1
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Chukwu CA, Wu HH, Pullerits K, Garland S, Middleton R, Chinnadurai R, Kalra PA. Incidence, Risk Factors, and Outcomes of De Novo Malignancy following Kidney Transplantation. J Clin Med 2024; 13:1872. [PMID: 38610636 PMCID: PMC11012944 DOI: 10.3390/jcm13071872] [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: 02/15/2024] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Introduction: Post-transplant malignancy is a significant cause of morbidity and mortality following kidney transplantation often emerging after medium- to long-term follow-up. To understand the risk factors for the development of de novo post-transplant malignancy (DPTM), this study aimed to assess the incidence, risk factors, and outcomes of DPTM at a single nephrology centre over two decades. Methods: This retrospective cohort study included 963 kidney transplant recipients who underwent kidney transplantation between January 2000 and December 2020 and followed up over a median follow-up of 7.1 years (IQR 3.9-11.4). Cox regression models were used to identify the significant risk factors of DPTM development, the association of DPTM with graft survival, and mortality with a functioning graft. Results: In total, 8.1% of transplant recipients developed DPTM, and the DPTM incidence rate was 14.7 per 100 patient-years. There was a higher mean age observed in the DPTM group (53 vs. 47 years, p < 0.001). The most affected organ systems were genitourinary (32.1%), gastrointestinal (24.4%), and lymphoproliferative (20.5%). Multivariate Cox analysis identified older age at transplant (aHR 9.51, 95%CI: 2.60-34.87, p < 0.001) and pre-existing glomerulonephritis (aHR 3.27, 95%CI: 1.10-9.77, p = 0.03) as significant risk factors for DPTM. Older age was significantly associated with poorer graft survival (aHR 8.71, 95%CI: 3.77-20.20, p < 0.001). When age was excluded from the multivariate Cox model, DPTM emerged as a significant risk factor for poor survival (aHR 1.76, 95%CI: 1.17-2.63, p = 0.006). Conclusion: These findings underscore the need for tailored screening, prevention, and management strategies to address DPTM in an aging and immunosuppressed kidney transplant population.
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Affiliation(s)
- Chukwuma A. Chukwu
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (C.A.C.); (R.M.); (P.A.K.)
| | - Henry H.L. Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia;
| | - Kairi Pullerits
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK; (K.P.); (S.G.)
| | - Shona Garland
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK; (K.P.); (S.G.)
| | - Rachel Middleton
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (C.A.C.); (R.M.); (P.A.K.)
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (C.A.C.); (R.M.); (P.A.K.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK; (K.P.); (S.G.)
| | - Philip A. Kalra
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (C.A.C.); (R.M.); (P.A.K.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK; (K.P.); (S.G.)
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2
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Fernández-Ruiz M, Redondo N, Parra P, Ruiz-Merlo T, Rodríguez-Goncer I, Polanco N, González E, López-Medrano F, San Juan R, Navarro D, Andrés A, Aguado JM. Comparison of intracellular cytokine staining versus an ELISA-based assay to assess CMV-specific cell-mediated immunity in high-risk kidney transplant recipients. J Med Virol 2023; 95:e28733. [PMID: 37185851 DOI: 10.1002/jmv.28733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023]
Abstract
The best method for monitoring cytomegalovirus (CMV)-specific cell-mediated immunity (CMV-CMI) among high-risk kidney transplant (KT) recipients remains uncertain. We assessed CMV-CMI by intracellular cytokine staining (ICS) by flow cytometry and a commercial interferon (IFN)-γ release assay (QuantiFERON®-CMV [QTF-CMV]) at posttransplant months 3, 4, and 5 in 53 CMV-seropositive KT recipients that had received induction therapy with antithymocyte globulin (ATG) and a 3-month course of valganciclovir prophylaxis. The discriminative capacity (areas under receiver operating characteristics curve [auROCs]) and diagnostic accuracy to predict immune protection against CMV infection from the discontinuation of prophylaxis to month 12 were compared between both methods. There was significant although moderate correlations between CMV-specific IFN-γ-producing CD8+ T-cell counts enumerated by ICS and IFN-γ levels by QTF-CMV at months 3 (rho: 0.493; p = 0.005) and 4 (rho: 0.440; p = 0.077). The auROCs for CMV-specific CD4+ and CD8+ T-cells by ICS were nonsignificantly higher than that of QTF-CMV (0.696 and 0.733 vs. 0.678; p = 0.900 and 0.692, respectively). The optimal cut-off of ≥0.395 CMV-specific CD8+ T-cells yielded a sensitivity of 86.4%, specificity of 54.6%, positive predictive value of 79.2% and negative predictive value of 66.7% to predict protection. The corresponding estimates for QTF-CMV (IFN-γ levels ≥0.2 IU/mL) were 78.9%, 37.5%, 75.0%, and 42.9%, respectively. The enumeration of CMV-specific IFN-γ-producing CD8+ T-cells at the time of cessation of prophylaxis performed slightly better than the QTF-CMV assay to predict immune protection in seropositive KT recipients previously treated with ATG.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Redondo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - David Navarro
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Microbiology, Hospital Clínico Universitario, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
- Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Amado Andrés
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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3
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Le Floc'h A, Nagashima K, Birchard D, Scott G, Ben LH, Ajithdoss D, Gayvert K, Romero Hernandez A, Herbin O, Tay A, Farrales P, Korgaonkar CK, Pan H, Shah S, Kamat V, Chatterjee I, Popke J, Oyejide A, Lim WK, Kim JH, Huang T, Franklin M, Olson W, Norton T, Perlee L, Yancopoulos GD, Murphy AJ, Sleeman MA, Orengo JM. Blocking common γ chain cytokine signaling ameliorates T cell-mediated pathogenesis in disease models. Sci Transl Med 2023; 15:eabo0205. [PMID: 36630481 DOI: 10.1126/scitranslmed.abo0205] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The common γ chain (γc; IL-2RG) is a subunit of the interleukin (IL) receptors for the γc cytokines IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21. The lack of appropriate neutralizing antibodies recognizing IL-2RG has made it difficult to thoroughly interrogate the role of γc cytokines in inflammatory and autoimmune disease settings. Here, we generated a γc cytokine receptor antibody, REGN7257, to determine whether γc cytokines might be targeted for T cell-mediated disease prevention and treatment. Biochemical, structural, and in vitro analysis showed that REGN7257 binds with high affinity to IL-2RG and potently blocks signaling of all γc cytokines. In nonhuman primates, REGN7257 efficiently suppressed T cells without affecting granulocytes, platelets, or red blood cells. Using REGN7257, we showed that γc cytokines drive T cell-mediated disease in mouse models of graft-versus-host disease (GVHD) and multiple sclerosis by affecting multiple aspects of the pathogenic response. We found that our xenogeneic GVHD mouse model recapitulates hallmarks of acute and chronic GVHD, with T cell expansion/infiltration into tissues and liver fibrosis, as well as hallmarks of immune aplastic anemia, with bone marrow aplasia and peripheral cytopenia. Our findings indicate that γc cytokines contribute to GVHD and aplastic anemia pathology by promoting these characteristic features. By demonstrating that broad inhibition of γc cytokine signaling with REGN7257 protects from immune-mediated disorders, our data provide evidence of γc cytokines as key drivers of pathogenic T cell responses, offering a potential strategy for the management of T cell-mediated diseases.
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Affiliation(s)
- Audrey Le Floc'h
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kirsten Nagashima
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dylan Birchard
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George Scott
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Li-Hong Ben
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dharani Ajithdoss
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kaitlyn Gayvert
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Olivier Herbin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Amanda Tay
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Pamela Farrales
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Hao Pan
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Sweta Shah
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Vishal Kamat
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Ishita Chatterjee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jon Popke
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Adelekan Oyejide
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Wei Keat Lim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jee H Kim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Tammy Huang
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew Franklin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - William Olson
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Thomas Norton
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Lorah Perlee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George D Yancopoulos
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Andrew J Murphy
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew A Sleeman
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jamie M Orengo
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
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4
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Thukral S, Rokde R, Ray DS. Comparison of Thymoglobulin and Grafalon as Induction Agents in Renal Transplantation: A Prospective Study. Transplant Proc 2022; 54:2133-2139. [PMID: 36116944 DOI: 10.1016/j.transproceed.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/14/2022] [Accepted: 07/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Induction immunosuppression is used to reduce the incidence of acute rejection and prevent delayed graft function. The 2 rabbit anti-thymocyte globulins- thymoglobulin and Grafalon (ATG Fresenius) have been commonly used for induction immunosuppression and treatment of acute rejection in solid organ transplantation. There are very few studies comparing the efficacy and side effects of both the anti-thymocyte globulins therefore this prospective study comparing the 2 types of anti-thymocyte globulins would be of clinical interest. PATIENTS AND METHODS This prospective single center study was conducted at Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India from April 2019 to June 2020. Sixty-two ABO-compatible renal transplant recipients were included in the study. They were divided in 2 groups of 31 patients each. One group received thymoglobulin (3 mg/kg) and the second group received Grafalon (6 mg/kg). All patients were followed up for 12 months and the 2 groups were compared for incidence of rejections, infections, graft function, patient survival, and graft survival. RESULTS There was no significant difference in the incidence of rejections, infective episodes, graft function, posttransplant diabetes mellitus, graft survival and patient survival in thymoglobulin or Grafalon groups. The hematological parameters were similar in both groups at 7 days, 1 month, and 6 months of follow-up. The absolute lymphocyte count was significantly lower in the thymoglobulin group at 12 months posttransplant. CONCLUSIONS Thymoglobulin and Grafalon were found to be equivalent in terms of safety and efficacy in short term, with no difference in rejections, infections, graft survival, or patient survival.
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Affiliation(s)
- Sharmila Thukral
- Rabindranath Tagore Hospital (Narayana Health Hospitals), Kolkata, India
| | - Ratnesh Rokde
- Department of Nephrology and Transplantation, Rabindranath Tagore Hospital (Narayana Health Hospitals), Kolkata, India
| | - Deepak Shankar Ray
- Department of Nephrology and Transplantation, Rabindranath Tagore Hospital (Narayana Health Hospitals), Kolkata, India.
