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Kanbay M, Copur S, Yilmaz ZY, Baydar DE, Bilge I, Susal C, Kocak B, Ortiz A. The role of anticomplement therapy in the management of the kidney allograft. Clin Transplant 2024; 38:e15277. [PMID: 38485664 DOI: 10.1111/ctr.15277] [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: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
As the number of patients living with kidney failure grows, the need also grows for kidney transplantation, the gold standard kidney replacement therapy that provides a survival advantage. This may result in an increased rate of transplantation from HLA-mismatched donors that increases the rate of antibody-mediated rejection (AMR), which already is the leading cause of allograft failure. Plasmapheresis, intravenous immunoglobulin therapy, anti-CD20 therapies (i.e., rituximab), bortezomib and splenectomy have been used over the years to treat AMR as well as to prevent AMR in high-risk sensitized kidney transplant recipients. Eculizumab and ravulizumab are monoclonal antibodies targeting the C5 protein of the complement pathway and part of the expanding field of anticomplement therapies, which is not limited to kidney transplant recipients, and also includes complement-mediated microangiopathic hemolytic anemia, paroxysmal nocturnal hemoglobinuria, and ANCA-vasculitis. In this narrative review, we summarize the current knowledge concerning the pathophysiological background and use of anti-C5 strategies (eculizumab and ravulizumab) and C1-esterase inhibitor in AMR, either to prevent AMR in high-risk desensitized patients or to treat AMR as first-line or rescue therapy and also to treat de novo thrombotic microangiopathy in 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
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dilek Ertoy Baydar
- Department of Pathology, Koc University School of Medicine, Istanbul, Turkey
| | - Ilmay Bilge
- Department of Pediatrics, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Susal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz, Madrid, Spain
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Novel Complement C5 Small-interfering RNA Lipid Nanoparticle Prolongs Graft Survival in a Hypersensitized Rat Kidney Transplant Model. Transplantation 2022; 106:2338-2347. [PMID: 35749284 DOI: 10.1097/tp.0000000000004207] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prophylaxis of antibody-mediated rejection (AMR) caused by donor-specific antibodies remains challenging. Given the critical roles of complement activity in antibody-mediated graft injury, we developed a lipid nanoparticle (LNP) formulation of small-interfering RNA against complement C5 (C5 siRNA-LNP) and investigated whether C5 siRNA-LNP could downregulate the complement activity and act as an effective treatment for AMR. METHODS Lewis recipient rats were sensitized by skin grafting from Brown Norway donor rats. Kidney transplantation was performed at 4 wk post-skin grafting.C5 siRNA- or control siRNA-LNP was administered intravenously, and the weekly injections were continued until the study's conclusion. Cyclosporin (CsA) and/or deoxyspergualin (DSG) were used as adjunctive immunosuppressants. Complement activity was evaluated using hemolysis assays. The deposition of C5b9 in the grafts was evaluated using immunohistochemical analysis on day 7 posttransplantation. RESULTS C5 siRNA-LNP completely suppressed C5 expression and complement activity (hemolytic activity ≤ 20%) 7 d postadministration. C5 siRNA-LNP in combination with CsA and DSG (median survival time: 56.0 d) prolonged graft survival compared with control siRNA-LNP in combination with CsA and DSG (median survival time: 21.0 d; P = 0.0012; log-rank test). Immunohistochemical analysis of the grafts revealed that downregulation of C5 expression was associated with a reduction in C5b9-positive area ( P = 0.0141, Steel-Dwass test). CONCLUSIONS C5 siRNA-LNP combined with immunosuppressants CsA and DSG downregulated C5 activity and significantly prolonged graft survival compared with control siRNA-LNP with CsA and DSG. Downregulation of C5 expression using C5 siRNA-LNP may be an effective therapeutic approach for AMR.
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Heo S, Park Y, Lee N, Kim Y, Kim YN, Shin HS, Jung Y, Rim H, Rennke HG, Chandraker A. Lack of Efficacy and Safety of Eculizumab for Treatment of Antibody-Mediated Rejection Following Renal Transplantation. Transplant Proc 2022; 54:2117-2124. [PMID: 36192209 DOI: 10.1016/j.transproceed.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/14/2022] [Accepted: 08/02/2022] [Indexed: 10/07/2022]
Abstract
BACKGROUND We evaluated the efficacy and safety of eculizumab in comparison with plasmapheresis and intravenous immunoglobulin therapy in renal transplant recipients diagnosed with antibody-mediated rejection (AMR). METHODS This was a multicenter, open-label, prospective, randomized analysis. The patients were randomized by therapy type (eg, eculizumab infusions or standard of care [SOC]: plasmapheresis/intravenous immunoglobulin). The patients (ie, eculizumab arm: 7 patients, SOC arm: 4 patients) were evaluated for the continued presence of donor-specific antibodies (DSAs) and C4d (staining on biopsy), as well as histologic evidence, using repeat renal biopsy after treatment. RESULTS The allograft biopsies revealed that eculizumab did not prevent the progression to transplant glomerulopathy. Only 2 patients in the SOC arm experienced rejection reversal, and no graft losses occurred in either group. After AMR treatment, the DSA titers generally decreased compared to titers taken at the time of AMR diagnosis. There were no serious adverse effects in the eculizumab arm. CONCLUSIONS Eculizumab alone cannot treat AMR effectively and does not prevent acute AMR from progressing to chronic AMR or transplant glomerulopathy. However, it should be considered as a potential alternative therapy because it may be associated with decreased DSA levels.
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Affiliation(s)
- Sujung Heo
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Youngchan Park
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Nagyeom Lee
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Yanghyeon Kim
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Ye Na Kim
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Ho Sik Shin
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea.
| | - Yeonsoon Jung
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Hark Rim
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea; Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Helmut G Rennke
- Renal Pathology, Department of Pathology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Yi SG, Gaber AO, Chen W. B-cell response in solid organ transplantation. Front Immunol 2022; 13:895157. [PMID: 36016958 PMCID: PMC9395675 DOI: 10.3389/fimmu.2022.895157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/11/2022] [Indexed: 11/21/2022] Open
Abstract
The transcriptional regulation of B-cell response to antigen stimulation is complex and involves an intricate network of dynamic signals from cytokines and transcription factors propagated from T-cell interaction. Long-term alloimmunity, in the setting of organ transplantation, is dependent on this B-cell response, which does not appear to be halted by current immunosuppressive regimens which are targeted at T cells. There is emerging evidence that shows that B cells have a diverse response to solid organ transplantation that extends beyond plasma cell antibody production. In this review, we discuss the mechanistic pathways of B-cell activation and differentiation as they relate to the transcriptional regulation of germinal center B cells, plasma cells, and memory B cells in the setting of solid organ transplantation.
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Affiliation(s)
- Stephanie G. Yi
- Division of Transplantation, Department of Surgery, Houston Methodist Hospital, Houston, TX, United States
- *Correspondence: Stephanie G. Yi,
| | - Ahmed Osama Gaber
- Division of Transplant Immunology, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Wenhao Chen
- Division of Transplantation, Department of Surgery, Houston Methodist Hospital, Houston, TX, United States
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5
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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Muff-Luett M, Sanderson KR, Engen RM, Zahr RS, Wenderfer SE, Tran CL, Sharma S, Cai Y, Ingraham S, Winnicki E, Weaver DJ, Hunley TE, Kiessling SG, Seamon M, Woroniecki R, Miyashita Y, Xiao N, Omoloja AA, Kizilbash SJ, Mansuri A, Kallash M, Yu Y, Sherman AK, Srivastava T, Nester CM. Eculizumab exposure in children and young adults: indications, practice patterns, and outcomes-a Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2021; 36:2349-2360. [PMID: 33693990 PMCID: PMC8263513 DOI: 10.1007/s00467-021-04965-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Eculizumab is approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use off-label is frequently reported. The aim of this study was to describe the broader use and outcomes of a cohort of pediatric patients exposed to eculizumab. METHODS A retrospective, cohort analysis was performed on the clinical and biomarker characteristics of eculizumab-exposed patients < 25 years of age seen across 21 centers of the Pediatric Nephrology Research Consortium. Patients were included if they received at least one dose of eculizumab between 2008 and 2015. Traditional summary statistics were applied to demographic and clinical data. RESULTS A total of 152 patients were identified, mean age 9.1 (+/-6.8) years. Eculizumab was used "off-label" in 44% of cases. The most common diagnoses were aHUS (47.4%), Shiga toxin-producing Escherichia coli HUS (12%), unspecified thrombotic microangiopathies (9%), and glomerulonephritis (9%). Genetic testing was available for 60% of patients; 20% had gene variants. Dosing regimens were variable. Kidney outcomes tended to vary according to diagnosis. Infectious adverse events were the most common adverse event (33.5%). No cases of meningitis were reported. Nine patients died of noninfectious causes while on therapy. CONCLUSIONS This multi-center retrospective cohort analysis indicates that a significant number of children and young adults are being exposed to C5 blockade for off-label indications. Dosing schedules were highly variable, limiting outcome conclusions. Attributable adverse events appeared to be low. Cohort mortality (6.6%) was not insignificant. Prospective studies in homogenous disease cohorts are needed to support the role of C5 blockade in kidney outcomes.
