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Eichenberger EM, Magua W, Rickert JB, Karadkhele G, Fallahzadeh MK, Vasanth P, Larsen C. Belatacept-based immunosuppression does not confer increased risk of BK polyomavirus-DNAemia relative to tacrolimus-based immunosuppression. Transpl Infect Dis 2024:e14298. [PMID: 38946227 DOI: 10.1111/tid.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The effect of belatacept on BK polyomavirus (BKPyV) control remains largely unknown. METHODS This is a propensity matched retrospective cohort study in adult kidney transplant recipients (KTR) transplanted between 2016-2020 who received a belatacept- versus tacrolimus-based immunosuppression regimen. A continuous time multi-state Markov model was used to evaluate BKPyV replication dynamics (BKPyV-dyn). Three BKPyV-dyn states were defined: BKPyV-dyn1 (viral load <3 log10), BKPyV-dyn2 (viral load ≥ 3 log10 and ≤4 log10), and BKPyV-dyn3 (viral load >4 log10). RESULTS Two hundred eighty KTR on belatacept- and 280 KTR on tacrolimus-based regimens were compared. The probability of transitioning between BKPyV-dyn states and time spent in each state in both groups was comparable. Total duration in BKPyV-dyn-1 was 632.1 days (95% CI 612.1, 648.5) for belatacept versus 615.2 days (95% CI 592.5, 635.8) for tacrolimus, BKPyV-dyn-2 was 49.2 days (95% CI 41.3, 58.4) for belatacept versus 55.6 days (95% CI 46.5, 66.8) for tacrolimus, and BKPyV-dyn-3 was 48.7 days (95% CI 37.1, 363.1) for belatacept versus 59.2 days (95% CI 45.8, 73.5) for tacrolimus. BKPyV associated nephropathy (PyVAN) occurred in 3.9% in belatacept- and 3.9% tacrolimus-treated KRT (P > .9). CONCLUSIONS Compared with tacrolimus-based immunosuppression, belatacept based immunosuppression was not associated with increased risk of BKPyV-DNAemia or nephropathy.
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Affiliation(s)
- Emily M Eichenberger
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Wairimu Magua
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Payaswini Vasanth
- Division of Nephrology, Department of Medicine, Emory University, Atlanta, Georgia, USA
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Eid R, Scemla A, Giral M, Arzouk N, Bertrand D, Peraldi MN, Mesnard L, Longuet H, Maanaoui M, Desbuissons G, Lefevre E, Snanoudj R. Use of a Belatacept-based Immunosuppression for Kidney Transplantation From Donors After Circulatory Death: A Paired Kidney Analysis. Transplant Direct 2024; 10:e1615. [PMID: 38617465 PMCID: PMC11013701 DOI: 10.1097/txd.0000000000001615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 04/16/2024] Open
Abstract
Background Efficacy and safety of belatacept have not been specifically reported for kidney transplantations from donors after circulatory death. Methods In this retrospective multicenter paired kidney study, we compared the outcome of kidney transplantations with a belatacept-based to a calcineurin inhibitor (CNI)-based immunosuppression. We included all kidney transplant recipients from donors after uncontrolled or controlled circulatory death performed in our center between February 2015 and October 2020 and treated with belatacept (n = 31). The control group included the recipients of the contralateral kidney that were treated with CNI in 8 other centers (tacrolimus n = 29, cyclosporine n = 2). Results There was no difference in the rate of delayed graft function. A higher incidence of biopsy-proven rejections was noted in the belatacept group (24 versus 6 episodes). Estimated glomerular filtration rate (eGFR) was significantly higher in the belatacept group at 3-, 12-, and 36-mo posttransplant, but the slope of eGFR was similar in the 2 groups. During a mean follow-up of 4.1 y, 12 patients discontinued belatacept and 2 patients were switched from CNI to belatacept. For patients who remained on belatacept, eGFR mean value and slope were significantly higher during the whole follow-up. At 5 y, eGFR was 80.7 ± 18.5 with belatacept versus 56.3 ± 22.0 mL/min/1.73 m2 with CNI (P = 0.003). No significant difference in graft and patient survival was observed. Conclusions The use of belatacept for kidney transplants from either uncontrolled or controlled donors after circulatory death resulted in a better medium-term renal function for patients remaining on belatacept despite similar rates of delayed graft function and higher rates of cellular rejection.