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5
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Impact of Anti-T-lymphocyte globulin dosing on GVHD and Immune reconstitution in matched unrelated myeloablative peripheral blood stem cell transplantation. Bone Marrow Transplant 2022; 57:1548-1555. [PMID: 35831408 PMCID: PMC9532245 DOI: 10.1038/s41409-022-01666-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022]
Abstract
Data on the influence of different Anti-lymphocyte globulin (ATLG) doses on graft versus host disease (GVHD) incidence and immune reconstitution in matched unrelated (MUD) allogeneic Stem cell transplantation (allo-SCT) is limited. This retrospective study conducted at the University Medical-Center Hamburg compares GVHD and Immune reconstitution after myeloablative MUD (HLA 10/10) PBSC allogeneic stem cell transplant between 30 mg/Kg (n = 73) and 60 mg/Kg (n = 216) ATLG. Detailed phenotypes of T, B natural killer (NK), natural killer T (NKT) cells were analyzed by multicolor flow at day 30, 100, and 180 posttransplant. Neutrophil and platelet engraftments were significantly delayed in the 60 mg/kg group with a higher Cumulative incidence of Infections (67% vs 75% p = 0.049) and EBV (21% vs 41% p = 0.049) reactivation at day 100 in this group. In the 30 mg/kg group, we observed a faster reconstitution of naïve-B cells (p < 0.0001) and γδ T cells (p = 0.045) at day+30 and a faster naïve helper T-cell (p = 0.046), NK-cells (p = 0.035), and naïve B-cell reconstitution (p = 0.009) at day+180. There were no significant differences in aGVHD, cGVHD, NRM, RI, PFS, and OS between the groups. The choice of ATLG dose has significant impact on IR but not on GVHD after MUD-allo-SCT. Higher doses are associated with delayed engraftment and increased infections.
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6
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Al-Adra D, Al-Qaoud T, Fowler K, Wong G. De Novo Malignancies after Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:434-443. [PMID: 33782034 PMCID: PMC8975024 DOI: 10.2215/cjn.14570920] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cancer is an important outcome after kidney transplantation because it is the second leading cause of death in most Western countries. The excess risk of cancer after transplantation is approximately two to three times higher than the age- and sex-matched general population, driven largely by viral- and immune-related cancers. Once cancer develops, outcomes are generally poor, particularly for those with melanoma, renal cell carcinoma, and post-transplant lymphoproliferative disease. More importantly, effective screening and treatment strategies are limited in this high-risk population. In this review, we begin with a patient's journey that maps the experience of living with a kidney transplant and understand the patient's knowledge, education, and experience of cancer in the context of transplantation. The epidemiology and burden of cancer in recipients of kidney transplants, along with the up-to-date screening and treatment strategies, are discussed. We also focus on the current understanding of optimal care for recipients of kidney transplants who are living with cancer from the patients' perspectives.
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Affiliation(s)
- David Al-Adra
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Talal Al-Qaoud
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin Fowler
- The Voice of the Patient, Inc., Columbia, Missouri
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia .,Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
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7
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Shaw BI, Schmitz R, Flores WJ, Magnani DM, Li J, Song M, Kirk AD. A comparative study of human-and rhesus-specific antithymocyte globulins in Rhesus macaques. Clin Transplant 2021; 35:e14369. [PMID: 34021521 DOI: 10.1111/ctr.14369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
Rabbit antithymocyte globulin (RATG) preparations are widely used in transplantation. They are developed in vivo against thymocytes and contain polyclonal antibodies specific for myriad cellular targets. The rhesus monkey is commonly used as a preclinical transplant model, but the fidelity of commercially available human-specific RATGs to anticipate the effects of RATGs in rhesus has not been established. We therefore developed two rhesus-specific ATGs (rhATG) and compared them to human-specific RATG (huATG, Thymoglobulin® ) in rhesus monkeys, assessing the magnitude and phenotype of depletion peripherally and in lymph nodes. Four primates were assigned to each group and received 20 mg/kg of drug. Depletion, repopulation, and changes in lymphocyte subsets were evaluated in peripheral blood and lymph nodes by flow cytometry over four months. We observed similar qualitative changes in lymphocyte subsets, but a generally more profound depletion with huATG compared to either rhATG. Peripheral homeostatic proliferation rather than thymic output was the major mechanism for repopulation with all RATGs. Repopulation was slower but qualitatively similar when examining RATGs in additional animals receiving concomitant chronic immunosuppression. Depletional induction is similar to human- and rhesus-specific RATGs in rhesus macaques. Both rhesus- and human-specific agents appear appropriate for preclinical modeling of clinical RATG use.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC, USA
| | - Robin Schmitz
- Department of Surgery, Duke University, Durham, NC, USA
| | - Walter J Flores
- MassBiologics, University of Massachusetts Medical School, Boston, MA, USA
| | - Diogo M Magnani
- MassBiologics, University of Massachusetts Medical School, Boston, MA, USA
| | - Jie Li
- Department of Surgery, Duke University, Durham, NC, USA
| | - Mingqing Song
- Department of Surgery, Duke University, Durham, NC, USA
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, USA
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8
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Natural Killer Cells in Post-Transplant Lymphoproliferative Disorders. Cancers (Basel) 2021; 13:cancers13081836. [PMID: 33921413 PMCID: PMC8068932 DOI: 10.3390/cancers13081836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/19/2022] Open
Abstract
Post-transplant lymphoproliferative disorders (PTLDs) are life-threatening complications arising after solid organ or hematopoietic stem cell transplantations. Although the majority of these lymphoproliferations are of B cell origin, and are frequently associated with primary Epstein-Barr virus (EBV) infection or reactivation in the post-transplant period, rare cases of T cell and natural killer (NK) cell-originated PTLDs have also been described. A general assumption is that PTLDs result from the impairment of anti-viral and anti-tumoral immunosurveillance due to the long-term use of immunosuppressants in transplant recipients. T cell impairment is known to play a critical role in the immune-pathogenesis of post-transplant EBV-linked complications, while the role of NK cells has been less investigated, and is probably different between EBV-positive and EBV-negative PTLDs. As a part of the innate immune response, NK cells are critical for protecting hosts during the early response to virus-induced tumors. The complexity of their function is modulated by a myriad of activating and inhibitory receptors expressed on cell surfaces. This review outlines our current understanding of NK cells in the pathogenesis of PTLD, and discusses their potential implications for current PTLD therapies and novel NK cell-based therapies for the containment of these disorders.
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9
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Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, Mandelbrot D, Verna E, Locke J, D'Cunha J, Farr M, Sawinski D, Agarwal PK, Plichta J, Pruthi S, Farr D, Carvajal R, Walker J, Zwald F, Habermann T, Gertz M, Bierman P, Dizon DS, Langstraat C, Al-Qaoud T, Eggener S, Richgels JP, Chang GJ, Geltzeiler C, Sapisochin G, Ricciardi R, Krupnick AS, Kennedy C, Mohindra N, Foley DP, Watt KD. Preexisting melanoma and hematological malignancies, prognosis, and timing to solid organ transplantation: A consensus expert opinion statement. Am J Transplant 2021; 21:475-483. [PMID: 32976703 PMCID: PMC8555431 DOI: 10.1111/ajt.16324] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
Patients undergoing evaluation for solid organ transplantation (SOT) frequently have a history of malignancy. Only patients with treated cancer are considered for SOT but the benefits of transplantation need to be balanced against the risk of tumor recurrence, taking into consideration the potential effects of immunosuppression. Prior guidelines on timing to transplant in patients with a prior treated malignancy do not account for current staging, disease biology, or advances in cancer treatments. To update these recommendations, the American Society of Transplantation (AST) facilitated a consensus workshop to comprehensively review contemporary literature regarding cancer therapies, cancer stage specific prognosis, the kinetics of cancer recurrence, as well as the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis, treatment, and transplant recommendations for melanoma and hematological malignancies. Given the limited data regarding the risk of cancer recurrence in transplant recipients, the goal of the AST-sponsored conference and the consensus documents produced are to provide expert opinion recommendations that help in the evaluation of patients with a history of a pretransplant malignancy for transplant candidacy.
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Affiliation(s)
- David P Al-Adra
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Hammel
- Department of Anesthesiology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - John Roberts
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - E Steve Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Levine
- Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth Verna
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Jayme Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Maryjane Farr
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer Plichta
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Sandhya Pruthi
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Richard Carvajal
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - John Walker
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fiona Zwald
- Piedmont Transplant Institute, Piedmont Atlanta Hospital, Atlanta, Georgia
| | | | - Morie Gertz
- Hematology Division, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip Bierman
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, Rhode Island
| | - Carrie Langstraat
- Departments of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Talal Al-Qaoud
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Scott Eggener
- Department of Urology, University of Chicago, Chicago, Illinois
| | - John P Richgels
- Department of Urology, University of Chicago, Chicago, Illinois
| | - George J Chang
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Cristina Geltzeiler
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | | | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Cassie Kennedy
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nisha Mohindra
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - David P Foley
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
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10
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Dujardin A, Lorent M, Foucher Y, Legendre C, Kerleau C, Brouard S, Giral M. Time-dependent lymphocyte count after transplantation is associated with higher risk of graft failure and death. Kidney Int 2020; 99:1189-1201. [PMID: 32891605 DOI: 10.1016/j.kint.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/11/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022]
Abstract
The transplantation field requires the identification of specific risk factors associated with the level of immunosuppression. Here, our aim was to analyze the association between the number of circulating lymphocytes, monitored routinely by complete blood cell counts during outpatient visits, and patient and graft survival. In total, 2,999 kidney or combined kidney-pancreas recipients transplanted between 2000 and 2016, from two University hospitals, were enrolled. We investigated the etiological relationship between time-dependent lymphocyte count beyond one year after transplantation and patient and graft survival, viral infection and cancer risk using time-dependent multivariate Cox models. Model 1 considered kidney function at one year and model 2 as time-dependent variable. At the time of inclusion (one year after transplantation), 584 patients (19.4%) had deep lymphopenia (under 750 /mm3) and 1,072 (35.7%) had a normal count (over 1,500 /mm3). A patient with deep lymphopenia at a given follow-up time had significantly higher risks of graft failure, death and viral infection than comparable patients with a normal lymphocyte count at the same time point. Thus, after the first year of transplantation, the occurrence of deep lymphopenia within a patient's follow-up is a risk factor for long-term graft failure, death and viral infection.
