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de Weerd AE, Roelen DL, Betjes MG, Clahsen-van Groningen MC, Haasnoot GW, Kho MM, Reinders ME, Roodnat JI, Severs D, Karahan GE, van de Wetering J. Anti-HLA Class II Antibodies Are the Most Resistant to Desensitization in Crossmatch-positive Living-donor Kidney Transplantations: A Patient Series. Transplant Direct 2024; 10:e1695. [PMID: 39220218 PMCID: PMC11365629 DOI: 10.1097/txd.0000000000001695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 09/04/2024] Open
Abstract
Background In HLA-incompatible kidney transplantation, the efficacy of desensitization in terms of anti-HLA antibody kinetics is not well characterized. We present an overview of the course of anti-HLA antibodies throughout plasma exchange (PE) desensitization in a series of crossmatch-positive patients. Methods All consecutive candidates in the Dutch HLA-incompatible kidney transplantation program between November 2012 and January 2022 were included. The eligibility criteria were a positive crossmatch with a living kidney donor and no options for compatible transplantation. Desensitization consisted of 5-10 PE with low-dose IVIg. Results A total of 16 patient-donor pairs were included. Patients had median virtual panel-reactive antibody of 99.58%. Cumulative donor-specific anti-HLA antibody (cumDSA) mean fluorescence intensity (MFI) was 31 399 median, and immunodominant DSA (iDSA) MFI was 18 677 for class I and 21 893 for class II. Median anti-HLA antibody MFI response to desensitization was worse in class II as compared with class I (P < 0.001), particularly for HLA-DQ. Class I cumDSA MFI decreased 68% after 4 PE versus 53% in class II. The decrease between the fifth and the 10th PE sessions was modest with 21% in class I versus 9% in class II. Antibody-mediated rejection occurred in 85% of patients, with the iDSA directed to the same mismatched HLA as before desensitization, except for 3 patients, of whom 2 had vigorous rebound of antibodies to repeated mismatches (RMMs). Rebound was highest (86%) in RMM-DSA with prior grafts removed (transplantectomy n = 7), lower (39%) in non-RMM-DSA (n = 30), and lowest (11%) for RMM-DSA with in situ grafts (n = 5; P = 0.018 for RMM-DSA transplantectomy versus RMM-DSA graft in situ). With a median follow-up of 59 mo, 1 patient had died resulting in a death-censored graft survival of 73%. Conclusions Patients with class II DSA, and particularly those directed against HLA-DQ locus, were difficult to desensitize.
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Affiliation(s)
- Annelies E. de Weerd
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Dave L. Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel G.H. Betjes
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | | | - Geert W. Haasnoot
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcia M.L. Kho
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marlies E.J. Reinders
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Joke I. Roodnat
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - David Severs
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Gonca E. Karahan
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
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2
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Smith TJ, Elmore ZC, Fusco RM, Hull JA, Rosales A, Martinez M, Tarantal AF, Asokan A. Engineered IgM and IgG cleaving enzymes for mitigating antibody neutralization and complement activation in AAV gene transfer. Mol Ther 2024; 32:2080-2093. [PMID: 38715362 PMCID: PMC11286816 DOI: 10.1016/j.ymthe.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 05/21/2024] Open
Abstract
Systemic dosing of adeno-associated viral (AAV) vectors poses potential risk of adverse side effects including complement activation triggered by anti-capsid immunity. Due to the multifactorial nature of toxicities observed in this setting, a wide spectrum of immune modulatory regimens are being investigated in the clinic. Here, we discover an IgM cleaving enzyme (IceM) that degrades human IgM, a key trigger in the anti-AAV immune cascade. We then engineer a fusion enzyme (IceMG) with dual proteolytic activity against human IgM and IgG. IceMG cleaves B cell surface antigen receptors and inactivates phospholipase gamma signaling in vitro. Importantly, IceMG is more effective at inhibiting complement activation compared with an IgG cleaving enzyme alone. Upon IV dosing, IceMG rapidly and reversibly clears circulating IgM and IgG in macaques. Antisera from these animals treated with IceMG shows decreased ability to neutralize AAV and activate complement. Consistently, pre-conditioning with IceMG restores AAV transduction in mice passively immunized with human antisera. Thus, IgM cleaving enzymes show promise in simultaneously addressing multiple aspects of anti-AAV immunity mediated by B cells, circulating antibodies and complement. These studies have implications for improving safety of AAV gene therapies and possibly broader applications including organ transplantation and autoimmune diseases.
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Affiliation(s)
- Timothy J Smith
- Department of Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Zachary C Elmore
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Robert M Fusco
- Department of Biomedical Engineering, Duke University, Durham, NC 27710, USA
| | - Joshua A Hull
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Alan Rosales
- Department of Biomedical Engineering, Duke University, Durham, NC 27710, USA
| | - Michele Martinez
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, Davis, CA 95616, USA
| | - Aravind Asokan
- Department of Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, NC 27710, USA; Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA; Department of Biomedical Engineering, Duke University, Durham, NC 27710, USA.
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3
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Krishnan N, Briggs D. Imlifidase: Is it the Magic Wand in Renal Transplantation? Indian J Nephrol 2024; 34:291-296. [PMID: 39156835 PMCID: PMC11326793 DOI: 10.25259/ijn_325_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/15/2023] [Indexed: 08/20/2024] Open
Abstract
Potential kidney transplant patients with HLA-specific antibodies have reduced access to transplantation. Their harmful effects are mediated by the Fc portion of IgG, including activation of the complement system and Fc receptor-initiated cytotoxic processes by circulating leucocytes. Avoiding antibody incompatibility is the conventional approach, but for some patients this can mean extended waiting times, or even no chance of a transplant if there are no alternative, compatible donors. For these cases, pretransplant antibody removal may provide access to transplantation. Plasmapheresis is currently used to achieve this, with acceptable outcome results, but the process can take days to reduce the antibody levels to a safe level, so has limited use for deceased donors. There is now an alternative, in the form of an IgG-digesting enzyme, Imlifidase, which can be administered for in vivo IgG inactivation. Imlifidase cleaves human IgG, separating the antigen-binding part, F(ab')2 from Fc. Typically, within six hours of dosing, most, if not all, of the circulating IgG has been inactivated, allowing safe transplantation from a previously incompatible donor. For deceased donor transplantation, where minimizing cold ischaemia is critical, this six-hour delay before implantation should be manageable, with the compatibility testing processes adjusted to accommodate the treatment. This agent has been used successfully in phase 2 clinical trials, with good short to medium term outcomes. While a donation rate that matches demand may be one essential answer to providing universal access to kidney transplantation, this is currently unrealistic. IgG inactivation, using Imlifidase, is, however, a realistic and proven alternative.
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Affiliation(s)
- Nithya Krishnan
- Department of Renal and Transplant Medicine, Institute of Cardiometabolic Medicine, University of Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute of Community and Health Care, Coventry University, Coventry, United Kingdom
| | - David Briggs
- Histocompatibility and Immunogenetics Lab, NHS Blood and Transplant, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Coventry, United Kingdom
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4
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Kanbay M, Copur S, Guldan M, Topcu AU, Ozbek L, Hasbal B, Süsal C, Kocak B, Callemeyn J, Segelmark M. Imlifidase in kidney transplantation. Clin Kidney J 2024; 17:sfae033. [PMID: 38504664 PMCID: PMC10949912 DOI: 10.1093/ckj/sfae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Indexed: 03/21/2024] Open
Abstract
Kidney transplantation, the gold-standard therapeutic approach for patients with end-stage kidney disease, offers improvement in patient survival and quality of life. However, broad sensitization against human leukocyte antigens often resulting in a positive crossmatch against the patient's living donor or the majority of potential deceased donors in the allocation system represents a major obstacle due to a high risk for antibody-mediated rejection, delayed graft function and allograft loss. Kidney-paired donation and desensitization protocols have been established to overcome this obstacle, with limited success. Imlifidase, a novel immunoglobulin G (IgG)-degrading enzyme derived from Streptococcus pyogenes and recombinantly produced in Escherichia coli, is a promising agent for recipients with a positive crossmatch against their organ donor with high specificity towards IgG, rapid action and high efficacy in early pre-clinical and clinical studies. However, the rebound of IgG after a few days can lead to antibody-mediated rejection, making the administration of potent immunosuppressive regimens in the early post-transplant phase necessary. There is currently no comparative study evaluating the efficiency of imlifidase therapy compared with conventional desensitization protocols along with the lack of randomized control trials, indicating the clear need for future large-scale clinical studies in this field. Besides providing a practical framework for the clinical use of the agent, our aim in this article is to evaluate the underlying mechanism of action, efficiency and safety of imlifidase therapy in immunologically high-risk kidney transplant recipients.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mustafa Guldan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmet U Topcu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Lasin Ozbek
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Hasbal
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Süsal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Jasper Callemeyn
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Endocrinology, Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
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5
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de Weerd AE, Roelen DL, van de Wetering J, Betjes MGH, Heidt S, Reinders MEJ. Imlifidase Desensitization in HLA-incompatible Kidney Transplantation: Finding the Sweet Spot. Transplantation 2024; 108:335-345. [PMID: 37340532 DOI: 10.1097/tp.0000000000004689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Imlifidase, derived from a Streptococcus pyogenes enzyme, cleaves the entire immunoglobulin G pool within hours after administration in fully cleaved antigen-binding and crystallizable fragments. These cleaved fragments can no longer exert their antibody-dependent cytotoxic functions, thereby creating a window to permit HLA-incompatible kidney transplantation. Imlifidase is labeled, in Europe only, for deceased donor kidney transplantation in highly sensitized patients, whose chances for an HLA-compatible transplant are negligible. This review discusses outcomes of preclinical and clinical studies on imlifidase and describes the phase III desensitization trials that are currently enrolling patients. A comparison is made with other desensitization methods. The review discusses the immunological work-up of imlifidase candidates and especially the "delisting strategy" of antigens that shift from unacceptable to acceptable with imlifidase desensitization. Other considerations for clinical implementation, such as adaptation of induction protocols, are also discussed. Imlifidase cleaves most of the currently used induction agents except for horse antithymocyte globulin, and rebound of donor-specific antibodies should be managed. Another consideration is the timing and interpretation of (virtual) crossmatches when bringing this novel desensitization agent into the clinic.
