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Lauener F, Schläpfer M, Mueller TF, Von Moos S, Janker S, Doswald S, Stark WJ, Beck-Schimmer B. Functionalized magnetic nanoparticles remove donor-specific antibodies (DSA) from patient blood in a first ex vivo proof of principle study. Sci Rep 2024; 14:15818. [PMID: 38982209 PMCID: PMC11233667 DOI: 10.1038/s41598-024-66876-3] [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: 12/24/2023] [Accepted: 07/04/2024] [Indexed: 07/11/2024] Open
Abstract
The presence of donor-specific antibodies (DSA) such as antibodies directed against donor class I human leucocyte antigen (e.g., HLA-A) is a major barrier to kidney transplant success. As a proof of concept, functionalized magnetic nanoparticles have been designed to eliminate DSA from saline, blood and plasma of healthy donors and sensitized patients. Specific HLA-A1 protein was covalently bound to functionalized cobalt nanoparticles (fNP), human serum albumin (HSA) as control. fNP were added to anti-HLA class I-spiked saline, spiked volunteers' whole blood, and to whole blood and plasma of sensitized patients ex vivo. Anti-HLA-A1 antibody levels were determined with Luminex technology. Antibodies' median fluorescent intensity (MFI) was defined as the primary outcome. Furthermore, the impact of fNP treatment on blood coagulation and cellular uptake was determined. Treatment with fNP reduced MFI by 97 ± 2% and by 94 ± 4% (p < 0.001 and p = 0.001) in spiked saline and whole blood, respectively. In six known sensitized anti-HLA-A1 positive patients, a reduction of 65 ± 26% (p = 0.002) in plasma and 65 ± 33% (p = 0.012) in whole blood was achieved. No impact on coagulation was observed. A minimal number of nanoparticles was detected in peripheral mononuclear blood cells. The study demonstrates-in a first step-the feasibility of anti-HLA antibody removal using fNP. These pilot data might pave the way for a new personalized DSA removal technology in the future.
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Affiliation(s)
- Francis Lauener
- Institute of Anesthesiology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland
- Institute of Physiology, University of Zurich (UZH), 8057, Zurich, Switzerland
| | - Martin Schläpfer
- Institute of Anesthesiology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland
- Institute of Physiology, University of Zurich (UZH), 8057, Zurich, Switzerland
| | - Thomas F Mueller
- Department of Nephrology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland
| | - Seraina Von Moos
- Department of Nephrology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland
| | - Stefanie Janker
- Institute of Anesthesiology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland
| | - Simon Doswald
- Functional Materials Laboratory, Swiss Federal Institute of Technology (ETH) Zurich, 8049, Zurich, Switzerland
| | - Wendelin J Stark
- Functional Materials Laboratory, Swiss Federal Institute of Technology (ETH) Zurich, 8049, Zurich, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Anesthesiology, University Hospital Zurich (USZ), University of Zurich (UZH), 8001, Zurich, Switzerland.
- Institute of Physiology, University of Zurich (UZH), 8057, Zurich, Switzerland.
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Ünal A, Leventoğlu E, Bakkaloğlu SA. Rituximab use in paediatric nephrology practice in Türkiye: TRTX. Nephrology (Carlton) 2024; 29:259-267. [PMID: 38113869 DOI: 10.1111/nep.14265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023]
Abstract
AIM Rituximab (RTX) is a genetically engineered chimeric monoclonal antibody which binds directly to CD20 antigen and mediates inhibition of B cell development. Although RTX has been widely used in paediatric nephrology, there is no routine protocol for its use. In this study, paediatric nephrologists in Türkiye were asked to fill out a questionnaire to understand their practice in using RTX. This study aimed to determine common practices and clarify the uncertainties regarding the use of RTX in paediatric nephrology. METHODS This was a nationwide, multicenter, retrospective cohort study based on data evaluating the use of RTX in paediatric nephrology practice. An online questionnaire was sent to all paediatric nephrology centers in Türkiye. The questionnaire forms included information about how many patients in total applied RTX treatment, for which indications they use RTX, and whether they made any preparations before using RTX. RESULTS According to this survey on RTX use in Türkiye, paediatric nephrologists use it most commonly in SSNS and followed by SRNS, ABMR, SLE and AAV, respectively. Dosing was highly standard but there is significant heterogeneity in pre-exposure tests and patient monitoring in the clinical practice of RTX. Also, the rate of encountering RTX-related allergic and infectious side effects at least once during the professional experience of our physicians can be quite high. CONCLUSION There is an increasing need for the preparation of a guideline on the indications for RTX use for each diagnosis, posology, and the practices to be performed before and after infusion.