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Affiliation(s)
- Amaury Dujardin
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marine Lorent
- Centre Hospitalier Universitaire de Nantes, Nantes, France; Inserm UMR 1246-SPHERE, Université de Nantes, Université de Tours, Nantes, France
| | - Yohann Foucher
- Centre Hospitalier Universitaire de Nantes, Nantes, France; Inserm UMR 1246-SPHERE, Université de Nantes, Université de Tours, Nantes, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS Centaure, Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | | | - Sophie Brouard
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Magali Giral
- CRTI UMR 1064, Inserm, Université de Nantes, ITUN, CHU Nantes, RTRS Centaure, Nantes, France; Centre Hospitalier Universitaire de Nantes, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Labex IGO, Nantes, France
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11
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Therapeutic management of HIV-infected patients with chronic kidney disease. J Nephrol 2020; 33:699-713. [PMID: 32020538 DOI: 10.1007/s40620-020-00701-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023]
Abstract
CKD and HIV infection are two chronic diseases impacting heavily on the survival of the affected patients. The interplay between HIV infection and chronic kidney disease (CKD) is complex and interactions occur at multiple levels. Approach to the management of HIV-infected patients requires special attention to face the numerous therapeutic difficulties ranging from drug-drug interactions to drug-toxicity. The most effective strategy is targeted to suppression of HIV viral load, as it dramatically changes the prognosis of the patients as well as prevents the development of HIV-associated kidney disease. As shown in this review, the approach to the therapeutic management of CKD in the setting of HIV infection varies in relation to the degree of renal impairment.
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12
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Lattimore S, Skill NJ, Maluccio MA, Elliott H, Dobben E, Shafuddin A, Goggins WC. Antithymocyte Globulin Antibody Titer Congruent With Kidney Transplantation: Analysis of Incidence, Outcomes, Cost, and Alternative Targets. Transplant Direct 2019; 5:e493. [PMID: 31723588 PMCID: PMC6791597 DOI: 10.1097/txd.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/19/2019] [Indexed: 11/25/2022] Open
Abstract
Rabbit antithymocyte globulin (rATG) use for immunosuppression induction is widespread but is contraindicated by the presence of anti-rATG antibodies. This study reports the incidence of positive anti-rATG antibody titers in patients before and after renal transplant and evaluates associated outcomes and costs. In addition, it will correlate CD40L and interleukin (IL)-21 with anti-rATG antibody titers. METHODS Clinical and billing records from the Indiana University Transplant Laboratory were reviewed for positive versus negative anti-rATG antibody titers, graft survival, and 7-day readmission costs between 2004 and 2018. Serum from patients with positive and negative rATG antibody titers were quantitated for CD40L and IL-21 by enzyme-linked immunosorbent assay. RESULTS On average, between 2004 and May 2018, 163 kidney transplants per year were performed. Anti-rATG antibody titers were ordered for 17 patients/year, of which 18.2% were positive at 1:100 titer either pre- or post-transplant. Time to graft loss correlated with a positive rATG titer at time of readmission. Moreover, second kidney transplant increased the anti-rATG positive rate. A weak correlation was observed between anti-rATG titer and recipient age. Seven-day readmission treatment costs were significantly lower in patients with positive anti-rATG titer. IL-21 and CD40L were significantly greater in patients with positive anti-rATG titers after transplant when compared with negative anti rATG patients. CONCLUSIONS Positive anti-rATG antibody titer is associated with a significant negative impact on outcomes. Monitoring of anti-rATG antibody titer is recommended to optimize treatment options in patients, especially in the setting of second transplants. Elucidation of the mechanisms associated with positive anti-rATG antibody is required. IL-21 and CD40L are potential targets for future study.
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Affiliation(s)
- Sherene Lattimore
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J. Skill
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mary A. Maluccio
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Holly Elliott
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Elizabeth Dobben
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Asif Shafuddin
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - William C. Goggins
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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13
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Spagnuolo V, Uberti-Foppa C, Castagna A. Pharmacotherapeutic management of HIV in transplant patients. Expert Opin Pharmacother 2019; 20:1235-1250. [PMID: 31081726 DOI: 10.1080/14656566.2019.1612364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In the last two decades, an increasing number of people living with HIV (PLWH) have undergone solid-organ and hematopoietic cell transplantation as a treatment of end-stage organ and hematological diseases, respectively. Although transplant outcomes are more than satisfactory, transplantation in PLWH is still challenging for clinicians because of concerns regarding potentially higher rates of infective complications, higher risks of allograft rejection, and drug-drug interactions between antiretroviral drugs and immunosuppressive agents. AREAS COVERED This review provides an overview of transplantation in PLWH, with focus on the management of combination antiretroviral therapy in this population. EXPERT OPINION Solid-organ and hematopoietic cell transplantations should be proposed without any reservation to all PLWH who may benefit from them. Particular attention should be paid to possible drug-drug interactions between antiretrovirals and immunosuppressive agents; moreover, when feasible, integrase strand transfer inhibitor-based antiretroviral regimens should be preferred to protease and non-nucleoside reverse transcriptase inhibitors. Considering the worse prognosis in HIV/hepatitis C virus (HCV) transplant recipients, treatment of HCV with new direct-acting antivirals (DAAs) represents a key issue in the management of this population. However, the timing of treatment (before or early after transplant) should be individualized by considering short-term prognosis, access to transplant, and comorbidities.
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Affiliation(s)
- Vincenzo Spagnuolo
- a Faculty of Medicine and Surgery , Vita-Salute San Raffaele University , Milan , Italy.,b Clinic of Infectious Diseases , Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Institute , Milan , Italy
| | - Caterina Uberti-Foppa
- a Faculty of Medicine and Surgery , Vita-Salute San Raffaele University , Milan , Italy.,b Clinic of Infectious Diseases , Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Institute , Milan , Italy
| | - Antonella Castagna
- a Faculty of Medicine and Surgery , Vita-Salute San Raffaele University , Milan , Italy.,b Clinic of Infectious Diseases , Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Institute , Milan , Italy
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14
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CMV-Specific Immune Response-New Patients, New Insight: Central Role of Specific IgG during Infancy and Long-Lasting Immune Deficiency after Allogenic Stem Cell Transplantation. Int J Mol Sci 2019; 20:ijms20020271. [PMID: 30641912 PMCID: PMC6358762 DOI: 10.3390/ijms20020271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/21/2022] Open
Abstract
Although the existing paradigm states that cytomegalovirus (CMV) reactivation is under the control of the cellular immune response, the role of humoral and innate counterparts are underestimated. The study analyzed the host–virus interaction i.e., CMV-immune response evolution during infection in three different clinical situations: (1) immunodeficient CMV-positive human leukocyte antigen (HLA)-matched bone marrow recipients after immunoablative conditioning as well as immunocompetent, (2) adult, and (3) infant with primary immune response. In the first situation, a fast and significant decrease of specific immunity was observed but reconstitution of marrow-derived B and natural killer (NK) cells was observed prior to thymic origin of T cells. The lowest CMV-IgG (93.2 RU/mL) was found just before CMV viremia. It is noteworthy that the sole and exclusive factor of CMV-specific immune response is a residual recipient antibody class IgG. The CMV-quantiferon increase was detected later, but in the first phase, phytohemagglutinin (PHA)-induced IFN-γ release was significantly lower than that of CMV-induced (“indeterminate” results). It corresponds with the increase of NK cells at the top of lymphocyte reconstitution and undetected CMV-specific CD8 cells using a pentamer technique. In immunocompetent adult (CMV-negative donor), the cellular and humoral immune response increased in a parallel manner, but symptoms of CMV mononucleosis persisted until the increase of specific IgG. During infancy, the decrease of the maternal CMV-IgG level to 89.08 RU/mL followed by clinical sequel, i.e., CMV replication, were described. My observations shed light on a unique host-CMV interaction and CMV-IgG role: they indicate that its significant decrease predicts CMV replication. Before primary cellular immune response development, the high level of residual CMV-IgG (about >100 R/mL) from mother or recipient prevents virus reactivation. The innate immune response and NK-dependent IFN-secretion should be further investigated.
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15
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Ong S, Levy RD, Yee J, Partovi N, Churg A, Roméo P, Chalaoui J, Nador R, Wright A, Manganas H, Ryerson CJ. Successful lung transplantation in an HIV seropositive patient with desquamative interstitial pneumonia: a case report. BMC Pulm Med 2018; 18:162. [PMID: 30326889 PMCID: PMC6191892 DOI: 10.1186/s12890-018-0727-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/02/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Until recently, lung transplantation was not considered in patients with human immunodeficiency virus (HIV). HIV seropositive patients with suppressed viral loads can now expect long-term survival with the advent of highly active antiretroviral therapies (HAART); however, HIV remains a relative contraindication to lung transplantation. We describe, to our knowledge, the first HIV seropositive lung transplant recipient in Canada. We also review the literature of previously reported cases of solid-organ transplantation in patients with HIV with a focus on immunosuppression considerations. CASE PRESENTATION A 48-year old man received a bilateral lung transplant for a diagnosis of desquamative interstitial pneumonia (DIP) attributed to cigarette and cannabis smoking. His control of HIV infection pre-transplant was excellent on HAART, and he had no other contraindications to lung transplantation. The patient underwent bilateral lung transplantation using basiliximab, methylprednisolone, and mycophenolate mofetil (MMF) as induction immunosuppression. He was maintained on MMF, prednisone, and tacrolimus thereafter, and restarted his HAART regimen immediately post-operatively. His post-transplant course was complicated by Grade A1 minimal acute cellular rejection, as well as an enterovirus/rhinovirus graft infection. Despite these complications, his functional status and control of HIV infection remain excellent 24 months post-transplant. CONCLUSIONS Our patient is one of only several HIV seropositive lung transplant recipients reported globally. With growing acceptance of transplantation in this population, there is a need for clarification of prognosis post-transplantation, as well as optimal immunosuppression regimens for these patients. This case report adds to the recent literature that suggests HIV seropositivity should not be considered a contraindication to lung transplantation, and that post-transplant patients with HIV can be managed safely with basiliximab, tacrolimus, MMF and prednisone.