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Affiliation(s)
- Annelies E de Weerd
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine, Erasmus Medical Center Transplant Institute, University Medical Center, Rotterdam, the Netherlands
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Müller L, Dabbiru VAS, Schönborn L, Greinacher A. Therapeutic strategies in FcγIIA receptor-dependent thrombosis and thromboinflammation as seen in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombocytopenia and thrombosis (VITT). Expert Opin Pharmacother 2024; 25:281-294. [PMID: 38465524 DOI: 10.1080/14656566.2024.2328241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Fcγ-receptors (FcγR) are membrane receptors expressed on a variety of immune cells, specialized in recognition of the Fc part of immunoglobulin G (IgG) antibodies. FcγRIIA-dependent platelet activation in platelet factor 4 (PF4) antibody-related disorders have gained major attention, when these antibodies were identified as the cause of the adverse vaccination event termed vaccine-induced immune thrombocytopenia and thrombosis (VITT) during the COVID-19 vaccination campaign. With the recognition of anti-PF4 antibodies as cause for severe spontaneous and sometimes recurrent thromboses independent of vaccination, their clinical relevance extended far beyond heparin-induced thrombocytopenia (HIT) and VITT. AREAS COVERED Patients developing these disorders show life-threatening thromboses, and the outcome is highly dependent on effective treatment. This narrative literature review summarizes treatment options for HIT and VITT that are currently available for clinical application and provides the perspective toward new developments. EXPERT OPINION Nearly all these novel approaches are based on in vitro, preclinical observations, or case reports with only limited implementation in clinical practice. The therapeutic potential of these approaches still needs to be proven in larger cohort studies to ensure treatment efficacy and long-term patient safety.
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Affiliation(s)
- Luisa Müller
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Venkata A S Dabbiru
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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7
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Happonen L, Collin M. Immunomodulating Enzymes from Streptococcus pyogenes-In Pathogenesis, as Biotechnological Tools, and as Biological Drugs. Microorganisms 2024; 12:200. [PMID: 38258026 PMCID: PMC10818452 DOI: 10.3390/microorganisms12010200] [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: 12/19/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Streptococcus pyogenes, or Group A Streptococcus, is an exclusively human pathogen that causes a wide variety of diseases ranging from mild throat and skin infections to severe invasive disease. The pathogenesis of S. pyogenes infection has been extensively studied, but the pathophysiology, especially of the more severe infections, is still somewhat elusive. One key feature of S. pyogenes is the expression of secreted, surface-associated, and intracellular enzymes that directly or indirectly affect both the innate and adaptive host immune systems. Undoubtedly, S. pyogenes is one of the major bacterial sources for immunomodulating enzymes. Major targets for these enzymes are immunoglobulins that are destroyed or modified through proteolysis or glycan hydrolysis. Furthermore, several enzymes degrade components of the complement system and a group of DNAses degrade host DNA in neutrophil extracellular traps. Additional types of enzymes interfere with cellular inflammatory and innate immunity responses. In this review, we attempt to give a broad overview of the functions of these enzymes and their roles in pathogenesis. For those enzymes where experimentally determined structures exist, the structural aspects of the enzymatic activity are further discussed. Lastly, we also discuss the emerging use of some of the enzymes as biotechnological tools as well as biological drugs and vaccines.
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Affiliation(s)
- Lotta Happonen
- Faculty of Medicine, Department of Clinical Sciences, Division of Infection Medicine, Lund University, SE-22184 Lund, Sweden
| | - Mattias Collin
- Faculty of Medicine, Department of Clinical Sciences, Division of Infection Medicine, Lund University, SE-22184 Lund, Sweden
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8
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Chuecos MA, Lagor WR. Liver directed adeno-associated viral vectors to treat metabolic disease. J Inherit Metab Dis 2024; 47:22-40. [PMID: 37254440 PMCID: PMC10687323 DOI: 10.1002/jimd.12637] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/01/2023]
Abstract
The liver is the metabolic center of the body and an ideal target for gene therapy of inherited metabolic disorders (IMDs). Adeno-associated viral (AAV) vectors can deliver transgenes to the liver with high efficiency and specificity and a favorable safety profile. Recombinant AAV vectors contain only the transgene cassette, and their payload is converted to non-integrating circular double-stranded DNA episomes, which can provide stable expression from months to years. Insights from cellular studies and preclinical animal models have provided valuable information about AAV capsid serotypes with a high liver tropism. These vectors have been applied successfully in the clinic, particularly in trials for hemophilia, resulting in the first approved liver-directed gene therapy. Lessons from ongoing clinical trials have identified key factors affecting efficacy and safety that were not readily apparent in animal models. Circumventing pre-existing neutralizing antibodies to the AAV capsid, and mitigating adaptive immune responses to transduced cells are critical to achieving therapeutic benefit. Combining the high efficiency of AAV delivery with genome editing is a promising path to achieve more precise control of gene expression. The primary safety concern for liver gene therapy with AAV continues to be the small risk of tumorigenesis from rare vector integrations. Hepatotoxicity is a key consideration in the safety of neuromuscular gene therapies which are applied at substantially higher doses. The current knowledge base and toolkit for AAV is well developed, and poised to correct some of the most severe IMDs with liver-directed gene therapy.
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Affiliation(s)
- Marcel A. Chuecos
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX USA
- Translational Biology and Molecular Medicine Program, Baylor College of Medicine, Houston, TX USA
| | - William R. Lagor
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX USA
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Carpenter MC, Souter SC, Zipkin RJ, Ackerman ME. Current Insights Into K-associated Fetal Anemia and Potential Treatment Strategies for Sensitized Pregnancies. Transfus Med Rev 2024; 38:150779. [PMID: 37926651 PMCID: PMC10856777 DOI: 10.1016/j.tmrv.2023.150779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
K-associated anemic disease of the fetus and newborn (K-ADFN) is a rare but life-threatening disease in which maternal alloantibodies cross the placenta and can mediate an immune attack on fetal red blood cells expressing the K antigen. A considerably more common disease, D-associated hemolytic disease of the fetus and newborn (D-HDFN), can be prophylactically treated using polyclonal α-D antibody preparations. Currently, no such prophylactic treatment exists for K-associated fetal anemia, and disease is usually treated with intrauterine blood transfusions. Here we review current understanding of the biology of K-associated fetal anemia, how the maternal immune system is sensitized to fetal red blood cells, and what is understood about potential mechanisms of prophylactic HDFN interventions. Given the apparent challenges associated with preventing alloimmunization, we highlight novel strategies for treating sensitized mothers to prevent fetal anemia that may hold promise not only for K-mediated disease, but also for other pathogenic alloantibody responses.
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Affiliation(s)
| | | | | | - Margaret E Ackerman
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA; Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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10
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DeLaura I, Zikos J, Anwar IJ, Yoon J, Ladowski J, Jackson A, Van Rompay K, Magnani D, Knechtle SJ, Kwun J. The impact of IdeS (imlifidase) on allo-specific, xeno-reactive, and protective antibodies in a sensitized rhesus macaque model. Xenotransplantation 2024; 31:e12833. [PMID: 37864433 PMCID: PMC10999173 DOI: 10.1111/xen.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Highly sensitized patients face many barriers to kidney transplantation, including higher rates of antibody-mediated rejection after HLA-incompatible transplant. IdeS, an endopeptidase that cleaves IgG nonspecifically, has been trialed as desensitization prior to kidney transplant, and successfully cleaves donor-specific antibody (DSA), albeit with rebound. METHODS IdeS was generated and tested (2 mg/kg, IV) in two naïve and four allosensitized nonhuman primates (NHP). Peripheral blood samples were collected at regular intervals following IdeS administration. Total IgG, total IgM, and anti-CMV antibodies were quantified with ELISA, and donor-specific antibody (DSA) and anti-pig antibodies were evaluated using flow cytometric crossmatch. B cell populations were assessed using flow cytometry. RESULTS IdeS successfully cleaved rhesus IgG in vitro. In allosensitized NHP, robust reduction of total, DSA, anti-pig, and anti-CMV IgG was observed within one day following IdeS administration. Rapid rebound of all IgG antibody populations was observed, with antibody levels returning to baseline around day 14 post-infusion. Total IgM level was not affected by IdeS. Interestingly, a comparable reduction in antibody populations was observed after the second dose of IdeS. However, we have not observed any significant modulation of B cell subpopulations after IdeS. CONCLUSIONS This study evaluated efficacy of IdeS in the allosensitized NHP in IgG with various specificities, mirroring antibody kinetics in human patients. The efficacy of IdeS on preexisting anti-pig antibodies may be useful in clinical xenotransplantation. However, given the limitation of IdeS on its durability as a monotherapy, optimization of IdeS with other agents targeting the humoral response is further needed.
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Affiliation(s)
- Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Joanna Zikos
- MassBiologics of University of Massachusetts Medical School, Boston, MA, 02126, USA
| | - Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Joseph Ladowski
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Annette Jackson
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Koen Van Rompay
- California National Primate Research Center, University of California, Davis, CA 95616, USA
| | - Diogo Magnani
- MassBiologics of University of Massachusetts Medical School, Boston, MA, 02126, USA
| | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
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11
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Srivastava PK, Kittleson MM. Modern advances in heart transplantation. Prog Cardiovasc Dis 2024; 82:147-156. [PMID: 38244826 DOI: 10.1016/j.pcad.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Heart transplantation (HTx) is the only definitive therapy for patients with end stage heart disease. With the increasing global prevalence of heart failure, the demand for HTx has continued to grow and outpace supply. In this paper, we will review advances in the field of HTx along the clinical journey of a HTx recipient. Starting with the sensitized patient, we discuss current methods to define sensitization, and assays to help identify clinically relevant anti-HLA antibodies. Desensitization strategies targeting all levels of the adaptive immune system are discussed with emphasis on novel techniques such as anti-CD 38 blockade and use of the Immunoglobulin G-Degrading Enzyme of Streptococcus Pyogenes. We next discuss donor procurement and the resurgence of donation after circulatory death as a viable strategy to significantly and safely increase the donor pool. Post-transplant, we evaluate non-invasive surveillance techniques including gene expression profiling and donor-derived cell-free DNA. Last, we discuss the ground-breaking developments in the field of xenotransplantation.
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Affiliation(s)
- Pratyaksh K Srivastava
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America.
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12
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Fernando SC, Polkinghorne KR, Lim WH, Mulley WR. Early Versus Late Acute AMR in Kidney Transplant Recipients-A Comparison of Treatment Approaches and Outcomes From the ANZDATA Registry. Transplantation 2023; 107:2424-2432. [PMID: 37322595 DOI: 10.1097/tp.0000000000004700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft failure and demonstrates different properties depending on whether it occurs early (<6 mo) or late (>6 mo) posttransplantation. We aimed to compare graft survival and treatment approaches for early and late AMR in Australia and New Zealand. METHODS Transplant characteristics were obtained for patients with an AMR episode reported to the Australia and New Zealand Dialysis and Transplant Registry from January 2003 to December 2019. The primary outcome of time to graft loss from AMR diagnosis, with death considered a competing risk, was compared between early and late AMR using flexible parametric survival models. Secondary outcomes included treatments used, response to treatment, and time from AMR diagnosis to death. RESULTS After adjustment for other explanatory factors, late AMR was associated with twice the risk of graft loss relative to early AMR. The risk was nonproportional over time, with early AMR having an increased early risk. Late AMR was also associated with an increased risk of death. Early AMR was treated more aggressively than late with more frequent use of plasma exchange and monoclonal/polyclonal antibodies. There was substantial variation in treatments used by transplant centers. Early AMR was reported to be more responsive to treatment than late. CONCLUSIONS Late AMR is associated with an increased risk of graft loss and death compared with early AMR. The marked heterogeneity in the treatment of AMR highlights the need for effective, new therapeutic options for these conditions.