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Affiliation(s)
- Ahmet Ünal
- Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Emre Leventoğlu
- Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
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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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Sazpinar O, Gaspert A, Sidler D, Rechsteiner M, Mueller TF. Histologic and Molecular Patterns in Responders and Non-responders With Chronic-Active Antibody-Mediated Rejection in Kidney Transplants. Front Med (Lausanne) 2022; 9:820085. [PMID: 35573002 PMCID: PMC9099145 DOI: 10.3389/fmed.2022.820085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThere is no proven therapy for chronic-active antibody-mediated rejection (caABMR), the major cause of late kidney allograft failure. Histological and molecular patterns associated with possible therapy responsiveness are not known.MethodsBased on rigorous selection criteria this single center, retrospective study identified 16 out of 1027 consecutive kidney transplant biopsies taken between 2008 and 2016 with pure, unquestionable caABMR, without other pathologic features. The change in estimated GFR pre- and post-biopsy/treatment were utilized to differentiate subjects into responders and non-responders. Gene sets reflecting active immune processes of caABMR were defined a priori, including endothelial, inflammatory, cellular, interferon gamma (IFNg) and calcineurin inhibitor (CNI) related-genes based on the literature. Transcript measurements were performed in RNA extracted from stored, formalin-fixed, paraffin-embedded (FFPE) samples using NanoString™ technology. Histology and gene expression patterns of responders and non-responders were compared.ResultsA reductionist approach applying very tight criteria to identify caABMR and treatment response excluded the vast majority of clinical ABMR cases. Only 16 out of 139 cases with a written diagnosis of chronic rejection fulfilled the caABMR criteria. Histological associations with therapy response included a lower peritubular capillaritis score (p = 0.028) along with less glomerulitis. In contrast, no single gene discriminated responders from non-responders. Activated genes associated with NK cells and endothelial cells suggested lack of treatment response.ConclusionIn caABMR active microvascular injury, in particular peritubular capillaritis, differentiates treatment responders from non-responders. Transcriptome changes in NK cell and endothelial cell associated genes may further help to identify treatment response. Future prospective studies will be needed which include more subjects, who receive standardized treatment protocols to identify biomarkers for treatment response.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT03430414].
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Affiliation(s)
- Onur Sazpinar
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, University Hospital Bern, Bern, Switzerland
| | - Markus Rechsteiner
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zurich, Switzerland
| | - Thomas F. Mueller
- Clinic of Nephrology, Department of Medicine, University Hospital Zürich, Zurich, Switzerland
- *Correspondence: Thomas F. Mueller,
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Yopes M, Fanek T, Fuselier B, Gaine M, Jackson R, Mabasa A, Kim A, Jennings DL, Clerkin K, Yuzefpolskaya M, Habal M, Latif F, Restaino S, Lee SH, Farr M, Colombo P, Sayer G, Uriel N. Chronic intermittent intravenous immunoglobulin in heart transplant recipients with elevated donor-specific antibody levels. Clin Transplant 2021; 36:e14524. [PMID: 34705286 DOI: 10.1111/ctr.14524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022]
Abstract
Donor-specific antibodies (DSA) are associated with antibody-mediated rejection (AMR) and poor patient survival. In heart transplant, the efficacy of intermittent intravenous immunoglobulin (IVIg) in reducing de novo DSA levels and treating AMR has not been characterized. We retrospectively studied a cohort of 19 patients receiving intermittent IVIg for elevated DSA and examined changes in DSA levels and graft function. Intermittent IVIg infusions were generally safe and well tolerated. Overall, 23 of 62 total DSA (37%) were undetectable after treatment, 21 DSA (34%) had MFI decrease by more than 25%, and 18 (29%) had MFI decrease by less than 25% or increase. The average change in MFI was -51% ± 71% (P < .001). Despite reductions in DSA, among the six patients (32%) with biopsy-confirmed AMR, left ventricular ejection fraction (LVEF) decreased in five (83%) and cardiac index (CI) decreased in three (50%). Conversely, LVEF increased in 91% and CI increased in 70% of biopsy-negative patients. All six AMR patients were readmitted during treatment, four for confirmed or suspected rejection. IVIg infusions may stabilize the allograft in patients with elevated DSA and negative biopsies, but once AMR has developed does not appear to improve allograft function despite decreasing DSA levels.