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Affiliation(s)
- Rita Eid
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Anne Scemla
- Department of Nephrology and Transplantation, Necker University Hospital for Sick Children, AP-HP, Paris, France
| | - Magali Giral
- Department of Nephrology and Transplantation, Nantes University Hospital Centre, Nantes, France
| | - Nadia Arzouk
- Department of Nephrology and Transplantation, Pitié Salpêtrière University Hospital, AP-HP, Paris, France
| | - Dominique Bertrand
- Department of Nephrology and Transplantation, Rouen University Hospital Centre, Rouen, France
| | - Marie-Noëlle Peraldi
- Department of Nephrology and Transplantation, Saint-Louis Hospital, AP-HP, Paris, France
| | - Laurent Mesnard
- Department of Nephrology and Transplantation, Tenon Hospital, AP-HP, Paris, France
| | - Helene Longuet
- Department of Nephrology and Transplantation, Tours University Hospital Centre, Tours, France
| | - Mehdi Maanaoui
- Department of Nephrology and Transplantation, Lille University Hospital Centre, Lille, France
| | - Geoffroy Desbuissons
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Edouard Lefevre
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Renaud Snanoudj
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
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Zou ZY, Dai LR, Hou YB, Yu CZ, Chen RJ, Chen YY, Liu B, Shi HB, Gong NQ, Chen ZS, Chen S, Chang S, Zhang WJ. Sirolimus in combination with low-dose extended-release tacrolimus in kidney transplant recipients. Front Med (Lausanne) 2023; 10:1281939. [PMID: 38105889 PMCID: PMC10722907 DOI: 10.3389/fmed.2023.1281939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Many challenges remain for long-term survival of renal allografts. Once-daily sirolimus (SRL) combined with low-dose extended-release tacrolimus (LER-TAC) may improve medication adherence and reduce the potential nephrotoxicity of calcineurin inhibitors (CNI) compared with standard immunosuppression regimens, thus potentially improving long-term graft survival. Methods This retrospective, observational, single-center, propensity score matching (PSM) study compared conversion to SRL combined with low-dose ER-TAC and mycophenolic acid (MPA) combined with standard-dose TAC in kidney transplant recipients. After PSM, there were 56 patients in each group. Efficacy, safety, and medication adherence were evaluated over 12 months. Results There was no significant difference between the two groups in terms of graft and recipient survival and incidence of biopsy-proven acute rejection (p = 1.000), and none of the recipients developed dnDSA after conversion. The mean eGFR improved in SRL + LER-TAC group after conversion compared to before conversion (51.12 ± 20.1 ml/min/1.73 m2 vs. 56.97 ± 19.23 ml/min/1.73 m2, p < 0.05). The medication adherence at 12 months after conversion was superior to before conversion (p = 0.002). Discussion Our findings suggest that an immunosuppressive regimen of SRL combined with low-dose ER-TAC is no less effective and safe than standard immunosuppressive regimens for renal transplant recipients and may improve graft renal function and medication adherence.
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Affiliation(s)
- Zhi-yu Zou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Lin-rui Dai
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Yi-bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Chen-zhen Yu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Ren-jie Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Yan-yan Chen
- Department of Information Management, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Liu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Hui-bo Shi
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Nian-qiao Gong
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Zhi-shui Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Wei-jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, and Key Laboratory of Organ Transplantation, Ministry of Education, and NHC Key Laboratory of Organ Transplantation, and Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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von Samson-Himmelstjerna FA, Messtorff ML, Kakavand N, Eisenberger U, Korth J, Lange U, Kolbrink B, Aldag L, Schulze Dieckhoff T, Feldkamp T, Kunzendorf U, Harth A, Schulte K. The Tacrolimus Concentration/Dose Ratio Does Not Predict Early Complications After Kidney Transplantation. Transpl Int 2023; 36:11027. [PMID: 37229240 PMCID: PMC10203205 DOI: 10.3389/ti.2023.11027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/21/2023] [Indexed: 05/27/2023]
Abstract
Early-on post kidney transplantation, there is a high risk of graft rejection and opportunistic viral infections. A low tacrolimus concentration/dose (C/D) ratio as a surrogate marker of fast tacrolimus metabolism has been established for risk stratification 3 months post-transplantation (M3). However, many adverse events occurring earlier might be missed, and stratification at 1 month post-transplantation (M1) has not been investigated. We retrospectively analyzed case data from 589 patients who had undergone kidney transplantation between 2011 and 2021 at three German transplant centers. Tacrolimus metabolism was estimated by use of the C/D ratio at M1, M3, M6, and M12. C/D ratios increased substantially during the year, particularly between M1 and M3. Many viral infections and most graft rejections occurred before M3. Neither at M1 nor at M3 was a low C/D ratio associated with susceptibility to BKV viremia or BKV nephritis. A low C/D ratio at M1 could not predict acute graft rejections or impaired kidney function, whereas at M3 it was significantly associated with subsequent rejections and impairment of kidney function. In summary, most rejections occur before M3, but a low C/D ratio at M1 does not identify patients at risk, limiting the predictive utility of this stratification approach.
