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Iesari S, Nava FL, Zais IE, Coubeau L, Ferraresso M, Favi E, Lerut J. Advancing immunosuppression in liver transplantation: A narrative review. Hepatobiliary Pancreat Dis Int 2024; 23:441-448. [PMID: 38523030 DOI: 10.1016/j.hbpd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
Immunosuppression is essential to ensure recipient and graft survivals after liver transplantation (LT). However, our understanding and management of the immune system remain suboptimal. Current immunosuppressive therapy cannot selectively inhibit the graft-specific immune response and entails a significant risk of serious side effects, i.e., among others, de novo cancers, infections, cardiovascular events, renal failure, metabolic syndrome, and late graft fibrosis, with progressive loss of graft function. Pharmacological research, aimed to develop alternative immunosuppressive agents in LT, is behind other solid-organ transplantation subspecialties, and, therefore, the development of new compounds and strategies should get priority in LT. The research trajectories cover mechanisms to induce T-cell exhaustion, to inhibit co-stimulation, to mitigate non-antigen-specific inflammatory response, and, lastly, to minimize the development and action of donor-specific antibodies. Moreover, while cellular modulation techniques are complex, active research is underway to foster the action of T-regulatory cells, to induce tolerogenic dendritic cells, and to promote the function of B-regulatory cells. We herein discuss current lines of research in clinical immunosuppression, particularly focusing on possible applications in the LT setting.
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Affiliation(s)
- Samuele Iesari
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 15 Via della Commenda, 20122 Milan, Italy
| | - Francesca Laura Nava
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 15 Via della Commenda, 20122 Milan, Italy
| | - Ilaria Elena Zais
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 15 Via della Commenda, 20122 Milan, Italy
| | - Laurent Coubeau
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, 10 Avenue Hippocrate, 1200 Brussels, Belgium; Service de Chirurgie et Transplantation Abdominale, Cliniques Universitaires Saint-Luc, 55 Avenue Hippocrate, 1200 Brussels, Belgium
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 15 Via della Commenda, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 19 Via della Commenda, 20122 Milan, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 15 Via della Commenda, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 19 Via della Commenda, 20122 Milan, Italy.
| | - Jan Lerut
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, 10 Avenue Hippocrate, 1200 Brussels, Belgium
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Aburahma K, de Manna ND, Kuehn C, Salman J, Greer M, Ius F. Pushing the Survival Bar Higher: Two Decades of Innovation in Lung Transplantation. J Clin Med 2024; 13:5516. [PMID: 39337005 PMCID: PMC11432129 DOI: 10.3390/jcm13185516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Revised: 09/13/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
Survival after lung transplantation has significantly improved during the last two decades. The refinement of the already existing extracorporeal life support (ECLS) systems, such as extracorporeal membrane oxygenation (ECMO), and the introduction of new techniques for donor lung optimization, such as ex vivo lung perfusion (EVLP), have allowed the extension of transplant indication to patients with end-stage lung failure after acute respiratory distress syndrome (ARDS) and the expansion of the donor organ pool, due to the better evaluation and optimization of extended-criteria donor (ECD) lungs and of donors after circulatory death (DCD). The close monitoring of anti-HLA donor-specific antibodies (DSAs) has allowed the early recognition of pulmonary antibody-mediated rejection (AMR), which requires a completely different treatment and has a worse prognosis than acute cellular rejection (ACR). As such, the standardization of patient selection and post-transplant management has significantly contributed to this positive trend, especially at high-volume centers. This review focuses on lung transplantation after ARDS, on the role of EVLP in lung donor expansion, on ECMO as a principal cardiopulmonary support system in lung transplantation, and on the diagnosis and therapy of pulmonary AMR.
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Affiliation(s)
- Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Nunzio Davide de Manna
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Mark Greer
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, 30625 Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
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3
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Berger M, Baliker M, Van Gelder T, Böhmig GA, Mannon RB, Kumar D, Chadban S, Nickerson P, Lee LA, Djamali A. Chronic Active Antibody-mediated Rejection: Opportunity to Determine the Role of Interleukin-6 Blockade. Transplantation 2024; 108:1109-1114. [PMID: 37941113 PMCID: PMC11042519 DOI: 10.1097/tp.0000000000004822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 11/10/2023]
Abstract
Chronic active antibody-mediated rejection (caAMR) is arguably the most important cause of late kidney allograft failure. However, there are no US Food and Drug Administration (FDA)-approved treatments for acute or chronic AMR and there is no consensus on effective treatment. Many trials in transplantation have failed because of slow and/or inadequate enrollment, and no new agent has been approved by the FDA for transplantation in over a decade. Several lines of evidence suggest that interleukin-6 is an important driver of AMR, and clazakizumab, a humanized monoclonal antibody that neutralizes interleukin-6, has shown promising results in phase 2 studies. The IMAGINE trial (Interleukin-6 Blockade Modifying Antibody-mediated Graft Injury and Estimated Glomerular Filtration Rate Decline) (NCT03744910) is the first to be considered by the FDA using a reasonably likely surrogate endpoint (slope of estimated glomerular filtration rate decline >1 y) for accelerated approval and is the only ongoing clinical trial for the treatment of chronic rejection. This trial offers us the opportunity to advance the care for our patients in need, and this article is a call to action for all transplant providers caring for patients with caAMR.
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Affiliation(s)
- Mel Berger
- Departments of Pediatrics and Pathology, Case Western Reserve University, Cleveland, OH
| | | | - Teun Van Gelder
- Department Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Deepali Kumar
- Department of Medicine, Division of Transplant Infectious Disease, Ajmera Transplant Centre, Toronto, ON, Canada
| | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Nickerson
- Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Laurie A. Lee
- Research and Development, Transplant Therapeutic Area, CSL Behring, King of Prussia, Pennsylvania, PA
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, ME
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Mathis S, Weissenbacher A, Putzer G, Gasteiger L, Cardini B, Hell T, Schlosser L, Oberhuber R, Schneeberger S, Martini J. Interleukin-6 Levels During Normothermic Machine Perfusion Impact Postreperfusion Hemodynamics of Liver Graft Recipients: A Prospective Single-center Observational Study. Transplantation 2024; 108:1166-1171. [PMID: 37967459 DOI: 10.1097/tp.0000000000004852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND Hemodynamic instability after liver graft reperfusion increases recipient morbidity after liver transplantation. The etiologies of hemodynamic disturbances appear to be multifactorial and are poorly understood. Normothermic machine perfusion (NMP) provides an opportunity to analyze graft quality prior to transplantation. In the present study, we aim to investigate the influence of interleukin-6 (IL-6) levels during NMP on postreperfusion hemodynamics of the recipient. METHODS Consecutive NMP-liver transplants at a single-center were prospectively analyzed. Perfusate samples were collected at the beginning, after 6 h, and at the end of perfusion and analyzed for IL-6 levels. Mean arterial pressure (MAP) and catecholamine consumption during surgery were recorded. IL-6 levels at the end of NMP were correlated to donor and perfusion characteristics as well as changes in MAP and catecholamine requirements during the anhepatic and reperfusion phase. RESULTS IL-6 perfusate measurements were assessed in 77 livers undergoing NMP and transplantation. Donor age, sex, cold ischemic time, and NMP time did not correlate with IL-6 levels. Perfusates of donation after circulatory death grafts showed higher IL-6 levels at the end of NMP than donation after brain death grafts. However, IL-6 levels at the end of NMP correlated with catecholamine requirements and MAP in the reperfusion phase. Per log10 increase in IL-6 levels, an increase of 42% points in administered catecholamine dose was observed, despite MAP being decreased by 3.6% points compared to baseline values. CONCLUSIONS IL-6 levels may be a predictor for recipient hemodynamic instability during liver reperfusion. Larger studies are needed to confirm this finding.
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Affiliation(s)
- Simon Mathis
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | | | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Judith Martini
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Chen W, Toda E, Takeuchi K, Sawa Y, Wakamatsu K, Kuwahara N, Ishikawa A, Igarashi Y, Terasaki M, Kunugi S, Terasaki Y, Yamada K, Terashima Y, Shimizu A. Disulfiram treatment suppresses antibody-producing reactions by inhibiting macrophage activation and B cell pyrimidine metabolism. Commun Biol 2024; 7:488. [PMID: 38649462 PMCID: PMC11035657 DOI: 10.1038/s42003-024-06183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
Antibody responses, involving B cells, CD4 + T cells, and macrophages, are implicated in autoimmune diseases and organ transplant rejection. We have previously shown that inhibiting FROUNT with disulfiram (DSF) suppresses macrophage activation and migration, effectively treating inflammatory diseases. In this study, we investigated the effectiveness of DSF in antibody-producing reactions. Using a heart transplantation mouse model with antibody-mediated rejection, we administered anti-CD8 antibody to exclude cellular rejection. DSF directly inhibited B cell responses in vitro and significantly reduced plasma donor-specific antibodies and graft antibody deposition in vivo, resulting in prolonged survival of the heart graft. DSF also mediated various effects, including decreased macrophage infiltration and increased Foxp3+ regulatory T-cells in the grafts. Additionally, DSF inhibited pyrimidine metabolism-related gene expression induced by B-cell stimulation. These findings demonstrate that DSF modulates antibody production in the immune response complexity by regulating B-cell and macrophage responses.