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Affiliation(s)
- Shaun Ong
- Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9 Canada
| | - Robert D Levy
- Lung Transplant Program, Vancouver General Hospital, 2775 Laurel Street, 5th Floor, Vancouver, BC V5Z 1M9 Canada
- Division of Respirology, Department of Medicine, University of British Columbia, 2775 Laurel Street, 7th Floor, Vancouver, BC V5Z 1M9 Canada
| | - John Yee
- Division of Thoracic Surgery, Department of Surgery, University of British Columbia, 950 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Nilu Partovi
- Department of Pharmacology, University of British Columbia, 217 – 2176 Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada
| | - Andrew Churg
- Vancouver Coastal Health Research Institute, University of British Columbia, 2635 Laurel Street, Vancouver, BC V5Z 1M9 Canada
- Department of Pathology, University of British Columbia, Room G227 – 2211 Wesbrook Mall, Vancouver, BC V6T 2B5 Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Room 166 – 1081 Burrard Street, Ward 8B, Vancouver, BC V6Z 1Y6 Canada
| | - Philippe Roméo
- Department of Pathology, Centre Hospitalier de l’Université de Montréal, University of Montreal, 1051 Sanguinet Street, Montreal, QC H2X 3E4 Canada
| | - Jean Chalaoui
- Department of Radiology, Centre Hospitalier de l’Université de Montréal, University of Montreal, 1051 Sanguinet Street, Montreal, QC H2X 3E4 Canada
| | - Roland Nador
- Lung Transplant Program, Vancouver General Hospital, 2775 Laurel Street, 5th Floor, Vancouver, BC V5Z 1M9 Canada
- Division of Respirology, Department of Medicine, University of British Columbia, 2775 Laurel Street, 7th Floor, Vancouver, BC V5Z 1M9 Canada
| | - Alissa Wright
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, 452D – 2733 Heather Street, Vancouver, BC V5Z 3J5 Canada
| | - Hélène Manganas
- Division of Respirology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, 1051 Sanguinet Street, Montreal, QC H2X 3E4 Canada
| | - Christopher J Ryerson
- Lung Transplant Program, Vancouver General Hospital, 2775 Laurel Street, 5th Floor, Vancouver, BC V5Z 1M9 Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Room 166 – 1081 Burrard Street, Ward 8B, Vancouver, BC V6Z 1Y6 Canada
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16
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Ducloux D, Bamoulid J, Crepin T, Rebibou JM, Courivaud C, Saas P. Posttransplant Immune Activation: Innocent Bystander or Insidious Culprit of Posttransplant Accelerated Atherosclerosis. Cell Transplant 2018; 26:1601-1609. [PMID: 29113470 PMCID: PMC5680959 DOI: 10.1177/0963689717735404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cardiovascular disease is a major cause of morbidity, disability, and mortality in kidney transplant patients. Cumulative reports indicate that the excessive risk of cardiovascular events is not entirely explained by the increased prevalence of traditional cardiovascular risk factors. Atherosclerosis is a chronic inflammatory disease, and it has been postulated that posttransplant immune disturbances may explain the gap between the predicted and observed risks of cardiovascular events. Although concordant data suggest that innate immunity contributes to the posttransplant accelerated atherosclerosis, only few arguments plead for a role of adaptive immunity. We report and discuss here consistent data demonstrating that CD8+ T cell activation is a frequent posttransplant immune feature that may have pro-atherogenic effects. Expansion of exhausted/activated CD8+ T cells in kidney transplant recipients is stimulated by several factors including cytomegalovirus infections, lymphodepletive therapy (e.g., antithymocyte globulins), chronic allogeneic stimulation, and a past history of renal insufficiency. This is observed in the setting of decreased thymic activity, a process also found in elderly individuals and reflecting accelerated immune senescence.
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Affiliation(s)
- Didier Ducloux
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,2 Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - Jamal Bamoulid
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,2 Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - Thomas Crepin
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,2 Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - Jean-Michel Rebibou
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,3 Department of Nephrology, Dialysis, and Renal Transplantation, CHU Dijon, Dijon, France
| | - Cecile Courivaud
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,2 Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, Besançon, France
| | - Philippe Saas
- 1 Inserm, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France.,4 EFS, UMR1098, Plateforme de BioMonitoring, Besançon, France.,5 Université Bourgogne Franche-Comté (UBFC), UMR1098, Besançon, France.,6 INSERM CIC-1431, Besançon, France
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17
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Bamoulid J, Staeck O, Crépin T, Halleck F, Saas P, Brakemeier S, Ducloux D, Budde K. Anti-thymocyte globulins in kidney transplantation: focus on current indications and long-term immunological side effects. Nephrol Dial Transplant 2018; 32:1601-1608. [PMID: 27798202 DOI: 10.1093/ndt/gfw368] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 09/12/2016] [Indexed: 11/12/2022] Open
Abstract
Antithymocyte globulins (ATGs) are part of the immunosuppression arsenal currently used by clinicians to prevent or treat acute rejection in solid organ transplantation. ATG is a mixture of non-specific anti-lymphocyte immunoglobulins targeting not only T cell subsets but also several other immune and non-immune cells, rendering its precise immunoglobulin composition difficult to appreciate or to compare from one preparation to another. Furthermore, several mechanisms of action have been described. Taken together, this probably explains the efficacy and the side effects associated with this drug. Recent data suggest a long-term negative impact on allograft and patient outcomes, pointing out the need to better characterize the potential toxicity and the benefit-risk balance associated to this immunosuppressive therapy within large clinical trials.
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Affiliation(s)
- Jamal Bamoulid
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
| | - Thomas Crépin
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
| | - Philippe Saas
- UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | | | - Didier Ducloux
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Besançon, France.,UMR1098, Federation hospitalo-universitaire INCREASE, France.,Faculté de Médecine et de Pharmacie, Université de Franche-Comté, France.,Structure Fédérative de Recherche, SFR FED4234, France
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Germany
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18
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Bamoulid J, Crépin T, Courivaud C, Rebibou JM, Saas P, Ducloux D. Antithymocyte globulins in renal transplantation-from lymphocyte depletion to lymphocyte activation: The doubled-edged sword. Transplant Rev (Orlando) 2017; 31:180-187. [PMID: 28456447 DOI: 10.1016/j.trre.2017.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 11/18/2022]
Abstract
Compelling data suggest that lymphocyte depletion following T cell depleting therapy may induce prolonged CD4 T cell lymphopenia and trigger lymphocyte activation in some patients. These profound and non-reversible immune changes in T cell pool subsets are the consequence of both impaired thymic renewal and peripheral homeostatic proliferation. Chronic viral challenges by CMV play a major role in these immune alterations. Even when the consequences of CD4 T cell lymphopenia have been now well described, recent studies shed new light on the clinical consequences of immune activation. In this review, we will first focus on the mechanisms involved in T cell pool reconstitution after T cell depletion and further consider the clinical consequences of ATG-induced T cell activation and senescence in renal transplant recipients.
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Affiliation(s)
- Jamal Bamoulid
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030 Besançon, France; UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon F-25020, France; Structure Fédérative de Recherche, SFR FED4234, Besançon F-25000, France
| | - Thomas Crépin
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030 Besançon, France; UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon F-25020, France; Structure Fédérative de Recherche, SFR FED4234, Besançon F-25000, France
| | - Cécile Courivaud
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030 Besançon, France; UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon F-25020, France; Structure Fédérative de Recherche, SFR FED4234, Besançon F-25000, France
| | - Jean-Michel Rebibou
- UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; CHU Dijon, Department of Nephrology, Dialysis and Renal Transplantation, 21000 Dijon, France
| | - Philippe Saas
- UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon F-25020, France; Structure Fédérative de Recherche, SFR FED4234, Besançon F-25000, France
| | - Didier Ducloux
- CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, F-25030 Besançon, France; UMR1098, Federation hospitalo-universitaire INCREASE, Besançon F-25020, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon F-25020, France; Structure Fédérative de Recherche, SFR FED4234, Besançon F-25000, France.
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19
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Burkhalter F, Schaub S, Bucher C, Gürke L, Bachmann A, Hopfer H, Dickenmann M, Steiger J, Binet I. A Comparison of Two Types of Rabbit Antithymocyte Globulin Induction Therapy in Immunological High-Risk Kidney Recipients: A Prospective Randomized Control Study. PLoS One 2016; 11:e0165233. [PMID: 27855166 PMCID: PMC5113896 DOI: 10.1371/journal.pone.0165233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 10/04/2016] [Indexed: 11/18/2022] Open
Abstract
Background Induction treatment with rabbit polyclonal antithymocyte globulins (ATGs) is frequent used in kidney transplant recipients with donorspecific HLA antibodies and shows acceptable outcomes. The two commonly used ATGs, Thymoglobulin and ATG-F have slightly different antigen profile and antibody concentrations. The two compounds have never been directly compared in a prospective trial in immunological high-risk recipients. Therefore we performed a prospective randomized controlled study comparing the two compounds in immunological high-risk kidney recipients in terms of safety and efficacy. Methods Immunological high-risk kidney recipients, defined as the presence of HLA DSA but negative CDC-B and T-cell crossmatches were randomized 1:1 to receive ATG-F or Thymoglobulin. Maintenance immunosuppressive therapy consisted of tacrolimus, mycophenolate mofetil and steroids. Results The per-protocol analysis included 35 patients. There was no immediate infusion reaction observed with both compounds. No PTLD or malignancy occurred during the follow-up in both groups. The incidence of viral and bacterial infections was similar in both groups (p = 0.62). The cumulative incidence of clinical and subclinical antibody mediated allograft rejection as well as T-cell mediated allograft rejection during the first year between ATG-F and Thymoglobulin was similar (35% versus 19%; p = 0.30 and 11% versus 18%; 0.54 respectively). The two-year graft function was similar with a median eGFR of 56 ml/min/1.73m2 (range 21–128) (ATG-F-group) and 51 ml/min/1.73m2 (range 22–132) (Thymo-group) (p = 0.69). Conclusion We found no significant differences between the compared study drugs for induction treatment in immunological high-risk patients regarding safety and efficacy during follow-up with good allograft function at 2 years after transplantation.