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Affiliation(s)
- Sanduni C Fernando
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - William R Mulley
- Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, VIC, Australia
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13
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Matsuoka Y, Goto N, Ichimori T, Narumi S, Takeda A, Kobayashi T, Uchida K, Watarai Y. Prediction models for the recipients' ideal perioperative estimated glomerular filtration rates for predicting graft survival after adult living-donor kidney transplantation. Front Med (Lausanne) 2023; 10:1187777. [PMID: 37720509 PMCID: PMC10501755 DOI: 10.3389/fmed.2023.1187777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction The impact of the perioperative estimated glomerular filtration rate (eGFR) on graft survival in kidney transplant recipients is yet to be evaluated. In this study, we developed prediction models for the ideal perioperative eGFRs in recipients. Methods We evaluated the impact of perioperative predicted ideal and actual eGFRs on graft survival by including 1,174 consecutive adult patients who underwent living-donor kidney transplantation (LDKT) between January 2008 and December 2020. Prediction models for the ideal perioperative eGFR were developed for 676 recipients who were randomly assigned to the training and validation sets (ratio: 7:3). The prediction models for the ideal best eGFR within 3 weeks and those at 1, 2, and 3 weeks after LDKT in 474 recipients were developed using 10-fold validation and stepwise multiple regression model analyzes. The developed prediction models were validated in 202 recipients. Finally, the impact of perioperative predicted ideal eGFRs/actual eGFRs on graft survival was investigated using Fine-Gray regression analysis. Results The correlation coefficients of the predicted ideal best eGFR within 3 weeks and the predicted ideal eGFRs at 1, 2, and 3 weeks after LDKT were 0.651, 0.600, 0.598, and 0.617, respectively. Multivariate analyzes for graft loss demonstrated significant differences in the predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT. Discussion The predicted ideal best eGFR/actual best eGFR within 3 weeks and the predicted ideal eGFRs/actual eGFRs at 1, 2, and 3 weeks after LDKT were independent prognostic factors for graft loss. Therefore, the perioperative predicted ideal eGFR/actual eGFR may be useful for predicting graft survival after adult LDKT.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yuki Hasegawa
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yutaka Matsuoka
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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14
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Locke AF, Hickey M, Valenzuela NM, Butler C, Sosa R, Zheng Y, Gjertson D, Reed EF, Zhang Q. Virtual and Reality: An Analysis of the UCLA Virtual Crossmatch Exchanges. Transplantation 2023; 107:1776-1785. [PMID: 36944607 PMCID: PMC10358445 DOI: 10.1097/tp.0000000000004586] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/05/2023] [Accepted: 01/29/2023] [Indexed: 03/23/2023]
Abstract
The "virtual" crossmatch (VXM) has become a critical tool to predict the compatibility between an organ donor and a potential recipient. Yet, nonstandardized laboratory practice can lead to variability in VXM interpretation. Therefore, UCLA's VXM Exchange survey was designed to understand factors that influence the variability of VXM prediction in the presence of HLA donor-specific antibody (DSA). Thirty-six donor blood samples and 72 HLA reference sera were sent to 35 participating laboratories to perform HLA antibody testing, flow crossmatch (FXM), and VXM from 2014 to 2019, consisting of 144 T/B-cell FXM pairs and 112 T/B-cell VXM pairs. In the FXM survey, 86% T-cell FXM and 84% B-cell FXM achieved >80% concordance among laboratories. In the VXM survey, 81% T-cell VXM and 80% VXM achieved >80% concordance. The concordance between FXM and VXM was 79% for T cell and 87% for B cell. The consensus between VXM and FXM was high with strong DSA. However, significant variability was observed in sera with (1) very high titer antibodies that exit prozone effect; (2) weak-to-moderate DSA, particularly in the presence of multiple weak DSAs; and (3) DSA against lowly expressed antigens. With the increasing use the VXM, standardization and continuous learning via exchange surveys will provide better understanding and quality controls for VXM to improve accuracy across all centers.
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Affiliation(s)
- Arlene F. Locke
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Michelle Hickey
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Nicole M. Valenzuela
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Carrie Butler
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Rebecca Sosa
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Ying Zheng
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - David Gjertson
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Elaine F. Reed
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
| | - Qiuheng Zhang
- UCLA Immunogenetics Center, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, CA
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15
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Guo Z, Zhao D, Sa R, Wang L, Li S, Zhao G, Zhu L, Chen G. A modified perioperative regimen for deceased donor kidney transplantation in presensitized recipients without prior desensitization therapy. Front Immunol 2023; 14:1223567. [PMID: 37475867 PMCID: PMC10355838 DOI: 10.3389/fimmu.2023.1223567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
Background Renal transplantation in HLA-presensitized recipients entails an increased risk of antibody-mediated rejection (AMR) and graft loss. There is currently no accepted standard treatment protocol that can help transplant surgeons safely perform deceased donor (DD) kidney transplantation in presensitized patients without pretransplant desensitization. Methods Fifty-one panel-reactive antibody (PRA)-positive recipients and 62 PRA-negative retransplant recipients (control) who received DD renal transplantation were included. Patients in the presensitized group (donor-specific antibody [DSA]-positive, n=25; DSA-negative, n=26) without desensitization received a modified perioperative treatment starting on day 0 or -1 with rituximab, thymoglobulin, and low daily doses of intravenous immunoglobulin (IVIG, 10-20 g/d, for 14 days). Plasmapheresis was performed once before surgery in DSA-positive recipients. Results The median follow-up time was 51 months in the presensitized group and 41 months in the control group. The incidence of early acute rejection (AR) and AMR (including mixed rejection) was 35.3% and 13.7% in the presensitized group, respectively, significantly higher than in the control group (14.5% and 1.6%, respectively). Within the presensitized group, the DSA-positive subgroup had more AMR than the DSA-negative subgroup (24.0% vs. 3.8%), but the incidence of T cell-mediated rejection was comparable (20.0% vs. 23.4%). In the presensitized group, all rejections were successfully reversed, and graft function remained stable during follow-up. The 1-year and 3-year survival rates of the grafts and recipients in this group were 98.0%. Conclusion With a modified IVIG-based perioperative regimen, excellent intermediate-term graft and recipient survival outcomes can be achieved in presensitized patients who received DD kidney transplantation without prior desensitization.
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Affiliation(s)
- Zhiliang Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daqiang Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Rula Sa
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Songxia Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangyuan Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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16
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Habibabady Z, McGrath G, Kinoshita K, Maenaka A, Ikechukwu I, Elias GF, Zaletel T, Rosales I, Hara H, Pierson RN, Cooper DKC. Antibody-mediated rejection in xenotransplantation: Can it be prevented or reversed? Xenotransplantation 2023; 30:e12816. [PMID: 37548030 PMCID: PMC11101061 DOI: 10.1111/xen.12816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Antibody-mediated rejection (AMR) is the commonest cause of failure of a pig graft after transplantation into an immunosuppressed nonhuman primate (NHP). The incidence of AMR compared to acute cellular rejection is much higher in xenotransplantation (46% vs. 7%) than in allotransplantation (3% vs. 63%) in NHPs. Although AMR in an allograft can often be reversed, to our knowledge there is no report of its successful reversal in a pig xenograft. As there is less experience in preventing or reversing AMR in models of xenotransplantation, the results of studies in patients with allografts provide more information. These include (i) depletion or neutralization of serum anti-donor antibodies, (ii) inhibition of complement activation, (iii) therapies targeting B or plasma cells, and (iv) anti-inflammatory therapy. Depletion or neutralization of anti-pig antibody, for example, by plasmapheresis, is effective in depleting antibodies, but they recover within days. IgG-degrading enzymes do not deplete IgM. Despite the expression of human complement-regulatory proteins on the pig graft, inhibition of systemic complement activation may be necessary, particularly if AMR is to be reversed. Potential therapies include (i) inhibition of complement activation (e.g., by IVIg, C1 INH, or an anti-C5 antibody), but some complement inhibitors are not effective in NHPs, for example, eculizumab. Possible B cell-targeted therapies include (i) B cell depletion, (ii) plasma cell depletion, (iii) modulation of B cell activation, and (iv) enhancing the generation of regulatory B and/or T cells. Among anti-inflammatory agents, anti-IL6R mAb and TNF blockers are increasingly being tested in xenotransplantation models, but with no definitive evidence that they reverse AMR. Increasing attention should be directed toward testing combinations of the above therapies. We suggest that treatment with a systemic complement inhibitor is likely to be most effective, possibly combined with anti-inflammatory agents (if these are not already being administered). Ultimately, it may require further genetic engineering of the organ-source pig to resolve the problem entirely, for example, knockout or knockdown of SLA, and/or expression of PD-L1, HLA E, and/or HLA-G.
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Affiliation(s)
- Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gannon McGrath
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ileka Ikechukwu
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela F. Elias
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tjasa Zaletel
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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17
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Mizera J, Pilch J, Giordano U, Krajewska M, Banasik M. Therapy in the Course of Kidney Graft Rejection-Implications for the Cardiovascular System-A Systematic Review. Life (Basel) 2023; 13:1458. [PMID: 37511833 PMCID: PMC10381422 DOI: 10.3390/life13071458] [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: 06/01/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Kidney graft failure is not a homogenous disease and the Banff classification distinguishes several types of graft rejection. The maintenance of a transplant and the treatment of its failure require specific medications and differ due to the underlying molecular mechanism. As a consequence, patients suffering from different rejection types will experience distinct side-effects upon therapy. The review is focused on comparing treatment regimens as well as presenting the latest insights into innovative therapeutic approaches in patients with an ongoing active ABMR, chronic active ABMR, chronic ABMR, acute TCMR, chronic active TCMR, borderline and mixed rejection. Furthermore, the profile of cardiovascular adverse effects in relation to the applied therapy was subjected to scrutiny. Lastly, a detailed assessment and comparison of different approaches were conducted in order to identify those that are the most and least detrimental for patients suffering from kidney graft failure.