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Affiliation(s)
- Margot Yopes
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Tala Fanek
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Byron Fuselier
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Maureen Gaine
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ruslana Jackson
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Angelo Mabasa
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea Kim
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin Clerkin
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Marlena Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Farhana Latif
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Restaino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sun Hi Lee
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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Gregorini M, Del Fante C, Pattonieri EF, Avanzini MA, Grignano MA, Cassaniti I, Baldanti F, Comolli G, Nocco A, Ramondetta M, Viarengo G, Sepe V, Libetta C, Klersy C, Perotti C, Rampino T. Photopheresis Abates the Anti-HLA Antibody Titer and Renal Failure Progression in Chronic Antibody-Mediated Rejection. BIOLOGY 2021; 10:biology10060547. [PMID: 34207225 PMCID: PMC8234140 DOI: 10.3390/biology10060547] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 12/28/2022]
Abstract
Simple Summary The most common cause of late allograft failure is chronic active antibody-mediated rejection (ABMR), but no effective therapy is available. Different immunosuppressive drugs in combination with procedures that remove serum antibodies have been used and the results have not shown to improve graft and patient outcome, but only an increased risk of adverse events. Extracorporeal pho-topheresis (ECP) is leukapheresis-based immunomodulatory therapy not associated with adverse effect, in which lymphocytes treat-ed with 8-methoxypsoralen (8-MOP) are irradiated with ultraviolet-A (UVA) ex vivo and re-infused into the patient. In this study we investigated therapeutic long-term effect of ECP in patients with biopsy proved chronic ABMR. Abstract Objective: Chronic renal antibody-mediated rejection (ABMR) is a common cause of allograft failure, but an effective therapy is not available. Extracorporeal photopheresis (ECP) has been proven successful in chronic lung and heart rejection, and graft versus host disease. The aim of this study was to evaluate the effectiveness of ECP in chronic ABMR patients. Patients and Methods: We investigated ECP treatment in 14 patients with biopsy-proven chronic ABMR and stage 2–3 chronic renal failure. The primary aim was to e valuate the eGFR lowering after 1 year of ECP therapy. The ECP responders (R) showed eGFR reduction greater than 20% vs the basal levels. We also evaluated the effectiveness of ECP on proteinuria, anti-HLA antibodies (HLAab), interleukin 6 (IL-6) serum levels, and CD3, CD4, CD8, CD19, NK, Treg and T helper 17 (Th17) circulating cells. Results: Three patients dropped out of the study. The R patients were eight (72.7%) out of the 11 remaining patients. Because ECP was not associated with any adverse reaction, the R patients continued such treatment for up to 3 years, showing a persisting eGFR stabilization. Twenty four hour proteinuria did not increase in the R patients over the follow-up when compared to the non-responder patients (NR). In the R patients, the HLAab levels were reduced and completely cleared in six out of eight patients when compared with the NR patients. The NR HLAab levels also increased after the discontinuation of the ECP. The ECP in the R patients showed a decrease in CD3, CD4, CD8, CD19, and NK circulating cells. The ECP treatment in the R patients also induced Tregs and Th17 cell increases, and a decrease of the IL-6 serum levels. Conclusions: ECP abates the HLAab titer and renal failure progression in patients with chronic renal ABMR, modulating the immune cellular and humoral responses.
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Affiliation(s)
- Marilena Gregorini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy;
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
- Correspondence: ; Tel.: +39-0382-502591; Fax: +39-0382-503666
| | - Claudia Del Fante
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Eleonora Francesca Pattonieri
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Maria Antonietta Avanzini
- Immunology and Transplantation Laboratory, Cell Factory, Pediatric Hematology Oncology, Fondazione IRCCS Policlinico S. Matteo, 27100 Pavia, Italy;
| | - Maria Antonietta Grignano
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Irene Cassaniti
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
| | - Fausto Baldanti
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Giuditta Comolli
- Molecular Virology Unit, Department of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.C.); (F.B.); (G.C.)