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Affiliation(s)
- Melissa Muff-Luett
- Department of Pediatrics, Pediatric Nephrology, University of Nebraska Medical School, Children's Hospital and Medical Center, 8200 Dodge St., Omaha, NE, 68114-4113, USA.
| | - Keia R Sanderson
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, USA
| | - Rachel M Engen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rima S Zahr
- Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Scott E Wenderfer
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN, USA
| | - Sheena Sharma
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, HI, USA
| | - Erica Winnicki
- Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Tracy E Hunley
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Stefan G Kiessling
- Division of Pediatric Nephrology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | | | - Robert Woroniecki
- Pediatric Nephrology and Hypertension, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - Yosuke Miyashita
- Department of Pediatrics, Division of Pediatric Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Abiodun A Omoloja
- Nephrology Department, The Children's Medical Center, Dayton, OH, USA
| | - Sarah J Kizilbash
- Department of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Asif Mansuri
- Children's Hospital of Georgia, Augusta University, Augusta, GA, USA
| | - Mahmoud Kallash
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yichun Yu
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, USA
| | - Ashley K Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Tarak Srivastava
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Carla M Nester
- Departments of Internal Medicine and Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Bhalla A, Alachkar N, Alasfar S. Complement-Based Therapy in the Management of Antibody-Mediated Rejection. Adv Chronic Kidney Dis 2020; 27:138-148. [PMID: 32553246 DOI: 10.1053/j.ackd.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
Antibody-mediated rejection (AMR) is one of the leading causes of kidney allograft failure and is usually mediated by anti-human leukocyte antigen donor-specific antibodies (DSAs). Activation of classical pathway of the complement system is responsible for downstream effects of DSA and account for significant manifestations of AMR. Currently, the treatment of AMR is based on strategies to remove preformed antibodies or to prevent their production; however, these strategies are often unsuccessful. It is theoretically possible to inhibit complement activity to prevent the effect of DSA on kidney allograft function. Complement inhibitors such as eculizumab, a complement 5 monoclonal antibody, and complement 1 esterase inhibitors (C1 INHs) have been used in prevention and treatment of AMR with variable success. Eculizumab and C1 INH seem to reduce the incidence of early AMR and allow transplantation in highly sensitized kidney transplant recipients, but data on their long-term effect on kidney allograft function are limited. Several case reports described the successful use of eculizumab in the treatment of AMR, but there are no randomized controlled studies that showed efficacy. Treatment of AMR with C1 INH, in addition to standard of care, did not change short-term outcome but long-term studies are underway.
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8
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Plaza Lara E, Hernández García E, Ruiz Fuentes MDC, Caba Molina M, De Gracia Guindo MDC, Osuna Ortega A. Plasma Cell-Rich Acute Rejection in Renal Transplantation: A Case Report. Transplant Proc 2020; 52:512-514. [PMID: 32059940 DOI: 10.1016/j.transproceed.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/06/2019] [Accepted: 12/26/2019] [Indexed: 01/10/2023]
Abstract
Plasma cell-rich acute rejection (PCAR) is a rare type of allograft rejection in renal transplantation. It is characterized by the presence of mature plasma cells that compromise more than 10% of inflammatory cells infiltrating the renal graft. The pathogenesis of PCAR is unknown, appears late, and has been related mainly to insufficient immunosuppression or infections. The treatment is not clearly defined, and the graft survival is poor. Here, we report a case series of 3 Spanish patients diagnosed with PCAR accompanied by donor-specific antibodies (DSA) after kidney transplantation. Mean to diagnosis was 2-12 years post-transplantation, and they began with abrupt deterioration of renal function. All patients were women and had preceding viral infection. In addition, two of the three patients recognize a doubtful adherence to immunosuppression. About treatment, 2 of the 3 patients, because the biopsy of the renal graft showed signs suggestive of incipient antibody-mediated rejection (ABMR) (glomerulitis, capilaritis, transplant glomerulopathy), were started with corticosteroids, anti-thymoglobulin, plasmapheresis, and intravenous immunoglobulins. The last patient, who only showed PCAR at biopsy, was treated with corticosteroids and anti-thymoglobulin. After treatment, graft function improved in all of them, but one patient developed an ABMR and another required a dialysis program, all of which indicates the difficulty in management and treatment of PCAR.
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Affiliation(s)
- Eva Plaza Lara
- Nephrology Deparment, University Hospital Virgen de las Nieves, Granada, Spain.
| | | | | | - Mercedes Caba Molina
- Pathological Anatomic Deparment, University Hospital San Cecilio, Granada, Spain
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9
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Tan EK, Bentall AJ, Dean PG, Shaheen MF, Stegall MD, Schinstock CA. Use of Eculizumab for Active Antibody-mediated Rejection That Occurs Early Post-kidney Transplantation: A Consecutive Series of 15 Cases. Transplantation 2019; 103:2397-2404. [PMID: 30801549 PMCID: PMC6699919 DOI: 10.1097/tp.0000000000002639] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Active antibody-mediated rejection (AMR) that occurs during the amnestic response within the first month posttransplant is a rare but devastating cause of early allograft loss after kidney transplant. Prior reports of eculizumab treatment for AMR have been in heterogeneous patient groups needing salvage therapy or presenting at varied time points. We investigated the role of eculizumab as primary therapy for active AMR early posttransplant. METHODS We performed a retrospective observational study of a consecutive cohort of solitary kidney transplant recipients who were transplanted between January 1, 2014, and January 31, 2018, and had AMR within the first 30 days posttransplant and treated with eculizumab ± plasmapheresis. RESULTS Fifteen patients had early active AMR at a median (interquartile range [IQR]) of 10 (7-11) days posttransplant and were treated with eculizumab ± plasmapheresis. Thirteen cases were biopsy proven, and 2 cases were presumed on the basis of donor-specific antibody trends and allograft function. Within 1 week of treatment, the median estimated glomerular filtration rate increased from 21 to 34 mL/min (P = 0.001); and persistent active AMR was only found in 16.7% (2/12) of biopsied patients within 4-6 months. No graft losses occurred, and at last follow-up (median [IQR] of 13 [12-19] mo), the median IQR estimated glomerular filtration rate increased to 52 (46-60) mL/min. CONCLUSIONS Prompt eculizumab treatment as primary therapy is safe and effective for early active AMR after kidney transplant or abrupt increases in donor-specific antibodies when biopsy cannot be performed for diagnosis confirmation.
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Affiliation(s)
- Ek Khoon Tan
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew J. Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Patrick G. Dean
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | | | - Mark D. Stegall
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
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10
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Glotz D, Russ G, Rostaing L, Legendre C, Tufveson G, Chadban S, Grinyó J, Mamode N, Rigotti P, Couzi L, Büchler M, Sandrini S, Dain B, Garfield M, Ogawa M, Richard T, Marks WH. Safety and efficacy of eculizumab for the prevention of antibody-mediated rejection after deceased-donor kidney transplantation in patients with preformed donor-specific antibodies. Am J Transplant 2019; 19:2865-2875. [PMID: 31012541 PMCID: PMC9328661 DOI: 10.1111/ajt.15397] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/17/2019] [Accepted: 04/04/2019] [Indexed: 01/25/2023]
Abstract
The presence of preformed donor-specific antibodies in transplant recipients increases the risk of acute antibody-mediated rejection (AMR). Results of an open-label single-arm trial to evaluate the safety and efficacy of eculizumab in preventing acute AMR in recipients of deceased-donor kidney transplants with preformed donor-specific antibodies are reported. Participants received eculizumab as follows: 1200 mg immediately before reperfusion; 900 mg on posttransplant days 1, 7, 14, 21, and 28; and 1200 mg at weeks 5, 7, and 9. All patients received thymoglobulin induction therapy and standard maintenance immunosuppression including steroids. The primary end point was treatment failure rate, a composite of biopsy-proved grade II/III AMR (Banff 2007 criteria), graft loss, death, or loss to follow-up, within 9 weeks posttransplant. Eighty patients received transplants (48 women); the median age was 52 years (range 24-70 years). Observed treatment failure rate (8.8%) was significantly lower than expected for standard care (40%; P < .001). By 9 weeks, 3 of 80 patients had experienced AMR, and 4 of 80 had experienced graft loss. At 36 months, graft and patient survival rates were 83.4% and 91.5%, respectively. Eculizumab was well tolerated and no new safety concerns were identified. Eculizumab has the potential to provide prophylaxis against injury caused by acute AMR in such patients (EudraCT 2010-019631-35).
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Affiliation(s)
- Denis Glotz
- Paris Translational Research Center for Organ TransplantationInstitut National de la Santé et de la Recherche MédicaleUnité Mixte de Recherche‐S970ParisFrance,Department of Nephrology and Organ TransplantationSaint‐Louis HospitalAssistance Publique‐Hôpitaux de ParisInstitut National de la Santé et de la Recherche MédicaleUnité U1160ParisFrance
| | - Graeme Russ
- Central and Northern Adelaide Renal and Transplantation ServicesRoyal Adelaide Hospital and University of AdelaideAdelaideSouth AustraliaAustralia
| | - Lionel Rostaing
- Formerly Department of Nephrology and Organ TransplantationRangueil University Hospital CenterToulouseFrance,Department of NephrologyHemodialysis, Apheresis and TransplantationGrenoble‐Alpes University Hospital CenterAvenue du Maquis du GrésivaudanLa TroncheFrance
| | - Christophe Legendre
- Adult Nephrology Transplantation ServiceHôpital Necker‐Enfants MaladesUniversité Paris DescartesSorbonne Paris CitéParisFrance,Institut National de la Santé et de la Recherche Médicale U1151Institut Necker‐Enfants MaladesHôpital Necker‐Enfants MaladesParisFrance
| | - Gunnar Tufveson
- Section of Transplantation SurgeryDepartment of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Steve Chadban
- Department of Renal MedicineRoyal Prince Alfred HospitalUniversity of SydneySydneyNew South WalesAustralia
| | - Josep Grinyó
- Department of NephrologyHospital Universitari de BellvitgeUniversity of BarcelonaBarcelonaSpain
| | - Nizam Mamode
- Department of Transplant SurgeryGuy's and St Thomas’, Evelina London Children's and Great Ormond Street Hospitals NHS TrustLondonUK
| | - Paolo Rigotti
- Kidney and Pancreas Transplant UnitUniversity Hospital of PaduaPaduaItaly
| | - Lionel Couzi
- UMR CNRS 5164ImmunoConcEpTBordeaux UniversityBordeauxFrance,Department of Nephrology–Transplantation–Dialysis–ApheresisCHUBordeauxFrance
| | | | - Silvio Sandrini
- Division of NephrologyUniversity of Brescia and Spedali Civili General HospitalBresciaItaly
| | - Bradley Dain
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent Statistics ConsultantGuilfordConnecticut
| | - Mary Garfield
- Formerly Alexion PharmaceuticalsBostonMassachusetts,ArvinasNew HavenConnecticut
| | | | | | - William H. Marks
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent ConsultantBellevueWashington
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11
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Abstract
Increasing evidence indicates an integral role for the complement system in the deleterious inflammatory reactions that occur during critical phases of the transplantation process, such as brain or cardiac death of the donor, surgical trauma, organ preservation and ischaemia-reperfusion injury, as well as in humoral and cellular immune responses to the allograft. Ischaemia is the most common cause of complement activation in kidney transplantation and in combination with reperfusion is a major cause of inflammation and graft damage. Complement also has a prominent role in antibody-mediated rejection (ABMR) owing to ABO and HLA incompatibility, which leads to devastating damage to the transplanted kidney. Emerging drugs and treatment modalities that inhibit complement activation at various stages in the complement cascade are being developed to ameliorate the damage caused by complement activation in transplantation. These promising new therapies have various potential applications at different stages in the process of transplantation, including inhibiting the destructive effects of ischaemia and/or reperfusion injury, treating ABMR, inducing accommodation and modulating the adaptive immune response.
