suppressants needed for transplants for a group of patient-donor pairs. Our simulation results show that (i) a significant reduction of suppressants can be achieved by implementing this proposal, (ii) it suffices to arrange 2-way exchanges for the best use of suppressants, and (iii) the welfare gain varies with the ABO blood-type distribution, and the gain in Korea appears to be larger than that in the United States. Finally, we assess the value (or cost) of each patient-donor pair by comparing the outcomes of the pools with and without the pair.
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Affiliation(s)
- Eun Jeong Heo
- Department of Economics, University of Seoul, Seoul 02504, South Korea.
| | - Sunghoon Hong
- Department of Science in Taxation, University of Seoul, Seoul 02504, South Korea.
| | - Youngsub Chun
- Department of Economics, Seoul National University, Seoul 08826, South Korea.
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Pierson RN, Allan JS, Cooper DK, D’Alessandro DA, Fishman JA, Kawai T, Lewis GD, Madsen JC, Markmann JF, Riella LV. Expert Opinion Special Feature: Patient Selection for Initial Clinical Trials of Pig Organ Transplantation. Transplantation 2022; 106:1720-1723. [PMID: 35761442 PMCID: PMC10124765 DOI: 10.1097/tp.0000000000004197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James S. Allan
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David K.C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David A. D’Alessandro
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jay A. Fishman
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory D. Lewis
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Joren C. Madsen
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James F. Markmann
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Mamode N, Bestard O, Claas F, Furian L, Griffin S, Legendre C, Pengel L, Naesens M. European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group. Transpl Int 2022; 35:10511. [PMID: 36033645 PMCID: PMC9399356 DOI: 10.3389/ti.2022.10511] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
This guideline, from a European Society of Organ Transplantation (ESOT) working group, concerns the management of kidney transplant patients with HLA antibodies. Sensitization should be defined using a virtual parameter such as calculated Reaction Frequency (cRF), which assesses HLA antibodies derived from the actual organ donor population. Highly sensitized patients should be prioritized in kidney allocation schemes and linking allocation schemes may increase opportunities. The use of the ENGAGE 5 ((Bestard et al., Transpl Int, 2021, 34: 1005–1018) system and online calculators for assessing risk is recommended. The Eurotransplant Acceptable Mismatch program should be extended. If strategies for finding a compatible kidney are very unlikely to yield a transplant, desensitization may be considered and should be performed with plasma exchange or immunoadsorption, supplemented with IViG and/or anti-CD20 antibody. Newer therapies, such as imlifidase, may offer alternatives. Few studies compare HLA incompatible transplantation with remaining on the waiting list, and comparisons of morbidity or quality of life do not exist. Kidney paired exchange programs (KEP) should be more widely used and should include unspecified and deceased donors, as well as compatible living donor pairs. The use of a KEP is preferred to desensitization, but highly sensitized patients should not be left on a KEP list indefinitely if the option of a direct incompatible transplant exists.
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Affiliation(s)
- Nizam Mamode
- Department of Transplantation, Guys Hospital, London, United Kingdom
- *Correspondence: Nizam Mamode,
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Frans Claas
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunology, University of Antwerp, Antwerp, Belgium
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical Gastroenterological and Oncological Sciences, University Hospital of Padua, Padua, Italy
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, United Kingdom
| | - Christophe Legendre
- Department of Nephrology and Adult Kidney Transplantation, Hôpital Necker and Université de Paris, Paris, France
| | - Liset Pengel
- Centre for Evidence in Transplantation, University of Oxford, Oxford, United Kingdom
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Firl DJ, Markmann JF. Measuring success in pig to non-human-primate renal xenotransplantation: Systematic review and comparative outcomes analysis of 1051 life-sustaining NHP renal allo- and xeno-transplants. Am J Transplant 2022; 22:1527-1536. [PMID: 35143091 DOI: 10.1111/ajt.16994] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/17/2022] [Accepted: 02/03/2022] [Indexed: 01/25/2023]
Abstract
Facile gene editing has accelerated progress in pig to non-human-primate (NHP) renal xenotransplantation, however, outcomes are considered inferior to NHP-allotransplantation. This systematic review and outcomes analysis of life-sustaining NHP-renal transplantation aimed to benchmark "preclinical success" and aggregated 1051 NHP-to-NHP or pig-to-NHP transplants across 88 articles. Although protocols varied, NHP-allotransplantation survival (1, 3, 12months, 67.5%, 37.1%, 13.2%) was significantly greater than NHP-xenotransplantation (1, 3, 12 months, 38.8%, 14.0%, 4.4%; p < .001); a difference partially mitigated by gene-edited donors containing at least knockout of alpha-1,3-galactosyltransferase (1, 3, 12 months, 47.1%, 24.2%, 7.6%; p < .001). Pathological analysis demonstrated more cellular rejection in allotransplantation (62.8% vs. 3.1%, p < .001) and more antibody-mediated rejection in xenotransplantation (6.8% vs. 45.5%, p < .001). Nonrejection causes of graft loss between allotransplants and xenotransplants differed; infection and animal welfare (1.7% vs. 11.2% and 3.9% vs. 17.0%, respectively, p < .001 for both). Importantly, even among a subgroup of unsensitized rhesus macaques under long-term immunosuppression, NHP-allotransplant survival was significantly inferior to clinical allotransplantation (6 months, 36.1% vs. 94.0%; p < .001), which suggests clinical outcomes with renal xenografts may be better than predicted by current preclinical data.