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Affiliation(s)
- Weili Chen
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Etsuko Toda
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
- Laboratory for Morphological and Biomolecular Imaging, Nippon Medical School, Tokyo, Japan.
- Division of Molecular Regulation of Inflammatory and Immune Diseases, Research Institute for Biomedical Sciences, Tokyo University of Science, Chiba, Japan.
| | - Kazuhiro Takeuchi
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
- Division of Organ Replacement and Xenotransplantation Surgery, Center for Advanced Biomedical Science and Swine Research, Kagoshima University, Kagoshima, Japan
| | - Yurika Sawa
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kyoko Wakamatsu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Naomi Kuwahara
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Arimi Ishikawa
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yuri Igarashi
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Shinobu Kunugi
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | | | - Kazuhiko Yamada
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Yuya Terashima
- Division of Molecular Regulation of Inflammatory and Immune Diseases, Research Institute for Biomedical Sciences, Tokyo University of Science, Chiba, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
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Heeger PS, Haro MC, Jordan S. Translating B cell immunology to the treatment of antibody-mediated allograft rejection. Nat Rev Nephrol 2024; 20:218-232. [PMID: 38168662 DOI: 10.1038/s41581-023-00791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 01/05/2024]
Abstract
Antibody-mediated rejection (AMR), including chronic AMR (cAMR), causes ~50% of kidney allograft losses each year. Despite attempts to develop well-tolerated and effective therapeutics for the management of AMR, to date, none has obtained FDA approval, thereby highlighting an urgent unmet medical need. Discoveries over the past decade from basic, translational and clinical studies of transplant recipients have provided a foundation for developing novel therapeutic approaches to preventing and treating AMR and cAMR. These interventions are aimed at reducing donor-specific antibody levels, decreasing graft injury and fibrosis, and preserving kidney function. Innovative approaches emerging from basic science findings include targeting interactions between alloreactive T cells and B cells, and depleting alloreactive memory B cells, as well as donor-specific antibody-producing plasmablasts and plasma cells. Therapies aimed at reducing the cytotoxic antibody effector functions mediated by natural killer cells and the complement system, and their associated pro-inflammatory cytokines, are also undergoing evaluation. The complexity of the pathogenesis of AMR and cAMR suggest that multiple approaches will probably be required to treat these disease processes effectively. Definitive answers await results from large, double-blind, multicentre, randomized controlled clinical trials.
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Affiliation(s)
- Peter S Heeger
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA
| | - Maria Carrera Haro
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA.
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7
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Huang CL, Fu XY, Feng Y, Li XK, Sun Y, Mao XL, Li SW. Relationship between the microenvironment and survival in kidney transplantation: a bibliometric analysis from 2013 to 2023. Front Immunol 2024; 15:1379742. [PMID: 38596670 PMCID: PMC11002143 DOI: 10.3389/fimmu.2024.1379742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024] Open
Abstract
Background Kidney transplantation is considered the most effective treatment for end-stage renal failure. Recent studies have shown that the significance of the immune microenvironment after kidney transplantation in determining prognosis of patients. Therefore, this study aimed to conduct a bibliometric analysis to provide an overview of the knowledge structure and research trends regarding the immune microenvironment and survival in kidney transplantation. Methods Our search included relevant publications from 2013 to 2023 retrieved from the Web of Science core repository and finally included 865 articles. To perform the bibliometric analysis, we utilized tools such as VOSviewer, CiteSpace, and the R package "bibliometrix". The analysis focused on various aspects, including country, author, year, topic, reference, and keyword clustering. Results Based on the inclusion criteria, a total of 865 articles were found, with a trend of steady increase. China and the United States were the countries with the most publications. Nanjing Medical University was the most productive institution. High-frequency keywords were clustered into 6 areas, including kidney transplantation, transforming growth factor β, macrophage, antibody-mediated rejection, necrosis factor alpha, and dysfunction. Antibody mediated rejection (2019-2023) was the main area of research in recent years. Conclusion This groundbreaking bibliometric study comprehensively summarizes the research trends and advances related to the immune microenvironment and survival after kidney transplantation. It identifies recent frontiers of research and highlights promising directions for future studies, potentially offering fresh perspectives to scholars in the field.
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Affiliation(s)
- Chun-Lian Huang
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Xin-Yu Fu
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Yi Feng
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Xiao-Kang Li
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yi Sun
- MRL Global Medical Affairs, MSD China, Shanghai, China
| | - Xin-Li Mao
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
- Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Shao-Wei Li
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
- Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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8
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Puliyanda DP, Jordan SC. Management of the sensitized pediatric renal transplant candidate. Pediatr Transplant 2024; 28:e14694. [PMID: 38400645 DOI: 10.1111/petr.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/14/2023] [Accepted: 01/05/2024] [Indexed: 02/25/2024]
Abstract
Kidney transplantation is the treatment of choice for patients with ESRD as it is associated with improved patient survival and better quality of life, especially in children. There are several barriers to a successful transplant including organ shortage, anatomic barriers, and immunologic barriers. One of the biggest immunologic barriers that precludes transplantation is sensitization, when patients have antibodies prior to transplantation, resulting in positive crossmatches with donor. 30%-40% of adult patients on the wait list are sensitized. There is a growing number of pediatric patients on the wait list who are sensitized. This poses a unique challenge to the pediatric transplant community. Therefore, attempts to perform desensitization to remove or suppress pathogenic HLA antibodies resulting in acceptable crossmatches, and ultimately a successful transplant, while reducing the risk of acute rejection, are much needed in these children. This review article aims to address the management of such patients both prior to transplantation, with strategies to overcome sensitization, and after transplantation with monitoring for allograft rejection and other complications.
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Affiliation(s)
- Dechu P Puliyanda
- Department of Pediatrics, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stanley C Jordan
- Department of Pediatrics, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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9
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Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
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Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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10
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Srivastava PK, Kittleson MM. Modern advances in heart transplantation. Prog Cardiovasc Dis 2024; 82:147-156. [PMID: 38244826 DOI: 10.1016/j.pcad.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Heart transplantation (HTx) is the only definitive therapy for patients with end stage heart disease. With the increasing global prevalence of heart failure, the demand for HTx has continued to grow and outpace supply. In this paper, we will review advances in the field of HTx along the clinical journey of a HTx recipient. Starting with the sensitized patient, we discuss current methods to define sensitization, and assays to help identify clinically relevant anti-HLA antibodies. Desensitization strategies targeting all levels of the adaptive immune system are discussed with emphasis on novel techniques such as anti-CD 38 blockade and use of the Immunoglobulin G-Degrading Enzyme of Streptococcus Pyogenes. We next discuss donor procurement and the resurgence of donation after circulatory death as a viable strategy to significantly and safely increase the donor pool. Post-transplant, we evaluate non-invasive surveillance techniques including gene expression profiling and donor-derived cell-free DNA. Last, we discuss the ground-breaking developments in the field of xenotransplantation.
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Affiliation(s)
- Pratyaksh K Srivastava
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America.
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11
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Basta G, Melandro F, Babboni S, Del Turco S, Ndreu R, Torri F, Martinelli C, Silvestrini B, Peris A, Lazzeri C, Guarracino F, Morganti R, Maremmani P, Bertini P, De Simone P, Ghinolfi D. An extensive evaluation of hepatic markers of damage and regeneration in controlled and uncontrolled donation after circulatory death. Liver Transpl 2023; 29:813-826. [PMID: 36879554 DOI: 10.1097/lvt.0000000000000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
Livers from donations after circulatory death (DCDs) are very sensitive to ischemia/reperfusion injury and thus need careful reconditioning, such as normothermic regional perfusion (NRP). So far, its impact on DCDs has not been thoroughly investigated. This pilot cohort study aimed to explore the NRP impact on liver function by evaluating dynamic changes of circulating markers and hepatic gene expression in 9 uncontrolled DCDs (uDCDs) and 10 controlled DCDs. At NRP start, controlled DCDs had lower plasma levels of inflammatory and liver damage markers, including α-glutathione s-transferase, sorbitol-dehydrogenase, malate dehydrogenase 1, liver-type arginase-1, and keratin-18, but higher levels of osteopontin, sFas, flavin mononucleotide, and succinate than uDCDs. During 4-hour NRP, some damage and inflammatory markers increased in both groups, while IL-6, HGF, and osteopontin increased only in uDCDs. At the NRP end, the tissue expression of early transcriptional regulators, apoptosis, and autophagy mediators was higher in uDCDs than in controlled DCDs. In conclusion, despite initial differences in liver damage biomarkers, the uDCD group was characterized by a major gene expression of regenerative and repair factors after the NRP procedure. Correlative analysis among circulating/tissue biomarkers and the tissue congestion/necrosis degree revealed new potential candidate biomarkers.