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12
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Thurman JM, Panzer SE, Le Quintrec M. The role of complement in antibody mediated transplant rejection. Mol Immunol 2019; 112:240-246. [PMID: 31195225 PMCID: PMC6646053 DOI: 10.1016/j.molimm.2019.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/23/2019] [Accepted: 06/02/2019] [Indexed: 12/26/2022]
Abstract
Antibody mediated transplant rejection (AMR) is a major cause of long-term allograft failure, and currently available treatments are of limited efficacy for treating the disease. AMR is caused by donor specific antibodies (DSA) that bind to antigens within the transplanted organ. DSA usually activate the classical pathway of complement within the allograft, and complement activation is believed to be an important cause of tissue injury in AMR. Several new clinical assays may improve our ability to identify patients at risk of AMR. Complement inhibitory drugs have also been tested in selected patients and in small series. Better understanding of the role of complement activation in the pathogenesis of AMR will likely improve our ability to diagnose the disease and to develop novel treatments.
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Affiliation(s)
- Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Sarah E Panzer
- Department of Medicine, University of Wisconsin Madison, Madison, WI, USA
| | - Moglie Le Quintrec
- Department of Nephrology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
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13
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Chun N, Horwitz J, Heeger PS. Role of Complement Activation in Allograft Inflammation. CURRENT TRANSPLANTATION REPORTS 2019; 6:52-59. [PMID: 31673484 PMCID: PMC6822566 DOI: 10.1007/s40472-019-0224-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Novel paradigms have broadened our understanding of mechanisms through which complement mediates allograft inflammation/injury. Herein we review advances in the field and highlight therapeutic implications. RECENT FINDINGS Pre-clinical and translational human trials have elucidated complement-dependent mechanisms of post-transplant ischemia-reperfusion (I/R) injury. Immune cell-derived, and intracellular, complement activation are newly linked to proinflammatory T cell immunity relevant to allograft rejection. Complement-induced immune regulation, including C5a ligation of C5a receptor 2 on T cells, C5a/C5a receptor 1 interactions on regulatory myeloid cells, and C1q binding to CD8+ T cells can inhibit proinflammatory T cells and/or prolong murine allograft survival. Pilot trials of complement inhibition to treat/prevent human I/R- or antibody-initiated allograft injury show promise. SUMMARY The complement system participates in allograft injury through multiple context- dependent mechanisms involving various components and receptors. These new insights along with development and implementation of individualized complement inhibitory strategies have potential to improve transplant outcomes.
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Affiliation(s)
- Nicholas Chun
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai
- Division of Nephrology in the Department of Medicine, Icahn School of Medicine at Mount Sinai
| | - Julian Horwitz
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai
- The Precision Institute of Immunology, Icahn School of Medicine at Mount Sinai
| | - Peter S Heeger
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai
- Division of Nephrology in the Department of Medicine, Icahn School of Medicine at Mount Sinai
- The Precision Institute of Immunology, Icahn School of Medicine at Mount Sinai
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14
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Roux A, Levine DJ, Zeevi A, Hachem R, Halloran K, Halloran PF, Gibault L, Taupin JL, Neil DAH, Loupy A, Adam BA, Mengel M, Hwang DM, Calabrese F, Berry G, Pavlisko EN. Banff Lung Report: Current knowledge and future research perspectives for diagnosis and treatment of pulmonary antibody-mediated rejection (AMR). Am J Transplant 2019; 19:21-31. [PMID: 29956477 DOI: 10.1111/ajt.14990] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 01/25/2023]
Abstract
The Lung session of the 2017 14th Banff Foundation for Allograft Pathology Conference, Barcelona focused on the multiple aspects of antibody-mediated rejection (AMR) in lung transplantation. Multidimensional approaches for AMR diagnosis, including classification, histological and immunohistochemical analysis, and donor- specific antibody (DSA) characterization with their current strengths and limitations were reviewed in view of recent research. The group also discussed the role of tissue gene expression analysis in the context of unmet needs in lung transplantation. The current best practice for monitoring of AMR and the therapeutic approach are summarized and highlighted in this report. The working group reached consensus of the major gaps in current knowledge and focused on the unanswered questions regarding pulmonary AMR. An important outcome of the meeting was agreement on the need for future collaborative research projects to address these gaps in the field of lung transplantation.
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Affiliation(s)
- A Roux
- Pneumology, Adult CF Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Paris Translational Research Center for Organ Transplantation, French National institute of Health and Medical Research (INSERM). Unit UMR S970, Paris, France.,Versailles Saint-Quentin-en-Yvelines University, UPRES EA 220, Suresnes, France
| | - D J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - R Hachem
- Washington University, School of Medicine Division of Pulmonary & Critical Care, St. Louis, MO, USA
| | - K Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P F Halloran
- Alberta Transplant Applied Genomics Center, University of Alberta, Edmonton, Alberta, Canada
| | - L Gibault
- Department of Pathology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - J L Taupin
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - D A H Neil
- Department of Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation, French National institute of Health and Medical Research (INSERM). Unit UMR S970, Paris, France
| | - B A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - M Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - D M Hwang
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - F Calabrese
- Department of Cardio-Thoracic and Vascular Sciences, Pathology Section, University of Padova, Italy
| | - G Berry
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - E N Pavlisko
- Department of Pathology, Duke University Hospital, Durham, NC, USA
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15
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Horwitz JK, Chun NH, Heeger PS. Complement and Transplantation: From New Mechanisms to Potential Biomarkers and Novel Treatment Strategies. Clin Lab Med 2018; 39:31-43. [PMID: 30709507 DOI: 10.1016/j.cll.2018.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The complement system, traditionally considered a component of innate immunity, is now recognized as a crucial mediator of the adaptive immune response in solid organ transplantation. Preclinical and early human trials have demonstrated the importance of complement effector mechanisms in driving allograft injury during specific antigraft immune responses, including ischemia-reperfusion injury, T-cell-mediated rejection, and antibody-mediated rejection, as well as a potential role for complement-derived risk stratification biomarkers. These data support the need for further testing of complement inhibitors in solid organ transplant recipients.
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Affiliation(s)
- Julian K Horwitz
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA; Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA
| | - Nicholas H Chun
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA
| | - Peter S Heeger
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA; The Precision Institute of Immunology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, New York, NY 10029, USA.
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16
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Desensitisation strategies in high-risk children before kidney transplantation. Pediatr Nephrol 2018; 33:2239-2251. [PMID: 29332219 DOI: 10.1007/s00467-017-3882-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/19/2017] [Accepted: 12/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transplantation is the preferred modality for renal replacement therapy in children. With increasing rates of re-transplantation within the paediatric population, there are more sensitised children on waiting lists. One issue with developing strategies to treat these children is the number of different definitions of sensitisation. and we would therefore recommend an immunological risk stratification approach. METHODS We discuss methods of sensitisation prevention, assessment and management, including paired exchange programmes and desensitisation protocols. RESULTS There are limited published evidence-based data for desensitisation in adults and none in children; thus, we present information on the available therapies currently in use. DISCUSSION Further research is required to investigate strategies which prevent sensitisation in children, including the healthcare utility of incorporating epitope-based matching into organ allocation algorithms. Controlled studies are also needed to establish the most appropriate desensitisation regimen(s).
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17
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McCaughan JA, Tinckam KJ. Donor specific HLA antibodies & allograft injury: mechanisms, methods of detection, manifestations and management. Transpl Int 2018; 31:1059-1070. [DOI: 10.1111/tri.13324] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/11/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jennifer A. McCaughan
- HLA Laboratory; Laboratory Medicine Program; University Health Network; Toronto ON Canada
- Department of Nephrology and Transplantation; Belfast City Hospital; Belfast UK
| | - Kathryn J. Tinckam
- HLA Laboratory; Laboratory Medicine Program; University Health Network; Toronto ON Canada
- Division of Nephrology; Department of Medicine; University Health Network; Toronto ON Canada
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18
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Román E, Mendizábal S, Jarque I, de la Rubia J, Sempere A, Morales E, Praga M, Ávila A, Górriz JL. Secondary thrombotic microangiopathy and eculizumab: A reasonable therapeutic option. Nefrologia 2018; 37:478-491. [PMID: 28946961 DOI: 10.1016/j.nefro.2017.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 12/16/2022] Open
Abstract
Understanding the role of the complement system in the pathogenesis of atypical haemolytic uraemic syndrome and other thrombotic microangiopathies (TMA) has led to the use of anti-complement therapy with eculizumab in these diseases, in addition to its original use in patients with paroxysmal nocturnal haemoglobinuria andatypical haemolytic uraemic syndrome. Scientific evidence shows that both primary and secondary TMAs with underlying complement activation are closely related. For this reasons, control over the complement system is a therapeutic target. There are 2scenarios in which eculizumab is used in patients with TMA: primary or secondary TMA that is difficult to differentiate (including incomplete clinical presentations) and complement-mediated damage in various processes in which eculizumab proves to be efficacious. This review summarises the evidence on the role of the complement activation in the pathophysiology of secondary TMAs and the efficacy of anti-complement therapy in TMAs secondary to pregnancy, drugs, transplant, humoral rejection, systemic diseases and glomerulonephritis. Although experience is scarce, a good response to eculizumab has been reported in patients with severe secondary TMAs refractory to conventional treatment. Thus, the role of the anti-complement therapy as a new treatment option in these patients should be investigated.