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Affiliation(s)
| | - Maja Lucia Messtorff
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ute Eisenberger
- Department of Nephrology, Essen University Hospital, Essen, Germany
| | - Johannes Korth
- Department of Nephrology, Essen University Hospital, Essen, Germany
| | - Ulrich Lange
- Department of Nephrology, Krankenhaus Köln-Merheim, Klinikum der Universität Witten/Herdecke, Cologne, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Leon Aldag
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Tobias Schulze Dieckhoff
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ana Harth
- Department of Nephrology, Krankenhaus Köln-Merheim, Klinikum der Universität Witten/Herdecke, Cologne, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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6
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Lombardi Y, François H. Belatacept in Kidney Transplantation: What Are the True Benefits? A Systematic Review. Front Med (Lausanne) 2022; 9:942665. [PMID: 35911396 PMCID: PMC9329606 DOI: 10.3389/fmed.2022.942665] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/20/2022] [Indexed: 12/05/2022] Open
Abstract
The current gold standard to prevent allograft rejection for maintenance immunosuppression in kidney transplantation currently consists in glucocorticoids, an antiproliferative agent and a calcineurin inhibitor (CNI), with better outcome for tacrolimus than cyclosporin. Although, CNI drastically improved early graft survival, so far, CNI have failed to significantly improve long-term survival mainly because of nephrotoxicity. In addition, CNI carry several other side effects such as an increased risk for cardiovascular events and for diabetes mellitus. Therefore, seeking alternatives to CNI remains of paramount importance in kidney transplantation. Belatacept is a fusion protein composed of the human IgG1 Fc fragment linked to the modified extracellular domain of cytotoxic T lymphocyte–associated antigen 4. In kidney transplant recipients, pivotal phase III randomized studies suggested clinical benefits of belatacept as an initial maintenance regimen, as compared with cyclosporine, mainly on kidney function. Recently, a randomized study also suggested a clinical benefit on renal function of a conversion from a CNI-based to a belatacept-based maintenance regimen in patients. However, conversion from CNIs to belatacept is probably associated with an increased risk of biopsy-proven acute rejection and should prompt close clinical surveillance. On the other hand, other studies suggest a decrease in de novo humoral transplant immunization. Belatacept is probably associated with an increase in both risk and severity of some infectious diseases, including EBV-linked post-transplantation lymphoproliferative disorders, and with a decreased response to vaccines. Most studies on belatacept are observational, retrospective, and non-comparative. Consequently, high-quality data about the safety and efficacy profile of belatacept, as compared with the current gold standard for maintenance regimens (tacrolimus-based), is uncertain. Our review will therefore focus on the most recent published data aiming at evaluating the evidence-based or the “true” benefits and risks of belatacept-based regimens in kidney transplantation.
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Affiliation(s)
- Yannis Lombardi
- Soins Intensifs Néphrologiques et Rein Aigu, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4 rue de la Chine, Paris, France
- Sorbonne Université, Paris, France
| | - Hélène François
- Soins Intensifs Néphrologiques et Rein Aigu, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4 rue de la Chine, Paris, France
- Sorbonne Université, Paris, France
- INSERM UMR_S 1155, Paris, France
- *Correspondence: Hélène François
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7
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Aziz F, Jorgenson M, Garg N, Parajuli S, Mohamed M, Raza F, Mandelbrot D, Djamali A, Dhingra R. New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients. Transplantation 2022; 106:1143-1158. [PMID: 34856598 DOI: 10.1097/tp.0000000000003990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.
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Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Margaret Jorgenson
- Department of Pharmacology, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Farhan Raza
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Ravi Dhingra
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
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Sridhar VS, Ambinathan JPN, Gillard P, Mathieu C, Cherney DZI, Lytvyn Y, Singh SK. Cardiometabolic and Kidney Protection in Kidney Transplant Recipients With Diabetes: Mechanisms, Clinical Applications, and Summary of Clinical Trials. Transplantation 2022; 106:734-748. [PMID: 34381005 DOI: 10.1097/tp.0000000000003919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for patients with end-stage renal disease. Preexisting diabetes is highly prevalent in kidney transplant recipients (KTR), and the development of posttransplant diabetes is common because of a number of transplant-specific risk factors such as the use of diabetogenic immunosuppressive medications and posttransplant weight gain. The presence of pretransplant and posttransplant diabetes in KTR significantly and variably affect the risk of graft failure, cardiovascular disease (CVD), and death. Among the many available therapies for diabetes, there are little data to determine the glucose-lowering agent(s) of choice in KTR. Furthermore, despite the high burden of graft loss and CVD among KTR with diabetes, evidence for strategies offering cardiovascular and kidney protection is lacking. Recent accumulating evidence convincingly shows glucose-independent cardiorenal protective effects in non-KTR with glucose-lowering agents, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Therefore, our aim was to review cardiorenal protective strategies, including the evidence, mechanisms, and rationale for the use of these glucose-lowering agents in KTR with diabetes.