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Affiliation(s)
- Giuseppina Basta
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Serena Babboni
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Rudina Ndreu
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Caterina Martinelli
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | | | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Chiara Lazzeri
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Division of Medical Statistics, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo Maremmani
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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12
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Rostaing LPE, Böhmig GA, Gibbons B, Taqi MM. Post-Transplant Surveillance and Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Patients in Europe. Transpl Int 2023; 36:11381. [PMID: 37529383 PMCID: PMC10389272 DOI: 10.3389/ti.2023.11381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023]
Abstract
Antibody mediated rejection (ABMR) is the leading cause of immune-related allograft failure following kidney transplantation. Chronic active ABMR (CABMR) typically occurs after one-year post-transplant and is the most common cause of late allograft failure. This study was designed to assess common practices in Europe for post-transplant surveillance 1 year after kidney transplant, as well as the diagnosis and management of CABMR. A 15-minute online survey with 58 multiple choice or open-ended questions was completed by EU transplant nephrologists, transplant surgeons and nephrologists. Survey topics included patient caseloads, post-transplant routine screening and treatment of CABMR. The results indicated that observing clinical measures of graft function form the cornerstone of post-transplant surveillance. This may be suboptimal, leading to late diagnoses and untreatable disease. Indeed, less than half of patients who develop CABMR receive treatment beyond optimization of immune suppression. This is attributable to not only late diagnoses, but also a lack of proven efficacious therapies. Intravenous Immunoglobulin (IVIG), steroid pulse and apheresis are prescribed by the majority to treat CABMR. While biologics can feature as part of treatment, there is no single agent that is being used by more than half of physicians.
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Affiliation(s)
- Lionel P. E. Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Georg A. Böhmig
- Clinical Department of Nephrology and Dialysis, University Clinic for Internal Medicine III, Medical University of Vienna, Vienna, Austria
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13
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Habibabady Z, McGrath G, Kinoshita K, Maenaka A, Ikechukwu I, Elias GF, Zaletel T, Rosales I, Hara H, Pierson RN, Cooper DKC. Antibody-mediated rejection in xenotransplantation: Can it be prevented or reversed? Xenotransplantation 2023; 30:e12816. [PMID: 37548030 PMCID: PMC11101061 DOI: 10.1111/xen.12816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Antibody-mediated rejection (AMR) is the commonest cause of failure of a pig graft after transplantation into an immunosuppressed nonhuman primate (NHP). The incidence of AMR compared to acute cellular rejection is much higher in xenotransplantation (46% vs. 7%) than in allotransplantation (3% vs. 63%) in NHPs. Although AMR in an allograft can often be reversed, to our knowledge there is no report of its successful reversal in a pig xenograft. As there is less experience in preventing or reversing AMR in models of xenotransplantation, the results of studies in patients with allografts provide more information. These include (i) depletion or neutralization of serum anti-donor antibodies, (ii) inhibition of complement activation, (iii) therapies targeting B or plasma cells, and (iv) anti-inflammatory therapy. Depletion or neutralization of anti-pig antibody, for example, by plasmapheresis, is effective in depleting antibodies, but they recover within days. IgG-degrading enzymes do not deplete IgM. Despite the expression of human complement-regulatory proteins on the pig graft, inhibition of systemic complement activation may be necessary, particularly if AMR is to be reversed. Potential therapies include (i) inhibition of complement activation (e.g., by IVIg, C1 INH, or an anti-C5 antibody), but some complement inhibitors are not effective in NHPs, for example, eculizumab. Possible B cell-targeted therapies include (i) B cell depletion, (ii) plasma cell depletion, (iii) modulation of B cell activation, and (iv) enhancing the generation of regulatory B and/or T cells. Among anti-inflammatory agents, anti-IL6R mAb and TNF blockers are increasingly being tested in xenotransplantation models, but with no definitive evidence that they reverse AMR. Increasing attention should be directed toward testing combinations of the above therapies. We suggest that treatment with a systemic complement inhibitor is likely to be most effective, possibly combined with anti-inflammatory agents (if these are not already being administered). Ultimately, it may require further genetic engineering of the organ-source pig to resolve the problem entirely, for example, knockout or knockdown of SLA, and/or expression of PD-L1, HLA E, and/or HLA-G.
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Affiliation(s)
- Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gannon McGrath
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ileka Ikechukwu
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela F. Elias
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tjasa Zaletel
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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14
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Fazeli SA, Alirezaei A, Miladipour A, Salarabedi MM, Karimi Toudeshki K. Kidney Allograft Rejection and Coronavirus Disease 2019 Infection: A Narrative Review. Adv Biomed Res 2023; 12:152. [PMID: 37564455 PMCID: PMC10410421 DOI: 10.4103/abr.abr_167_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 09/20/2022] [Accepted: 09/24/2022] [Indexed: 08/12/2023] Open
Abstract
The world has experienced a global medical and socioeconomic burden following the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is a systemic disease and may affect different organs including the kidneys. Current literature contains reports on COVID-19-related conditions such as acute kidney injury, and complications experienced by chronic kidney disease, end stage kidney disease, and kidney transplant patients. Here, we discuss the incidence of kidney allograft rejection, immunosuppression management and rejection risk, donor-specific antibodies and previous rejection episodes, and rejection outcomes in kidney transplant recipients with COVID-19 by reviewing current studies.
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Affiliation(s)
- Seyed Amirhossein Fazeli
- Department of Nephrology, Clinical Research and Development Center at Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirhesam Alirezaei
- Department of Nephrology, Clinical Research and Development Center at Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirhossein Miladipour
- Department of Nephrology, Clinical Research and Development Center at Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Mahdi Salarabedi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kimia Karimi Toudeshki
- Department of Cardiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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15
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Deng C, Jin Q, Xu J, Fu W, He M, Xu L, Song Y, Wang W, Yi L, Chen Y, Gao T, Wang J, Lv Q, Yang Y, Zhang L, Xie M. Electrospun polymer fibers modified with FK506 for the long-term treatment of acute cardiac allograft rejection in a heart transplantation model. Biomater Sci 2023; 11:4032-4042. [PMID: 37129635 DOI: 10.1039/d3bm00374d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
FK506, a first-line immunosuppressant, is routinely administered orally and intravenously following heart transplantation. However, frequent administration can result in a substantial psychological burden to patients, resulting in non-adherence to medication. The purpose of our study is to overcome the disadvantages of systemic drug administration by developing a polymer-based delivery system that is tunable and biodegradable and that can release highly hydrophobic FK506 over extended periods to treat or prevent acute cardiac allograft rejection. Using an electrospinning method, long-acting microfibers were prepared, and FK506 appeared to be continuously released for up to 14 days based on the in vitro release profiles. After implanting the microfiber subcutaneously into the abdominals of transplanted rats, it was found that the infiltration of T cells and macrophages and the secretion of interleukin-2 (IL-2) and IL-1β were significantly reduced compared with those of the free FK506 groups. More importantly, the mean survival time (MST) of the PCL-FK506 group was significantly extended in comparison with that of untreated control recipients and free FK506 (MST of untreated control recipients, free FK506, and PCL-FK506 was 8, 26.1, and 37, respectively). In conclusion, we propose that this drug delivery approach would be suitable for developing long-lasting immunomodulatory agents that prolong cardiac graft survival safely and effectively.
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Affiliation(s)
- Cheng Deng
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qiaofeng Jin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jia Xu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Wenpei Fu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Mengrong He
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Lingling Xu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yishu Song
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Wenyuan Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Luyang Yi
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yihan Chen
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Tang Gao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jing Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yali Yang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
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16
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Lion J, Maitre ML, de Truchis C, Taupin JL, Poussin K, Haziot A, Chong E, Glotz D, Mooney N. Restriction of interleukin-6 alters endothelial cell immunogenicity in an allogenic environment. Clin Transplant 2023; 37:e14851. [PMID: 36495142 DOI: 10.1111/ctr.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/15/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
The microvascular endothelium of the renal transplant is the first site of graft interaction with the host immune system and is often injured in chronic Antibody Mediated Rejection (AMR). Microvascular inflammation is an independent determinant of AMR and heightens endothelial expression of HLA molecules thereby increasing the possibility of Donor Specific Antibody (DSA) binding. Endothelial cells produce IL-6 in the steady-state and this is increased by inflammation or by HLA-DR antibody binding in an allogeneic setting. Because IL-6 has been implicated in AMR, IL-6 blockade is currently under investigation as a therapeutic target. To further understand the role of IL-6 in endothelial cell immunogenicity, we have examined whether humanized antibody blockade of IL-6 altered endothelial cell interactions with allogeneic PBMC and after anti-HLA or DSA binding to endothelial cells in an in vitro human experimental model. Soluble factors, endothelial phenotype, Stat-3 activation, CD4+ -T differentiation, and C4d deposition were examined. Blockade of IL-6 reduced endothelial cell secretion of IL-6 and of the monocyte chemoattractant MCP-1. Pre-activation of endothelial cells by anti-HLA or DSA binding increased IL-6 secretion, that was further increased by concurrent binding of both antibodies and this was inhibited by IL-6 blockade. Activation of Stat-3 in CD4+ -T mediated by soluble factors produced in endothelial-PBMC interactions, and endothelial differentiation of CD4+ -T cell subsets (Th1, Th17, Treg), were impaired whereas activation of Complement by anti-HLA antibody binding remained unchanged by IL-6 blockade. Together, these data identify EC-mediated pro-inflammatory responses (T cell expansion, EC auto-activation, chemokine secretion) targeted by IL-6 blockade.