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Affiliation(s)
- Jakub Mizera
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Justyna Pilch
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Ugo Giordano
- University Clinical Hospital, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
| | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-551 Wroclaw, Poland
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18
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Szumilas K, Wilk A, Wiśniewski P, Gimpel A, Dziedziejko V, Kipp M, Pawlik A. Current Status Regarding Immunosuppressive Treatment in Patients after Renal Transplantation. Int J Mol Sci 2023; 24:10301. [PMID: 37373448 DOI: 10.3390/ijms241210301] [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: 05/05/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Renal transplantation is now the best treatment for end-stage renal failure. To avoid rejection and prolong graft function, organ recipients need immunosuppressive therapy. The immunosuppressive drugs used depends on many factors, including time since transplantation (induction or maintenance), aetiology of the disease, and/or condition of the graft. Immunosuppressive treatment needs to be personalised, and hospitals and clinics have differing protocols and preparations depending on experience. Renal transplant recipient maintenance treatment is mostly based on triple-drug therapy containing calcineurin inhibitors, corticosteroids, and antiproliferative drugs. In addition to the desired effect, the use of immunosuppressive drugs carries risks of certain side effects. Therefore, new immunosuppressive drugs and immunosuppressive protocols are being sought that exert fewer side effects, which could maximise efficacy and reduce toxicity and, in this way, reduce both morbidity and mortality, as well as increase opportunities to modify individual immunosuppression for renal recipients of all ages. The aim of the current review is to describe the classes of immunosuppressive drugs and their mode of action, which are divided by induction and maintenance treatment. An additional aspect of the current review is a description of immune system activity modulation by the drugs used in renal transplant recipients. Complications associated with the use of immunosuppressive drugs and other immunosuppressive treatment options used in kidney transplant recipients have also been described.
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Affiliation(s)
- Kamila Szumilas
- Department of Physiology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Aleksandra Wilk
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Piotr Wiśniewski
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Anna Gimpel
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Markus Kipp
- Institute of Anatomy, Rostock University Medical Center, Gertrudenstrasse 9, 18057 Rostock, Germany
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
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Boksha IS, Lunin VG, Danilova TA, Poponova MS, Polyakov NB, Lyashchuk AM, Konstantinova SV, Galushkina ZM, Ustenko EV. Recombinant Endopeptidases IdeS and IdeZ and Their Potential Application. BIOCHEMISTRY. BIOKHIMIIA 2023; 88:731-740. [PMID: 37748870 DOI: 10.1134/s0006297923060020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 09/27/2023]
Abstract
Endopeptidases IdeS and IdeZ (streptococcal virulence factors that specifically cleave IgG heavy chains) are of particular interest because of their potential use in biotechnology, medicine, and veterinary. Genes encoding these enzymes were cloned and expressed in Escherichia coli heterologous expression system (ideS was cloned from a Streptococcus pyogenes collection strain; ideZ from Streptococcus zooepidemicus was synthesized). The 6His-tag was introduced into the amino acid sequence of each endopeptidase, and IdeS and IdeZ were purified by metal affinity chromatography to an apparent homogeneity (according to polyacrylamide gel electrophoresis). Purified enzymes were active against human and animal IgGs; their specificity toward human IgGs was confirmed by polyacrylamide gel electrophoresis. Recombinant IdeZ was used for immunological analysis of equine strangles infection (diagnostics and determination of the titer of specific antibodies in blood). Hence, IdeZ can be used in veterinary and sanitary microbiology to diagnose infections caused by Streptococcus equi and S. zooepidemicus in addition to its application in medicine and biotechnology.
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Affiliation(s)
- Irina S Boksha
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia.
- Mental Health Research Centre, Moscow, 115522, Russia
| | - Vladimir G Lunin
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Tatyana A Danilova
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Maria S Poponova
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Nikita B Polyakov
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Alexander M Lyashchuk
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Svetlana V Konstantinova
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Zoya M Galushkina
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
| | - Ekaterina V Ustenko
- Gamaleya National Research Center for Epidemiology and Microbiology, Ministry of Health of the Russian Federation, Moscow, 123098, Russia
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Romei MG, Leonard B, Kim I, Kim HS, Lazar GA. Antibody-guided proteases enable selective and catalytic degradation of challenging therapeutic targets. J Biol Chem 2023; 299:104685. [PMID: 37031819 DOI: 10.1016/j.jbc.2023.104685] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/08/2023] [Accepted: 03/23/2023] [Indexed: 04/11/2023] Open
Abstract
The exquisite specificity, natural biological functions, and favorable development properties of antibodies make them highly effective agents as drugs. Monoclonal antibodies are particularly strong as inhibitors of systemically accessible targets where trough-level concentrations can sustain full target occupancy. Yet beyond this pharmacologic wheelhouse, antibodies perform suboptimally for targets of high abundance and those not easily accessible from circulation. Fundamentally, this restraint on broader application is due largely to the stoichiometric nature of their activity - one drug molecule is generally able to inhibit a maximum of two target molecules at a time. Enzymes in contrast are able to catalytically turnover multiple substrates, making them a natural sub-stoichiometric solution for targets of high abundance or in poorly accessible sites of action. However, enzymes have their own limitations as drugs, including, in particular the polypharmacology and broad specificity often seen with native enzymes. In this study, we introduce antibody-guided proteolytic enzymes to enable selective sub-stoichiometric turnover of therapeutic targets. We demonstrate that antibody-mediated substrate targeting can enhance enzyme activity and specificity, with proof of concept for two challenging target proteins, amyloid-β (Aβ) and immunoglobulin G (IgG). This work advances a new biotherapeutic platform that combines the favorable properties of antibodies and proteolytic enzymes to more effectively suppress high-bar therapeutic targets.
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Affiliation(s)
- Matthew G Romei
- Department of Antibody Engineering, Genentech Inc., South San Francisco, CA, USA.
| | - Brandon Leonard
- Department of Antibody Engineering, Genentech Inc., South San Francisco, CA, USA
| | - Ingrid Kim
- Department of Antibody Engineering, Genentech Inc., South San Francisco, CA, USA
| | - Hok Seon Kim
- Department of Antibody Engineering, Genentech Inc., South San Francisco, CA, USA
| | - Greg A Lazar
- Department of Antibody Engineering, Genentech Inc., South San Francisco, CA, USA
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21
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Bobo TA, Samowitz PN, Robinson MI, Montes LI, Forsberg LJ, Feng R, Nicely NI, Fu H. IgG-cleavage protein allows therapeutic AAV gene delivery in passively immunized MPS IIIA mice. Gene Ther 2023; 30:377-385. [PMID: 36253453 DOI: 10.1038/s41434-022-00368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/21/2022] [Accepted: 09/27/2022] [Indexed: 11/08/2022]
Abstract
The widespread pre-existing αAAV-Abs in humans pose a critical challenge in translation of AAV gene therapy. The IgG degrading enzyme of Streptococci (IdeS) is demonstrated to specifically cleave IgG of humans and other species (not mouse). This study developed a modified new modified IdeS protein product (IdeSop). When incubated in vitro, IdeSop was shown to completely cleave human and rabbit IgGs within 6 h. To test IdeSop in a disease setting, we established a rabbitized αAAV9-Ab+ mouse by an IV infusion of purified acute αAAV9-Ab+ rabbit IgG into MPS IIIA mice, resulting in serum αAAV9-IgG at 1:6,400 and αAAV9-nAbs at 1:800. IdeSop-Ab-cleavage was shown to be dose-dependent. An IV IdeSop infusion at the effective doses resulted in rapid IgG depletion and clearance of pre-existing αAAV9-IgG and αAAV9-nAbs in rabbitized αAAV9-Abs+ MPS IIIA mice. Importantly, an IV injection of a high dose AAV9-hSGSHop vector (5 × 1013vg/kg) at 24 h post IdeSop treatment led to transduction as effective in αAAV9-Abs+ MPS IIIA mice, as in αAAV9-Abs-negative controls. We believe that transient IdeSop administration may offer a great tool to address the pre-existing-αAAV-Abs for the translation of rAAV gene therapy to treat diseases in humans, making effective rAAV gene therapy available to all patients in need.
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Affiliation(s)
- Tierra A Bobo
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Genetics and Metabolism, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Preston N Samowitz
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael I Robinson
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura I Montes
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lawrence J Forsberg
- Protein Production & Purification Core, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Richard Feng
- Protein Production & Purification Core, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nathan I Nicely
- Protein Production & Purification Core, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Haiyan Fu
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Division of Genetics and Metabolism, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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22
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DeFilippis EM, Kransdorf EP, Jaiswal A, Zhang X, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Detection and management of HLA sensitization in candidates for adult heart transplantation. J Heart Lung Transplant 2023; 42:409-422. [PMID: 36631340 DOI: 10.1016/j.healun.2022.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Abstract
Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.
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Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, Florida
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23
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Courtwright A, Atkinson C, Pelaez A. The Highly Sensitized Recipient: Pretransplant and Posttransplant Considerations. Clin Chest Med 2023; 44:85-93. [PMID: 36774171 DOI: 10.1016/j.ccm.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Highly sensitized patients, who are often black and Hispanic women, are less likely to be listed for lung transplant and are at higher risk for prolonged waitlist time and waitlist death. In this review, the authors discuss strategies for improving access to transplant in this population, including risk stratification of crossing pretransplant donor-specific antibodies, based on antibody characteristics. The authors also review institutional protocols, such as perioperative desensitization, for tailoring transplant immunosuppression in the highly sensitized population. The authors conclude with suggestions for future research, including development of novel donor-specific antibody-directed therapeutics.
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Affiliation(s)
- Andrew Courtwright
- Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Carl Atkinson
- University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Andres Pelaez
- Jackson Health System, University of Miami, Miller School of Medicine, Miami Transplant Institute, 1801 Northwest 9th Avenue, Miami, FL 33136, USA.
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24
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Abstract
Access to kidney transplantation is limited by HLA-specific sensitization. Desensitization strategies enable crossmatch-positive kidney transplantation. In this review, we describe clinical experience gained over the last 20 y using desensitization strategies before kidney transplantation and describe the different tools used (both drugs and apheresis options), including IVIg, rituximab, apheresis techniques, interleukin-6 interference, proteasome inhibition, enzymatic degradation of HLA antibodies, complement inhibition, and B cytokine interference. Although access to transplantation for highly sensitized kidney transplantation candidates has been vastly improved by desensitization strategies, it remains, however, limited by the recurrence of HLA antibodies after transplantation and the occurrence of antibody-mediated rejection.
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25
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Abstract
By 2014, strategies to prevent antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) were established in Japan and expanded primarily to Asia, where LDLT is now the predominant form of LT owing to the scarcity of brain-dead donors. A desensitization protocol consisting of rituximab (375 mg/m 2 ), plasma pheresis, tacrolimus, and mycophenolate mofetil before LDLT, followed by standard immunosuppression, is currently the best option in terms of safety and efficacy. Rituximab administration is now known not to increase the risk of hepatocellular carcinoma recurrence, and the feasibility of rituximab for LDLT for acute liver failure and the need for desensitization before LDLT in children older than 1 y have been documented. Strategies are needed to distinguish patients at high risk of AMR from those at low risk and to adjust immunosuppression to prevent both AMR and infection. Specific single-nucleotide polymorphisms in genes encoding Fcγ receptors affecting the cytotoxicity of rituximab on B cells could be useful for adjusting immunosuppression levels to decrease infectious complications. Immunological accommodation after ABO-I transplantation could be provided by immune factors in both the grafts and recipients.