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Affiliation(s)
- Daniel J Firl
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Surgery, Duke University Hospital, Durham, North Carolina, USA
| | - James F Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Difficulties In Qualifying for Kidney Transplantation In a Highly Immunized Patient With Urinary Tract Defects. Transplant Proc 2022; 54:1152-1154. [DOI: 10.1016/j.transproceed.2022.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/09/2022] [Indexed: 11/18/2022]
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Huang E, Maldonado AQ, Kjellman C, Jordan SC. Imlifidase for the treatment of anti-HLA antibody-mediated processes in kidney transplantation. Am J Transplant 2022; 22:691-697. [PMID: 34467625 PMCID: PMC9293130 DOI: 10.1111/ajt.16828] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 01/25/2023]
Abstract
The IgG-degrading enzyme derived from Streptococcus pyogenes (Imlifidase, Hansa Biopharma) is a novel agent that cleaves all four human subclasses of IgG and has therapeutic potential for HLA desensitization in kidney transplantation and antibody-mediated rejection. Data from clinical trials in kidney transplantation demonstrated rapid degradation of anti-HLA donor-specific antibodies facilitating HLA-incompatible transplantation, which led to conditional approval of imlifidase by the European Medicines Agency for desensitization in kidney transplant recipients of a deceased donor with a positive cross match. Important considerations arising from the early experiences with imilfidase on kinetics of donor-specific antibodies after administration, timing of complementary therapeutic monoclonal or polyclonal IgG antibodies, and interference with cross match assays should be recognized as imlifidase emerges as a therapeutic agent for clinical transplantation.
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Affiliation(s)
- Edmund Huang
- Department of MedicineDivision of NephrologyTransplant Immunotherapy ProgramCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | | | - Stanley C. Jordan
- Department of MedicineDivision of NephrologyTransplant Immunotherapy ProgramCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
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The Effects of Different Induction Regimes on Serial Lymphocyte Subsets in Kidney Transplant Recipients: A Single Tertiary Center Experience. Transplant Proc 2022; 54:299-306. [PMID: 35181166 DOI: 10.1016/j.transproceed.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immunosuppressive therapy is the backbone of kidney transplantation in preventing acute rejection. T-cell depletion after doses of thymoglobulin is dose-dependent, as are their side effects. At the same time, basiliximab and other maintenance immunosuppressive drugs act at different signals on T lymphocytes. Therefore, studying the pattern of lymphocyte subset depletion depending on the induction regime given at transplantation could be an added tool in managing post-transplant recipients. METHODOLOGY This prospective observational study recruited kidney transplant recipients from August 2019 through April 2021 at the University of Malaya Medical Centre. Blood tests for lymphocyte subsets were taken at pre-transplant, 1 week, 1 month, 3 months, and 6 months post-transplantation. At transplantation, recipients received either basiliximab, low-dose thymoglobulin (cumulative dose: 1.5 mg/kg), or standard-dose thymoglobulin (cumulative dose: 5 mg/kg). RESULTS A total of 39 patients were recruited: 38.5% received basiliximab (15 of 39), 15.4% received low-dose thymoglobulin (6 of 39), and 46.2% received standard-dose thymoglobulin (18 of 39). Absolute lymphocyte counts 1 week post-transplantation were 1.5 ± 0.84 × 109/L for basiliximab, 0.7 ± 0.57 × 109/L for low-dose thymoglobulin, and 0.1 ± 0.08 × 109/L for standard-dose thymoglobulin (P < .001). The CD4+ and CD8+ counts were severely depleted in the standard-dose thymoglobulin group, with a statistically significant differenceup to 6 months post-transplantation. In the low-dose thymoglobulin group, the CD4+ and CD8+ counts were depleted at 1 week post-transplantation and recovered at 1 month post-transplantation. There was no difference in allograft function and incidence of allograft rejection across groups. CONCLUSIONS The effects on lymphocyte counts, CD4+ and CD8+, vary depending on the type and dose of induction immunosuppression. This could be a guiding tool in managing immunosuppression post-transplantation depending on the patient's immunologic risk.
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