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Affiliation(s)
- Julien Lion
- INSERM U976, Institut de Recherche Saint Louis, Paris
| | | | | | | | | | - Alain Haziot
- INSERM U976, Institut de Recherche Saint Louis, Paris.,Université de Paris, Paris
| | | | - Denis Glotz
- INSERM U976, Institut de Recherche Saint Louis, Paris.,Université de Paris, Paris
| | - Nuala Mooney
- INSERM U976, Institut de Recherche Saint Louis, Paris.,Université de Paris, Paris
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17
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Kapten K, Orczyk K, Smolewska E. Immunity in SARS-CoV-2 Infection: Clarity or Mystery? A Broader Perspective in the Third Year of a Worldwide Pandemic. Arch Immunol Ther Exp (Warsz) 2023; 71:7. [PMID: 36810662 PMCID: PMC9943048 DOI: 10.1007/s00005-023-00673-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/09/2023] [Indexed: 02/23/2023]
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its mechanisms have been thoroughly studied by researchers all over the world with the hope of finding answers that may aid the discovery of new treatment options or effective means of prevention. Still, over 2 years into the pandemic that is an immense burden on health care and economic systems, there seem to be more questions than answers. The character and multitude of immune responses elicited in coronavirus disease 2019 (COVID-19) vary from uncontrollable activation of the inflammatory system, causing extensive tissue damage and consequently leading to severe or even fatal disease, to mild or asymptomatic infections in the majority of patients, resulting in the unpredictability of the current pandemic. The aim of the study was to systematize the available data regarding the immune response to SARS-CoV-2, to provide some clarification among the abundance of the knowledge available. The review contains concise and current information on the most significant immune reactions to COVID-19, including components of both innate and adaptive immunity, with an additional focus on utilizing humoral and cellular responses as effective diagnostic tools. Moreover, the authors discussed the present state of knowledge on SARS-CoV-2 vaccines and their efficacy in cases of immunodeficiency.
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Affiliation(s)
- Katarzyna Kapten
- Department of Pediatric Cardiology and Rheumatology, Central Teaching Hospital of Medical University of Lodz, Lodz, Poland
| | - Krzysztof Orczyk
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland
| | - Elzbieta Smolewska
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland.
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18
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Anti-interleukin-6 Antibody Clazakizumab in Antibody-mediated Renal Allograft Rejection: Accumulation of Antibody-neutralized Interleukin-6 Without Signs of Proinflammatory Rebound Phenomena. Transplantation 2023; 107:495-503. [PMID: 35969004 DOI: 10.1097/tp.0000000000004285] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blockade of interleukin-6 (IL-6) has emerged as a promising therapeutic option for antibody-mediated rejection. Subtherapeutic anti-IL-6 antibody level or treatment cessation following prolonged cytokine neutralization may result in proinflammatory rebound phenomena via accumulation of IL-6 and/or modulated gene expression of major components of the IL-6/IL-6 receptor (IL-6R) axis. METHODS We evaluated biologic material obtained from a randomized controlled, double-blind phase 2 trial designed to evaluate the safety and efficacy of the anti-IL-6 monoclonal antibody clazakizumab in late antibody-mediated rejection. Twenty kidney transplant recipients, allocated to clazakizumab or placebo, received 4-weekly doses over 12 wks, followed by a 40-wk extension where all recipients received clazakizumab. Serum proteins were detected using bead-based immunoassays and RNA transcripts using quantitative real-time polymerase chain reaction (peripheral blood) or microarray analysis (serial allograft biopsies). RESULTS Clazakizumab treatment resulted in a substantial increase in median total (bound and unbound to drug) serum IL-6 level (1.4, 8015, and 13 600 pg/mL at 0, 12, and 52 wks), but median level of free (unbound to drug) IL-6 did not increase (3.0, 2.3, and 2.3 pg/mL, respectively). Neutralization of IL-6 did not boost soluble IL-6R or leukocyte or allograft expression of IL-6, IL-6R, and glycoprotein 130 mRNA. Cessation of treatment at the end of the trial did not result in a meaningful increase in C-reactive protein or accelerated progression of graft dysfunction during 12 mo of follow-up. CONCLUSION Our results argue against clinically relevant rebound phenomena and modulation of major components of the IL-6/IL-6R axis following prolonged IL-6 neutralization with clazakizumab.
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19
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Lion J, Maitre ML, de Truchis C, Taupin JL, Poussin K, Haziot A, Chong E, Glotz D, Mooney N. Restriction of interleukin-6 alters endothelial cell immunogenicity in an allogenic environment. Clin Transplant 2022; 36:e14815. [PMID: 36114597 DOI: 10.1111/ctr.14815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 12/27/2022]
Abstract
The microvascular endothelium of the renal transplant is the first site of graft interaction with the host immune system and is often injured in chronic Antibody Mediated Rejection (AMR). Microvascular inflammation is an independent determinant of AMR and heightens endothelial expression of human leukocyte antigen (HLA) molecules thereby increasing the possibility of Donor Specific Antibody (DSA) binding. Endothelial cells (ECs) produce IL-6 in the steady-state that is increased by inflammation or by HLA-DR antibody binding in an allogeneic setting. Because IL-6 has been implicated in AMR, IL-6 blockade is currently under investigation as a therapeutic target. To further understand the role of IL-6 in EC immunogenicity, we have examined whether humanized antibody blockade of IL-6 altered EC interactions with allogeneic PBMC and after anti-HLA or DSA binding to ECs in an in vitro human experimental model. Soluble factors, endothelial phenotype, Stat-3 activation, CD4+ -T differentiation and C4d deposition were examined. Blockade of IL-6 reduced EC secretion of IL-6 and of the monocyte chemoattractant MCP-1. Pre-activation of ECs by anti-HLA or DSA binding increased IL-6 secretion, that was further increased by concurrent binding of both antibodies and this was inhibited by IL-6 blockade. Activation of Stat-3 in CD4+ -T mediated by soluble factors produced in endothelial-PBMC interactions, and endothelial differentiation of CD4+ -T cell subsets (Th1, Treg), were impaired whereas activation of Complement by anti-HLA antibody binding remained unchanged by IL-6 blockade. Together, these data identify EC-mediated pro-inflammatory responses (T cell expansion, EC auto-activation, chemokine secretion) targeted by IL-6 blockade.
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Affiliation(s)
- Julien Lion
- INSERM U976, Institut de Recherche Saint Louis, Paris, France
| | | | | | - Jean-Luc Taupin
- INSERM U976, Institut de Recherche Saint Louis, Paris, France
| | - Karine Poussin
- INSERM U976, Institut de Recherche Saint Louis, Paris, France
| | - Alain Haziot
- INSERM U976, Institut de Recherche Saint Louis, Paris, France.,Université de Paris, Paris, France
| | | | - Denis Glotz
- INSERM U976, Institut de Recherche Saint Louis, Paris, France.,Université de Paris, Paris, France
| | - Nuala Mooney
- INSERM U976, Institut de Recherche Saint Louis, Paris, France.,Université de Paris, Paris, France
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20
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Jordan SC, Ammerman N, Huang E, Vo A. Importance of IL-6 inhibition in prevention and treatment of antibody-mediated rejection in kidney allografts. Am J Transplant 2022; 22 Suppl 4:28-37. [PMID: 36453709 DOI: 10.1111/ajt.17207] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/30/2022] [Accepted: 09/23/2022] [Indexed: 12/03/2022]
Abstract
Interleukin-6 (IL-6) is a cytokine critical for innate and adaptive immune responses. However, persistent expression of high levels of IL-6 are associated with a number of pathologic conditions including autoimmune diseases and capillary leak syndrome. Importantly, in kidney transplant patients, IL-6 may play a role in mediation of cell-mediated rejection (CMR) and antibody-mediated rejection (AMR). This is likely due to the importance of IL-6 in stimulating B cell responses with pathogenic donor-specific antibody (DSA) generation and stimulation of T effector cell responses while inhibiting T regulatory cells. Data from preliminary clinical trials and clinical observations show that tocilizumab (anti-IL-6R) and clazakizumab (anti-IL-6) may have promise in treatment of CMR, AMR and chronic (cAMR). This has led to a phase 3 placebo, randomized clinical trial of clazakizumab for treatment of cAMR, a condition for which there is currently no treatment. The identification of IL-6 production in vascular endothelia cells after alloimmune activation reveals another potential pathway for vasculitis as endothelia cell IL-6 may stimulate immune cell responses that are potentially inhibitable with anti-IL-6/IL-6R treatment. Importantly, anti-IL-6/IL-6R treatments have shown the ability to induce Treg and Breg cells in vivo which may have potential importance for prevention and treatment of DSA development and allograft rejection.