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Affiliation(s)
- Elena Román
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Santiago Mendizábal
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario Dr. Peset, Valencia, España
| | - Amparo Sempere
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Ana Ávila
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
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19
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Coutance G, Van Aelst L, Hékimian G, Vidal C, Rouvier P, Saheb S, Gautreau C, Leprince P, Varnous S. Antibody-mediated rejection induced cardiogenic shock: Too late for conventional therapy. Clin Transplant 2018; 32:e13253. [DOI: 10.1111/ctr.13253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Guillaume Coutance
- Department of Cardiac and Thoracic Surgery; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Lucas Van Aelst
- Department of Cardiac and Thoracic Surgery; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
- Department of Cardiovascular Sciences; KULeuven Campus Gasthuisberg O&N1; Leuven Belgium
| | - Guillaume Hékimian
- Department of Medical Intensive Care Unit; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Charles Vidal
- Department of Cardiac Anesthesia and Reanimation; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Philippe Rouvier
- Department of Pathology; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Samir Saheb
- Department of Hemo-biotherapies; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Chantal Gautreau
- Laboratory of Immunology and Histocompatibility, AP-HP; Saint Louis Hospital; Paris France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
| | - Shaida Varnous
- Department of Cardiac and Thoracic Surgery; Cardiology Institute; Pitié Salpêtrière Hospital; University of Paris VI; Paris France
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20
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Aguilar PR, Carpenter D, Ritter J, Yusen RD, Witt CA, Byers DE, Mohanakumar T, Kreisel D, Trulock EP, Hachem RR. The role of C4d deposition in the diagnosis of antibody-mediated rejection after lung transplantation. Am J Transplant 2018; 18:936-944. [PMID: 28992372 PMCID: PMC5878693 DOI: 10.1111/ajt.14534] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/10/2017] [Accepted: 09/29/2017] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, P = .035), there was no significant difference in the presence of other histologic findings. Despite aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but that the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may respond initially to therapy, there is a high incidence of CLAD and poor survival after AMR.
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Affiliation(s)
- PR Aguilar
- Baylor University Medical Center Division of Pulmonary & Critical Care, Dallas, TX
| | - D Carpenter
- St. Louis University School of Medicine Department of Pathology, St. Louis, MO
| | - J Ritter
- Washington University School of Medicine Department of Pathology & Immunology, St. Louis, MO
| | - RD Yusen
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - CA Witt
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - DE Byers
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | | | - D Kreisel
- Washington University School of Medicine Division of Cardiothoracic Surgery, St. Louis, MO
| | - EP Trulock
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
| | - RR Hachem
- Washington University School of Medicine Division of Pulmonary & Critical Care, St Louis, MO
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21
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Kaabak M, Babenko N, Shapiro R, Zokoyev A, Dymova O, Kim E. A prospective randomized, controlled trial of eculizumab to prevent ischemia-reperfusion injury in pediatric kidney transplantation. Pediatr Transplant 2018; 22. [PMID: 29377474 DOI: 10.1111/petr.13129] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/30/2022]
Abstract
Ischemia-reperfusion injury has multiple effects on a transplanted allograft, including delayed or impaired graft function, compromised long-term survival, and an association with an increased incidence of rejection. Eculizumab, a monoclonal antibody blocking terminal complement activation, has been postulated to be an effective agent in the prevention or amelioration of IRI. We performed a single-center prospective, randomized controlled trial involving 57 pediatric kidney transplant recipients between 2012 and 2016. The immunosuppressive protocol included two doses of alemtuzumab; half of the patients were randomized to receive a single dose of eculizumab prior to transplantation. Maintenance immunosuppression was based on a combination of low-dose tacrolimus and mycophenolate, without steroids. Eculizumab-treated patients had a significantly better early graft function, less arteriolar hyalinosis and chronic glomerulopathy on a protocol biopsies taken on day 30, 1 year, and 3 years after transplantation. In the eculizumab group, four non-vaccinated children lost their grafts during the course of a flu-like infection. Eculizumab is associated with better early graft function and improved graft morphology; however, there was an unacceptably high number of early graft losses among the eculizumab-treated children. While a promising strategy, the best approach to complement inhibition remains to be established.
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Affiliation(s)
- Michael Kaabak
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
| | - Nadeen Babenko
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
| | - Ron Shapiro
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
| | - Allan Zokoyev
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
| | - Olga Dymova
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
| | - Edward Kim
- Kidney Transplantation, National Research Center of Surgery, Moscow, Russia
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22
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Winthrop KL, Mariette X, Silva JT, Benamu E, Calabrese LH, Dumusc A, Smolen JS, Aguado JM, Fernández-Ruiz M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors). Clin Microbiol Infect 2018; 24 Suppl 2:S21-S40. [PMID: 29447987 DOI: 10.1016/j.cmi.2018.02.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection. IMPLICATIONS Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.
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Affiliation(s)
- K L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - X Mariette
- Department of Rheumatology, Hôpitaux Universitaire Paris-Sud, Université Paris-Sud, INSERM U1184, Paris, France
| | - J T Silva
- Department of Infectious Diseases, University Hospital of Badajoz, Fundación para La Formación e Investigación de Los Profesionales de La Salud (FundeSalud), Badajoz, Spain
| | - E Benamu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L H Calabrese
- Department of Rheumatic and Immunological Diseases, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH, USA
| | - A Dumusc
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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23
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Infections associated with the use of eculizumab: recommendations for prevention and prophylaxis. Curr Opin Infect Dis 2018; 29:319-29. [PMID: 27257797 DOI: 10.1097/qco.0000000000000279] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Eculizumab inhibits complement effector functions and has significantly impacted the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. However, the risks of potentially life-threatening infections, notably with Neisseria spp. in addition to its cost, are major challenges in clinical practice. In this review, we characterize and summarize the infectious complications reported with the use of eculizumab in the context of its typical and expanding indications. RECENT FINDINGS Use of eculizumab is rapidly extending to the fields of transplantation and neurology. Eculizumab has been primarily associated with an increased risk of meningococcal infections. Immunization against its commonest serotypes (ABCWY) is now possible with the advent of the meningococcal B vaccine. A combined ABCWY vaccine is underway. Preventive strategies against breakthrough Neisseria infections should also include chemoprophylaxis. Less is known about the association of eculizumab with other infections as recently reported. Surrogate markers of complement blockade, notably CH50, and eculizumab efficacy may help in the risk assessment of infection. SUMMARY Eculizumab has opened new horizons in the treatment of complement-mediated disorders. Prophylactic and immunization strategies against the risk of Nesseria spp. infections are sound and feasible. The use of eculizumab is expanding beyond complement-mediated diseases to transplantation and neurological disorders. Further research is needed to better define and stratify the risk of infection and prevention strategies in patients with the latter indications.
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24
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Montgomery RA, Loupy A, Segev DL. Antibody-mediated rejection: New approaches in prevention and management. Am J Transplant 2018; 18 Suppl 3:3-17. [PMID: 29292861 DOI: 10.1111/ajt.14584] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/26/2017] [Accepted: 11/04/2017] [Indexed: 01/25/2023]
Abstract
Despite the success of desensitization protocols, antibody-mediated rejection (AMR) remains a significant contributor to renal allograft failure in patients with donor-specific antibodies. Plasmapheresis and high-dose intravenous immunoglobulin have proved to be effective treatments to prevent and treat AMR, but irreversible injury in the form of transplant glomerulopathy can commonly manifest months to years later. There is an unmet need to improve the outcomes for patients at risk for AMR. Updated Banff criteria now take into account the increasing understanding of the complex and heterogeneous nature of AMR phenotypes, including the timing of rejection, subclinical and chronic AMR, C4d-negative AMR, and antibody-mediated vascular rejection. Treatment for AMR is not standardized, and there is little in the way of evidence-based treatment guidelines. Refining more precisely the mechanisms of injury responsible for different AMR phenotypes and establishing relevant surrogate endpoints to facilitate more informative studies will likely allow for more accurate determination of prognosis and efficacious intervention using new therapeutic approaches. In addition to plasma exchange and intravenous immunoglobulin, a number of other add-on therapies have been tried in small studies without consistent benefit, including anti-CD20, proteasome inhibitors, complement inhibitors, anti-interleukin-6 receptor blockers, and immunoglobulin G-degrading enzyme of Streptococcus pyogenes (called IdeS).
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Affiliation(s)
- R A Montgomery
- Department of Surgery and NYU Langone Transplant Institute, NYU Langone Medical Center, New York, NY, USA
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation and Department of Nephrology and Kidney Transplantation, Hôpital Necker, INSERM U 970, Paris Descartes University, Paris, France
| | - D L Segev
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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25
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Eculizumab for Thrombotic Microangiopathy Associated with Antibody-Mediated Rejection after ABO-Incompatible Kidney Transplantation. Case Rep Transplant 2017; 2017:3197042. [PMID: 29445563 PMCID: PMC5763091 DOI: 10.1155/2017/3197042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/16/2017] [Indexed: 12/27/2022] Open
Abstract
Thrombotic microangiopathy is a form of antibody-mediated rejection (ABMR): it is the main complication of ABO-incompatible (ABOi) kidney transplantation (KT). Herein, we report on two cases of ABMR with biological and histological features of thrombotic microangiopathy (TMA) that were treated by eculizumab after ABOi KT. The first patient presented with features of TMA at postoperative day (POD) 13. Because of worsening biological parameters and no recovery of kidney function, despite seven sessions of immunoadsorption, a salvage therapy of eculizumab was started on POD 23. Kidney function slightly improved during the first 4 months after transplantation. Eculizumab was stopped at month 4. However, kidney function worsened progressively, leading to dialysis at month 13 after transplantation. The second patient presented with features of TMA at POD 1. In addition to immunoadsorption therapy, eculizumab was started on POD 6. Kidney function improved. Eculizumab was stopped on POD 64 and immunoadsorption sessions were stopped on POD 102. At the last follow-up (after 9 months), eGFR was at 43 mL/min/1.73 m2. Our case reports show the beneficial effect of eculizumab to treat ABMR after ABOi KT. However, it should be given early after diagnosing TMA associated with ABMR.