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Affiliation(s)
- Vikas S Sridhar
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jaya Prakash N Ambinathan
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pieter Gillard
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - David Z I Cherney
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sunita K Singh
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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9
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Bae S, Garonzik-Wang JM, Massie AB, McAdams-DeMarco MA, Coresh J, Segev DL. Inconsistencies in the association of clinical factors with the choice of early steroid withdrawal across kidney transplant centers: A national registry study. Clin Transplant 2021; 35:e14176. [PMID: 33259086 PMCID: PMC8284554 DOI: 10.1111/ctr.14176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Approximately 30% of kidney transplant recipients undergo early steroid withdrawal (ESW) for maintenance immunosuppression. However, there is no consensus on which patients are suitable for ESW, and transplant centers may disagree on how various clinical factors characterize individual recipients' suitability for ESW. METHODS To examine center-level variation in the association of clinical factors with the choice of ESW, we studied 206 544 kidney transplant recipients from 278 centers in 2002-2017 using SRTR data. We conducted multi-level logistic regressions to characterize the association of clinical factors with the choice of ESW at each transplant center. RESULTS The association of clinical factors with the choice of ESW varied substantially across centers. We found particularly greater inconsistency in recipient age, PRA, re-transplantation, living/deceased donor, post-transplant length of stay, and delayed graft function. For example, across the entire population, re-transplantation was associated with lower odds of ESW (population odds ratio = 0.35 0.400.46 ). When estimated at each center, this odds ratio was significantly lower than the population odds ratio at 48 (17.3%) centers and significantly higher at 28 (10.1%) centers. CONCLUSIONS We have observed apparent inconsistencies across transplant centers in the practice of tailoring ESW to the recipient's risk profile. Standardized guidelines for ESW tailoring are needed.
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Affiliation(s)
- Sunjae Bae
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Allan B Massie
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Prevention of acute rejection after rescue with Belatacept by association of low-dose Tacrolimus maintenance in medically complex kidney transplant recipients with early or late graft dysfunction. PLoS One 2020; 15:e0240335. [PMID: 33057374 PMCID: PMC7561183 DOI: 10.1371/journal.pone.0240335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/24/2020] [Indexed: 01/23/2023] Open
Abstract
Background Increased acute rejection risk in rescue protocols with Belatacept may limit its use particularly in medically complex patients where preexisting increased risk of rejection couples with CNI toxicity. Methods Retrospective analysis was performed in 19 KTs shifted to a Belatacept-based immunosuppression with low-dose Tacrolimus (2–3 ng/mL) after evidence of allograft disfunction, including patients with primary non-function (PNF), chronic-active antibody-mediated rejection (cAMR), history of previous KTs and/or other concomitant transplants (liver, pancreas). Evaluation of CD28+ CD4+ effector memory T cell (TEM) before conversion was performed in 10/19. Results Kidney function significantly improved (median eGFR 16.5 ml/min/1.73m2 before vs 25 ml/min after; p = 0.001) at a median time after conversion of 12.5 months (9.1–17.8). Overall graft and patient survival were 89.5% and 100% respectively. Definitive weaning from dialysis in 5/5 KTs with PNF was observed, whereas 7/8 patients lost their graft within first year in a control group. eGFR significantly ameliorated in re-trasplants (p = 0.001) and stabilized in KTs with other organ transplants or cAMR. No acute rejection episodes occurred, despite the significant risk suggested by high frequency of CD28+ CD4+ TEM in most patients. Opportunistic infections were limited and most common in early vs late-converted. Conclusions Rescue association of Belatacept with low-dose Tacrolimus in medically complex KTs is a feasible option that allows prevention of acute rejection and amelioration of graft function.
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11
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Abstract
Costimulation between T cells and antigen-presenting cells is essential for the regulation of an effective alloimmune response and is not targeted with the conventional immunosuppressive therapy after kidney transplantation. Costimulation blockade therapy with biologicals allows precise targeting of the immune response but without non-immune adverse events. Multiple costimulation blockade approaches have been developed that inhibit the alloimmune response in kidney transplant recipients with varying degrees of success. Belatacept, an immunosuppressive drug that selectively targets the CD28-CD80/CD86 pathway, is the only costimulation blockade therapy that is currently approved for kidney transplant recipients. In the last decade, belatacept therapy has been shown to be a promising therapy in subgroups of kidney transplant recipients; however, the widespread use of belatacept has been tempered by an increased risk of acute kidney transplant rejection. The purpose of this review is to provide an overview of the costimulation blockade therapies that are currently in use or being developed for kidney transplant indications.