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Affiliation(s)
- F Burkhalter
- Clinic for Transplant Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - S Schaub
- Clinic for Transplant Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Ch Bucher
- Nephrology and Transplantation Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - L Gürke
- Department of Vascular and Transplant Surgery, University Hospital Basel, Basel, Switzerland
| | - A Bachmann
- Department of Urology, Basel University Hospital, Basel, Switzerland
| | - H Hopfer
- Institute for Pathology, University Hospital Basel, Basel, Switzerland
| | - M Dickenmann
- Clinic for Transplant Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - J Steiger
- Clinic for Transplant Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - I Binet
- Nephrology and Transplantation Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
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Suarez JF, Rosa R, Lorio MA, Morris MI, Abbo LM, Simkins J, Guerra G, Roth D, Kupin WL, Mattiazzi A, Ciancio G, Chen LJ, Burke GW, Goldstein MJ, Ruiz P, Camargo JF. Pretransplant CD4 Count Influences Immune Reconstitution and Risk of Infectious Complications in Human Immunodeficiency Virus-Infected Kidney Allograft Recipients. Am J Transplant 2016; 16:2463-72. [PMID: 26953224 PMCID: PMC4956530 DOI: 10.1111/ajt.13782] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/25/2016] [Accepted: 02/27/2016] [Indexed: 01/25/2023]
Abstract
In current practice, human immunodeficiency virus-infected (HIV(+) ) candidates with CD4 >200 cells/mm(3) are eligible for kidney transplantation; however, the optimal pretransplant CD4 count above this threshold remains to be defined. We evaluated clinical outcomes in patients with baseline CD4 >350 and <350 cells/mm(3) among 38 anti-thymocyte globulin (ATG)-treated HIV-negative to HIV(+) kidney transplants performed at our center between 2006 and 2013. Median follow-up was 2.6 years. Rates of acute rejection and patient and graft survival were not different between groups. Occurrence of severe CD4 lymphopenia (<200 cells/mm(3) ), however, was more common among patients with a baseline CD4 count 200-349 cells/mm(3) compared with those transplanted at higher counts (75% vs. 30% at 4 weeks [p = 0.04] and 71% vs. 5% at 52 weeks [p = 0.001], respectively, after transplant). After adjusting for age, baseline CD4 count of 200-349 cells/mm(3) was an independent predictor of severe CD4 lymphopenia at 4 weeks (relative risk [RR] 2.6; 95% confidence interval [CI] 1.3-5.1) and 52 weeks (RR 14.3; 95% CI 2-100.4) after transplant. Patients with CD4 <200 cells/mm(3) at 4 weeks had higher probability of serious infections during first 6 months after transplant (19% vs. 50%; log-rank p = 0.05). These findings suggest that ATG must be used with caution in HIV(+) kidney allograft recipients with a pretransplant CD4 count <350 cells/mm(3) .
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Affiliation(s)
- J. F. Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - R. Rosa
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - M. A. Lorio
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - M. I. Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - L. M. Abbo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - J. Simkins
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G. Guerra
- Department of Medicine, Division of Nephrology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - D. Roth
- Department of Medicine, Division of Nephrology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - W. L. Kupin
- Department of Medicine, Division of Nephrology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - A. Mattiazzi
- Department of Medicine, Division of Nephrology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G. Ciancio
- Department of Surgery, University of Miami Miller School of Medicine and Miami Transplant Institute at the Jackson Memorial Hospital, Miami, FL, USA
| | - L. J. Chen
- Department of Surgery, University of Miami Miller School of Medicine and Miami Transplant Institute at the Jackson Memorial Hospital, Miami, FL, USA
| | - G. W. Burke
- Department of Surgery, University of Miami Miller School of Medicine and Miami Transplant Institute at the Jackson Memorial Hospital, Miami, FL, USA
| | - M. J. Goldstein
- Department of Surgery, University of Miami Miller School of Medicine and Miami Transplant Institute at the Jackson Memorial Hospital, Miami, FL, USA
| | - P. Ruiz
- Department of Surgery, University of Miami Miller School of Medicine and Miami Transplant Institute at the Jackson Memorial Hospital, Miami, FL, USA
| | - J. F. Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
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A Proposal for Early Dosing Regimens in Heart Transplant Patients Receiving Thymoglobulin and Calcineurin Inhibition. Transplant Direct 2016; 2:e81. [PMID: 27500271 PMCID: PMC4946520 DOI: 10.1097/txd.0000000000000594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 12/19/2022] Open
Abstract
There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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Luque Y, Jamme M, Rabant M, DeWolf S, Noël LH, Thervet E, Chatenoud L, Snanoudj R, Anglicheau D, Legendre C, Candon S, Zuber J. Long-term CD4 lymphopenia is associated with accelerated decline of kidney allograft function. Nephrol Dial Transplant 2015; 31:487-95. [DOI: 10.1093/ndt/gfv362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/15/2015] [Indexed: 11/12/2022] Open
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25
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Virus infection in HLA-haploidentical hematopoietic stem cell transplantation: incidence in the context of immune recovery in two different transplantation settings. Ann Hematol 2015; 94:1677-88. [DOI: 10.1007/s00277-015-2423-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/01/2015] [Indexed: 11/28/2022]
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26
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Crepin T, Carron C, Roubiou C, Gaugler B, Gaiffe E, Simula-Faivre D, Ferrand C, Tiberghien P, Chalopin JM, Moulin B, Frimat L, Rieu P, Saas P, Ducloux D, Bamoulid J. ATG-induced accelerated immune senescence: clinical implications in renal transplant recipients. Am J Transplant 2015; 15:1028-38. [PMID: 25758660 DOI: 10.1111/ajt.13092] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/16/2014] [Accepted: 11/01/2014] [Indexed: 01/25/2023]
Abstract
Persistent ATG-induced CD4(+) T cell lymphopenia is associated with serious clinical complications. We tested the hypothesis that ATG induces accelerated immune senescence in renal transplant recipients (RTR). Immune senescence biomarkers were analyzed at transplant and one-year later in 97 incident RTR -62 patients receiving ATG and 35 receiving anti-CD25 mAb (α-CD25). This consisted in: (i) thymic output; (ii) bone marrow renewal of CD34(+) hematopoietic progenitor cells (CD34(+) HPC) and lymphoid (l-HPC) and myeloid (m-HPC) progenitor ratio; (iii) T cell phenotype; and (iv) measurement of T cell relative telomere length (RTL) and telomerase activity (RTA). Clinical correlates were analyzed with a 3 year follow-up. Thymic output significantly decreased one-year posttransplant in ATG-treated patients. ATG was associated with a significant decrease in l-HPC/m-HPC ratio. Late stage differentiated CD57(+) /CD28(-) T cells increased in ATG-treated patients. One-year posttransplant T cell RTL and RTA were consequently lower in ATG-treated patients. ATG is associated with accelerated immune senescence. Increased frequency of late differentiated CD4(+) T cell frequency at transplantation tended to be predictive of a higher risk of subsequent opportunistic infections and of acute rejection only in ATG-treated patients but this needs confirmation. Considering pretransplant immune profile may help to select those patients who may benefit from ATG to prevent severe infections and acute rejection.
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Affiliation(s)
- T Crepin
- INSERM, UMR1098, Federation Hospitalo-Universitaire INCREASE, Besançon, France; Université de Franche-Comté, Faculté de Médecine et de Pharmacie, Besançon, France; Structure Fédérative de Recherche, SFR FED4234, Besançon, France; CHU Besançon, Department of Nephrology, Dialysis, and Renal Transplantation, Besançon, France
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27
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Roll P, Muhammad K, Stuhler G, Grigoleit U, Einsele H, Tony HP. Effect of ATG-F on B-cell reconstitution after hematopoietic stem cell transplantation. Eur J Haematol 2015; 95:514-23. [PMID: 25677646 DOI: 10.1111/ejh.12524] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 01/03/2023]
Abstract
Antithymocyte globulin Fresenius (ATG-F) is used before hematopoietic stem cell transplantation to prevent graft rejection and graft-versus-host disease in patients with HLA-matched unrelated donors or mismatched volunteers. However, little is known about the effect of ATG-F on the reconstitution of B-cell subsets. Sixty-seven patients were longitudinally studied at day 15, day 30, and then monthly after hematopoietic stem cell transplantation. Conditioning regimes included ATG-F, which was infused at days 3, 2 and 1 at a dosage of 10 mg/kg/d. Twenty-seven patients received conditioning regimes without ATG. ATG-treated patients showed a significant delay of CD19+ B cells in the early recovery period. The absolute numbers of circulating CD19+ B cells were significantly lower (P < 0.05) up to 5 months post-transplantation compared to non-ATG patients. The recovery of the memory compartment was delayed in both groups and did not reach normal values 1-year post-transplantation. ATG-treated patient showed significantly lower absolute numbers of circulating CD27+ memory B cells in the first-month after transplantation compared to non-ATG patients. In conclusion, treatment with ATG in the conditioning regime of patients undergoing allogeneic hematopoietic stem cell transplantation leads to a significant delay of CD19+ B cells. Thus, ATG seems also to negatively influence B-cell immune reconstitution.
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Affiliation(s)
- Petra Roll
- Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Khalid Muhammad
- Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Gernot Stuhler
- Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Ulrich Grigoleit
- Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Hermann Einsele
- Department of Medicine II, University of Würzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Department of Medicine II, University of Würzburg, Würzburg, Germany
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28
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Rosenblum JM, Kirk AD. Recollective homeostasis and the immune consequences of peritransplant depletional induction therapy. Immunol Rev 2015; 258:167-82. [PMID: 24517433 DOI: 10.1111/imr.12155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
One's cellular immune repertoire is composed of lymphocytes in multiple stages of maturation - the dynamic product of their responses to antigenic challenges and the homeostatic contractions necessary to accommodate immune expansions within physiologic norms. Given that alloreactivity is predominantly a cross-reactive phenomenon that is stochastically distributed throughout the overall T-cell repertoire, one's allospecific repertoire is similarly made up of cells in a variety of differentiation states. As such, the continuous expansion and elimination of activated memory populations, producing a 'recollective homeostasis' of sorts, has the potential over time to alter the maturation state and effector composition of both ones protective and alloreactive T-cell repertoire. Importantly, a T cell's maturation state significantly influences its response to numerous immunomodulatory therapies used in organ transplantation, including depletional antibody induction. In this review, we discuss clinically utilized depletional induction strategies, how their use alters a transplant recipient's cellular immune repertoire, and how a recipient's repertoire influences the clinical effects of induction therapy.