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26
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First use of imlifidase desensitization in a highly sensitized lung transplant candidate: a case report. Am J Transplant 2023; 23:294-297. [PMID: 36695676 DOI: 10.1016/j.ajt.2022.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/10/2022] [Accepted: 11/13/2022] [Indexed: 01/15/2023]
Abstract
Lung transplant candidates who are highly sensitized against human leucocyte antigen present an ongoing challenge with regards to finding immunologically acceptable donors. Desensitization strategies aimed at reducing preformed donor-specific antibodies have a number of limitations. Imlifidase, an IgG-degrading enzyme derived from Streptococcus pyogenes, is a novel agent that has been used to convert positive crossmatches to negative in kidney transplant candidates, allowing transplantation to occur. We present the first case of imlifidase use for antibody depletion in a highly sensitized lung transplant candidate who went on to undergo a successful bilateral lung transplant.
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27
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Tambur AR, Bestard O, Campbell P, Chong AS, Barrio MC, Ford ML, Gebel HM, Heidt S, Hickey M, Jackson A, Kosmoliaptsis V, Lefaucheur C, Louis K, Mannon RB, Mengel M, Morris A, Pinelli DF, Reed EF, Schinstock C, Taupin JL, Valenzuela N, Wiebe C, Nickerson P. Sensitization in transplantation: Assessment of Risk 2022 Working Group Meeting Report. Am J Transplant 2023; 23:133-149. [PMID: 36695615 DOI: 10.1016/j.ajt.2022.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/20/2022] [Accepted: 11/02/2022] [Indexed: 01/13/2023]
Abstract
The Sensitization in Transplantation: Assessment of Risk workgroup is a collaborative effort of the American Society of Transplantation and the American Society of Histocompatibility and Immunogenetics that aims at providing recommendations for clinical testing, highlights gaps in current knowledge, and proposes areas for further research to enhance histocompatibility testing in support of solid organ transplantation. This report provides updates on topics discussed by the previous Sensitization in Transplantation: Assessment of Risk working groups and introduces 2 areas of exploration: non-human leukocyte antigen antibodies and utilization of human leukocyte antigen antibody testing measurement to evaluate the efficacy of antibody-removal therapies.
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Affiliation(s)
- Anat R Tambur
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA.
| | - Oriol Bestard
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Patricia Campbell
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Anita S Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - Martha Crespo Barrio
- Department of Nephrology, Hospital del Mar & Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Mandy L Ford
- Department of Surgery and Emory Transplant Center, Emory University, Atlanta, Georgia, USA
| | - Howard M Gebel
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Netherlands
| | - Michelle Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Annette Jackson
- Department of Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale UMR-S970, Université de Paris, Paris, France
| | - Kevin Louis
- Paris Translational Research Center for Organ Transplantation, Institut national de la santé et de la recherche médicale UMR-S970, Université de Paris, Paris, France
| | - Roslyn B Mannon
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Mengel
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Anna Morris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David F Pinelli
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Jean-Luc Taupin
- Department of Immunology, Saint Louis Hospital and University Paris-Cité, Paris, France
| | - Nicole Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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28
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Chandak P, Phillips BL, Bennett D, Uwechue R, Kessaris N, Shaw O, Maggs T, Woodford L, Veniard D, Perera R, Parmar K, Hunt BJ, Callaghan C, Dorling A, Mamode N. Modelling acute antibody-mediated rejection of human kidney transplants using ex-vivo warm machine perfusion. EBioMedicine 2022; 86:104365. [PMID: 36427468 PMCID: PMC9699940 DOI: 10.1016/j.ebiom.2022.104365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Transplant rejection is a major cause of graft loss and morbidity. Currently, no human models of antibody-mediated rejection (AMR) exist, limiting mechanistic investigation and organ-specific targeted therapy. Here, using 12 human kidneys and ex-vivo normothermic machine perfusion, we demonstrate phenotypes of AMR after addition of antibodies against either human HLA class I or blood group antigens (A, B), thus modelling clinical AMR that can follow HLA incompatible (HLAi) or blood group incompatible (ABOi) transplantation. METHODS Discarded human kidneys with wide ranging demographics and cold ischaemia times (11-54 h) were perfused with red blood cells and fresh frozen plasma (FFP) as a source of complement/coagulation factors. For the HLAi model, 600 μg of W6/32 anti-class 1 HLA antibody was added to the circuit (time '0'). For the ABOi model, high titre FFP of the relevant blood group antibody was added. Renal blood flow index (RBFi, mL/min/100 g), C3 desArg, prothrombin fragments 1 + 2 and histology were determined. Our endpoints included haemodynamic changes, thrombosis, and biopsy proven complement deposition. FINDINGS Compared to control kidneys perfused without anti-donor antibodies, both models demonstrated haemodynamic collapse after antibody perfusion with only the HLAi model showing glomerular C4d deposition. INTERPRETATION We show that a clinically relevant human kidney model of AMR is feasible, and anticipate that these models, with refinements, could provide a basis to test different strategies to prevent AMR. FUNDING The Rosetrees and Stonygate Trust, The Royal College of Surgeons of England Fellowship Grant, NIHR Biomedical Research Centre/KCL Early Career Grant, Kidney Research U.K.
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Affiliation(s)
- Pankaj Chandak
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.
| | - Benedict L Phillips
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Danothy Bennett
- Interface Analysis Centre, HH Wills Physics Laboratory, School of Physics, University of Bristol, Bristol, United Kingdom
| | - Raphael Uwechue
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Nicos Kessaris
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Olivia Shaw
- Synnovis, Clinical Transplantation Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Tim Maggs
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Luke Woodford
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - David Veniard
- Synnovis, Blood Transfusion Laboratory, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Ranmith Perera
- Department of Cellular Pathology, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, United Kingdom
| | - Kiran Parmar
- Thrombosis and Vascular Biology Group, Rayne Institute, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Vascular Biology Group, Rayne Institute, Guys and St Thomas' NHS Foundation Trust and King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Chris Callaghan
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Anthony Dorling
- Transplant, Renal and Urology Directorate, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, Great Maze Pond, London, United Kingdom; Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Nizam Mamode
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
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29
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Durlik M. New approach to desensitization in solid organ transplantation-imlifidase. FRONTIERS IN TRANSPLANTATION 2022; 1:951360. [PMID: 38994389 PMCID: PMC11235339 DOI: 10.3389/frtra.2022.951360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/26/2022] [Indexed: 07/13/2024]
Abstract
The IgG-degrading enzyme derived from Streptococcus pyogenes is a recombinant cysteine protease of S. pyogenes produced in Escherichia coli that cleaves all four human subclasses of IgG with strict specificity. The proteolytic activity on IgG molecules prevents the occurrence of IgG-mediated antibody-dependent, cellular cytotoxicity and complement-mediated cytotoxicity, two processes that are critical for antibody rejection. The results from phase II studies demonstrated that desensitization with imlifidase represents a therapeutic strategy that can operationalize desensitization, allowing life-saving transplants from deceased donors (DD) and living donors (LD) to proceed in highly sensitized kidney transplant candidates with low risk of hyperacute rejection. Its action onset is rapid, allowing kidney transplantation from a deceased donor. Disadvantages of imlifidase include a quick reappearance of DSAs, which poses a risk of antibody-mediated rejection, the quick development of anti-Ides antibodies, which rules out repeated use of imlifidase and its IgG-degrading potential, limiting the use of therapeutic antibodies. Imlifdase received conditional approval on 26 August 2020 in the EU for desensitization treatment of highly sensitized adult kidney transplant patients with positive crossmatch against an available deceased donor.
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Affiliation(s)
- Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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30
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van Vugt LK, Schagen MR, de Weerd A, Reinders ME, de Winter BC, Hesselink DA. Investigational drugs for the treatment of kidney transplant rejection. Expert Opin Investig Drugs 2022; 31:1087-1100. [PMID: 36175360 DOI: 10.1080/13543784.2022.2130751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Kidney transplant rejection remains an important clinical problem despite the development of effective immunosuppressive drug combination therapy. Two major types of rejection are recognized, namely T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), which have a different pathophysiology and are treated differently. Unfortunately, long-term outcomes of both TCMR and ABMR remain unsatisfactory despite current therapy. Hence, alternative therapeutic drugs are urgently needed. AREAS COVERED This review covers novel and investigational drugs for the pharmacological treatment of kidney transplant rejection. Potential therapeutic strategies and future directions are discussed. EXPERT OPINION The development of alternative pharmacologic treatment of rejection has focused mostly on ABMR, since this is the leading cause of kidney allograft loss and currently lacks an effective, evidence-based therapy. At present, there is insufficient high-quality evidence for any of the covered investigational drugs to support their use in ABMR. However, with the emergence of targeted therapies, this potential arises for individualized treatment strategies. In order to generate more high-quality evidence for such strategies and overcome the obstacles of classic, randomized, controlled trials, we advocate the implementation of adaptive trial designs and surrogate clinical endpoints. We believe such adaptive trial designs could help to understand the risks and benefits of promising drugs such as tocilizumab, clazakizumab, belimumab, and imlifidase.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maaike R Schagen
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annelies de Weerd
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies Ej Reinders
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda Cm de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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31
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Fan X, Yuan Z, Zhao Y, Xiong W, Hsiao HC, Pare R, Ding J, Almosa A, Sun K, Zhang S, Jordan RE, Lee CS, An Z, Zhang N. Impairment of IgG Fc functions promotes tumor progression and suppresses NK cell antitumor actions. Commun Biol 2022; 5:960. [PMID: 36104515 PMCID: PMC9474879 DOI: 10.1038/s42003-022-03931-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/01/2022] [Indexed: 11/15/2022] Open
Abstract
Natural killer (NK) cells mediate antibody dependent cytotoxic killing of cancer cells via cross-linking FcγR on NK cells with IgG-Fc. Studies have shown that the single-hinge cleaved IgGs (scIgGs) have dysfunctional Fc and failed engagement with FcγRs on immune cells. However, little is known about how scIgGs impact on antitumor immunity in the tumor microenvironment. In this study, we revealed a significant association of tumor scIgGs with tumor progression and poor outcomes of breast cancer patients (n = 547). Using multiple mouse tumor models, we demonstrated that tumor scIgGs reduced NK cell cytotoxic activities and resulted in aggressive tumor progression. We further showed that an anti-hinge specific monoclonal antibody (AHA) rescued the dysfunctional Fc in scIgGs by providing a functional Fc and restored NK cell cytotoxic activity. These findings point to a novel immunotherapeutic strategy to enhance Fc engagement with FcγRs for activation of anticancer immunity.