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12
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Conversion From Calcineurin Inhibitors to Belatacept in HLA-sensitized Kidney Transplant Recipients With Low-level Donor-specific Antibodies. Transplantation 2020; 103:2150-2156. [PMID: 30720681 DOI: 10.1097/tp.0000000000002592] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Belatacept could be the treatment of choice in renal-transplant recipients with renal dysfunction attributed to calcineurin inhibitor (CNI) nephrotoxicity. Few studies have described its use in patients with donor-specific antibody (DSA). METHODS We retrospectively evaluated conversion from CNIs to belatacept in 29 human leukocyte antigen-immunized renal-transplant recipients. Data about acute rejection, DSA, and renal function were collected. These patients were compared with 42 nonimmunized patients treated with belatacept. RESULTS Patients were converted from CNIs to belatacept a median of 444 days (interquartile range, 85-1200) after transplantation and were followed up after belatacept conversion, for a median of 308 days (interquartile range, 125-511). At conversion, 16 patients had DSA. Nineteen DSA were observed in these 16 patients, of which 11/19 were <1000 mean fluorescence intensity (MFI), 7/19 were between 1000 and 3000 MFI, and one was >3000 MFI. At last follow-up, preexisting DSA had decreased or stabilized. Seven patients still had DSA with a mean MFI of 1298 ± 930 at the last follow-up. No patient developed a de novo DSA in the DSA-positive group. In the nonimmunized group, one patient developed de novo DSA (A24-MFI 970; biopsy for cause did not show biopsy-proven acute rejection or microinflammation score). After belatacept conversion, one antibody-mediated rejection was diagnosed. The mean estimated glomerular filtration rate improved from 31.7 ± 14.2 mL/min/1.73 m to 40.7 ± 12.3 mL/min/1.73 m (P < 0.0001) at 12 months after conversion. We did not find any significant difference between groups in terms of renal function, proteinuria, or biopsy-proven acute rejection. CONCLUSIONS We report on a safe conversion to belatacept in human leukocyte antigen-immunized patients with low DSA levels.
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13
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Jorgenson MR, Descourouez JL, Brady BL, Bowman L, Hammad S, Kaiser TE, Laub MR, Melaragno JI, Park JM, Chandran MM. Alternatives to immediate release tacrolimus in solid organ transplant recipients: When the gold standard is in short supply. Clin Transplant 2020; 34:e13903. [DOI: 10.1111/ctr.13903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Bethany L. Brady
- Pharmacy Department Indiana University Health University Hospital Indianapolis IN USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa FL USA
| | - Sara Hammad
- Department of Pharmacy University of Maryland Medical Center Baltimore MD USA
| | - Tiffany E. Kaiser
- Department of Pharmacy University of Cincinnati Medical Center Cincinnati OH USA
| | - Melissa R. Laub
- Department of Pharmacy Augusta University Medical Center Augusta GA USA
| | | | - Jeong M. Park
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor MI USA
| | - Mary M. Chandran
- Department of Pharmacy Children's Hospital of Colorado Aurora CO USA
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14
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Conversion to Belatacept in Maintenance Kidney Transplant Patients: A Retrospective Multicenter European Study. Transplantation 2019; 102:1545-1552. [PMID: 29570163 DOI: 10.1097/tp.0000000000002192] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of belatacept is not yet approved for maintenance in kidney transplant patients. This retrospective multicenter European study aimed to assess the efficacy and safety of conversion to belatacept in a large cohort of patients in a real-life setting and to identify the predictive factors for improved kidney function after the switch. METHODS Two hundred nineteen maintenance kidney transplant patients from 5 European kidney transplant centers were converted to belatacept at 21.2 months (0.1-337.1 months) posttransplantation, mainly because of impaired kidney function. Thirty-two patients were converted to belatacept within the first 3 months posttransplantation. The mean duration of follow-up was 21.9 ± 20.2 months. RESULTS The actuarial rate of patients still on belatacept-based therapy was 77.6%. Mean estimated glomerular filtration rate increased from 32 ± 16.4 at baseline to 38 ± 20 mL/min per 1.73 m (P < 0.0001) at last follow-up. Conversion to belatacept before 3 months posttransplantation was the main predictive factor for a significant increase in estimated glomerular filtration rate (of 5 and 10 mL/min per 1.73 m at 3 and 12 months after the switch, respectively). Eighteen patients (8.2%) presented with an acute rejection episode after conversion; 3 developed a donor-specific antibody. Overall efficacy and safety were good, including for the 35 patients that had a donor-specific antibody at conversion. CONCLUSIONS The conversion to belatacept was effective, especially when performed early after transplantation.