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26
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Midterm Outcomes of 12 Renal Transplant Recipients Treated With Eculizumab to Prevent Atypical Hemolytic Syndrome Recurrence. Transplantation 2017; 101:2924-2930. [DOI: 10.1097/tp.0000000000001909] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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27
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Lefaucheur C, Viglietti D, Hidalgo LG, Ratner LE, Bagnasco SM, Batal I, Aubert O, Orandi BJ, Oppenheimer F, Bestard O, Rigotti P, Reisaeter AV, Kamar N, Lebranchu Y, Duong Van Huyen JP, Bruneval P, Glotz D, Legendre C, Empana JP, Jouven X, Segev DL, Montgomery RA, Zeevi A, Halloran PF, Loupy A. Complement-Activating Anti-HLA Antibodies in Kidney Transplantation: Allograft Gene Expression Profiling and Response to Treatment. J Am Soc Nephrol 2017; 29:620-635. [PMID: 29042454 DOI: 10.1681/asn.2017050589] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/14/2017] [Indexed: 12/22/2022] Open
Abstract
Complement-activating anti-HLA donor-specific antibodies (DSAs) are associated with impaired kidney transplant outcome; however, whether these antibodies induce a specific rejection phenotype and influence response to therapy remains undetermined. We prospectively screened 931 kidney recipients for complement-activating DSAs and used histopathology, immunostaining, and allograft gene expression to assess rejection phenotypes. Effector cells were evaluated using in vitro human cell cultures. Additionally, we assessed the effect of complement inhibition on kidney allograft rejection phenotype and the clinical response to complement inhibition in 116 independent kidney recipients with DSAs at transplant receiving rejection prophylaxis with eculizumab or standard of care (plasma exchange and intravenous Ig) at ten international centers. The histomolecular rejection phenotype associated with complement-activating DSA was characterized by complement deposition and accumulation of natural killer cells and monocytes/macrophages in capillaries and increased expression of five biologically relevant genes (CXCL11, CCL4, MS4A7, MS4A6A, and FCGR3A) indicative of endothelial activation, IFNγ response, CD16-mediated natural killer cell activation, and monocyte/macrophage activation. Compared with standard of care, eculizumab specifically abrogated this histomolecular rejection phenotype and associated with a decreased 3-month rejection incidence rate in patients with complement-activating DSAs (56%; 95% confidence interval [95% CI], 38% to 74% versus 19%; 95% CI, 8% to 35%; P=0.001) but not in those with noncomplement-activating DSAs (9%; 95% CI, 2% to 25% versus 13%; 95% CI, 2% to 40%; P=0.65). In conclusion, circulating complement-activating anti-HLA DSAs are associated with a specific histomolecular kidney allograft rejection phenotype that can be abrogated by complement inhibition.
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Affiliation(s)
- Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France; .,Kidney Transplant Department, Saint-Louis Hospital
| | - Denis Viglietti
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Kidney Transplant Department, Saint-Louis Hospital
| | - Luis G Hidalgo
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lloyd E Ratner
- Department of Surgery, University of California, San Francisco School of Medicine, San Francisco, California
| | - Serena M Bagnasco
- Kidney Transplant Department, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Ibrahim Batal
- Kidney Pancreas Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France
| | - Babak J Orandi
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Federico Oppenheimer
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Rangueil, Toulouse, Institut National de la Santé et de la Recherche Médicale U1043, Structure Fédérative de Recherche Bio-Médicale de Toulouse, Centre Hospitalier Universitaire Purpan, Toulouse, Université Paul Sabatier, Toulouse, France
| | - Oriol Bestard
- Department of Nephrology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | | | | | - Nassim Kamar
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yvon Lebranchu
- Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean-Paul Duong Van Huyen
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Alberta Transplant Applied Genomics Center, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick Bruneval
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Kidney Transplant Department, Saint-Louis Hospital
| | - Christophe Legendre
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Departments of Pathology and
| | - Jean-Philippe Empana
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France
| | - Dorry L Segev
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Robert A Montgomery
- Department of Surgery, New York University Langone Medical Center, New York, New York; and
| | - Adriana Zeevi
- Department of Transplantation Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Philip F Halloran
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche-S970, Paris, France.,Departments of Pathology and
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28
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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29
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Complement-Mediated Enhancement of Monocyte Adhesion to Endothelial Cells by HLA Antibodies, and Blockade by a Specific Inhibitor of the Classical Complement Cascade, TNT003. Transplantation 2017. [PMID: 28640789 PMCID: PMC5482566 DOI: 10.1097/tp.0000000000001486] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Antibody-mediated rejection (AMR) of most solid organs is characterized by evidence of complement activation and/or intragraft macrophages (C4d + and CD68+ biopsies). We previously demonstrated that crosslinking of HLA I by antibodies triggered endothelial activation and monocyte adhesion. We hypothesized that activation of the classical complement pathway at the endothelial cell surface by HLA antibodies would enhance monocyte adhesion through soluble split product generation, in parallel with direct endothelial activation downstream of HLA signaling. Methods Primary human aortic endothelial cells (HAEC) were stimulated with HLA class I antibodies in the presence of intact human serum complement. C3a and C5a generation, endothelial P-selectin expression, and adhesion of human primary and immortalized monocytes (Mono Mac 6) were measured. Alternatively, HAEC or monocytes were directly stimulated with purified C3a or C5a. Classical complement activation was inhibited by pretreatment of complement with an anti-C1s antibody (TNT003). Results Treatment of HAEC with HLA antibody and human complement increased the formation of C3a and C5a. Monocyte recruitment by human HLA antibodies was enhanced in the presence of intact human serum complement or purified C3a or C5a. Specific inhibition of the classical complement pathway using TNT003 or C1q-depleted serum significantly reduced adhesion of monocytes in the presence of human complement. Conclusions Despite persistent endothelial viability in the presence of HLA antibodies and complement, upstream complement anaphylatoxin production exacerbates endothelial exocytosis and leukocyte recruitment. Upstream inhibition of classical complement may be therapeutic to dampen mononuclear cell recruitment and endothelial activation characteristic of microvascular inflammation during AMR. Valenzuela et al show that HLA antibody binding to human endothelial cells in vitro, triggered complement C3a and C5a deposition that mediated monocyte recruitment, and the salutary effects of inhibiting the classical complement pathway with an anti-C1s antibody. Supplemental digital content is available in the text.
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30
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Moktefi A, Parisot J, Desvaux D, Canoui-Poitrine F, Brocheriou I, Peltier J, Audard V, Kofman T, Suberbielle C, Lang P, Rondeau E, Grimbert P, Matignon M. C1q binding is not an independent risk factor for kidney allograft loss after an acute antibody-mediated rejection episode: a retrospective cohort study. Transpl Int 2017; 30:277-287. [PMID: 27992962 DOI: 10.1111/tri.12905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
Abstract
After kidney transplantation, C4d is an incomplete marker of acute antibody-mediated rejection (AMR) and C1q-binding donor-specific antibodies (DSA) have been associated with allograft survival. However, the impact on allograft survival of C1q+ DSA after clinical AMR has not been studied yet. We analysed retrospectively in clinical AMR C4d staining and C1q-binding impact on allograft survival. We compared clinical, histological and serological features of C4d- and C4d+ AMR, C1q+ and C1q- DSA AMR and analysed C4d and C1q-binding impact on allograft survival. Among 500 for-cause kidney allograft biopsies, 48 fulfilled AMR criteria. C4d+ AMR [N = 18 (37.5%)] have significantly higher number class I DSA (P = 0.02), higher microvascular score (P = 0.02) and more transplant glomerulopathy (P = 0.04). C1q+ AMR [N = 20 (44%)] presented with significantly more class I and class II DSA (P = 0.005 and 0.04) and C4d+ staining (P = 0.01). Graft losses were significantly higher in the C4d+ group (P = 0.04) but similar in C1q groups. C4d+ but not C1q+ binding was an independent risk factor for graft loss [HR = 2.65; (1.11-6.34); P = 0.028]. In our cohort of clinical AMR, C4d+ staining but not C1q+ binding is an independent risk factor for graft loss. Allograft loss and patient survival were similar in C1q+ and C1q- AMR.