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Affiliation(s)
- Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Noriko Ammerman
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California, USA
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21
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Kervella D, Blancho G. New immunosuppressive agents in transplantation. Presse Med 2022; 51:104142. [PMID: 36252821 DOI: 10.1016/j.lpm.2022.104142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immunosuppressive agents have enabled the development of allogenic transplantation during the last 40 years, allowing considerable improvement in graft survival. However, several issues remain such as the nephrotoxicity of calcineurin inhibitors, the cornerstone of immunosuppressive regimens and/or the higher risk of opportunistic infections and cancers. Most immunosuppressive agents target T cell activation and may not be efficient enough to prevent allo-immunization in the long term. Finally, antibody mediated rejection due to donor specific antibodies strongly affects allograft survival. Many drugs have been tested in the last decades, but very few have come to clinical use. The most recent one is CTLA4-Ig (belatacept), a costimulation blockade molecule that targets the second signal of T cell activation and is associated with a better long term kidney function than calcineurin inhibitors, despite an increased risk of acute cellular rejection. The research of new maintenance long-term immunosuppressive agents focuses on costimulation blockade. Agents inhibiting CD40-CD40 ligand interaction may enable a good control of both T cells and B cells responses. Anti-CD28 antibodies may promote regulatory T cells. Agents targeting this costimulation pathways are currently evaluated in clinical trials. Immunosuppressive agents for ABMR treatment are scarce since anti-CD20 agent rituximab and proteasome inhibitor bortezomib have failed to demonstrate an interest in ABMR. New drugs focusing on antibodies removal (imlifidase), B cell and plasmablasts (anti-IL-6/IL-6R, anti-CD38…) and complement inhibition are in the pipeline, with the challenge of their evaluation in such a heterogeneous pathology.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France.
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22
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Tang PC, Haft JW, Lei I, Wang Z, Chen YE, Abou El Ela A, Wu X, Pitt B, Aaronson KD, Pagani FD. Impact of donor blood type on outcomes after prolonged allograft ischemic times. J Thorac Cardiovasc Surg 2022; 164:981-993.e8. [PMID: 33558115 PMCID: PMC11170339 DOI: 10.1016/j.jtcvs.2020.12.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/29/2020] [Accepted: 12/23/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The study objective was to determine the influence of allograft ischemic time on heart transplant outcomes among ABO donor organ types given limited prior reports of its survival impact. METHODS We identified 32,454 heart transplants (2000-2016) from the United Network for Organ Sharing database. Continuous and categoric variables were analyzed by parametric and nonparametric testing. Survival was determined using log-rank or Cox regression tests. Propensity matching adjusted for preoperative variables. RESULTS By comparing allograft ischemic time less than 4 hours (n = 6579) with 4 hours or more (n = 25,875), the hazard ratios for death at 15 years after prolonged ischemic time (≥4 hours) for blood types O, A, B, and AB were 1.106 (P < .001), 1.062 (P < .001), 1.059 (P = .062), and 1.114 (P = .221), respectively. Unadjusted data demonstrated higher mortality for transplantation of O versus non-O donor hearts for ischemic time 4 hours or more (hazard ratio, 1.164; P < .001). After propensity matching, O donor hearts continued to have worse survival if preserved for 4 hours or more (hazard ratio, 1.137, P = .008), but not if ischemic time was less than 4 hours (hazard ratio, 1.042, P = .113). In a matched group with 4 hours or more of ischemic time, patients receiving O donor organs were more likely to experience death from primary graft dysfunction (2.5% vs 1.7%, P = .052) and chronic allograft rejection (1.9% vs 1.1%, P = .021). No difference in death from primary graft dysfunction or chronic allograft rejection was seen with less than 4 hours of ischemic time (P > .150). CONCLUSIONS Compared with non-O donor hearts, transplantation with O donor hearts with ischemic time 4 hours or more leads to worse survival, with higher rates of primary graft dysfunction and chronic rejection. Caution should be practiced when considering donor hearts with the O blood type when anticipating extended cold ischemic times.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Zhong Wang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Y Eugene Chen
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich; Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Bertram Pitt
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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23
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Kervella D, Le Bas-Bernardet S, Bruneau S, Blancho G. Protection of transplants against antibody-mediated injuries: from xenotransplantation to allogeneic transplantation, mechanisms and therapeutic insights. Front Immunol 2022; 13:932242. [PMID: 35990687 PMCID: PMC9389360 DOI: 10.3389/fimmu.2022.932242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term allograft survival in allotransplantation, especially in kidney and heart transplantation, is mainly limited by the occurrence of antibody-mediated rejection due to anti-Human Leukocyte Antigen antibodies. These types of rejection are difficult to handle and chronic endothelial damages are often irreversible. In the settings of ABO-incompatible transplantation and xenotransplantation, the presence of antibodies targeting graft antigens is not always associated with rejection. This resistance to antibodies toxicity seems to associate changes in endothelial cells phenotype and modification of the immune response. We describe here these mechanisms with a special focus on endothelial cells resistance to antibodies. Endothelial protection against anti-HLA antibodies has been described in vitro and in animal models, but do not seem to be a common feature in immunized allograft recipients. Complement regulation and anti-apoptotic molecules expression appear to be common features in all these settings. Lastly, pharmacological interventions that may promote endothelial cell protection against donor specific antibodies will be described.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Sarah Bruneau
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
- *Correspondence: Gilles Blancho,
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24
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DeWolf SE, Kasimsetty SG, Hawkes AA, Stocks LM, Kurian SM, McKay DB. DAMPs Released From Injured Renal Tubular Epithelial Cells Activate Innate Immune Signals in Healthy Renal Tubular Epithelial Cells. Transplantation 2022; 106:1589-1599. [PMID: 34954736 PMCID: PMC9218002 DOI: 10.1097/tp.0000000000004038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renal ischemia-reperfusion injury (IRI) predictably causes acute kidney injury after shock and major cardiovascular procedures in all kidneys procured for transplantation. The earliest events of IRI are triggered by molecules released from injured cells, damage-associated molecular patterns (DAMPs), that bind pattern recognition receptors (PRRs) constitutively expressed on many cells within the kidney. Activation of PRR signaling leads to production of proinflammatory molecules, which incite a cascade of inflammatory events leading to acute kidney injury. Renal tubular epithelial cells (RTECs) are particularly susceptible to ischemic injury, and proximal RTEC injury is pathognomonic of renal IRI. To better understand how injured RTECs contribute to the cycle of deleterious inflammation in the setting of renal IRI, this study asked whether DAMPs released from injured RTECs induced PRR signals in healthy RTECs. METHODS Human RTECs were necrosed ex vivo to release intracellular DAMPs and resulting necrotic supernatant used to stimulate healthy RTECs, T lymphocytes, and monocytes. RESULTS DAMPs released from necrosed RTECs upregulated PRRs known to be associated with renal IRI and activated mitogen-activated protein kinase signaling pathways. Proinflammatory cytokines were upregulated in response to necrotic supernatant, and this upregulation was abrogated by MEK-1 inhibition. The RTEC-derived DAMPs were also potent inducers of T-cell activation/proliferation and monocyte migration. CONCLUSIONS This is the first study to our knowledge to show that endogenous DAMPs released from injured RTECs directly activate PRR signaling in healthy RTECs. These findings provide new insights directed to therapeutics for renal IRI.
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Affiliation(s)
- Sean E DeWolf
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA
- Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA
| | - Sashi G Kasimsetty
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA
| | - Alana A Hawkes
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA
| | - Lisa M Stocks
- LifeSharing Organ Procurement Organization, San Diego, CA
| | - Sunil M Kurian
- Division of Cell and Organ Transplantion, Scripps Clinic and Green Hospital, La Jolla, CA
| | - Dianne B McKay
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA
- Division of Cell and Organ Transplantion, Scripps Clinic and Green Hospital, La Jolla, CA
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25
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Sagray E, Johnson JN, Schumacher KR, West S, Lowery RE, Simpson K. Protein-losing enteropathy recurrence after pediatric heart transplantation: Multicenter case series. Pediatr Transplant 2022; 26:e14295. [PMID: 35451219 DOI: 10.1111/petr.14295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/03/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Protein-losing enteropathy (PLE) is a devastating complication of the Fontan circulation. Although orthotopic heart transplantation (HTx) typically results in resolution of PLE symptoms, isolated cases of PLE relapse have been described after HTx. METHODS Patients with Fontan-related PLE who had undergone HTx at participating centers and experienced relapse of PLE during follow-up were retrospectively identified. Available data related to pre- and post-HTx characteristics and PLE events were collected. RESULTS Eight patients from four different centers were identified. Median time from Fontan procedure to the development of PLE was 8 years, and median age at HTx was 17 years (range 7.7-21). In all patients, PLE resolved at a median time of 1 month after HTx (0.3-5). PLE recurrences occurred at a median time of 7.5 months after HTx (2-132). Each occurrence was associated with one or more significant clinical events; most commonly cellular- or antibody-mediated rejection; and less commonly graft dysfunction, infection, thrombosis, and posttransplant lymphoproliferative disease. PLE recurrences resolved after the successful treatment of the concomitant event, after a median time of 2 months in seven cases, while persisted and recurred in one patient in association with atypical mycobacterium infection and subsequent PTLD onset and relapses. Six patients were alive during follow-up at a median time of 4 years (1.3-22.5) after HTx. CONCLUSIONS This is the largest series of PLE recurrence after HTx. All cases were associated with one or more concomitant and significant clinical events. PLE typically resolved after resolution of the inciting clinical event.