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15
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Abstract
De novo donor-specific antibody (DSA) formation is a major problem in transplantation, and associated with long-term graft decline and loss as well as sensitization, limiting future transplant options. Forming high-affinity, long-lived antibody responses involves a process called the germinal center (GC) reaction, and requires interaction between several cell types, including GC B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cells. T follicular regulatory cells are an essential component of the GC reaction, limiting its size and reducing nonspecific or self-reactive responses.An imbalance between helper function and regulatory function can lead to excessive antibody production. High proportions of Tfh cells have been associated with DSA formation in transplantation; therefore, Tfr cells are likely to play an important role in limiting DSA production. Understanding the signals that govern Tfr cell development and the balance between helper and regulatory function within the GC is key to understanding how these cells might be manipulated to reduce the risk of DSA development.This review discusses the development and function of Tfr cells and their relevance to transplantation. In particular how current and future immunosuppressive strategies might allow us to skew the ratio between Tfr and Tfh cells to increase or decrease the risk of de novo DSA formation.
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16
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Noble J, Jouve T, Janbon B, Rostaing L, Malvezzi P. Belatacept in kidney transplantation and its limitations. Expert Rev Clin Immunol 2019; 15:359-367. [DOI: 10.1080/1744666x.2019.1574570] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
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17
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Laaksonen MA, Webster AC, McCaughan GW, Keogh AM, Grulich AE, Vajdic CM. Longitudinal immunosuppression data can minimize misclassification bias in solid organ transplantation cohorts. Clin Transplant 2018; 33:e13470. [PMID: 30586213 DOI: 10.1111/ctr.13470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Most cohort studies investigating the effect of immunosuppression on transplant outcomes use drugs at first hospital discharge. We evaluated the extent of drug exposure misclassification and its impact on outcome prediction. METHODS We retrospectively collected longitudinal immunosuppression data, at discharge and at 1, 5, 10, and 15 years after transplantation, and outcomes for solid organ transplant recipients 1984-2006 (n = 3133). We compared the risk of death from exposure to individual immunosuppressive drugs (cyclosporine, tacrolimus, azathioprine, and mycophenolate) and dual therapies, as defined by discharge only vs longitudinal immunosuppression data, using adjusted Cox proportional hazards models. RESULTS During a median follow-up of 5.2 years, immunosuppressive drugs were altered for 947 (30%) recipients and 955 recipients died. Longitudinal receipt of cyclosporine and azathioprine were associated with an increased risk (HR 1.41, 95% CI 1.07-1.89, and HR 1.34, 95% CI 1.00-1.80), and mycophenolate with a reduced risk (HR 0.35, 0.16-0.78), of death. Recipients on mycophenolate and tacrolimus dual therapy had a lower risk of death compared to those on azathioprine and cyclosporine dual therapy (HR 0.30, 0.10-0.93). The increased risk of death associated with the receipt of cyclosporine or azathioprine was not shown in the analyses based on drugs allocated at discharge, and all of the associations between immunosuppressive regimens and death were strengthened in the analyses based on longitudinal immunosuppression data. CONCLUSIONS Cohort findings based on immunosuppressive drugs allocated at discharge should be interpreted with caution due to potential exposure misclassification. The use of granular, longitudinal data on immunosuppressive regimens could improve prediction.
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Affiliation(s)
- Maarit A Laaksonen
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Angela C Webster
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Geoff W McCaughan
- The Centenary Research Institute, Australian National Liver Transplant Unit Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Anne M Keogh
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew E Grulich
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Claire M Vajdic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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18
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Abstract
BACKGROUND The effect of conversion to cytotoxic T lymphocyte-associated protein 4 immunoglobulin (CTLA4Ig) treatment on tacrolimus (TAC)-induced renal dysfunction is well known, but its effect on TAC-induced diabetes mellitus (DM) is still undetermined. In the present study, we tested the diabetogenicity of CTLA4Ig and evaluated the effect of conversion to CTLA4Ig treatment on TAC-induced diabetic rats. METHODS We tested diabetogenicity of CTLA4Ig by escalating doses (0.25, 0.5, 1, 2, and 4 mg/kg weekly) for 4 weeks. In the conversion study, we administered TAC (1.5 mg/kg) for 3 weeks and confirmed TAC-induced DM by intraperitoneal glucose tolerance test. Thereafter, TAC administration was continued, withdrawn, or replaced by CTLA4Ig treatment (1 or 2 mg/kg) for additional 3 weeks. The effect of CTLA4Ig on TAC-induced DM in vivo and in vitro was evaluated by assessing pancreatic islet function, histopathology, oxidative stress, apoptosis, and macrophage infiltration. RESULTS Intraperitoneal glucose tolerance test in the CTLA4Ig groups did not differ from the control group. In addition, plasma insulin level, glucose-induced insulin secretion, and islet viability were not different between the CTLA4Ig and control groups. In the conversion study, TAC withdrawal ameliorated pancreatic islet dysfunction compared with the TAC group, and conversion to CTLA4Ig further improved pancreatic islet function compared with the TAC withdrawal group. TAC-induced oxidative stress, apoptotic cell death, and infiltration of macrophages decreased with TAC withdrawal, and CTLA4Ig conversion further reduced those values. In the in vitro study, CTLA4Ig decreased TAC-induced pancreatic islet cell death and reactive oxygen species production. CONCLUSIONS CTLA4Ig was not diabetogenic, and conversion to CTLA4Ig reduced TAC-induced pancreatic islet injury.