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Affiliation(s)
- Anissa Moktefi
- APHP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France
| | - Juliette Parisot
- AP-HP (Assistance Publique-Hôpitaux de Paris), Public Health Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France
| | - Dominique Desvaux
- APHP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France
| | - Florence Canoui-Poitrine
- AP-HP (Assistance Publique-Hôpitaux de Paris), Public Health Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France.,DHU (Département Hositalo-Universitaire) A-TVB, IMRB (Institut Mondor de Recherche Biomédicale)- EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Université Paris-Est-Créteil, UPEC, Créteil, France
| | - Isabelle Brocheriou
- AP-HP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Tenon Hospital, Paris, France.,INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France
| | - Julie Peltier
- INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Intensive Care Nephrology and Renal Transplantation, Tenon Hospital, Paris, France
| | - Vincent Audard
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Tomek Kofman
- AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Caroline Suberbielle
- AP-HP (Assistance Publique-Hôpitaux de Paris), Immunology and Histocompatibility Department, Saint Louis Hospital, Paris, France
| | - Philippe Lang
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Eric Rondeau
- INSERM UMRS_1155, Université Pierre et Marie Curie, Paris, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Intensive Care Nephrology and Renal Transplantation, Tenon Hospital, Paris, France
| | - Philippe Grimbert
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,AP-HP, CIC-BT 504, Créteil, France
| | - Marie Matignon
- DHU (Département Hospitalo-Universitaire) VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Université Paris-Est-Créteil (UPEC), Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France.,AP-HP, CIC-BT 504, Créteil, France
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31
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Cozzi E, Colpo A, De Silvestro G. The mechanisms of rejection in solid organ transplantation. Transfus Apher Sci 2017; 56:498-505. [PMID: 28916402 DOI: 10.1016/j.transci.2017.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Organ transplantation represents the preferred treatment option for many patients in terminal organ failure. The half-life of transplanted organs, however, is still far from being satisfactory with the vast majority of the organs failing within the first two decades following transplantation. At this stage, it has become apparent that rejection (prevalently mediated by humoral events) remains the primary cause of graft loss after the first year. In this light, studies are underway to better comprehend the immune events underlying graft rejection and novel immunosuppressive strategies are being explored. In this context, therapeutic apheresis techniques, that include therapeutic plasma exchange (TPE), immunoadsorption (IA) and extracorporeal photochemotherapy (ECP), represent an important adjunct in the current immunosuppressive armamentarium. This article briefly reviews our current understanding of the immune process underlying rejection of a solid organ transplant and describes the principal areas of application of therapeutic apheresis techniques in transplantation.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences, Transplant Immunology Unit, Padua University Hospital, Padova, Italy; CORIT (Consortium for Research in Organ Transplantation), Padova, Italy.
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Padova, Italy
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32
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Cernoch M, Viklicky O. Complement in Kidney Transplantation. Front Med (Lausanne) 2017; 4:66. [PMID: 28611987 PMCID: PMC5447724 DOI: 10.3389/fmed.2017.00066] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/09/2017] [Indexed: 12/12/2022] Open
Abstract
The complement system is considered to be an important part of innate immune system with a significant role in inflammation processes. The activation can occur through classical, alternative, or lectin pathway, resulting in the creation of anaphylatoxins C3a and C5a, possessing a vast spectrum of immune functions, and the assembly of terminal complement cascade, capable of direct cell lysis. The activation processes are tightly regulated; inappropriate activation of the complement cascade plays a significant role in many renal diseases including organ transplantation. Moreover, complement cascade is activated during ischemia/reperfusion injury processes and influences delayed graft function of kidney allografts. Interestingly, complement system has been found to play a role in both acute cellular and antibody-mediated rejections and thrombotic microangiopathy. Therefore, complement system may represent an interesting therapeutical target in kidney transplant pathologies.
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Affiliation(s)
- Marek Cernoch
- Transplant Laboratory, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Ondrej Viklicky
- Transplant Laboratory, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czechia.,Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czechia
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33
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Béland S, Vallin P, Désy O, Lévesque E, De Serres SA. Effects of alloantibodies to human leukocyte antigen on endothelial expression and serum levels of thrombomodulin. J Thromb Haemost 2017; 15:1020-1031. [PMID: 28239987 DOI: 10.1111/jth.13661] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 12/25/2022]
Abstract
Essentials The effect of alloantibodies on the endothelial expression of thrombomodulin is unknown. Thrombomodulin was quantified in stimulated endothelial cells and measured in serum samples. Anti-human leukocyte antigen (HLA) I vs. II antibodies have different effects on thrombomodulin. Anti-HLA II antibodies may promote a prothrombotic state and contribute to microangiopathy. SUMMARY Rationale Thrombomodulin (TBM) is an anticoagulant and anti-inflammatory transmembrane protein expressed on endothelial cells. Donor-specific alloantibodies, particularly those against human leukocyte antigen (HLA) class II, are associated with microvascular endothelial damage in solid allografts. Objective Our aim was to characterize the effects of anti-HLA antibodies on endothelial expression of TBM, and in particular, the differential effects of anti-HLA class I compared with those of anti-HLA class II. Methods We used human glomerular microvascular endothelial cells to examine TBM expression on anti-HLA-treated cells, and we tested sera from transplant recipients for soluble TBM. Results We found that whereas membrane TBM expression increased in a dose-dependent manner in the presence of anti-HLA class I antibodies, treatment with anti-HLA class II led to minimal TBM expression on the endothelial surface but to a cytosolic accumulation. Platelet adhesion studies confirmed the functional impact of anti-HLA class II. Quantitative densitometry of the membrane lysates further suggested that anti-HLA class II impairs TBM glycosylation. Furthermore, we found a significant association between the presence of circulating anti-HLA class II antibodies in transplant recipients and low serum levels of TBM. Conclusion These results indicate that ligation of anti-HLA class I and II antibodies produces different effects on the endothelial expression of TBM and on serum levels of TBM in transplant recipients. Anti-HLA class II antibodies may be associated with a prothrombotic state, which could explain the higher occurrence of microangiopathic lesions in the allograft and the poor outcomes observed in patients with these alloantibodies.
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Affiliation(s)
- S Béland
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - P Vallin
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - O Désy
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - E Lévesque
- Hematology and Oncology Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - S A De Serres
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Quebec City, QC, Canada
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34
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Tatapudi VS, Montgomery RA. Pharmacologic Complement Inhibition in Clinical Transplantation. CURRENT TRANSPLANTATION REPORTS 2017; 4:91-100. [PMID: 29214126 PMCID: PMC5707230 DOI: 10.1007/s40472-017-0148-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review Over the past two decades, significant strides made in our understanding of the etiology of antibody-mediated rejection (AMR) in transplantation have put the complement system in the spotlight. Here, we review recent progress made in the field of pharmacologic complement inhibition in clinical transplantation and aim to understand the impact of this therapeutic approach on outcomes in transplant recipients. Recent Findings Encouraged by the success of agents targeting the complement cascade in disorders of unrestrained complement activation like paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), investigators are testing the safety and efficacy of pharmacologic complement blockade in mitigating allograft injury in conditions ranging from AMR to recurrent post-transplant aHUS, C3 glomerulopathies and antiphospholipid anti-body syndrome (APS). A recent prospective study demonstrated the efficacy of terminal complement inhibition with eculizumab in the prevention of acute AMR in human leukocyte antigen (HLA)-incompatible living donor renal transplant recipients. C1 esterase inhibitor (C1-INH) was well tolerated in two recent studies in the treatment of AMR and was associated with improved renal allograft function. Summary Pharmacologic complement inhibition is emerging as valuable therapeutic tool, especially in the management of highly sensitized renal transplant recipients. Novel and promising agents that target various elements in the complement cascade are in development. Graphical Abstractᅟ.
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Affiliation(s)
- Vasishta S Tatapudi
- Division of Nephrology, Department of Internal Medicine, NYU Langone Medical Center, New York, NY 10016 USA
| | - Robert A Montgomery
- NYU Langone Transplant Institute, 530 First Avenue, HCC 7A, New York, NY 10016 USA
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35
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Go RS, Winters JL, Leung N, Murray DL, Willrich MA, Abraham RS, Amer H, Hogan WJ, Marshall AL, Sethi S, Tran CL, Chen D, Pruthi RK, Ashrani AA, Fervenza FC, Cramer CH, Rodriguez V, Wolanskyj AP, Thomé SD, Hook CC. Thrombotic Microangiopathy Care Pathway: A Consensus Statement for the Mayo Clinic Complement Alternative Pathway-Thrombotic Microangiopathy (CAP-TMA) Disease-Oriented Group. Mayo Clin Proc 2016; 91:1189-211. [PMID: 27497856 DOI: 10.1016/j.mayocp.2016.05.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/12/2016] [Accepted: 05/27/2016] [Indexed: 12/15/2022]
Abstract
Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.
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Affiliation(s)
- Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | - Carl H Cramer
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
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Volk AL, Hu FJ, Berglund MM, Nordling E, Strömberg P, Uhlen M, Rockberg J. Stratification of responders towards eculizumab using a structural epitope mapping strategy. Sci Rep 2016; 6:31365. [PMID: 27509843 PMCID: PMC4980765 DOI: 10.1038/srep31365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/18/2016] [Indexed: 11/24/2022] Open
Abstract
The complement component 5 (C5)-binding antibody eculizumab is used to treat patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical haemolytic uremic syndrome (aHUS). As recently reported there is a need for a precise classification of eculizumab responsive patients to allow for a safe and cost-effective treatment. To allow for such stratification, knowledge of the precise binding site of the drug on its target is crucial. Using a structural epitope mapping strategy based on bacterial surface display, flow cytometric sorting and validation via haemolytic activity testing, we identified six residues essential for binding of eculizumab to C5. This epitope co-localizes with the contact area recently identified by crystallography and includes positions in C5 mutated in non-responders. The identified epitope also includes residue W917, which is unique for human C5 and explains the observed lack of cross-reactivity for eculizumab with other primates. We could demonstrate that Ornithodorus moubata complement inhibitor (OmCI), in contrast to eculizumab, maintained anti-haemolytic function for mutations in any of the six epitope residues, thus representing a possible alternative treatment for patients non-responsive to eculizumab. The method for stratification of patients described here allows for precision medicine and should be applicable to several other diseases and therapeutics.