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30
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Wright AJ, Fishman JA. Central nervous system syndromes in solid organ transplant recipients. Clin Infect Dis 2014; 59:1001-11. [PMID: 24917660 DOI: 10.1093/cid/ciu428] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Solid organ transplant recipients have a high incidence of central nervous system (CNS) complications, including both focal and diffuse neurologic deficits. In the immunocompromised host, the initial clinical evaluation must focus on both life-threatening CNS infections and vascular or anatomic lesions. The clinical signs and symptoms of CNS processes are modified by the immunosuppression required to prevent graft rejection. In this population, these etiologies often coexist with drug toxicities and metabolic abnormalities that complicate the development of a specific approach to clinical management. This review assesses the multiple risk factors for CNS processes in solid organ transplant recipients and establishes a timeline to assist in the evaluation and management of these complex patients.
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Affiliation(s)
- Alissa J Wright
- Transplant Infectious Disease Program, Massachusetts General Hospital
| | - Jay A Fishman
- Transplant Infectious Disease Program, Massachusetts General Hospital Transplant Center, Harvard Medical School, Boston, Massachusetts
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31
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ATG induction in renal transplant recipients: Long-term hazard of severe infection is associated with long-term functional T cell impairment but not the ATG-induced CD4 cell decline. Hum Immunol 2014; 75:561-9. [DOI: 10.1016/j.humimm.2014.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 01/03/2014] [Accepted: 02/04/2014] [Indexed: 11/22/2022]
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Fernández-Ruiz M, López-Medrano F, Allende LM, Andrés A, García-Reyne A, Lumbreras C, San-Juan R, Morales JM, Paz-Artal E, Aguado JM. Kinetics of peripheral blood lymphocyte subpopulations predicts the occurrence of opportunistic infection after kidney transplantation. Transpl Int 2014; 27:674-85. [DOI: 10.1111/tri.12321] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 01/26/2014] [Accepted: 03/16/2014] [Indexed: 12/20/2022]
Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Luis M. Allende
- Department of Immunology; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Amado Andrés
- Department of Nephrology; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Ana García-Reyne
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Carlos Lumbreras
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - José M. Morales
- Department of Nephrology; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - Estela Paz-Artal
- Department of Immunology; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
| | - José M. Aguado
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12). School of Medicine; Universidad Complutense; Madrid Spain
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Ducloux D, Courivaud C, Bamoulid J, Crepin T, Chalopin JM, Tiberghien P, Saas P. Polyclonal antithymocyte globulin and cardiovascular disease in kidney transplant recipients. J Am Soc Nephrol 2014; 25:1349-56. [PMID: 24511120 DOI: 10.1681/asn.2013060663] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
T-lymphocyte activation may contribute to atherosclerosis, the prevalence of which is increased in transplant patients. However, the cardiovascular consequences of polyclonal antithymocyte globulin (ATG)-induced immune modifications, which include alterations in T-cell subsets, are unknown. We conducted a retrospective single-center study to assess whether ATG associates with an increased incidence of atherosclerotic events (CVEs) in kidney transplant patients. Propensity score analysis was performed to address potential confounding by indication. We also tested whether ATG use induces a proatherogenic immune status. Sixty-nine (12.2%) CVEs occurred during follow-up (87±31 months). The cumulative incidence of CVEs was higher in ATG-treated patients (14.7% versus 8.2%; P=0.03). Cox regression analysis revealed that ATG use was an independent risk factor for CVEs (hazard ratio [HR], 2.36; 95% confidence interval [95% CI], 1.35 to 4.13; P=0.003). Results obtained in the propensity score match analysis recapitulated those obtained from the overall cohort (HR, 2.09; 95% CI, 1.11 to 3.98; P=0.02). Late-stage differentiated CD8(+) T cells increased 1 year after transplantation only in ATG-treated patients. More generally, ATG associated with features of immune activation. These modifications increased markedly in patients exposed to cytomegalovirus (CMV). Subanalyses suggest that the effect of ATG on CVEs is restricted to CMV-exposed patients. However, CMV infection associated significantly with CVEs only in ATG-treated patients (HR, 2.07; 95% CI, 1.16 to 3.70; P=0.01). In conclusion, ATG associated with both immune activation and post-transplant CVEs in this cohort. Further studies should precisely determine whether ATG-induced immune activation is the causal link between ATG and CVEs.
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Affiliation(s)
- Didier Ducloux
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital of Besançon, Besançon, France; Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), University Hospital of Besançon, Besançon, France; and
| | - Cécile Courivaud
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital of Besançon, Besançon, France
| | - Jamal Bamoulid
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital of Besançon, Besançon, France
| | - Thomas Crepin
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital of Besançon, Besançon, France
| | - Jean-Marc Chalopin
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital of Besançon, Besançon, France; Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), University Hospital of Besançon, Besançon, France; and
| | - Pierre Tiberghien
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), University Hospital of Besançon, Besançon, France; and Biomonitoring Platform, French Blood Service Bourgogne Franche-Comté, Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), Besançon, France
| | - Philippe Saas
- Integrated Center for Research in Inflammatory Diseases (UMR1098), French Institute of Health and Medical Research, University Hospital Federation, Besançon, France; French Federal Research Institute for Engineering for Cellular and Tissue Biology (IFR133), University of Franche-Comté, Besançon, France; Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), University Hospital of Besançon, Besançon, France; and Biomonitoring Platform, French Blood Service Bourgogne Franche-Comté, Clinical Investigation Centre-Integrated Biotherapeutics (CIC-BT 506), Besançon, France
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Kinetics of homeostatic proliferation and thymopoiesis after rATG induction therapy in kidney transplant patients. Transplantation 2014; 96:904-13. [PMID: 23985721 DOI: 10.1097/tp.0b013e3182a203e4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lymphocyte-depleting therapy is associated with long-lasting effects on repopulated T cells and subsequent increased rates of infections and malignancies. The mechanisms of T-cell repopulation and their posttransplantation kinetics are not fully understood. METHODS We studied thymopoiesis by CD31(+) naïve T cells (recent thymic emigrants) and homeostatic proliferation by Ki-67(+) T cells in rabbit antithymocyte globulin (rATG)-treated patients the first 6 months after transplantation. Patients receiving basiliximab or no induction therapy served as controls. RESULTS At 6 months after transplantation, T-cell numbers were lower than before transplantation in rATG-treated patients, whereas T-cell numbers remained stable in both control groups. In this time period, thymopoiesis was similar between the three treatment groups; CD8(+) T cells showed the highest percentage of recent thymic emigrants. At month 1, percentages of Ki-67(+) naïve and memory CD4(+) and CD8(+) T cells were the highest in rATG-treated patients, but these percentages declined in the months thereafter. When CD31 was used to distinguish between cytokine- and antigen-driven proliferation in naïve T cells, we found evidence for cytokine-dependent proliferation. Cytokine-dependent proliferation was also shown by in vivo increased percentages of phosphorylated STAT5 and high expression levels of the interleukin-7 receptor-α and interleukin-15 receptor-α by T cells. CONCLUSION These findings demonstrate that, in the first month after rATG therapy, cytokine-induced homeostatic proliferation is involved in T-cell repopulation of both naïve and memory T cells. At later time points, the contribution of homeostatic proliferation diminished, which explains the observed incomplete T-cell recovery.
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Kudva YC, Erickson JR, Parsaik A, Rostambeigi N, Thapa P, Abraham RS. Comprehensive immune monitoring reveals profound immunological changes in pancreas after kidney (PAK) transplant recipients. Hum Immunol 2013; 74:738-45. [PMID: 23474226 DOI: 10.1016/j.humimm.2013.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 01/12/2013] [Accepted: 02/19/2013] [Indexed: 02/07/2023]
Abstract
Pancreas transplantation is a therapeutic option for the management of complicated Type 1 diabetes mellitus. While standard protocols include use of induction therapy followed by maintenance immunosuppression, the amount, frequency and duration of induction treatment has not been clearly defined. While the effect of various induction regimens on lymphocytes has been demonstrated, a prospective immune monitoring approach is not widely used to determine "immunological titration" of immunosuppression. In this study, we analyzed a patient cohort with pancreas after kidney transplantation and measured a wide range of quantitative and functional T and B cell parameters to identify those that would provide greatest value in personalized prospective immune assessment and design of immunosuppression. While there were significant quantitative differences observed in the 2 groups of PAK patients for various lymphocyte subsets, the notable observation was that lymphocyte subset quantitation was uninformative with regard to T cell function. Patients with normal lymphocyte counts had impaired T cell functional responses and vice versa. The use of immune monitoring to determine optimal IS regimens needs to be studied further to facilitate personalized management of immunosuppression with reduced risk of allograft rejection in PAK, and limited morbidity and mortality related to infection and malignancy.
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Affiliation(s)
- Yogish C Kudva
- Division of Endocrinology and Transplant Center, Mayo Clinic, Rochester, MN 55905, USA
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Xia CQ, Chernatynskaya AV, Wasserfall CH, Wan S, Looney BM, Eisenbeis S, Williams J, Clare-Salzler MJ, Atkinson MA. Anti-thymocyte globulin (ATG) differentially depletes naïve and memory T cells and permits memory-type regulatory T cells in nonobese diabetic mice. BMC Immunol 2012; 13:70. [PMID: 23237483 PMCID: PMC3547787 DOI: 10.1186/1471-2172-13-70] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 11/24/2012] [Indexed: 12/28/2022] Open
Abstract
Background ATG has been employed to deplete T cells in several immune-mediated conditions. However, whether ATG administration affects naïve and memory T cell differently is largely unknown. The context and purpose of the study In this study, we assessed how murine ATG therapy affected T cell subsets in NOD mice, based on their regulatory and naïve or memory phenotype, as well as its influence on antigen-specific immune responses. Results Peripheral blood CD4+ and CD8+ T cells post-ATG therapy declined to their lowest levels at day 3, while CD4+ T cells returned to normal levels more rapidly than CD8+ T cells. ATG therapy failed to eliminate antigen-primed T cells. CD4+ T cell responses post-ATG therapy skewed to T helper type 2 (Th2) and possibly IL-10-producing T regulatory type 1 (Tr1) cells. Intriguingly, Foxp3+ regulatory T cells (Tregs) were less sensitive to ATG depletion and remained at higher levels following in vivo recovery compared to controls. Of note, the frequency of Foxp3+ Tregs with memory T cell phenotype was significantly increased in ATG-treated animals. Conclusion ATG therapy may modulate antigen-specific immune responses through inducing memory-like regulatory T cells as well as other protective T cells such as Th2 and IL-10-producing Tr1 cells.
