1
|
Pérez-Escobar J, Jimenez JV, Rodríguez-Aguilar EF, Servín-Rojas M, Ruiz-Manriquez J, Safar-Boueri L, Carrillo-Maravilla E, Navasa M, García-Juárez I. Immunotolerance in liver transplantation: a primer for the clinician. Ann Hepatol 2023; 28:100760. [PMID: 36179797 DOI: 10.1016/j.aohep.2022.100760] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/08/2022] [Indexed: 02/04/2023]
Abstract
The use of immunosuppressive medications for solid organ transplantation is associated with cardiovascular, metabolic, and oncologic complications. On the other hand, the development of graft rejection is associated with increased mortality and graft dysfunction. Liver transplant recipients can withdraw from immunosuppression without developing graft injury while preserving an adequate antimicrobial response - a characteristic known as immunotolerance. Immunotolerance can be spontaneously or pharmacologically achieved. Contrary to the classic dogma, clinical studies have elucidated low rates of true spontaneous immunotolerance (no serologic or histological markers of immune injury) among liver transplant recipients. However, clinical, serologic, and tissue biomarkers can aid in selecting patients in whom immunosuppression can be safely withdrawn. For those who failed an immunosuppression withdrawal trial or are at high risk of rejection, pharmacological interventions for immunotolerance induction are under development. In this review, we provide an overview of the mechanisms of immunotolerance, the clinical studies investigating predictors and biomarkers of spontaneous immunotolerance, as well as the potential pharmacological interventions for inducing it.
Collapse
Affiliation(s)
- Juanita Pérez-Escobar
- Department of Hepatology and Liver Transplant, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jose Victor Jimenez
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Erika Faride Rodríguez-Aguilar
- Department of Hepatology and Liver Transplant, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Maximiliano Servín-Rojas
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jesus Ruiz-Manriquez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luisa Safar-Boueri
- Comprehensive Transplant Center, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Eduardo Carrillo-Maravilla
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miquel Navasa
- Liver Transplant Unit, Hepatology Service, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Ignacio García-Juárez
- Department of Hepatology and Liver Transplant, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| |
Collapse
|
2
|
Fehr T, Hübel K, de Rougemont O, Abela I, Gaspert A, Güngör T, Hauri M, Helmchen B, Linsenmeier C, Müller T, Nilsson J, Riesterer O, Scandling JD, Schanz U, Cippà PE. Successful Induction of Specific Immunological Tolerance by Combined Kidney and Hematopoietic Stem Cell Transplantation in HLA-Identical Siblings. Front Immunol 2022; 13:796456. [PMID: 35173720 PMCID: PMC8841472 DOI: 10.3389/fimmu.2022.796456] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022] Open
Abstract
Induction of immunological tolerance has been the holy grail of transplantation immunology for decades. The only successful approach to achieve it in patients has been a combined kidney and hematopoietic stem cell transplantation from an HLA-matched or -mismatched living donor. Here, we report the first three patients in Europe included in a clinical trial aiming at the induction of tolerance by mixed lymphohematopoietic chimerism after kidney transplantation. Two female and one male patient were transplanted with a kidney and peripherally mobilized hematopoietic stem cells from their HLA-identical sibling donor. The protocol followed previous studies at Stanford University: kidney transplantation was performed on day 0 including induction with anti-thymocyte globulin followed by conditioning with 10x 1.2 Gy total lymphoid irradiation and the transfusion of CD34+ cells together with a body weight-adjusted dose of donor T cells on day 11. Immunosuppression consisted of cyclosporine A and steroids for 10 days, cyclosporine A and mycophenolate mofetil for 1 month, and then cyclosporine A monotherapy with tapering over 9–20 months. The 3 patients have been off immunosuppression for 4 years, 19 months and 8 months, respectively. No rejection or graft-versus-host disease occurred. Hematological donor chimerism was stable in the first, but slowly declining in the other two patients. A molecular microscope analysis in patient 2 revealed the genetic profile of a normal kidney. No relevant infections were observed, and the quality of life in all three patients is excellent. During the SARS-CoV-2 pandemic, all three patients were vaccinated with the mRNA vaccine BNT162b2 (Comirnaty®), and they showed excellent humoral and in 2 out 3 patients also cellular SARS-CoV-2-specific immunity. Thus, combined kidney and hematopoietic stem cell transplantation is a feasible and successful approach to induce specific immunological tolerance in the setting of HLA-matched sibling living kidney donation while maintaining immune responsiveness to an mRNA vaccine (ClinicalTrials.gov: NCT00365846).
Collapse
Affiliation(s)
- Thomas Fehr
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubuenden, Chur, Switzerland
- *Correspondence: Thomas Fehr,
| | - Kerstin Hübel
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Irene Abela
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Tayfun Güngör
- Division of Stem Cell Transplantation, University Children’s Hospital Zurich – Eleonore Foundation & Children`s Research Center (CRC), Zurich, Switzerland
| | - Mathias Hauri
- Division of Stem Cell Transplantation, University Children’s Hospital Zurich – Eleonore Foundation & Children`s Research Center (CRC), Zurich, Switzerland
| | - Birgit Helmchen
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Claudia Linsenmeier
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Müller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Jakob Nilsson
- Laboratory for Transplantation Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - John D. Scandling
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
| | - Urs Schanz
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Pietro E. Cippà
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| |
Collapse
|