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Affiliation(s)
- Anna-Luisa Volk
- KTH - Royal Institute of Technology, School of Biotechnology, Department of Proteomics and Nanobiotechnology, 106 91 Stockholm, Sweden.,KTH Center for Applied Proteomics, School of Biotechnology, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Francis Jingxin Hu
- KTH - Royal Institute of Technology, School of Biotechnology, Department of Proteomics and Nanobiotechnology, 106 91 Stockholm, Sweden.,KTH Center for Applied Proteomics, School of Biotechnology, KTH - Royal Institute of Technology, Stockholm, Sweden
| | | | - Erik Nordling
- Swedish Orphan Biovitrum AB, 11276 Stockholm, Sweden
| | | | - Mathias Uhlen
- KTH - Royal Institute of Technology, School of Biotechnology, Department of Proteomics and Nanobiotechnology, 106 91 Stockholm, Sweden.,KTH Center for Applied Proteomics, School of Biotechnology, KTH - Royal Institute of Technology, Stockholm, Sweden.,KTH - Royal Institute of Technology, Science for Life Laboratory, 17165 Stockholm, Sweden.,Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, DK-2970 Hørsholm, Denmark
| | - Johan Rockberg
- KTH - Royal Institute of Technology, School of Biotechnology, Department of Proteomics and Nanobiotechnology, 106 91 Stockholm, Sweden
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Eculizumab for the Treatment of Severe Antibody-Mediated Rejection: A Case Report and Review of the Literature. Case Rep Transplant 2016; 2016:9874261. [PMID: 27478676 PMCID: PMC4958444 DOI: 10.1155/2016/9874261] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/27/2022] Open
Abstract
In renal transplantation, treatment options for antibody-mediated rejection are limited. Here, we report a case of severe AMR treated with eculizumab. A 50-year-old woman known for end stage kidney disease secondary to IgA nephropathy received a kidney transplant from a 50-year-old deceased donor. At 5 months after transplantation, she presented with acute graft dysfunction and biopsy showed a severe antibody-mediated rejection associated with thrombotic microangiopathy. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted and the patient was treated with 3 doses of eculizumab. Following the therapy, markers of TMA improved and graft function stabilized. However, ongoing signs of rejection remained in the repeated biopsy. In kidney transplantation, eculizumab is an expensive treatment and its role in the treatment of antibody-mediated rejection remains to be determined.
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38
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Stites E, Le Quintrec M, Thurman JM. The Complement System and Antibody-Mediated Transplant Rejection. THE JOURNAL OF IMMUNOLOGY 2016; 195:5525-31. [PMID: 26637661 DOI: 10.4049/jimmunol.1501686] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Complement activation is an important cause of tissue injury in patients with Ab-mediated rejection (AMR) of transplanted organs. Complement activation triggers a strong inflammatory response, and it also generates tissue-bound and soluble fragments that are clinically useful markers of inflammation. The detection of complement proteins deposited within transplanted tissues has become an indispensible biomarker of AMR, and several assays have recently been developed to measure complement activation by Abs reactive to specific donor HLA expressed within the transplant. Complement inhibitors have entered clinical use and have shown efficacy for the treatment of AMR. New methods of detecting complement activation within transplanted organs will improve our ability to diagnose and monitor AMR, and they will also help guide the use of complement inhibitory drugs.
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Affiliation(s)
- Erik Stites
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
| | - Moglie Le Quintrec
- Department of Nephrology and Renal Transplantation, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045; and
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Viglietti D, Gosset C, Loupy A, Deville L, Verine J, Zeevi A, Glotz D, Lefaucheur C. C1 Inhibitor in Acute Antibody-Mediated Rejection Nonresponsive to Conventional Therapy in Kidney Transplant Recipients: A Pilot Study. Am J Transplant 2016; 16:1596-603. [PMID: 26693703 DOI: 10.1111/ajt.13663] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/08/2015] [Accepted: 11/27/2015] [Indexed: 02/06/2023]
Abstract
Complement inhibitors have not been thoroughly evaluated in the treatment of acute antibody-mediated rejection (ABMR). We performed a prospective, single-arm pilot study to investigate the potential effects and safety of C1 inhibitor (C1-INH) Berinert added to high-dose intravenous immunoglobulin (IVIG) for the treatment of acute ABMR that is nonresponsive to conventional therapy. Kidney recipients with nonresponsive active ABMR and acute allograft dysfunction were enrolled between April 2013 and July 2014 and received C1-INH and IVIG for 6 months (six patients). The primary end point was the change in eGFR at 6 months after inclusion (M+6). Secondary end points included the changes in histology and DSA characteristics and adverse events as evaluated at M+6. All patients showed an improvement in eGFR between inclusion and M+6: from 38.7 ± 17.9 to 45.2 ± 21.3 mL/min/1.73 m(2) (p = 0.0277). There was no change in histological features, except a decrease in the C4d deposition rate from 5/6 to 1/6 (p = 0.0455). There was a change in DSA C1q status from 6/6 to 1/6 positive (p = 0.0253). One deep venous thrombosis was observed. In a secondary analysis, C1-INH patients were compared with a similar historical control group (21 patients). C1-INH added to IVIG is safe and may improve allograft function in kidney recipients with nonresponsive acute ABMR.
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Affiliation(s)
- D Viglietti
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - C Gosset
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Kidney Transplantation, Necker Hospital, Assitance Publique - Hôpitaux de Paris, Paris, France
| | - L Deville
- Department of Pharmacy, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - J Verine
- Department of Pathology, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - A Zeevi
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - D Glotz
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - C Lefaucheur
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
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40
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Lion J, Taflin C, Cross AR, Robledo-Sarmiento M, Mariotto E, Savenay A, Carmagnat M, Suberbielle C, Charron D, Haziot A, Glotz D, Mooney N. HLA Class II Antibody Activation of Endothelial Cells Promotes Th17 and Disrupts Regulatory T Lymphocyte Expansion. Am J Transplant 2016; 16:1408-20. [PMID: 26614587 DOI: 10.1111/ajt.13644] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 01/25/2023]
Abstract
Kidney transplantation is the most successful treatment option for patients with end-stage renal disease, and chronic antibody-mediated rejection is the principal cause of allograft loss. Predictive factors for chronic rejection include high levels of HLA alloantibodies (particularly HLA class II) and activation of graft endothelial cells (ECs). The mechanistic basis for this association is unresolved. We used an experimental model of HLA-DR antibody stimulation of microvascular ECs to examine the mechanisms underlying the association between HLA class II antibodies, EC activation and allograft damage. Activation of ECs with the F(Ab')2 fragment of HLA-DR antibody led to phosphorylation of Akt, ERK and MEK and increased IL-6 production by ECs cocultured with allogeneic peripheral blood mononuclear cells (PBMCs) in an Akt-dependent manner. We previously showed that HLA-DR-expressing ECs induce polarization of Th17 and FoxP3(bright) regulatory T cell (Treg) subsets. Preactivation of ECs with anti-HLA-DR antibody redirected EC allogenicity toward a proinflammatory response by decreasing amplification of functional Treg and by further increasing IL-6-dependent Th17 expansion. Alloimmunized patient serum containing relevant HLA-DR alloantibodies selectively bound and increased EC secretion of IL-6 in cocultures with PBMCs. These data contribute to understanding of potential mechanisms of antibody-mediated endothelial damage independent of complement activation and FcR-expressing effector cells.
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Affiliation(s)
- J Lion
- Inserm, UMRs 1160, Paris, France
| | - C Taflin
- Inserm, UMRs 1160, Paris, France.,Service de Néphrologie et Transplantation, Hôpital Saint-Louis, Paris, France
| | | | | | | | - A Savenay
- Inserm, UMRs 1160, Paris, France.,Laboratoire de Histocompatibilité, Paris, France
| | - M Carmagnat
- Inserm, UMRs 1160, Paris, France.,Laboratoire de Histocompatibilité, Paris, France
| | - C Suberbielle
- Inserm, UMRs 1160, Paris, France.,Laboratoire de Histocompatibilité, Paris, France
| | - D Charron
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris, France
| | - A Haziot
- Inserm, UMRs 1160, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - D Glotz
- Inserm, UMRs 1160, Paris, France.,Service de Néphrologie et Transplantation, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris, France
| | - N Mooney
- Inserm, UMRs 1160, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris, France
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41
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Jordan S, Choi J, Kahwaji J, Vo A. Complement Inhibition for Prevention and Treatment of Antibody-Mediated Rejection in Renal Allograft Recipients. Transplant Proc 2016; 48:806-8. [DOI: 10.1016/j.transproceed.2015.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/11/2015] [Indexed: 12/30/2022]
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Abstract
PURPOSE OF REVIEW Eculizumab suppresses the effector functions of the complement system and represents a therapeutic breakthrough for patients with paroxysmal nocturnal hemoglobinuria or atypical hemolytic uremic syndrome (aHUS). Safety monitoring is ongoing; so far, most notable is the expected increase in infection risk with encapsulated organisms. Despite potential applicability in multiple complement-mediated disorders, the off-label use of eculizumab has been limited, mainly by its prohibitive cost. The purpose of this review is to summarize the current data relevant to the use of eculizumab in kidney transplantation. RECENT FINDINGS In aHUS, prone to high rates of recurrence and allograft loss, eculizumab has made the most notable therapeutic impact. Further clarification of complement defects may help predict therapeutic responses and hopefully guide treatment duration. In C3 glomerulopathies, the clinical response to eculizumab appears more heterogeneous and less effective in processes mediated by upstream to C5 complement deregulation. A large clinical trial of eculizumab for prevention of delayed graft function is ongoing. In antibody-mediated rejection, the role of eculizumab is unclear as its use has been limited to very complex, mostly presensitized, patients in mixed combinations of therapeutic modalities. SUMMARY Overall, eculizumab has raised awareness of complement-mediated disorders as an exciting, new therapeutic option with multiple potential applications in kidney transplantation. Further research is needed to develop a better understanding of eculizumab applicability, efficacy, and treatment monitoring and beyond, to future therapeutic tools targeting the complement.