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Affiliation(s)
- Ezequiel Sagray
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn West
- Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado, USA
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26
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Mayer KA, Budde K, Jilma B, Doberer K, Böhmig GA. Emerging drugs for antibody-mediated rejection after kidney transplantation: a focus on phase II & III trials. Expert Opin Emerg Drugs 2022; 27:151-167. [PMID: 35715978 DOI: 10.1080/14728214.2022.2091131] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antibody-mediated rejection (ABMR) is a leading cause of kidney allograft failure. Its therapy continues to be challenge, and no treatment has been approved for the market thus far. AREAS COVERED In this article, we discuss the pathophysiology and phenotypic presentation of ABMR, the current level of evidence to support the use of available therapeutic strategies, and the emergence of tailored drugs now being evaluated in systematic clinical trials. We searched PubMed, Clinicaltrials.gov and Citeline's Pharmaprojects for pertinent information on emerging anti-rejection strategies, laying a focus on phase II and III trials. EXPERT OPINION Currently, we rely on the use of apheresis for alloantibody depletion and intravenous immunoglobulin (referred to as standard of care), preferentially in early active ABMR. Recent systematic trials have questioned the benefits of using the CD20 antibody rituximab or the proteasome inhibitor bortezomib. However, there are now several promising treatment approaches in the pipeline, which are being trialed in phase II and III studies. These include interleukin-6 antagonism, CD38-targeting antibodies, and selective inhibitors of complement. On the basis of the information that has emerged so far, it seems that innovative treatment strategies for clinical use in ABMR may be available within the next 5-10 years.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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27
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Laks JA, Dipchand AI. Cardiac allograft vasculopathy: A review. Pediatr Transplant 2022; 26:e14218. [PMID: 34985793 DOI: 10.1111/petr.14218] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease, and outcomes have consistently improved over the last few decades. CAV, however, remains a leading cause of morbidity and mortality in heart transplantation and is the leading cause of death beyond 3 years post-transplantation. We sought out to provide an in-depth overview of CAV in the pediatric heart transplant population. METHODS Database searches were conducted in both Medline and Embase on the topic of cardiac vasculopathy in pediatric heart transplant recipients. The search used five broad concept terms: heart transplant; pediatric; CAV; diagnosis, prognosis, and risk factors; and guidelines and reviews. References were captured if there was at least one term in each of the concepts. The search was limited to articles in the English language. RESULTS A total of 148 articles were identified via the literature search with further articles identified via review of references. Pediatric data regarding the etiology and development of CAV remain limited although knowledge about the immune and non-immune factors playing a role are increasing. CAV continues to be difficult to detect with many invasive and non-invasive methods available, yet their effectiveness in the detection of CAV remains suboptimal. There remains no proven medical intervention to treat or reverse established CAV disease, and CAV is associated with high rates of graft loss once detected. However, several medications are used in hopes of preventing, slowing progression, or modifying the outcomes. CONCLUSION This review provides a comprehensive overview of CAV, discusses its clinical presentation, risk factors, diagnostic tools used to identify CAV in the pediatric population, and highlights the current therapeutic options and the need for ongoing research.
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Affiliation(s)
- Jessica A Laks
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
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28
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Vo AA, Huang E, Ammerman N, Toyoda M, Ge S, Haas M, Zhang X, Peng A, Najjar R, Williamson S, Myers C, Sethi S, Lim K, Choi J, Gillespie M, Tang J, Jordan SC. Clazakizumab for desensitization in highly sensitized patients awaiting transplantation. Am J Transplant 2022; 22:1133-1144. [PMID: 34910841 DOI: 10.1111/ajt.16926] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 12/12/2021] [Accepted: 12/12/2021] [Indexed: 01/25/2023]
Abstract
Alloantibodies are a significant barrier to successful transplantation. While desensitization has emerged, efficacy is limited. Interleukin-6 (IL-6) is an important mediator of inflammation and immune cell activation. Persistent IL-6 production increases the risk for alloantibody production. Here we report our experience with clazakizumab (anti-IL-6) for desensitization of highly HLA-sensitized patients (HS). From March 2018 to September 2020, 20 HS patients were enrolled in an open label pilot study to assess safety and limited efficacy of clazakizumab desensitization. Patients received PLEX, IVIg, and clazakizumab 25 mg monthly X6. If transplanted, graft function, pathology, HLA antibodies and regulatory immune cells were monitored. Transplanted patients received standard immunosuppression and clazakizumab 25 mg monthly posttransplant. Clazakizumab was well tolerated and associated with significant reductions in class I and class II antibodies allowing 18 of 20 patients to receive transplants with no DSA rebound in most. Significant increases in Treg and Breg cells were seen posttransplant. Antibody-mediated rejection occurred in three patients. The mean estimated glomerular filtration rate at 12 months was 58 ± 29 ml/min/1.73 m2 . Clazakizumab was generally safe and associated with significant reductions in HLA alloantibodies and high transplant rates for highly-sensitized patients. However, confirmation of efficacy for desensitization requires assessment in randomized controlled trials.
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Affiliation(s)
- Ashley A Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Noriko Ammerman
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mieko Toyoda
- Department of Transplant Immunology and Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shili Ge
- Department of Transplant Immunology and Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mark Haas
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaohai Zhang
- Department of HLA & Immunogenetics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Reiad Najjar
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Summer Williamson
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Catherine Myers
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Supreet Sethi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kathlyn Lim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Gillespie
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jacqueline Tang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
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Salvadori M, Tsalouchos A. Innovative immunosuppression in kidney transplantation: A challenge for unmet needs. World J Transplant 2022; 12:27-41. [PMID: 35433332 PMCID: PMC8968476 DOI: 10.5500/wjt.v12.i3.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/27/2022] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the optimal results obtained in kidney transplantation and to the lack of interest of the industries, new innovative drugs in kidney transplantation are difficult to be encountered. The best strategy to find the new drugs recently developed or under development is to search in the sections of kidney transplantation still not completely covered by the drugs on the market. These unmet needs are the prevention of delayed graft function (DGF), the protection of the graft over the long time and the desensitization of preformed anti human leukocyte antigen antibodies and the treatment of the acute antibody-mediated rejection. These needs are particularly relevant due to the expansion of some kind of kidney transplantation as transplantation from non-heart beating donor and in the case of antibody-incompatible grafts. The first are particularly exposed to DGF, the latter need a safe desensitization and a safe treatments of the antibody mediated rejections that often occur. Particular caution is needed in treating these drugs. First, they are described in very recent studies and the follow-up of their effect is of course rather short. Second, some of these drugs are still in an early phase of study, even if in well-conducted randomized controlled trials. Particular caution and a careful check need to be used in trials launched 2 or 3 years ago. Indeed, is always necessary to verify whether the study is still going on or whether and why the study itself was abandoned.
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Affiliation(s)
- Maurizio Salvadori
- Department of Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Division of Nephrology, Santa Maria Annunziata Hospital, Florence 50012, Italy
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30
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Evaluation of Clazakizumab (anti-IL-6) in Patients with Treatment-Resistant Chronic Active Antibody Mediated Rejection of Kidney Allografts. Kidney Int Rep 2022; 7:720-731. [PMID: 35497778 PMCID: PMC9039906 DOI: 10.1016/j.ekir.2022.01.1074] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction Interleukin-6 (IL-6) is an important mediator of inflammation and activation of T cells, B cells, and plasma cells. Excessive IL-6 production is linked to human diseases characterized by unregulated antibody production, including alloimmunity, where persistence of donor-specific antibodies (DSAs), chronic active antibody-mediated rejection (cAMR), and graft loss are noted. Here, we report our experience investigating clazakizumab, a novel IL-6 inhibitor, in treating human leukocyte antigen (HLA)-sensitized patients with cAMR. Methods Between February 2018 and January 2019, 10 adults with biopsy-proven cAMR were enrolled in a phase 2, single-center, open-label study. Patients received clazakizumab 25 mg subcutaneously (s.c.) monthly for 12 months, with a 6-month protocol biopsy. Primary end points included patient survival, graft survival, estimated glomerular filtration rate (eGFR), and safety. Secondary end points assessed immune markers (DSAs, IgG, T-regulatory [Treg] cells). At 12 months, stable patients entered a long-term extension (LTE). Results LTE patients received clazakizumab for >2.5 years. Mean eGFRs showed significant declines from −24 months to study initiation (0 months) (52.8 ± 14.6 to 38.11 ± 12.23 ml/min per 1.73 m2, P = 0.03). However, after initiation of clazakizumab, eGFR stabilized at (41.6 ± 14.2 and 38.1 ± 20.3 ml/min per 1.73 m2, at 12 and 24 months, respectively). Banff 2017 analysis of pre- and post-treatment biopsies showed reductions in g+ptc and C4d scores. DSA reductions were seen in most patients. Adverse events (AEs) were minimal, and 2 graft losses occurred, both in patients who discontinued clazakizumab therapy at 6 months and 12 months after study initiation. Conclusion In this small cohort of patients with cAMR, clazakizumab treatment showed a trend toward stabilization of eGFR and reductions in DSA and graft inflammation. No significant safety issues were observed. A randomized, placebo-controlled clinical trial (IMAGINE) of clazakizumab in cAMR treatment is underway (NCT03744910).