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Affiliation(s)
- Chang-Qing Xia
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing, P.R. China.
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Tang Q, Leung J, Melli K, Lay K, Chuu EL, Liu W, Bluestone JA, Kang SM, Peddi VR, Vincenti F. Altered balance between effector T cells and FOXP3+ HELIOS+ regulatory T cells after thymoglobulin induction in kidney transplant recipients. Transpl Int 2012; 25:1257-67. [PMID: 22994802 DOI: 10.1111/j.1432-2277.2012.01565.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This study examined the effect of thymoglobulin induction therapy on leukocyte population dynamics in kidney transplant patients. Patients receiving standard immunosuppression were compared with those who received additional thymoglobulin at the time of kidney transplantation. Thymoglobulin induction led to an immediate and significant decrease of all T cells and NK cells, but not B cells or monocytes. CD8(+) T cells recovered to near pretransplant level by 4 weeks post-transplant. CD4(+) T cells remained at less than 30% of pretransplant level for the entire study period of 78 weeks. Both CD4(+) and CD8(+) T cells showed reduced cytokine production after recovery. Deletion of CD4(+) FOXP3(+) HELIOS(+) regulatory T cells (Tregs) was less profound than that of CD4(+) FOXP3(-) cells, thus the relative percentage of Tregs elevated significantly when compared with pretransplant levels in thymoglobulin-treated patients. In contrast, the percentages of Tregs and their expression of FOXP3 in the standard immunosuppression group decreased steadily and by 12 weeks after transplant the average percentage of Tregs was 56% of the pretransplant level. Thus, thymoglobulin-induced deletion of T cells led to significant and long-lasting alterations of the T-cell compartment characterized by a preservation of Tregs and long-lasting reduction in CD4(+) , and potentially pathogenic, T cells.
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Affiliation(s)
- Qizhi Tang
- Department of Surgery, University of California-San Francisco, 513 Parnassus Ave., San Francisco, CA 94143, USA.
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Havenith SHC, Remmerswaal EBM, Bemelman FJ, Yong SL, van Donselaar-van der Pant KAMI, van Lier RAW, Ten Berge IJM. Rapid T cell repopulation after rabbit anti-thymocyte globulin (rATG) treatment is driven mainly by cytomegalovirus. Clin Exp Immunol 2012; 169:292-301. [PMID: 22861369 PMCID: PMC3445006 DOI: 10.1111/j.1365-2249.2012.04622.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rabbit anti-thymocyte globulin (rATG) induces a long-lasting lymphocytopenia. CD4(+) T cells remain depleted for up to 2 years, whereas the CD8(+) T cell compartment is refilled rapidly by highly differentiated CD27(-) CD45RA(+) CD57(+) effector-type cells. Because the presence of these highly differentiated CD8(+) T cells has been associated with cytomegalovirus (CMV) infection, we questioned to what extent restoration of CMV T cell immunity contributes to the re-emergence of T cells following rATG treatment. We compared T cell repopulation in six CMV-seropositive patients with CMV reactivation (reactivating CMV(+) ) to that in three CMV(+) patients without reactivation (non-reactivating CMV(+) ), and to that in three CMV-seronegative recipients receiving a kidney from a CMV-seronegative donor (CMV(-/-) ). All patients received rATG because of acute allograft rejection. Total CD4 and CD8 counts, frequency and phenotype of virus-specific CD8(+) T cells were determined. In reactivating CMV(+) patients, total CD8(+) T cells reappeared rapidly, whereas in non-reactivating CMV(+) patients they lagged behind. In CMV(-/-) patients, CD8(+) T cell counts had not yet reached pretransplant levels after 2 years. CMV reactivation was indeed followed by a progressive accumulation of CMV-specific CD8(+) T cells. During lymphocytopenia following rATG treatment, serum interleukin (IL)-7 levels were elevated. Although this was most prominent in the CMV-seronegative patients, it did not result in an advantage in T cell repopulation in these patients. Repopulated CD8(+) T cells showed increased skewing in their Vβ repertoire in both CMV(-/-) and reactivating CMV-seropositive patients. We conclude that rapid T cell repopulation following rATG treatment is driven mainly by CMV.
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Affiliation(s)
- S H C Havenith
- Renal Transplant Unit, Department of Internal Medicine Department of Experimental Immunology, Academic Medical Center Landsteiner Laboratory, Sanquin Research, Department of Experimental Immunology, Amsterdam, the Netherlands.
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Kho MML, Bouvy AP, Cadogan M, Kraaijeveld R, Baan CC, Weimar W. The effect of low and ultra-low dosages Thymoglobulin on peripheral T, B and NK cells in kidney transplant recipients. Transpl Immunol 2012; 26:186-90. [PMID: 22410573 DOI: 10.1016/j.trim.2012.02.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/24/2012] [Accepted: 02/27/2012] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Rabbit Anti-Thymocyte Globulin (r-ATG) is a polyclonal antibody preparation, used to prevent and treat acute rejection episodes after organ transplantation. However, despite more than 40 years of clinical use, the optimal dose of r-ATG is still not defined. To find a better balance between efficacy and infectious complications, we embarked on a controlled study and monitored the effect of low and ultra-low dosages Thymoglobulin (Genzyme) on peripheral T, B, and NK cells. PATIENTS AND METHODS Kidney transplant recipients received either 0.5 mg/kg, 1.0 mg/kg or 2.0 mg/kg on the first 3 consecutive days post-transplantation. Thus, total doses were 1.5 mg/kg, 3.0 mg/kg and 6.0 mg/kg. A total of 40 patients were enrolled, including 11 controls. All patients were treated with Prednisolon, Advagraf (Astellas) and Mycophenolate Mofetil (Roche). T (CD3+), B (CD19+) and NK (CD3-CD16+56+) cells were analyzed by flow cytometry. Baseline cell counts were compared to forty age and sex matched healthy persons. Post-transplantation cell counts of the 3 Thymoglobulin groups were compared to the 11 control patients, who received no induction therapy. RESULTS Absolute numbers of T, B, and NK cells were comparable in all patients pre-transplantation, but T and B cells were lower than in healthy persons (p=0.007 and p=0.0003, Mann Whitney test). In the first week, T cells and NK cells were significantly lower in all Thymoglobulin groups compared to controls. B cells were not affected. One month after Thymoglobulin NK cells had returned to control numbers in all groups, while T cells had already recovered to control counts in the 1.5 mg/kg group. During follow-up, T cells in the 3.0mg/kg group also returned to control values, but at one year the patients in the 6.0 mg/kg group still had significantly lower T cells (p=0.03). Patient and graft survival, rejection and infection incidence and renal function did not differ between groups. CONCLUSION Patients with end stage renal disease have significantly lower peripheral T and B cell counts than healthy persons. (Ultra-) low Thymoglobulin schedules deplete peripheral lymphocytes in a dose dependent way. Knowledge of the duration of this depletion contributes to finding the optimal immunosuppressive strategy for kidney transplant recipients.
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Affiliation(s)
- M M L Kho
- Department of Internal Medicine, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Patel M, Stefanidou M, Long CB, Fazzari MJ, Tesfa L, Del Rio M, Lamour J, Ricafort R, Madan RP, Herold BC. Dynamics of cell-mediated immune responses to cytomegalovirus in pediatric transplantation recipients. Pediatr Transplant 2012; 16:18-28. [PMID: 21762326 PMCID: PMC3214231 DOI: 10.1111/j.1399-3046.2011.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CMI responses, combined with quantification of CMV DNA (DNAemia), may identify transplantation recipients at risk for invasive disease. PBMC were collected in pediatric transplantation candidates at one, three, and six months post-transplant in 10 subjects (six renal, three cardiac, one stem cell) and at single time points in eight HC and 14 children greater than one yr post-transplant (LTTx). Cells were stimulated with anti-CD3mAb or CMV pp65 peptide pools and responses assessed by IFNG enzyme-linked immunosorbent spot assay and cytokine secretion. IFNG responses to anti-CD3mAb were significantly lower pretransplant relative to HC and were further decreased at one and three months post-transplant, but recovered to levels comparable to HC by six months. Responses to pp65 among CMV-seropositive recipients followed a similar pattern but recovered by three months. CMV-seropositive LTTx and HC showed a Th1 cytokine response to pp65 stimulation. Three LTTx subjects developed CMV DNAemia; two demonstrated decreased responses to anti-CD3mAB (and pp65 in the CMV seropositive subject) at the onset of DNAemia, which recovered as DNAemia resolved. Monitoring CMI in children is feasible and may provide an adjunct biomarker to predict CMV progression and recovery.
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Affiliation(s)
- Manisha Patel
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | | | | | | | - Lydia Tesfa
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcela Del Rio
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Jacqueline Lamour
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Rosanna Ricafort
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Rebecca P. Madan
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
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Low-dose rabbit antithymocyte globulin induction therapy results in prolonged selective lymphocyte depletion irrespective of maintenance immunosuppression. Transplant Proc 2011; 43:462-5. [PMID: 21440734 DOI: 10.1016/j.transproceed.2011.01.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rabbit antithymocyte globulin therapy (rATG) is a potent lymphocyte-depleting agent commonly used following renal transplantation to reduce the risk of acute rejection. Standard doses (7-10 mg/kg) of rATG result in profound lymphopenia and predispose patients to infection and malignancy. The effects of lower doses of rATG (LoD-rATG, 3-5 mg/kg) on peripheral blood lymphocytes (PBL) are as yet unknown. In this prospective clinical trial, PBL subsets were characterized by flow cytometry over 12 months following LoD-rATG therapy. All patients were initially treated with standard doses of tacrolimus, mycophenolic acid, and prednisone. At 3 months, patients were randomized to either lower doses of tacrolimus or sirolimus to examine the effects of maintenance immunosuppression on PBL reemergence. LoD-rATG therapy resulted in prolonged suppression of CD19+ B cells, total CD3+ T cells, as well as naïve and memory CD4+ T cell and CD4/CD25/Foxp3+ T-regulatory subsets irrespective of chronic immunosuppressive therapy. Selective depletion was only noted in the CD4CD45RA+ naïve T-cell subset resulting in an altered memory/naïve CD4+ ratio. LoD-rATG failed to deplete CD8+ T cells, which increased their relative contribution to the total CD3+ pool. All other lymphocyte subsets maintained near normal proportions. Thus, LoD-rATG therapy may lessen the adverse effects of full dose rATG while maintaining overall efficacy.