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19
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Kraaijeveld R, de Graav GN, Dieterich M, Litjens NHR, Hesselink DA, Baan CC. Co-inhibitory profile and cytotoxicity of CD57 + PD-1 - T cells in end-stage renal disease patients. Clin Exp Immunol 2018; 191:363-372. [PMID: 29027667 PMCID: PMC5801492 DOI: 10.1111/cei.13070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2017] [Indexed: 12/14/2022] Open
Abstract
Blockade of the CD80/86-CD28 pathway by belatacept after kidney transplantation is associated with an increased risk of rejection compared with standard, calcineurin inhibitor (CNI)-based therapy. CD28- T cells, which express CD57, are not susceptible to belatacept treatment. High numbers of CD4+ CD57+ programmed death 1 (PD-1)- T cells pretransplantation have been associated with a higher chance of rejection, although conflicting data have been reported. To investigate the working mechanism behind this possible higher chance of rejection, we studied the expression of co-inhibitory molecules (CD223, CD244 and PD-1), proliferative capacity and cytotoxic potential of fluorescence activated cell sorted (FACS) CD4+ CD57+ PD-1- and CD8+ CD57+ PD-1- T cells, and their CD57- control populations, after alloantigen stimulation. The effect of belatacept on the cytotoxic capacity of pretransplantation peripheral blood mononuclear cells from 20 patients who received belatacept post-transplantation was also tested. Expression of co-inhibitory molecule CD223 increased by approximately 10-fold after allogeneic stimulation in all four T cell subsets. Proliferation and up-regulation of CD244 and PD-1 was observed for CD4+ CD57- PD-1- T cells after allogeneic stimulation, but no up-regulation of these markers occurred on CD8+ T cells or CD4+ CD57+ PD-1- T cells. However, CD4+ CD57+ PD-1- T cells and, to a lesser extent, CD8+ CD57+ PD-1- T cells displayed higher cytotoxicity as indicated by granzyme B expression. Belatacept inhibited the cytotoxic potential of CD4+ CD57+ PD-1- T cells (median of inhibition 31%, P < 0·01) and CD8+ CD57+ PD-1- T cells (median of inhibition 10%, P < 0·05). In conclusion, alloantigen-activated CD4+ CD57+ PD-1- T cells exhibited a less proliferative but more cytotoxic profile than their CD57- counterparts. Their cytotoxic capacity can be inhibited partly by belatacept and was not associated with development of rejection after kidney transplantation.
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Affiliation(s)
- R. Kraaijeveld
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - G. N. de Graav
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - M. Dieterich
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - N. H. R. Litjens
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - D. A. Hesselink
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
| | - C. C. Baan
- Department of Internal MedicineErasmus MC, University Medical Center RotterdamRotterdamthe Netherlands
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20
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Early Conversion to Belatacept in Kidney Transplant Recipients With Low Glomerular Filtration Rate. Transplantation 2018; 102:478-483. [DOI: 10.1097/tp.0000000000001985] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Improved Glucose Tolerance in a Kidney Transplant Recipient With Type 2 Diabetes Mellitus After Switching From Tacrolimus To Belatacept: A Case Report and Review of Potential Mechanisms. Transplant Direct 2018; 4:e350. [PMID: 29707621 PMCID: PMC5912016 DOI: 10.1097/txd.0000000000000767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/31/2017] [Indexed: 12/15/2022] Open
Abstract
Supplemental digital content is available in the text. The introduction of immunosuppressant belatacept, an inhibitor of the CD28-80/86 pathway, has improved 1-year outcomes in kidney transplant recipients with preexistent diabetes mellitus and has also reduced the risk of posttransplant diabetes mellitus. So far, no studies have compared a tacrolimus-based with a belatacept-based immunosuppressive regimen with regard to improving glucose tolerance after kidney transplantation. Here, we present the case of a 54-year-old man with type 2 diabetes mellitus who was converted from belatacept to tacrolimus 1 year after a successful kidney transplantation. Thereafter, he quickly developed severe hyperglycemia, and administration of insulin was needed to improve metabolic control. Six months after this episode, he was converted back to belatacept because of nausea, diarrhea, and hyperglycemia. After switching back to belatacept and within 4 days after stopping tacrolimus glucose tolerance improved and insulin therapy could be discontinued. Although belatacept is considered less diabetogenic than tacrolimus, the rapid improvement of glucose tolerance after switching to belatacept is remarkable. In this article, the potential mechanisms of this observation are discussed.