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Off-label use of the expensive orphan drug eculizumab in France 2009-2013 and the impact of literature: focus on the transplantation field. Eur J Clin Pharmacol 2016; 72:737-46. [PMID: 26915814 DOI: 10.1007/s00228-016-2027-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/11/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The orphan drug eculizumab (Soliris ®) is one of the most expensive in the world and based on expenditures is classed among the highest in France, a scenario suggestive of off-label use. Given its pharmacological properties, it is likely to be used in organ transplantation. Our purposes were to describe the consumption trends of eculizumab for off-label indications overall and in the organ transplantation field and to assess the impact of publications on the latter use. METHODS We carried out a temporal ecological study within the French national hospitalization database (PMSI). First, the trend of eculizumab consumption (2009-2013) was compared to our estimate of the maximum on-label consumption (overall and for transplantation). Second, we evaluated the impact of the publications supporting the effectiveness of eculizumab in the transplantation field on temporal trends of eculizumab consumption. RESULTS Eculizumab total consumption exceeded our estimate of the maximum on-label consumption since the end of 2011 and increased until the end of the study. The off-label consumption represented at least 50 % of the total consumption. The off-label consumption in organ transplantation also increased since 2011. The amount of publications grew through the study period, but overall, the evidence level remained low. Statistically, publications were neither associated with the drug consumption for transplantation in the long term nor in the short term. CONCLUSION Eculizumab started being notably used for off-label indications in France since the end of 2011, and this use increased until the end of the study. We found only low-level evidence concerning the off-label use of eculizumab in the transplantation field through the studied period.
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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Eskandary F, Wahrmann M, Mühlbacher J, Böhmig GA. Complement inhibition as potential new therapy for antibody-mediated rejection. Transpl Int 2015; 29:392-402. [DOI: 10.1111/tri.12706] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/07/2015] [Accepted: 10/13/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Farsad Eskandary
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
| | - Jakob Mühlbacher
- Department of Surgery; Medical University Vienna; Vienna Austria
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
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46
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Abstract
PURPOSE OF REVIEW To summarize the current knowledge regarding mechanisms linking the complement system to transplant injury, highlighting findings reported since 2013. RECENT FINDINGS Building upon the documentation that complement activation is a pathogenic mediator of posttransplant ischemia-reperfusion injury, emerging evidence from animal models indicates that blocking either the classical or lectin pathways attenuates ischemia-reperfusion injury. Immune cell-derived and locally activated complement, including intracellular C3, positively modulates alloreactive T-cell activation and expansion, whereby simultaneously inhibiting regulatory T-cell induction and function, and together promoting transplant rejection. Although alloantibody-initiated complement activation directly injures target cells, complement-dependent signals activate endothelial cells to facilitate T-cell-dependent inflammation. Complement activation within allografts contributes to progressive chronic injury and fibrosis. SUMMARY The complement cascade, traditionally considered to be relevant to transplantation only as an effector mechanism of antibody-initiated allograft injury, is now understood to damage the allograft through multiple mechanisms. Complement activation promotes posttransplant ischemia-reperfusion injury, formation and function of alloantibody, differentiation and function of alloreactive T cells, and contributes to chronic progressive allograft failure. The recognition that complement affects transplant injury at many levels provides a foundation for targeting complement as a therapy to prolong transplant survival and improve patient health.
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Lefaucheur C, Viglietti D, Bentlejewski C, Duong van Huyen JP, Vernerey D, Aubert O, Verine J, Jouven X, Legendre C, Glotz D, Loupy A, Zeevi A. IgG Donor-Specific Anti-Human HLA Antibody Subclasses and Kidney Allograft Antibody-Mediated Injury. J Am Soc Nephrol 2015; 27:293-304. [PMID: 26293822 DOI: 10.1681/asn.2014111120] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/27/2015] [Indexed: 12/24/2022] Open
Abstract
Antibodies may have different pathogenicities according to IgG subclass. We investigated the association between IgG subclasses of circulating anti-human HLA antibodies and antibody-mediated kidney allograft injury. Among 635 consecutive kidney transplantations performed between 2008 and 2010, we enrolled 125 patients with donor-specific anti-human HLA antibodies (DSA) detected in the first year post-transplant. We assessed DSA characteristics, including specificity, HLA class specificity, mean fluorescence intensity (MFI), C1q-binding, and IgG subclass, and graft injury phenotype at the time of sera evaluation. Overall, 51 (40.8%) patients had acute antibody-mediated rejection (aABMR), 36 (28.8%) patients had subclinical ABMR (sABMR), and 38 (30.4%) patients were ABMR-free. The MFI of the immunodominant DSA (iDSA, the DSA with the highest MFI level) was 6724±464, and 41.6% of patients had iDSA showing C1q positivity. The distribution of iDSA IgG1-4 subclasses among the population was 75.2%, 44.0%, 28.0%, and 26.4%, respectively. An unsupervised principal component analysis integrating iDSA IgG subclasses revealed aABMR was mainly driven by IgG3 iDSA, whereas sABMR was driven by IgG4 iDSA. IgG3 iDSA was associated with a shorter time to rejection (P<0.001), increased microcirculation injury (P=0.002), and C4d capillary deposition (P<0.001). IgG4 iDSA was associated with later allograft injury with increased allograft glomerulopathy and interstitial fibrosis/tubular atrophy lesions (P<0.001 for all comparisons). Integrating iDSA HLA class specificity, MFI level, C1q-binding status, and IgG subclasses in a Cox survival model revealed IgG3 iDSA and C1q-binding iDSA were strongly and independently associated with allograft failure. These results suggest IgG iDSA subclasses identify distinct phenotypes of kidney allograft antibody-mediated injury.
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Affiliation(s)
- Carmen Lefaucheur
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France;
| | - Denis Viglietti
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | | | - Jean-Paul Duong van Huyen
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France; Department of Pathology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dewi Vernerey
- Methodology Unit (Research team 3181), University Hospital de Besançon, Besançon, France
| | - Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | - Jérôme Verine
- Department of Pathology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France
| | - Christophe Legendre
- Department of Kidney Transplantation, Necker Hospital, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Denis Glotz
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, National Institute of Health and Medical Research, Mixed Research Unit-S970, Paris, France; Department of Kidney Transplantation, Necker Hospital, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Adriana Zeevi
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Thomas KA, Valenzuela NM, Gjertson D, Mulder A, Fishbein MC, Parry GC, Panicker S, Reed EF. An Anti-C1s Monoclonal, TNT003, Inhibits Complement Activation Induced by Antibodies Against HLA. Am J Transplant 2015; 15:2037-49. [PMID: 25904443 PMCID: PMC4654252 DOI: 10.1111/ajt.13273] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) of solid organ transplants (SOT) is characterized by damage triggered by donor-specific antibodies (DSA) binding donor Class I and II HLA (HLA-I and HLA-II) expressed on endothelial cells. While F(ab')2 portions of DSA cause cellular activation and proliferation, Fc regions activate the classical complement cascade, resulting in complement deposition and leukocyte recruitment, both hallmark features of AMR. We characterized the ability of an anti-C1s monoclonal antibody, TNT003, to inhibit HLA antibody (HLA-Ab)-induced complement activation. Complement deposition induced by HLA-Ab was evaluated using novel cell- and bead-based assays. Human aortic endothelial cells (HAEC) were cultured with HLA-Ab and human complement; production of activated complement proteins was measured by flow cytometry. Additionally, C3d deposition was measured on single antigen beads (SAB) mixed with HLA-Ab and human complement. TNT003 inhibited HLA-Ab mediated complement deposition on HAEC in a concentration-dependent manner; C3a, C4a and C5a anaphylatoxin production was also diminished by TNT003. Finally, TNT003 blocked C3d deposition induced by Class I (HLAI-Ab)- and Class II (HLAII-Ab)-specific antibodies on SAB. These data suggest TNT003 may be useful for modulating the effects of DSA, as TNT003 inhibits complement deposition and split product formation generated by HLA-I/II-Ab in vitro.
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Affiliation(s)
- K A Thomas
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - N M Valenzuela
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - D Gjertson
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - A Mulder
- Department of Immunohematology and Blood Transfusion, Leiden University Medical CenterLeiden, the Netherlands
| | - M C Fishbein
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - G C Parry
- True North Therapeutics, Inc.South San Francisco, CA
| | - S Panicker
- True North Therapeutics, Inc.South San Francisco, CA
| | - E F Reed
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA,*Corresponding author: Elaine F. Reed,
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Valenzuela NM, Trinh KR, Mulder A, Morrison SL, Reed EF. Monocyte recruitment by HLA IgG-activated endothelium: the relationship between IgG subclass and FcγRIIa polymorphisms. Am J Transplant 2015; 15:1502-18. [PMID: 25648976 PMCID: PMC4439339 DOI: 10.1111/ajt.13174] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/01/2014] [Accepted: 12/15/2014] [Indexed: 01/25/2023]
Abstract
It is currently unclear which donor specific HLA antibodies confer the highest risk of antibody-mediated rejection (AMR) and allograft loss. In this study, we hypothesized that two distinct features (HLA IgG subclass and Fcγ receptor [FcγR] polymorphisms) which vary from patient to patient, influence the process of monocyte trafficking to and macrophage accumulation in the allograft during AMR in an interrelated fashion. Here, we investigated the contribution of human IgG subclass and FcγR polymorphisms in monocyte recruitment in vitro by primary human aortic endothelium activated with chimeric anti-HLA I human IgG1 and IgG2. Both subclasses triggered monocyte adhesion to endothelial cells, via a two-step process. First, HLA I crosslinking by antibodies stimulated upregulation of P-selectin on endothelium irrespective of IgG subclass. P-selectin-induced monocyte adhesion was enhanced by secondary interactions of IgG with FcγRs, which was highly dependent upon subclass. IgG1 was more potent than IgG2 through differential engagement of FcγRs. Monocytes homozygous for FcγRIIa-H131 adhered more readily to HLA antibody-activated endothelium compared with FcγRIIa-R131 homozygous. Finally, direct modification of HLA I antibodies with immunomodulatory enzymes EndoS and IdeS dampened recruitment by eliminating antibody-FcγR binding, an approach that may have clinical utility in reducing AMR and other forms of antibody-induced inflammation.
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Affiliation(s)
- Nicole M. Valenzuela
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - K. Ryan Trinh
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA
| | - Arend Mulder
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Sherie L. Morrison
- Department of Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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