- Experimental Research Laboratories, Biotechnology Area, Fondazione IRCCS Policlinico S. Matteo, 27100 Pavia, Italy
| | - Angela Nocco
- Laboratory of Transplant Immunology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.N.); (M.R.)
| | - Miriam Ramondetta
- Laboratory of Transplant Immunology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, 20122 Milano, Italy; (A.N.); (M.R.)
| | - Gianluca Viarengo
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Vincenzo Sepe
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Carmelo Libetta
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy;
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Cesare Perotti
- Immunohematology and Transfusion Service, IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (C.D.F.); (G.V.); (C.P.)
| | - Teresa Rampino
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (E.F.P.); (M.A.G.); (V.S.); (T.R.)
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Bhargava R, Maeda K, Tsokos MG, Pavlakis M, Stillman IE, Tsokos GC. N-glycosylated IgG in patients with kidney transplants increases calcium/calmodulin kinase IV in podocytes and causes injury. Am J Transplant 2021; 21:148-160. [PMID: 32531122 PMCID: PMC8188503 DOI: 10.1111/ajt.16140] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 01/25/2023]
Abstract
Transplant glomerulopathy (TG) is a major cause of late allograft loss. Increased urine podocin/creatinine ratio in TG signifies accelerated podocyte loss. The mechanisms that lead to podocyte injury in TG remain unclear. We report that IgG from kidney transplant recipients with TG, but not from those without TG, cause a reduction in the expression of nephrin, significant podocyte actin cytoskeleton, and motility changes. These changes are preceded by increased expression of calcium/calmodulin kinase IV (CAMK4). Mechanistically, we found that CAMK4 phosphorylates GSK3β (glycogen synthase kinase 3 beta), activates the Wnt pathway and stabilizes the nephrin transcriptional repressor SNAIL. Silencing neonatal Fc Receptor (FcRn) or CAMK4 prevented the podocyte-damaging effects of IgG from patients with TG. Furthermore, we show that removal of N-linked glycosyl residues from these IgG did not interfere with its entry into the podocytes but eliminated its ability to upregulate CAMK4 and cause podocyte injury. The translational value of these findings is signified by the fact that CAMK4 is increased in podocytes of patients with TG but not in those without TG despite other forms of renal dysfunction. Our results offer novel considerations to limit podocyte injury in patients with kidney transplants, which may lead to eventual glomerular destabilization and transplant glomerulopathy.
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Affiliation(s)
- Rhea Bhargava
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kayaho Maeda
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maria G. Tsokos
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Isaac E. Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - George C. Tsokos
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Lavacca A, Presta R, Gai C, Mella A, Gallo E, Camussi G, Abbasciano I, Barreca A, Caorsi C, Fop F, Messina M, Rossetti M, Biancone L. Early effects of first-line treatment with anti-interleukin-6 receptor antibody tocilizumab for chronic active antibody-mediated rejection in kidney transplantation. Clin Transplant 2020; 34:e13908. [PMID: 32415711 DOI: 10.1111/ctr.13908] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/09/2020] [Accepted: 05/09/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Chronic active antibody-mediated rejection (cAMR) is a major determinant of late allograft failure. Rituximab/immunoglobulins (IVIg) + plasma exchange (PLEX) showed controversial results in cAMR treatment. Tocilizumab (TCZ), a humanized anti-interleukin 6 receptor antibody, has been recently used as rescue therapy in patients non-responsive to rituximab/IVIg/PLEX with favorable outcomes. Whether TCZ acts "per se" or requires a priming effect from previous treatments is currently unknown. METHODS Fifteen patients with cAMR were treated with TCZ as a first-line therapy and followed for a median time of 20.7 months. RESULTS Despite the majority of patients experiencing advanced transplant glomerulopathy (TG) at diagnosis (60% with cg3), glomerular filtration rate and proteinuria stabilized during the follow-up, with a significant reduction in donor-specific antibodies. Protocol biopsies after 6 months demonstrated significant amelioration of microvascular inflammation and no TG, C4d deposition, or IF/TA progression. Gene-expression and immunofluorescence analysis showed upregulation of three genes (TJP-1, AKR1C3, and CASK) involved in podocyte, mesangial, and tubular restoration. CONCLUSION Tocilizumab adopted as a first-line approach in cAMR was associated with early serological and histological improvements and functional stabilization even in advanced TG, suggesting a role for the use of TCZ alone with the avoidance of unnecessary previous immunosuppressants.