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Affiliation(s)
- Xuejun Fan
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Zihao Yuan
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Yueshui Zhao
- Center for Metabolic and Degenerative Diseases, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Wei Xiong
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Hao-Ching Hsiao
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Rahmawati Pare
- School of Medicine, Western Sydney University, Department of Anatomical Pathology, Liverpool Hospital, Cancer Pathology Laboratory, Ingham Institute for Applied Medical Research, Liverpool BC, NSW, 1871, Australia
- Medicine & Health Sciences, University Malaysia Sabah, Jalan UMS, 88400, Kota Kinabalu, Sabah, Malaysia
| | - Jianmin Ding
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Ahmad Almosa
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Kai Sun
- Center for Metabolic and Degenerative Diseases, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Songlin Zhang
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Robert E Jordan
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA
| | - Cheok Song Lee
- School of Medicine, Western Sydney University, Department of Anatomical Pathology, Liverpool Hospital, Cancer Pathology Laboratory, Ingham Institute for Applied Medical Research, Liverpool BC, NSW, 1871, Australia
| | - Zhiqiang An
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA.
| | - Ningyan Zhang
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1825 Pressler St., Houston, TX, 77030, USA.
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32
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Yang TY, Braun M, Lembke W, McBlane F, Kamerud J, DeWall S, Tarcsa E, Fang X, Hofer L, Kavita U, Upreti VV, Gupta S, Loo L, Johnson AJ, Chandode RK, Stubenrauch KG, Vinzing M, Xia CQ, Jawa V. Immunogenicity assessment of AAV-based gene therapies: An IQ consortium industry white paper. Mol Ther Methods Clin Dev 2022; 26:471-494. [PMID: 36092368 PMCID: PMC9418752 DOI: 10.1016/j.omtm.2022.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immunogenicity has imposed a challenge to efficacy and safety evaluation of adeno-associated virus (AAV) vector-based gene therapies. Mild to severe adverse events observed in clinical development have been implicated with host immune responses against AAV gene therapies, resulting in comprehensive evaluation of immunogenicity during nonclinical and clinical studies mandated by health authorities. Immunogenicity of AAV gene therapies is complex due to the number of risk factors associated with product components and pre-existing immunity in human subjects. Different clinical mitigation strategies have been employed to alleviate treatment-induced or -boosted immunogenicity in order to achieve desired efficacy, reduce toxicity, or treat more patients who are seropositive to AAV vectors. In this review, the immunogenicity risk assessment, manifestation of immunogenicity and its impact in nonclinical and clinical studies, and various clinical mitigation strategies are summarized. Last, we present bioanalytical strategies, methodologies, and assay validation applied to appropriately monitor immunogenicity in AAV gene therapy-treated subjects.
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33
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Klontz EH. Chop-chop: The future of bacterial enzymes in transfusion medicine. Transfus Med Rev 2022; 36:246-251. [DOI: 10.1016/j.tmrv.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/25/2022] [Indexed: 10/15/2022]
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Bockermann R, Järnum S, Runström A, Lorant T, Winstedt L, Palmqvist N, Kjellman C. Imlifidase-generated Single-cleaved IgG: Implications for Transplantation. Transplantation 2022; 106:1485-1496. [PMID: 34966107 PMCID: PMC9213077 DOI: 10.1097/tp.0000000000004031] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Imlifidase is an immunoglobulin G (IgG)-specific protease conditionally approved in the EU for desensitization in highly sensitized crossmatch positive kidney transplant patients. Imlifidase efficiently cleaves both heavy chains of IgG in a 2-step process. However, low levels of the intermediate cleavage product, single-cleaved IgG (scIgG), may persist in the circulation. The study objective was to investigate Fc-mediated effector functions of scIgG and its potential impact on common clinical immunologic assays used to assess transplant eligibility. METHODS Imlifidase-generated scIgG, obtained by in vitro cleavage of HLA-sensitized patient serum or selected antibodies, was investigated in different complement- and FcγR-dependent assays and models, including clinical tests used to evaluate HLA-specific antibodies. RESULTS ScIgG had significantly reduced Fc-mediated effector function compared with intact IgG, although some degree of activity in complement- and FcγR-dependent models was still detectable. A preparation of concentrated scIgG generated from a highly HLA-sensitized individual gave rise to a positive signal in the anti-HLA IgG LABScreen, which uses anti-Fc detection, but was entirely negative in the C1qScreen. The same high-concentration HLA-binding scIgG preparation also generated positive complement-dependent cytotoxicity responses against 80%-100% of donor T and B cells, although follow-up titrations demonstrated a much lower intrinsic activity than for intact anti-HLA IgG. CONCLUSIONS ScIgG has a significantly reduced capacity to mediate Fc-dependent effector functions. However, remaining HLA-reactive scIgG in plasma after imlifidase treatment can cause positive assay results equivalent to intact IgG in clinical assays. Therefore, complete IgG cleavage after imlifidase treatment is essential to allow correct decision-making in relation to transplant eligibility.
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Affiliation(s)
| | | | | | - Tomas Lorant
- Department of Surgical Sciences, Section of Transplantation Surgery, Uppsala University, Uppsala, Sweden
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35
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Mayer KA, Budde K, Jilma B, Doberer K, Böhmig GA. Emerging drugs for antibody-mediated rejection after kidney transplantation: a focus on phase II & III trials. Expert Opin Emerg Drugs 2022; 27:151-167. [PMID: 35715978 DOI: 10.1080/14728214.2022.2091131] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antibody-mediated rejection (ABMR) is a leading cause of kidney allograft failure. Its therapy continues to be challenge, and no treatment has been approved for the market thus far. AREAS COVERED In this article, we discuss the pathophysiology and phenotypic presentation of ABMR, the current level of evidence to support the use of available therapeutic strategies, and the emergence of tailored drugs now being evaluated in systematic clinical trials. We searched PubMed, Clinicaltrials.gov and Citeline's Pharmaprojects for pertinent information on emerging anti-rejection strategies, laying a focus on phase II and III trials. EXPERT OPINION Currently, we rely on the use of apheresis for alloantibody depletion and intravenous immunoglobulin (referred to as standard of care), preferentially in early active ABMR. Recent systematic trials have questioned the benefits of using the CD20 antibody rituximab or the proteasome inhibitor bortezomib. However, there are now several promising treatment approaches in the pipeline, which are being trialed in phase II and III studies. These include interleukin-6 antagonism, CD38-targeting antibodies, and selective inhibitors of complement. On the basis of the information that has emerged so far, it seems that innovative treatment strategies for clinical use in ABMR may be available within the next 5-10 years.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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36
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Ros-Gañán I, Hommel M, Trigueros-Motos L, Tamarit B, Rodríguez-García E, Salas D, Pérez G, Douar A, Combal JP, Benichou B, Ferrer V, González-Aseguinolaza G. Optimising the IgG-degrading enzyme treatment regimen for enhanced adeno-associated virus transduction in the presence of neutralising antibodies. Clin Transl Immunology 2022; 11:e1375. [PMID: 35228870 PMCID: PMC8867416 DOI: 10.1002/cti2.1375] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/07/2021] [Accepted: 01/24/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Pre‐existing neutralising antibodies (NAbs) to adeno‐associated viruses (AAVs) remain an impediment for systemically administered AAV‐mediated gene therapy treatment in many patients, and various strategies are under investigation to overcome this limitation. Here, IgG‐degrading enzymes (Ides) derived from bacteria of the genus Streptococcus were tested for their ability to cleave human IgG and allow AAV‐mediated transduction in individuals with pre‐existing NAbs. Methods Cleavage activity of three different Ides was evaluated in vitro in serum from different species. Passively immunised mice or non‐human primates (NHP) with naturally occurring anti‐AAV NAbs were used to define the optimal IdeS dose and administration window for AAVAnc80 and AAV8 vectors in mice and AAV3B in NHPs. Results The selected candidate, IdeS, was found to be highly efficient at cleaving human IgG, less efficient against NHP IgG and inefficient against mouse IgG. In vivo, we observed differences in how IdeS affected liver transduction in the presence of NAbs depending on the AAV serotype. For AAVAnc80 and AAV3B, the best transduction levels were achieved when the vector was administered after IgG digestion products were cleared from circulation. However, for AAV8 we only observed a modest and transient inhibition of transduction by IdeS cleavage products. Conclusion Preconditioning with IdeS represents a unique treatment opportunity for patients primarily excluded from participation in gene therapy clinical trials because of elevated circulating anti‐AAV NAb levels. However, careful determination of the optimal IdeS dose and timing for the administration of each AAV serotype is essential for optimal transduction.
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Affiliation(s)
| | - Mirja Hommel
- Division of Gene Therapy and Regulation of Gene Expression CIMA University of Navarra Pamplona Spain.,Institute for Sanitary Research (IdiSNA) Pamplona Spain
| | | | | | - Estefanía Rodríguez-García
- Division of Gene Therapy and Regulation of Gene Expression CIMA University of Navarra Pamplona Spain.,Institute for Sanitary Research (IdiSNA) Pamplona Spain
| | - David Salas
- Division of Gene Therapy and Regulation of Gene Expression CIMA University of Navarra Pamplona Spain.,Institute for Sanitary Research (IdiSNA) Pamplona Spain
| | - Guiomar Pérez
- Division of Gene Therapy and Regulation of Gene Expression CIMA University of Navarra Pamplona Spain.,Institute for Sanitary Research (IdiSNA) Pamplona Spain
| | | | | | | | | | - Gloria González-Aseguinolaza
- Vivet Therapeutics S.L. Pamplona Spain.,Division of Gene Therapy and Regulation of Gene Expression CIMA University of Navarra Pamplona Spain.,Institute for Sanitary Research (IdiSNA) Pamplona Spain
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Sullivan JC, Peña JR. Use of Human Leukocyte Antigen (HLA)-Incompatible Platelet Units in HLA Platelet-Refractory Patients With Limited Number of or Low-Level HLA Donor-Specific Antibodies Results in Permissive Transfusions. Arch Pathol Lab Med 2022; 146:1243-1251. [PMID: 35171984 DOI: 10.5858/arpa.2021-0051-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— In human leukocyte antigen (HLA)-mediated alloimmune platelet refractoriness, HLA-incompatible platelets may produce adequate posttransfusion corrected count increment ("permissive transfusion") and increase the donor pool. OBJECTIVE.— To determine if a lower number of or low-level anti-HLA donor-specific antibodies (DSAs) predict permissive transfusion and could be used to prioritize platelet selection. DESIGN.— We categorized platelets administered from 2016 to 2018 as HLA-compatible or HLA-incompatible based on presence of DSAs against the donor unit. We further divided HLA-incompatible units based on the number of DSAs and the level of DSAs (measured by mean fluorescence intensity [MFI]), where cumulative MFI ≥6000 defines high-level DSA. We compared posttransfusion corrected count increments (CCIs) and transfusion reactions among these transfusions. RESULTS.— Of 279 HLA-selected units transfused into 26 platelet-refractory patients, we resorted to using 39 HLA-incompatible units (14%). Posttransfusion CCI and transfusion reaction frequency were similar among units targeted by 1 or low-level DSAs and HLA-compatible units. Units targeted by ≥2 distinct or high-level DSAs produced lower CCIs. Regardless of ABO compatibility, similarly HLA-categorized units yielded comparable CCIs and comparable frequency of transfusion reactions. CONCLUSIONS.— HLA-incompatible platelets transfused across 1 or low-level DSAs were commonly permissive, whereas those transfused across ≥2 DSAs or high levels of DSA (MFI ≥6000) were nonpermissive. The use of such donor units offers transfusion services alternative platelet units for support of platelet-refractory patients.