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22
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Young JS, Khiew SHW, Yang J, Vannier A, Yin D, Sciammas R, Alegre ML, Chong AS. Successful Treatment of T Cell-Mediated Acute Rejection with Delayed CTLA4-Ig in Mice. Front Immunol 2017; 8:1169. [PMID: 28970838 PMCID: PMC5609110 DOI: 10.3389/fimmu.2017.01169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/04/2017] [Indexed: 12/25/2022] Open
Abstract
Clinical observations that kidney transplant recipients receiving belatacept who experienced T cell-mediated acute rejection can be successfully treated and subsequently maintained on belatacept-based immunosuppression suggest that belatacept is able to control memory T cells. We recently reported that treatment with CTLA4-Ig from day 6 posttransplantation successfully rescues allografts from acute rejection in a BALB/c to C57BL/6 heart transplant model, in part, by abolishing B cell germinal centers and reducing alloantibody titers. Here, we show that CTLA4-Ig is additionally able to inhibit established T cell responses independently of B cells. CTLA4-Ig inhibited the in vivo cytolytic activity of donor-specific CD8+ T cells, and the production of IFNγ by graft-infiltrating T cells. Delayed CTLA4-Ig treatment did not reduce the numbers of graft-infiltrating T cells nor prevented the accumulation of antigen-experienced donor-specific memory T cells in the spleen. Nevertheless, delayed CTLA4-Ig treatment successfully maintained long-term graft acceptance in the majority of recipients that had experienced a rejection crisis, and enabled the acceptance of secondary BALB/c heart grafts transplanted 30 days after the first transplantation. In summary, we conclude that delayed CTLA4-Ig treatment is able to partially halt ongoing T cell-mediated acute rejection. These findings extend the functional efficacy of CTLA4-Ig therapy to effector T cells and provide an explanation for why CTLA4-Ig-based immunosuppression in the clinic successfully maintains long-term graft survival after T cell-mediated rejection.
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Affiliation(s)
- James S Young
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Stella H-W Khiew
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Jinghui Yang
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States.,Department of Organ Transplantation, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Augustin Vannier
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Dengping Yin
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
| | - Roger Sciammas
- Center for Comparative Medicine, University of California, Davis, Davis, CA, United States
| | - Maria-Luisa Alegre
- Department of Medicine, Section of Rheumatology, The University of Chicago, Chicago, IL, United States
| | - Anita S Chong
- Department of Surgery, Section of Transplantation, The University of Chicago, Chicago, IL, United States
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23
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Khiew SH, Yang J, Young JS, Chen J, Wang Q, Yin D, Vu V, Miller ML, Sciammas R, Alegre ML, Chong AS. CTLA4-Ig in combination with FTY720 promotes allograft survival in sensitized recipients. JCI Insight 2017; 2:92033. [PMID: 28469082 PMCID: PMC5414557 DOI: 10.1172/jci.insight.92033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/21/2017] [Indexed: 12/30/2022] Open
Abstract
Despite recent evidence of improved graft outcomes and safety, the high incidence of early acute cellular rejection with belatacept, a high-affinity CTLA4-Ig, has limited its use in clinical transplantation. Here we define how the incomplete control of endogenous donor-reactive memory T cells results in belatacept-resistant rejection in an experimental model of BALB/c.2W-OVA donor heart transplantation into C57BL/6 recipients presensitized to donor splenocytes. These sensitized mice harbored modestly elevated numbers of endogenous donor-specific memory T cells and alloantibodies compared with naive recipients. Continuous CTLA4-Ig treatment was unexpectedly efficacious at inhibiting endogenous graft-reactive T cell expansion but was unable to inhibit late CD4+ and CD8+ T cell infiltration into the allografts, and rejection was observed in 50% of recipients by day 35 after transplantation. When CTLA4-Ig was combined with the sphingosine 1-phosphate receptor-1 (S1PR1) functional antagonist FTY720, alloantibody production was inhibited and donor-specific IFN-γ-producing T cells were reduced to levels approaching nonsensitized tolerant recipients. Late T cell recruitment into the graft was also restrained, and graft survival improved with this combination therapy. These observations suggest that a rational strategy consisting of inhibiting memory T cell expansion and trafficking into the allograft with CTLA4-Ig and FTY720 can promote allograft survival in allosensitized recipients.
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Affiliation(s)
| | - Jinghui Yang
- Section of Transplantation, Department of Surgery
| | | | - Jianjun Chen
- Section of Transplantation, Department of Surgery
| | - Qiang Wang
- Section of Transplantation, Department of Surgery
| | - Dengping Yin
- Section of Transplantation, Department of Surgery
| | - Vinh Vu
- Section of Transplantation, Department of Surgery
| | - Michelle L. Miller
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Roger Sciammas
- Center for Comparative Medicine, University of California, Davis, California, USA
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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