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Affiliation(s)
- Antonio Lavacca
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Roberto Presta
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Chiara Gai
- Stem Cell Laboratory, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Mella
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Ester Gallo
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Giovanni Camussi
- Stem Cell Laboratory, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Isabella Abbasciano
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Cristiana Caorsi
- Department of Medical Sciences, Immunogenetic and Transplant Biology Center, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Maria Messina
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Maura Rossetti
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
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9
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Shiu KY, Stringer D, McLaughlin L, Shaw O, Brookes P, Burton H, Wilkinson H, Douthwaite H, Tsui TL, Mclean A, Hilton R, Griffin S, Geddes C, Ball S, Baker R, Roufosse C, Horsfield C, Dorling A. Effect of Optimized Immunosuppression (Including Rituximab) on Anti-Donor Alloresponses in Patients With Chronically Rejecting Renal Allografts. Front Immunol 2020; 11:79. [PMID: 32117242 PMCID: PMC7012933 DOI: 10.3389/fimmu.2020.00079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/13/2020] [Indexed: 12/22/2022] Open
Abstract
RituxiCAN-C4 combined an open-labeled randomized controlled trial (RCT) in 7 UK centers to assess whether rituximab could stabilize kidney function in patients with chronic rejection, with an exploratory analysis of how B cell-depletion influenced T cell anti-donor responses relative to outcome. Between January 2007 and March 2015, 59 recruits were enrolled after screening, 23 of whom consented to the embedded RCT. Recruitment was halted when in a pre-specified per protocol interim analysis, the RCT was discovered to be significantly underpowered. This report therefore focuses on the exploratory analysis, in which we confirmed that when B cells promoted CD4+ anti-donor IFNγ production assessed by ELISPOT, this associated with inferior clinical outcome; these patterns were inhibited by optimized immunosuppression but not rituximab. B cell suppression of IFNγ production, which associated with number of transitional B cells and correlated with slower declines in kidney function was abolished by rituximab, which depleted transitional B cells for prolonged periods. We conclude that in this patient population, optimized immunosuppression but not rituximab promotes anti-donor alloresponses associated with favorable outcomes. Clinical Trial Registration: Registered with EudraCT (2006-002330-38) and www.ClinicalTrials.gov, identifier: NCT00476164.
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Affiliation(s)
- Kin Yee Shiu
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Dominic Stringer
- Biostatistics and Health Informatics, The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Laura McLaughlin
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Olivia Shaw
- Viapath Analytics LLP, London, United Kingdom
| | - Paul Brookes
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hannah Burton
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Hannah Wilkinson
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Harriet Douthwaite
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Tjir-Li Tsui
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
| | - Adam Mclean
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rachel Hilton
- Department of Nephrology and Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sian Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, United Kingdom
| | - Colin Geddes
- Renal Unit, Western Infirmary, NHS Greater Glasgow and Clyde Trust, Glasgow, United Kingdom
| | - Simon Ball
- Department of Nephrology, University Hospital Birmingham, Birmingham, United Kingdom
| | - Richard Baker
- Renal Unit, St. James's University Hospital, Leeds, United Kingdom
| | - Candice Roufosse
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Catherine Horsfield
- Department of Histopathology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Anthony Dorling
- Department of Inflammation Biology, MRC Centre for Transplantation, Guy's Hospital, King's College London, London, United Kingdom
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10