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31
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Nikolova A, Patel JK. Induction Therapy and Therapeutic Antibodies. Handb Exp Pharmacol 2022; 272:85-116. [PMID: 35474024 DOI: 10.1007/164_2021_570] [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] [Indexed: 06/14/2023]
Abstract
Prevention of allograft rejection is one of the crucial goals in solid organ transplantation to ensure durability of the graft and is chiefly mediated by cellular and humoral pathways targeting cell surface alloantigens. The risk of rejection is highest in the first post-transplant year and wanes with time albeit the risk always exists and varies with the type of organ transplanted. Induction therapies refer to the use of high-intensity immunosuppression in the immediate post-operative period to mitigate the highest risk of rejection. This term encompasses chiefly the use of antibody therapies directed against one of the key pathways in T-cell activation or abrogating effects of circulating alloantibodies. These antibodies carry more potent immunomodulatory effect than maintenance immunosuppressive therapy alone and many of them lead to durable immune cell depletion. A variety of monoclonal and polyclonal antibodies have been utilized for use not only for induction therapy, but also for treatment of allograft rejection when it occurs and as components of desensitization therapy before and after transplantation to modulate circulating alloantibodies.
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32
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Deng C, Jin Q, Wu Y, Li H, Yi L, Chen Y, Gao T, Wang W, Wang J, Lv Q, Yang Y, Xu J, Fu W, Zhang L, Xie M. Immunosuppressive effect of PLGA-FK506-NPs in treatment of acute cardiac rejection via topical subcutaneous injection. Drug Deliv 2021; 28:1759-1768. [PMID: 34463172 PMCID: PMC8409942 DOI: 10.1080/10717544.2021.1968978] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
FK506, a first-line immunosuppressant, is routinely administered orally and intravenously to inhibit activation and proliferation of T cells after heart transplantation (HT). Current administration route is not conducive enough to exert its efficacy in lymphatic system. Herein, we proposed that subcutaneous (SC) administration of FK506-loaded nanoparticles (PLGA-FK506-NPs) would be valuable for treating acute rejection after HT. The biodistribution and pharmacokinetic study revealed that it could effectively deliver FK506 to the lymph nodes (LNs) due to their suitable particle size, especially in inguinal LNs. Subsequently, the therapeutic efficacy of PLGA-FK506-NPs on the HT model was evaluated using intravenous (IV), intragastric (IG), or SC injection. Histopathological analysis revealed that 80% of allografts exhibited only grade 1R rejection with negligible lymphocyte infiltration in the SC group. The IV group exhibited 40% 1R rejection with mild lymphocyte infiltration and 20% grade 3R that require further intervention, and the IG group exhibited grades 40% 3R rejection with more lymphocyte infiltration. Moreover, the infiltration of T cells and the secretion of IL-2 and IFN-γ were significantly reduced in the SC group compared with the IG or IV group. The mean survival time (MST) further revealed that 50% of grafts treated with PLGA-FK506-NPs via SC injection survived longer than IG and IV groups. Moreover, the MST of single-dose SC injection of PLGA-FK506-NPs demonstrated that it would effectively reduce the required dose for a similar therapeutic effect. Overall, these results indicate that SC administration of PLGA-FK506-NPs is a more effective route for chronic FK506 treatment.
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Affiliation(s)
- Cheng Deng
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qiaofeng Jin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ya Wu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Huiling Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Luyang Yi
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yihan Chen
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tang Gao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenyuan Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jing Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yali Yang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jia Xu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenpei Fu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Mühlbacher J, Schörgenhofer C, Doberer K, Dürr M, Budde K, Eskandary F, Mayer KA, Schranz S, Ely S, Reiter B, Chong E, Adler SH, Jilma B, Böhmig GA. Anti-interleukin-6 antibody clazakizumab in late antibody-mediated kidney transplant rejection: effect on cytochrome P450 drug metabolism. Transpl Int 2021; 34:1542-1552. [PMID: 34153143 PMCID: PMC8456861 DOI: 10.1111/tri.13954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/27/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
Targeting interleukin-6 (IL-6) is a promising strategy to counteract antibody-mediated rejection (ABMR). In inflammatory states, IL-6 antagonism was shown to modulate cytochrome P450 (CYP), but its impact on drug metabolism in ABMR treatment was not addressed so far. We report a sub-study of a phase 2 trial of anti-IL-6 antibody clazakizumab in late ABMR (ClinicalTrials.gov, NCT03444103). Twenty kidney transplant recipients were randomized to clazakizumab versus placebo (4-weekly doses; 12 weeks), followed by a 9-month extension where all recipients received clazakizumab. To study CYP2C19/CYP3A4 metabolism, we administered pantoprazole (20 mg intravenously) at prespecified time points. Dose-adjusted C0 levels (C0 /D ratio) of tacrolimus (n = 13) and cyclosporin A (CyA, n = 6) were monitored at 4-weekly intervals. IL-6 and C-reactive protein were not elevated at baseline, the latter was then suppressed to undetectable levels under clazakizumab. IL-6 blockade had no clinically meaningful impact on pantoprazole pharmacokinetics (area under the curve; baseline versus week 52: 3.16 [2.21-7.84] versus 4.22 [1.99-8.18] μg/ml*h, P = 0.36) or calcineurin inhibitor C0 /D ratios (tacrolimus: 1.49 [1.17-3.20] versus 1.37 [0.98-2.42] ng/ml/mg, P = 0.21; CyA: 0.69 [0.57-0.85] versus 1.08 [0.52-1.38] ng/ml/mg, P = 0.47). We conclude that IL-6 blockade in ABMR - in absence of systemic inflammation - may have no meaningful effect on CYP metabolism.
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Affiliation(s)
- Jakob Mühlbacher
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Dürr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sabine Schranz
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Sarah Ely
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Edward Chong
- Vitaeris Inc. (a subsidiary of CSL Behring, King of Prussia, PA, USA), Vancouver, BC, Canada
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Abstract
Purpose of Review IL-6 is a pleiotropic, pro-inflammatory cytokine that plays an integral role in the development of acute and chronic rejection after solid organ transplantation. This article reviews the experimental evidence and current clinical application of IL-6/IL-6 receptor (IL-6R) signaling inhibition for the prevention and treatment of allograft injury. Recent Findings There exists a robust body of evidence linking IL-6 to allograft injury mediated by acute inflammation, adaptive cellular/humoral responses, innate immunity, and fibrosis. IL-6 promotes the acute phase reaction, induces B cell maturation/antibody formation, directs cytotoxic T-cell differentiation, and inhibits regulatory T-cell development. Importantly, blockade of the IL-6/IL-6R signaling pathway has been shown to mitigate its harmful effects in experimental studies, particularly in models of kidney and heart transplant rejection. Currently, available agents for IL-6 signaling inhibition include monoclonal antibodies against IL-6 or IL-6R and janus kinase inhibitors. Recent clinical trials have investigated the use of tocilizumab, an anti-IL-6R mAb, for desensitization and treatment of antibody-mediated rejection (AMR) in kidney transplant recipients, with promising initial results. Further studies are underway investigating the use of alternative agents including clazakizumab, an anti-IL-6 mAb, and application of IL-6 signaling blockade to clinical cardiac transplantation. Summary IL-6/IL-6R signaling inhibition provides a novel therapeutic option for the prevention and treatment of allograft injury. To date, evidence from clinical trials supports the use of IL-6 blockade for desensitization and treatment of AMR in kidney transplant recipients. Ongoing and future clinical trials will further elucidate the role of IL-6 signaling inhibition in other types of solid organ transplantation.
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35
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Jordan SC. Innate and adaptive immune responses to SARS-CoV-2 in humans: relevance to acquired immunity and vaccine responses. Clin Exp Immunol 2021; 204:310-320. [PMID: 33534923 PMCID: PMC8013613 DOI: 10.1111/cei.13582] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/02/2021] [Accepted: 01/18/2021] [Indexed: 12/13/2022] Open
Abstract
The factors responsible for the spectrum of coronavirus 19 (COVID-19) disease severity and the genesis and nature of protective immunity against COVID-19 remain elusive. Multiple studies have investigated the immune responses to COVID-19 in various populations, including those without evidence of COVID-19 infection. Information regarding innate and adaptive immune responses to the novel severe respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved rapidly. Data are accumulating defining disease phenotypes that aid in rational and informed development of new therapeutic approaches for the treatment of patients infected with SARS-CoV-2 and the development of novel vaccines. In this paper, data on important innate immune responses are summarized, including cytokines, specifically interleukin (IL)-6 and complement, and potential treatments are explored. Adaptive immune responses and derivative therapeutics such as monoclonal antibodies directed at spike proteins are also examined. Finally, data on real-time assessments of adaptive immune responses are explored, which include CD4+ /CD8+ T cells, natural killer (NK) T cells, memory B cells and T follicular cells with specificities for COVID-19 peptides in infected and normal individuals. Data of two novel vaccines have been released, both showing > 95% efficacy in preventing SARS-CoV-2 infection. Analysis of humoral and cellular responses to the vaccines will determine the robustness and durability of protection. In addition, long-term assessment of SARS-CoV-2 memory B and T cell-mediated immune responses in patients recovering from an infection or those with cross-reactive immunological memory will help to define risk for future SARS-CoV infections. Finally, patients recovering from SARS-CoV-2 infection may experience prolonged immune activation probably due to T cell exhaustion. This will be an important new frontier for study.