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Courivaud C, Bamoulid J, Ferrand C, Tiberghien P, Chalopin JM, Saas P, Ducloux D. The COX-2 gene promoter polymorphism -765 delays CD4 T-cell reconstitution after lymphocyte depletion with antithymocyte globulins. Hum Immunol 2011; 72:1060-3. [PMID: 21782872 DOI: 10.1016/j.humimm.2011.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 05/10/2011] [Accepted: 05/20/2011] [Indexed: 11/19/2022]
Abstract
Polyclonal antithymocyte globulins (ATG) induce persistent changes in T-lymphocyte subsets characterized by low CD4 T. The mechanisms remain partly unknown. Prostaglandin E(2) (PGE(2)) is involved in lymphocyte homeostasis. Whether PGE(2) may be involved in persistent CD4 T-cell lymphopenia after ATG is unknown. We examined the association between this polymorphism and CD4 T-cell count in 159 renal transplant recipients (RTR) who received ATG. Analysis of these patients identified 6 CC (3.8%), 32 GC (22.6%), and 117 GG (73.6%) genotypes. Patients with the GG genotype had significantly higher serum PGE(2) concentrations, leading us to compare C carriers with GG patients. Carriers of the C allele had lower CD4 T cell count 1 year (235 ± 96 vs 323 ± 227/mm(3); p = 0.022) and 2 years posttransplant (325 ± 79 vs 422 ± 231/mm(3); p = 0.024). In multivariate analysis, the C allele (p = 0.029) conferred an increased risk of posttransplant CD4 T-cell lymphocytopenia. Pretransplant T-cell receptor excision circle levels were lower in C carriers. COX-2 gene promoter polymorphism at position -765 (G → C) is associated with persistent CD4 T-cell lymphopenia after ATG in RTR. This effect is likely to be mediated by the actions of PGE(2) on thymus function and viability.
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Ducloux D, Bamoulid J, Courivaud C, Gaugler B, Rebibou JM, Ferrand C, Chalopin JM, Borg C, Tiberghien P, Saas P. Thymic function, anti-thymocytes globulins, and cancer after renal transplantation. Transpl Immunol 2011; 25:56-60. [PMID: 21620972 DOI: 10.1016/j.trim.2011.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/10/2011] [Accepted: 05/11/2011] [Indexed: 01/18/2023]
Abstract
BACKGROUND Prolonged CD4 T cell lymphopenia after polyclonal antithymocyte globulins (ATG) is associated with an increased rate of cancers. Here, we examined whether pre-transplant thymic function estimated by TREC levels is predictive of cancer occurrence following ATG treatment. PATIENTS AND METHODS The impact of TREC on cancer occurrence was analyzed in 115 consecutive incident renal transplant recipients having received ATG. RESULTS Mean follow-up was 7.5±2.6years. After ATG induction, patients with the lowest pre-transplant TREC values had lower post-transplant CD4(+) and CD4(+) CD45RA(+) CD45RO(-) T cell counts, and a higher frequency of T cells with a regulatory phenotype (CD127(+)CD4(+)CD25(+)Foxp3(+)). Log-transformed pre-transplant TREC values were significantly lower in patients who developed cancer after transplantation (p<0.0001). The cumulative incidence of cancer was higher in patients having the lowest pre-transplant TREC values (T1 [low]: 47.4%, T2 [medium]: 12.5%, and T3 [high]: 2.7%; p<0.0001). In multivariate analysis, pre-transplant TREC value was the only predictive factor of cancer (HR, 0.39; 95% CI, 0.16 to 0.97, for one log (TREC/10(6) PBMC); p=0.046). CONCLUSIONS Pre-transplant thymic function is associated with an increased rate of post-transplant cancer in patients having received ATG. Omitting ATG in recipients with low pre-transplant TREC values should be considered.
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Gajarski RJ, Blume ED, Urschel S, Schechtman K, Zheng J, West LJ, Altamirano L, Miyamoto S, Naftel DC, Kirklin JK, Zamberlan MC, Canter CE. Infection and malignancy after pediatric heart transplantation: The role of induction therapy. J Heart Lung Transplant 2011; 30:299-308. [DOI: 10.1016/j.healun.2010.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 09/04/2010] [Accepted: 09/22/2010] [Indexed: 01/24/2023] Open
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Laftavi M, Alnimri M, Weber-Shrikant E, Kohli R, Said M, Patel S, Pankewycz O. Low-Dose Rabbit Antithymocyte Globulin Versus Basiliximab Induction Therapy in Low-Risk Renal Transplant Recipients: 8-Year Follow-Up. Transplant Proc 2011; 43:458-61. [DOI: 10.1016/j.transproceed.2011.01.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Opportunistic Infections in Heart Transplant Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2010. [DOI: 10.1097/ipc.0b013e3181e9b7e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morelon E, Lefrançois N, Besson C, Prévautel J, Brunet M, Touraine JL, Badet L, Touraine-Moulin F, Thaunat O, Malcus C. Preferential increase in memory and regulatory subsets during T-lymphocyte immune reconstitution after Thymoglobulin induction therapy with maintenance sirolimus vs cyclosporine. Transpl Immunol 2010; 23:53-8. [PMID: 20406686 DOI: 10.1016/j.trim.2010.04.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 02/17/2010] [Accepted: 04/05/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sirolimus maintenance therapy with Thymoglobulin induction is a promising regimen that may preserve renal function. Data are lacking, however, about the immunologic effects of combined Thymoglobulin-sirolimus. METHODS In a 12-month, prospective, randomised, open-label, single-centre pilot study, de novo deceased-donor kidney transplant patients were randomised to receive cyclosporine or sirolimus, with Thymoglobulin induction, mycophenolate mofetil and corticosteroids. Flow cytometry analysis of peripheral blood was used to evaluate immune reconstitution. RESULTS Nineteen patients were recruited (sirolimus 9, cyclosporine 10). Reconstitution of the CD4(+) T-lymphocyte subset was significantly lower with sirolimus versus cyclosporine over year 1, but CD8(+) reconstitution did not differ significantly between groups. The proportion of naïve CD4(+) T-lymphocytes showed an initial decrease with sirolimus versus cyclosporine. Naïve CD8(+) T-lymphocytes increased versus baseline in the cyclosporine cohort at months 1 and 3, but remained unchanged with sirolimus. Memory CD4(+) T-lymphocytes occurred more frequently in sirolimus- versus cyclosporine-treated patients during year 1. The proportion of memory CD8(+) T-lymphocytes decreased at months 1 and 3 compared to baseline in the CsA arm, but did not change in the sirolimus cohort. By month 12, the proportion of both naïve and memory CD4(+) and CD8(+) T-lymphocytes had become similar with sirolimus or cyclosporine. There were fewer naïve B-lymphocytes in the sirolimus cohort and more CD19(-)IgD(+/-)CD27(+) memory B-lymphocytes. CONCLUSIONS In this small population, homeostatic reconstitution after Thymoglobulin induction showed disproportionately high recovery of memory T-lymphocyte subsets during sirolimus therapy, which may explain the higher rejection rate seen with sirolimus versus cyclosporine following kidney transplantation.
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Ducloux D, Courivaud C, Bamoulid J, Vivet B, Chabroux A, Deschamps M, Rebibou JM, Ferrand C, Chalopin JM, Tiberghien P, Saas P. Prolonged CD4 T cell lymphopenia increases morbidity and mortality after renal transplantation. J Am Soc Nephrol 2010; 21:868-75. [PMID: 20203160 DOI: 10.1681/asn.2009090976] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Prolonged CD4 T cell lymphopenia after administration of polyclonal anti-thymocyte globulins increases the rate of posttransplantation morbidity, but whether impaired immune reconstitution affects survival is unknown. We studied the effect of CD4 T cell lymphopenia on survival in 302 consecutive prevalent renal transplant recipients and the role of thymic function in CD4 T cell reconstitution and posttransplantation outcomes in 100 consecutive incident renal transplant recipients. We followed the prevalent cohort for a mean duration of 92 months. Of these 302 patients, 81 (27%) had persistent CD4 T cell counts <300/mm3 and 36 (12%) died during follow-up. We observed a higher death rate in patients with CD4 T cell lymphopenia persisting for >1 year (24.1 versus 7.6%; P < 0.001). Furthermore, in Cox regression analysis, CD4 T cell lymphopenia associated with a nearly five-fold risk for death (adjusted hazard ratio [HR] 4.63; 95% confidence interval [CI] 1.91 to 10.65; P = 0.001). In the incident cohort, we estimated thymic function by T cell receptor excision circles (TRECs) per 150,000 CD3+ cells, which predicted efficient CD4 T cell reconstitution. Higher pretransplantation TREC values associated with lower risks for cancer (adjusted HR 0.39; 95% CI 0.15 to 0.97; P = 0.046) and infection (HR 0.29; 95% CI 0.11 to 0.78; P = 0.013). In summary, prolonged polyclonal anti-thymocyte globulin-induced CD4 T cell lymphopenia is an independent risk factor for death. Determination of pretransplantation thymic function may identify patients at higher risk for CD4 T cell lymphopenia and posttransplantation morbidity, including cancer and infections.
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Affiliation(s)
- Didier Ducloux
- Institut National de la Santé Et de la Recherche Médicale, UMR645, Besançon, France.
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Cantarovich D, Rostaing L, Kamar N, Saint-Hillier Y, Ducloux D, Mourad G, Garrigue V, Wolf P, Ellero B, Cassuto E, Albano L, Soulillou JP. Corticosteroid avoidance in adult kidney transplant recipients under rabbit anti-T-lymphocyte globulin, mycophenolate mofetil and delayed cyclosporine microemulsion introduction. Transpl Int 2010; 23:313-24. [DOI: 10.1111/j.1432-2277.2009.00971.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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