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Nair P, Gheith O, Al-Otaibi T, Mostafa M, Rida S, Sobhy I, Halim MA, Mahmoud T, Abdul-Hameed M, Maher A, Emam M. Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Recipients: Single-Center Experience. EXP CLIN TRANSPLANT 2019; 17:113-119. [PMID: 30777534 DOI: 10.6002/ect.mesot2018.o58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Data on the management of chronic antibody-mediated rejection after kidney transplantation are limited. We aimed to assess the impact of treatment of biopsy-proven chronic active antibodymediated rejection with combined plasma exchange, intravenous immunoglobulin, and rituximab treatment versus intravenous immunoglobulin alone or conservative management on the evolution of renal function in renal transplant recipients. MATERIALS AND METHODS In this retrospective study, we compared patients diagnosed with chronic active antibody-mediated rejection who were treated with standard of care steroids, intravenous immunoglobulin, plasma exchange, and rituximab (n = 40) at our center versus those who received intravenous immunoglobulin only or just intensified maintenance immunosuppression (n = 28). All patients were followed for 12 months clinically and by laboratory tests for graft and patient outcomes. RESULTS The two groups were matched regarding mean recipient age (41.9 ± 15.4 vs 37.8 ± 15.5 y in patients with conservative versus combined treatment), recipient sex, mean body weight, and the cause of end-stage kidney disease. Most patients and their donors were males. Glomerulonephritis represented the most common cause of end-stage kidney disease in both groups followed by diabetic nephropathy. The type of induction and pretransplant comorbidities were not different between groups (P > .05) except for the significantly higher number of chronic hepatitis C infections in patients who received conservative treatment (P = .007). Mean serum creatinine values before and after treatment of chronic active antibodymediated rejection were comparable between groups (P > .05). Active treatment with heavier immunosuppression (rituximab and plasma exchange) was associated with posttreatment viral (cytomegalovirus and BK virus) and bacterial infections that necessitated more hospitalization (P > .05). However, graft and patient outcomes were significantly better in the active treatment group than in patients with conservative treatment (P = .002 and .028, respectively). CONCLUSIONS Combined treatment of chronic active antibody-mediated rejection with plasma exchange, intravenous immunoglobulin, and rituximab can significantly improve outcomes after renal transplant.
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Affiliation(s)
- Prasad Nair
- From the Kuwait Ministry of Health, Hamed Al-Essa Organ Transplant Center, Sabah area, Kuwait
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11
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Böhmig GA, Eskandary F, Doberer K, Halloran PF. The therapeutic challenge of late antibody-mediated kidney allograft rejection. Transpl Int 2019; 32:775-788. [PMID: 30955215 PMCID: PMC6850109 DOI: 10.1111/tri.13436] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/06/2019] [Accepted: 04/01/2019] [Indexed: 01/01/2023]
Abstract
Late antibody‐mediated rejection (ABMR) is a cardinal cause of kidney allograft failure, manifesting as a continuous and, in contrast with early rejection, often clinically silent alloimmune process. While significant progress has been made towards an improved understanding of its molecular mechanisms and the definition of diagnostic criteria, there is still no approved effective treatment. In recent small randomized controlled trials, therapeutic strategies with promising results in observational studies, such as proteasome inhibitor bortezomib, anti‐C5 antibody eculizumab, or high dose intravenous immunoglobulin plus rituximab, had no significant impact in late and/or chronic ABMR. Such disappointing results reinforce a need of new innovative treatment strategies. Potential candidates may be the interference with interleukin‐6 to modulate B cell alloimmunity, or innovative compounds that specifically target antibody‐producing plasma cells, such as antibodies against CD38. Given the phenotypic heterogeneity of ABMR, the design of adequate systematic trials to assess the safety and efficiency of such therapies, however, is challenging. Several trials are currently being conducted, and new developments will hopefully provide us with effective ways to counteract the deleterious impact of antibody‐mediated graft injury. Meanwhile, the weight of evidence would suggest that, when approaching using existing treatments for established antibody‐mediated rejection, “less may be more”.