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Affiliation(s)
- Jensyn Cone Sullivan
- From the Department of Pathology, Tufts Medical Center, Boston, Massachusetts (Sullivan)
| | - Jeremy Ryan Peña
- the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Peña)
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Ramírez-Larrota JS, Eckhard U. An Introduction to Bacterial Biofilms and Their Proteases, and Their Roles in Host Infection and Immune Evasion. Biomolecules 2022; 12:306. [PMID: 35204806 PMCID: PMC8869686 DOI: 10.3390/biom12020306] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 12/15/2022] Open
Abstract
Bacterial biofilms represent multicellular communities embedded in a matrix of extracellular polymeric substances, conveying increased resistance against environmental stress factors but also antibiotics. They are shaped by secreted enzymes such as proteases, which can aid pathogenicity by degrading host proteins of the connective tissue or the immune system. Importantly, both secreted proteases and the capability of biofilm formation are considered key virulence factors. In this review, we focus on the basic aspects of proteolysis and protein secretion, and highlight various secreted bacterial proteases involved in biofilm establishment and dispersal, and how they aid bacteria in immune evasion by degrading immunoglobulins and components of the complement system. Thus, secreted proteases represent not only prominent antimicrobial targets but also enzymes that can be used for dedicated applications in biotechnology and biomedicine, including their use as laundry detergents, in mass spectrometry for the glycoprofiling of antibodies, and the desensitization of donor organs intended for positive crossmatch patients.
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Affiliation(s)
| | - Ulrich Eckhard
- Department of Structural Biology, Molecular Biology Institute of Barcelona, CSIC, Barcelona Science Park, Baldiri Reixac, 15-21, 08028 Barcelona, Spain;
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Bertacchi M, Parvex P, Villard J. Antibody-mediated rejection after kidney transplantation in children; therapy challenges and future potential treatments. Clin Transplant 2022; 36:e14608. [PMID: 35137982 PMCID: PMC9286805 DOI: 10.1111/ctr.14608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
Antibody‐mediated rejection (AMR) remains one of the most critical problems in renal transplantation, with a significant impact on patient and graft survival. In the United States, no treatment has received FDA approval jet. Studies about treatments of AMR remain controversial, limited by the absence of a gold standard and the difficulty in creating large, multi‐center studies. These limitations emerge even more in pediatric transplantation because of the limited number of pediatric studies and the occasional use of some therapies with unknown and poorly documented side effects. The lack of recommendations and the unsharp definition of different forms of AMR contribute to the challenging management of the therapy by pediatric nephrologists. In an attempt to help clinicians involved in the care of renal transplanted children affected by an AMR, we rely on the latest recommendations of the Transplantation Society (TTS) for the classification and treatment of AMR to describe treatments available today and potential new treatments with a particular focus on the pediatric population.
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Affiliation(s)
| | - Paloma Parvex
- Division of Pediatric Nephrology, University Children Hospital of Geneva, Geneva, Switzerland
| | - Jean Villard
- Division of Nephrology, University Hospital of Geneva, Geneva, Switzerland.,Division of Transplantation Immunology, University Hospital of Geneva, Geneva, Switzerland
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40
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Potential therapeutic strategies in chronic inflammatory demyelinating polyradiculoneuropathy. Clin Exp Rheumatol 2022; 21:103032. [PMID: 34999243 DOI: 10.1016/j.autrev.2022.103032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/01/2022] [Indexed: 11/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune neuropathy involving peripheral nerve and nerve roots. The pathological hallmark of CIDP is macrophage-induced demyelination. Antibodies against nerve fibers, complement decomposition, abnormalities in plasma and cerebrospinal fluid cytokine profile, and changes of peripheral blood cell proportion were also reported in CIDP patients. These findings in immunopathology provide support for the introduction of potential therapeutic options for the treatment of CIDP. In this review, we systematically listed the potential therapeutic strategies targeting different components of the immune system by comparing the treatment of other autoimmune inflammatory diseases of the nervous system. Several ongoing clinical trials will assess the efficacy and safety of potential CIDP treatments.
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41
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Gomathy SB, Agarwal A, Vishnu VY. Molecular Therapy in Myasthenia Gravis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder caused by antibodies that act against the myoneural junction. Conventional immunosuppressants such as corticosteroids, azathioprine and mycophenolate are associated with long-term side effects and many patients do not achieve remission and may become refractory. Thus, there is an unmet need for target-specific therapies that act faster, have fewer side effects and lead to stable disease remission. However, many of the novel therapeutic agents being described are not meeting their primary endpoints. We reviewed the current status of novel immunotherapies for MG, their mechanisms of action, along with the side effect profiles. Fast onset of action, sustained disease remission and relatively low frequency of side effects of the new agents are attractive. However, the unknown long-term safety and high cost are precluding factors. Better preclinical studies and more randomized trials are needed before novel agents are routinely employed.
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42
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Kjellman C, Maldonado AQ, Sjöholm K, Lonze BE, Montgomery RA, Runström A, Lorant T, Desai NM, Legendre C, Lundgren T, von Zur Mühlen B, Vo AA, Olsson H, Jordan SC. Outcomes at 3 years posttransplant in imlifidase-desensitized kidney transplant patients. Am J Transplant 2021; 21:3907-3918. [PMID: 34236770 PMCID: PMC9290474 DOI: 10.1111/ajt.16754] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/11/2021] [Accepted: 07/04/2021] [Indexed: 01/25/2023]
Abstract
Imlifidase is a cysteine proteinase which specifically cleaves IgG, inhibiting Fc-mediated effector function within hours of administration. Imlifidase converts a positive crossmatch to a potential donor (T cell, B cell, or both), to negative, enabling transplantation to occur between previously HLA incompatible donor-recipient pairs. To date, 39 crossmatch positive patients received imlifidase prior to a kidney transplant in four single-arm, open-label, phase 2 studies. At 3 years, for patients who were AMR+ compared to AMR-, death-censored allograft survival was 93% vs 77%, patient survival was 85% vs 94%, and mean eGFR was 49 ml/min/1.73 m2 vs 61 ml/min/1.73 m2 , respectively. The incidence of AMR was 38% with most episodes occurring within the first month post-transplantation. Sub-analysis of patients deemed highly sensitized with cPRA ≥ 99.9%, and unlikely to be transplanted who received crossmatch-positive, deceased donor transplants had similar rates of patient survival, graft survival, and eGFR but a higher rate of AMR. These data demonstrate that outcomes and safety up to 3 years in recipients of imlifidase-enabled allografts is comparable to outcomes in other highly sensitized patients undergoing HLA-incompatible transplantation. Thus, imlifidase is a potent option to facilitate transplantation among patients who have a significant immunologic barrier to successful kidney transplantation. Clinical Trial: ClinicalTrials.gov (NCT02790437), EudraCT Number: 2016-002064-13.
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Affiliation(s)
| | | | | | | | | | | | - Tomas Lorant
- Department of Surgical SciencesUppsala UniversityUppsalaSweden
| | | | | | - Torbjörn Lundgren
- Department of Transplantation SurgeryKarolinska InstitutetStockholmSweden
| | | | - Ashley A. Vo
- Cedars‐Sinai Medical CenterComprehensive Transplant CenterLos AngelesCaliforniaUSA
| | | | - Stanley C. Jordan
- Cedars‐Sinai Medical CenterComprehensive Transplant CenterLos AngelesCaliforniaUSA
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Adams AB, Lovasik BP, Faber DA, Burlak C, Breeden C, Estrada JL, Reyes LM, Vianna RM, Tector MF, Tector AJ. Anti-C5 Antibody Tesidolumab Reduces Early Antibody-mediated Rejection and Prolongs Survival in Renal Xenotransplantation. Ann Surg 2021; 274:473-480. [PMID: 34238812 PMCID: PMC8915445 DOI: 10.1097/sla.0000000000004996] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Pig-to-primate renal xenotransplantation is plagued by early antibody-mediated graft loss which precludes clinical application of renal xenotransplantation. We evaluated whether temporary complement inhibition with anti-C5 antibody Tesidolumab could minimize the impact of early antibody-mediated rejection in rhesus monkeys receiving pig kidneys receiving costimulatory blockade-based immunosuppression. METHODS Double (Gal and Sda) and triple xenoantigen (Gal, Sda, and SLA I) pigs were created using CRISPR/Cas. Kidneys from DKO and TKO pigs were transplanted into rhesus monkeys that had the least reactive crossmatches. Recipients received anti-C5 antibody weekly for 70 days, and T cell depletion, anti-CD154, mycophenolic acid, and steroids as baseline immunosuppression (n = 7). Control recipients did not receive anti-C5 therapy (n = 10). RESULTS Temporary anti-C5 therapy reduced early graft loss secondary to antibody-mediated rejection and improved graft survival (P < 0.01). Deleting class I MHC (SLA I) in donor pigs did not ameliorate early antibody-mediated rejection (table). Anti-C5 therapy did not allow for the use of tacrolimus instead of anti-CD154 (table), prolonging survival to a maximum of 62 days. CONCLUSION Inhibition of the C5 complement subunit prolongs renal xenotransplant survival in a pig to non-human primate model.
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Affiliation(s)
- Andrew B Adams
- University of Minnesota School of Medicine, Minneapolis MN
| | | | | | | | | | | | - Luz M Reyes
- University of Miami School of Medicine, Miami, FL
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Markmann C, Bhoj VG. On the road to eliminating long-lived plasma cells-"are we there yet?". Immunol Rev 2021; 303:154-167. [PMID: 34351644 DOI: 10.1111/imr.13015] [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: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/19/2023]
Abstract
Central to protective humoral immunity is the activation of B cells and their terminal differentiation into antibody-secreting plasma cells. Long-lived plasma cells (LLPC) may survive for years to decades. Such long-lived plasma cells are also responsible for producing pathogenic antibodies that cause a variety of challenges such as autoimmunity, allograft rejection, and drug neutralization. Up to now, various therapeutic strategies aimed at durably eliminating pathogenic antibodies have failed, in large part due to their inability to efficiently target LLPCs. Several antibody-based therapies have recently gained regulatory approval or are in clinical phases of development for the treatment of multiple myeloma, a malignancy of plasma cells. We discuss the exciting potential of using these emerging cancer immunotherapies to solve the antibody problem.