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Affiliation(s)
- S. C. Jordan
- Comprehensive Transplant CenterCedars‐Sinai Medical CenterLos AngelesCAUSA
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36
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Joher N, Matignon M, Grimbert P. HLA Desensitization in Solid Organ Transplantation: Anti-CD38 to Across the Immunological Barriers. Front Immunol 2021; 12:688301. [PMID: 34093594 PMCID: PMC8173048 DOI: 10.3389/fimmu.2021.688301] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
The presence of anti-human leucocyte antigen (HLA) antibodies in the potential solid organ transplant recipient's blood is one of the main barriers to access to a transplantation. The HLA sensitization is associated with longer waitlist time, antibody mediated rejection and transplant lost leading to increased recipient's morbidity and mortality. However, solid organ transplantation across the HLA immunological barriers have been reported in recipients who were highly sensitized to HLA using desensitization protocols. These desensitization regimens are focused on the reduction of circulating HLA antibodies. Despite those strategies improve rates of transplantation, it remains several limitations including persistent high rejection rate and worse long-term outcomes when compare with non-sensitized recipient population. Currently, interest is growing in the development of new desensitization approaches which, beyond targeting antibodies, would be based on the modulation of alloimmune pathways. Plasma cells appears as an interesting target given their critical role in antibody production. In the last decade, CD38-targeting immunotherapies, such as daratumumab, have been recognized as a key component in the treatment of myeloma by inducing an important plasma cell depletion. This review focuses on an emerging concept based on targeting CD38 to desensitize in the field of transplantation.
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Affiliation(s)
- Nizar Joher
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
| | - Marie Matignon
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
| | - Philippe Grimbert
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
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37
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Thompson CP, Jagdale A, Walcott G, Iwase H, Foote JB, Cron RQ, Hara H, Cleveland DC, Cooper DKC. A perspective on the potential detrimental role of inflammation in pig orthotopic heart xenotransplantation. Xenotransplantation 2021; 28:e12687. [PMID: 33786912 DOI: 10.1111/xen.12687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/26/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023]
Abstract
There is a critical shortage of deceased human donor organs for transplantation. The need is perhaps most acute in neonates and infants with life-threatening congenital heart disease, in whom mechanical support devices are largely unsuccessful. If orthotopic (life-supporting) heart transplantation (OHTx) were consistently successful in the genetically engineered pig-to-nonhuman primate (NHP) model, a clinical trial of bridging with a pig heart in such patients might be justified. However, the results of pig OHTx in NHPs have been mixed and largely poor. We hypothesise that a factor is the detrimental effects of the inflammatory response that is known to develop (a) during any surgical procedure that requires cardiopulmonary bypass, and (b) immediately after an NHP recipient is exposed to a pig xenograft. We suggest that the combination of these two inflammatory responses has a direct detrimental effect on pig heart graft function, but also, and possibly of more importance, on recipient baboon pulmonary function, which further impacts survival of the pig heart graft. In addition, the inflammatory response almost certainly adversely impacts the immune response to the graft. If our hypothesis is correct, the potential steps that could be taken to reduce the inflammatory response or its effects (with varying degrees of efficacy) include (a) white blood cell filtration, (b) complement depletion or inactivation, (c) immunosuppressive therapy, (d) high-dose corticosteroid therapy, (e) cytokine/chemokine-targeted therapy, (f) ultrafiltration or CytoSorb hemoperfusion, (g) reduction in the levels of endogenous catecholamines, (h) triiodothyronine therapy and (i) genetic engineering of the organ-source pig. Prevention of the inflammatory response, or attenuation of its effects, by judicious anti-inflammatory therapy may contribute not only to early survival of the recipient of a genetically engineered pig OHTx, but also to improved long-term pig heart graft survival. This would open the possibility of initiating a clinical trial of genetically engineered pig OHTx as a bridge to allotransplantation.
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Affiliation(s)
- Charles P Thompson
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abhijit Jagdale
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory Walcott
- Department of Medicine/Cardiovascular Diseases, the University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Randall Q Cron
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Cleveland
- Division of Cardiothoracic Surgery, Children's Hospital of Alabama, and Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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38
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Doberer K, Duerr M, Halloran PF, Eskandary F, Budde K, Regele H, Reeve J, Borski A, Kozakowski N, Reindl-Schwaighofer R, Waiser J, Lachmann N, Schranz S, Firbas C, Mühlbacher J, Gelbenegger G, Perkmann T, Wahrmann M, Kainz A, Ristl R, Halleck F, Bond G, Chong E, Jilma B, Böhmig GA. A Randomized Clinical Trial of Anti-IL-6 Antibody Clazakizumab in Late Antibody-Mediated Kidney Transplant Rejection. J Am Soc Nephrol 2021; 32:708-722. [PMID: 33443079 PMCID: PMC7920172 DOI: 10.1681/asn.2020071106] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/10/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Late antibody-mediated rejection (ABMR) is a leading cause of transplant failure. Blocking IL-6 has been proposed as a promising therapeutic strategy. METHODS We performed a phase 2 randomized pilot trial to evaluate the safety (primary endpoint) and efficacy (secondary endpoint analysis) of the anti-IL-6 antibody clazakizumab in late ABMR. The trial included 20 kidney transplant recipients with donor-specific, antibody-positive ABMR ≥365 days post-transplantation. Patients were randomized 1:1 to receive 25 mg clazakizumab or placebo (4-weekly subcutaneous injections) for 12 weeks (part A), followed by a 40-week open-label extension (part B), during which time all participants received clazakizumab. RESULTS Five (25%) patients under active treatment developed serious infectious events, and two (10%) developed diverticular disease complications, leading to trial withdrawal. Those receiving clazakizumab displayed significantly decreased donor-specific antibodies and, on prolonged treatment, modulated rejection-related gene-expression patterns. In 18 patients, allograft biopsies after 51 weeks revealed a negative molecular ABMR score in seven (38.9%), disappearance of capillary C4d deposits in five (27.8%), and resolution of morphologic ABMR activity in four (22.2%). Although proteinuria remained stable, the mean eGFR decline during part A was slower with clazakizumab compared with placebo (-0.96; 95% confidence interval [95% CI], -1.96 to 0.03 versus -2.43; 95% CI, -3.40 to -1.46 ml/min per 1.73 m2 per month, respectively, P=0.04). During part B, the slope of eGFR decline for patients who were switched from placebo to clazakizumab improved and no longer differed significantly from patients initially allocated to clazakizumab. CONCLUSIONS Although safety data indicate the need for careful patient selection and monitoring, our preliminary efficacy results suggest a potentially beneficial effect of clazakizumab on ABMR activity and progression.
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Affiliation(s)
- Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Duerr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Philip F. Halloran
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Heinz Regele
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Anita Borski
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Nicolas Kozakowski
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Waiser
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Lachmann
- Centre for Tumor Medicine, Histocompatibility & Immunogenetics Laboratory, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Schranz
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jakob Mühlbacher
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Kainz
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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39
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Arjuna A, Olson MT, Walia R, Bremner RM, Smith MA, Mohanakumar T. An update on current treatment strategies for managing bronchiolitis obliterans syndrome after lung transplantation. Expert Rev Respir Med 2020; 15:339-350. [PMID: 33054424 DOI: 10.1080/17476348.2021.1835475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bronchiolitis obliterans syndrome (BOS), a subtype of chronic lung allograft dysfunction, is quite common, with up to half of all lung recipients developing BOS within 5 years of transplantation. Preventive efforts are aimed at alleviating known risk factors of BOS development, while the primary goal of treatment is to delay the irreversible, fibrotic airway changes, and progressive loss of lung function. AREAS COVERED This narrative review will briefly discuss the updated definition, clinical presentation, pathogenesis, risk factors, and survival after BOS while paying particular attention to the salient evidence for optimal preventive strategies and treatments based on investigations in the modern era. EXPERT OPINION Future translational research focused on further characterizing the complex interplay between immune and nonimmune mechanisms mediating chronic lung rejection is the first step toward mitigating risk of allograft injury, improving early disease detection with noninvasive biomarkers, and ultimately, developing an effective, targeted therapy that can extend the life of the lung allograft.
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Affiliation(s)
- Ashwini Arjuna
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael T Olson
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA.,Phoenix Campus, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Rajat Walia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Ross M Bremner
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Michael A Smith
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ, USA
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