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Affiliation(s)
- Caroline Markmann
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Vijay G Bhoj
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Jordan SC, Legendre C, Desai NM, Lorant T, Bengtsson M, Lonze BE, Vo AA, Runström A, Laxmyr L, Sjöholm K, Schiött Å, Sonesson E, Wood K, Winstedt L, Kjellman C, Montgomery RA. Imlifidase Desensitization in Crossmatch-positive, Highly Sensitized Kidney Transplant Recipients: Results of an International Phase 2 Trial (Highdes). Transplantation 2021; 105:1808-1817. [PMID: 33093408 PMCID: PMC8294837 DOI: 10.1097/tp.0000000000003496] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Highly HLA sensitized patients have limited access to life-saving kidney transplantation because of a paucity of immunologically suitable donors. Imlifidase is a cysteine protease that cleaves IgG leading to a rapid decrease in antibody level and inhibition of IgG-mediated injury. This study investigates the efficacy and safety of imlifidase in converting a positive crossmatch test to negative, allowing highly sensitized patients to be transplanted with a living or deceased donor kidney. METHODS This open-label, single-arm, phase 2 trial conducted at 5 transplant centers, evaluated the ability of imlifidase to create a negative crossmatch test within 24 h. Secondary endpoints included postimlifidase donor-specific antibody levels compared with predose levels, renal function, and pharmacokinetic/pharmacodynamic profiles. Safety endpoints included adverse events and immunogenicity profile. RESULTS Of the transplanted patients, 89.5% demonstrated conversion of baseline positive crossmatch to negative within 24 h after imlifidase treatment. Donor-specific antibodies most often rebounded 3-14 d postimlifidase dose, with substantial interpatient variability. Patient survival was 100% with graft survival of 88.9% at 6 mo. With this, 38.9% had early biopsy proven antibody-mediated rejection with onset 2-19 d posttransplantation. Serum IgG levels began to normalize after ~3-7 d posttransplantation. Antidrug antibody levels were consistent with previous studies. Seven adverse events in 6 patients were classified as possibly or probably related to treatment and were mild-moderate in severity. CONCLUSIONS Imlifidase was well tolerated, converted positive crossmatches to negative, and enabled patients with a median calculated panel-reactive antibody of 99.83% to undergo kidney transplantation resulting in good kidney function and graft survival at 6 mo.
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Affiliation(s)
| | | | | | - Tomas Lorant
- Uppsala University, Uppsala, Sweden
- Hansa Biopharma AB, Lund, Sweden
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Abstract
PURPOSE OF REVIEW In this review, we discuss achievements in immunosuppression in kidney transplant recipients published at last 18 months. RECENT FINDINGS Results of recent trials with everolimus in low-risk primary kidney transplant recipients suggest that lowTAC/EVR combination is noninferior and CMV and BKV viral infections are less frequent to standTAC/MPA. Iscalimab monoclonal antibody, which prevents CD40 to CD154 binding, has just recently entered phase II clinical studies in kidney transplantation. Eculizumab, anti-C5 monoclonal antobody was recently shown to improve outcomes in DSA+ living-donor kidney transplant recipients requiring pretransplant desensitization because of crossmatch positivity. Proximal complement C1 inhibition in patients with antibody-mediated rejection was studied in several phase I trials. SUMMARY Recent knowledge creates a path towards future immunosuppression success in sensitized recipients and in those in high risk of viral infections or CNI nephrotoxicity.
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Runström A, Sjöholm K, Roupé KM, Lorant T, Kjellman C, Bockermann R. IgM single antigen bead HLA-assay is affected by imlifidase through the cleavage of IgG but not IgM. Transpl Immunol 2021; 68:101436. [PMID: 34265468 DOI: 10.1016/j.trim.2021.101436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to investigate if human IgM is a cleavable substrate for imlifidase and to explain an observed effect in anti-HLA IgM single antigen bead (SAB) assays in sensitized patients. METHODS Serum samples collected pre- and 24 h post-imlifidase administration from sensitized patients enrolled in a phase II trial were investigated for anti-HLA IgG and IgM using SAB assays, with and without in vitro IgG depletion using a CaptureSelect™ affinity matrix. In addition, pre-dose samples and purified human IgM samples were treated with imlifidase in vitro and evaluated by SDS-PAGE, Western blot (PE-conjugated anti-human IgM) and SAB (IgG, IgM) assays. RESULTS By comparing the mean fluorescence intensity (MFI) of HLA-beads, pre- and post-imlifidase administration, three IgM-related patterns were observed; IgM-specific HLA-SABs with an increased MFI post-imlifidase, IgM-specific HLA-SABs with a decreased MFI post-imlifidase, and IgM-specific HLA-SABs with a marginal MFI difference between the pre- and post-imlifidase administration. These IgM signal patterns were observed despite neither purified IgM nor serum IgM could be cleaved by imlifidase. After removing IgG, the effects observed on anti-HLA IgM was largely eliminated with the biggest differences seen in patients with very high anti-HLA IgG in pre-dose samples. CONCLUSION We demonstrate that imlifidase does not cleave human IgM, including HLA-specific IgM antibodies from highly sensitized subjects. Observed decreases of SAB-HLA IgM signals after imlifidase treatment may result from the cleavage of IgG-IgM complexes which are bound to SAB-HLA. Serum analysis of patients with high levels of anti-HLA IgG will result in a more accurate SAB-HLA IgM reading after IgG depletion.
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Affiliation(s)
| | | | | | - Tomas Lorant
- Uppsala University, Department of Surgical Sciences, Uppsala, Sweden
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48
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Kardol-Hoefnagel T, Otten HG. A Comprehensive Overview of the Clinical Relevance and Treatment Options for Antibody-mediated Rejection Associated With Non-HLA Antibodies. Transplantation 2021; 105:1459-1470. [PMID: 33208690 PMCID: PMC8221725 DOI: 10.1097/tp.0000000000003551] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/06/2020] [Indexed: 12/24/2022]
Abstract
Although solid organ transplant results have improved significantly in recent decades, a pivotal cause of impaired long-term outcome is the development of antibody-mediated rejection (AMR), a condition characterized by the presence of donor-specific antibodies to HLA or non-HLA antigens. Highly HLA-sensitized recipients are treated with desensitization protocols to rescue the transplantation. These and other therapies are also applied for the treatment of AMR. Therapeutic protocols include removal of antibodies, depletion of plasma and B cells, inhibition of the complement cascade, and suppression of the T-cell-dependent antibody response. As mounting evidence illustrates the importance of non-HLA antibodies in transplant outcome, there is a need to evaluate the efficacy of treatment protocols on non-HLA antibody levels and graft function. Many reviews have been recently published that provide an overview of the literature describing the association of non-HLA antibodies with rejection in transplantation, whereas an overview of the treatment options for non-HLA AMR is still lacking. In this review, we will therefore provide such an overview. Most reports showed positive effects of non-HLA antibody clearance on graft function. However, monitoring non-HLA antibody levels after treatment along with standardization of therapies is needed to optimally treat solid organ transplant recipients.
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Affiliation(s)
- Tineke Kardol-Hoefnagel
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Henny G. Otten
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Matsuda Y, Watanabe T, Li XK. Approaches for Controlling Antibody-Mediated Allograft Rejection Through Targeting B Cells. Front Immunol 2021; 12:682334. [PMID: 34276669 PMCID: PMC8282180 DOI: 10.3389/fimmu.2021.682334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/17/2021] [Indexed: 01/14/2023] Open
Abstract
Both acute and chronic antibody-mediated allograft rejection (AMR), which are directly mediated by B cells, remain difficult to treat. Long-lived plasma cells (LLPCs) in bone marrow (BM) play a crucial role in the production of the antibodies that induce AMR. However, LLPCs survive through a T cell-independent mechanism and resist conventional immunosuppressive therapy. Desensitization therapy is therefore performed, although it is accompanied by severe side effects and the pathological condition may be at an irreversible stage when these antibodies, which induce AMR development, are detected in the serum. In other words, AMR control requires the development of a diagnostic method that predicts its onset before LLPC differentiation and enables therapeutic intervention and the establishment of humoral immune monitoring methods providing more detailed information, including individual differences in the susceptibility to immunosuppressive agents and the pathological conditions. In this study, we reviewed recent studies related to the direct or indirect involvement of immunocompetent cells in the differentiation of naïve-B cells into LLPCs, the limitations of conventional methods, and the possible development of novel control methods in the context of AMR. This information will significantly contribute to the development of clinical applications for AMR and improve the prognosis of patients who undergo organ transplantation.
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Affiliation(s)
- Yoshiko Matsuda
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Takeshi Watanabe
- Laboratory of Immunology, Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto, Japan
| | - Xiao-Kang Li
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
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Manook M, Flores WJ, Schmitz R, Fitch Z, Yoon J, Bae Y, Shaw B, Kirk A, Harnois M, Permar S, Farris AB, Magnani DM, Kwun J, Knechtle S. Measuring the Impact of Targeting FcRn-Mediated IgG Recycling on Donor-Specific Alloantibodies in a Sensitized NHP Model. Front Immunol 2021; 12:660900. [PMID: 34149698 PMCID: PMC8207189 DOI: 10.3389/fimmu.2021.660900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background In transplantation, plasmapheresis and IVIg provide the mainstay of treatment directed at reducing or removing circulating donor-specific antibody (DSA), yet both have limitations. We sought to test the efficacy of targeting the IgG recycling mechanism of the neonatal Fc receptor (FcRn) using anti-FcRn mAb therapy in a sensitized non-human primate (NHP) model, as a pharmacological means of lowering DSA. Methods Six (6) rhesus macaque monkeys, previously sensitized by skin transplantation, received a single dose of 30mg/kg anti-RhFcRn IV, and effects on total IgG, as well as DSA IgG, were measured, in addition to IgM and protective immunity. Subsequently, 60mg/kg IV was given in the setting of kidney transplantation from skin graft donors. Kidney transplant recipients received RhATG, and tacrolimus, MMF, and steroid for maintenance immunosuppression. Results Circulating total IgG was reduced from a baseline 100% on D0 to 32.0% (mean, SD ± 10.6) on d4 post infusion (p<0.05), while using a DSA assay. T-cell flow cross match (TFXM) was reduced to 40.6±12.5% of baseline, and B-cell FXCM to 52.2±19.3%. Circulating total IgM and DSA IgM were unaffected by treatment. Pathogen-specific antibodies (anti-gB and anti-tetanus toxin IgG) were significantly reduced for 14d post infusion. Post-transplant, circulating IgG responded to anti-FcRn mAb treatment, but DSA increased rapidly. Conclusion Targeting the FcRn-mediated recycling of IgG is an effective means of lowering circulating donor-specific IgG in the sensitized recipient, although in the setting of organ transplantation mechanisms of rapid antibody rise post-transplant remains unaffected.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Walter J Flores
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Robin Schmitz
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Zachary Fitch
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Allan Kirk
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Melissa Harnois
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, GA, United States
| | - Diogo M Magnani
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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