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Affiliation(s)
- Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre (ATAGC), University of Alberta, Edmonton, AB, Canada
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12
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Timofeeva OA. Donor-Specific HLA Antibodies as Biomarkers of Transplant Rejection. Clin Lab Med 2019; 39:45-60. [DOI: 10.1016/j.cll.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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13
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Eskandary F, Dürr M, Budde K, Doberer K, Reindl-Schwaighofer R, Waiser J, Wahrmann M, Regele H, Spittler A, Lachmann N, Firbas C, Mühlbacher J, Bond G, Halloran PF, Chong E, Jilma B, Böhmig GA. Clazakizumab in late antibody-mediated rejection: study protocol of a randomized controlled pilot trial. Trials 2019; 20:37. [PMID: 30635033 PMCID: PMC6329051 DOI: 10.1186/s13063-018-3158-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 12/22/2018] [Indexed: 01/23/2023] Open
Abstract
Background Late antibody-mediated rejection (ABMR) triggered by donor-specific antibodies (DSA) is a cardinal cause of kidney allograft dysfunction and loss. Diagnostic criteria for this rejection type are well established, but effective treatment remains a major challenge. Recent randomized controlled trials (RCT) have failed to demonstrate the efficacy of widely used therapies, such as rituximab plus intravenous immunoglobulin or proteasome inhibition (bortezomib), reinforcing a great need for new therapeutic concepts. One promising target in this context may be interleukin-6 (IL-6), a pleiotropic cytokine known to play an important role in inflammation and adaptive immunity. Methods This investigator-driven RCT was designed to assess the safety and efficacy of clazakizumab, a genetically engineered humanized monoclonal antibody directed against IL-6. The study will include 20 DSA-positive kidney allograft recipients diagnosed with ABMR ≥ 365 days after transplantation. Participants will be recruited at two study sites in Austria and Germany (Medical University of Vienna; Charité University Medicine Berlin). First, patients will enter a three-month double-blind RCT (1,1 randomization, stratification according to ABMR phenotype and study site) and will receive either clazakizumab (subcutaneous administration of 25 mg in monthly intervals) or placebo. In a second open-label part of the trial (months 4–12), all patients will receive clazakizumab at 25 mg every month. The primary endpoint is safety and tolerability. Secondary endpoints are the pharmacokinetics and pharmacodynamics of clazakizumab, its effect on drug metabolism in the liver, DSA characteristics, morphological ABMR lesions and molecular gene expression patterns in three- and 12-month protocol biopsies, serum/urinary biomarkers of inflammation and endothelial activation/injury, Torque Teno viral load as a measure of overall immunosuppression, kidney function, urinary protein excretion, as well as transplant and patient survival. Discussion Currently, there is no treatment proven to be effective in halting the progression of late ABMR. Based on the hypothesis that antagonizing the effects of IL-6 improves the outcome of DSA-positive late ABMR by counteracting DSA-triggered inflammation and B cell/plasma cell-driven alloimmunity, we suggest that our trial has the potential to provide proof of concept of a novel treatment of this type of rejection. Trial registration ClinicalTrials.gov, NCT03444103. Registered on 23 February 2018 (retrospective registration). Electronic supplementary material The online version of this article (10.1186/s13063-018-3158-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Michael Dürr
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Johannes Waiser
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Heinz Regele
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Andreas Spittler
- Core Facility Flow Cytometry, Medical University of Vienna, Vienna, Austria
| | - Nils Lachmann
- Centre for Tumor Medicine, H&I Laboratory, Charité University Medicine Berlin, Berlin, Germany
| | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Jakob Mühlbacher
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Philipp F Halloran
- Alberta Transplant Applied Genomics Centre, Faculty of Medicine & Dentistry, #250 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
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14
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Piñeiro GJ, De Sousa-Amorim E, Solé M, Ríos J, Lozano M, Cofán F, Ventura-Aguiar P, Cucchiari D, Revuelta I, Cid J, Palou E, Campistol JM, Oppenheimer F, Rovira J, Diekmann F. Rituximab, plasma exchange and immunoglobulins: an ineffective treatment for chronic active antibody-mediated rejection. BMC Nephrol 2018; 19:261. [PMID: 30309322 PMCID: PMC6182805 DOI: 10.1186/s12882-018-1057-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/24/2018] [Indexed: 12/20/2022] Open
Abstract
Background Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants. Methods To determine the efficacy and safety of combined therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF’17 classification, was identified. Results We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively. Conclusions Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications. Trial registration Agencia Española de Medicametos y Productos Sanitarios (AEMPS): 14566/RG 24161. Study code: UTR-INM-2017-01. Electronic supplementary material The online version of this article (10.1186/s12882-018-1057-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gastón J Piñeiro
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - Erika De Sousa-Amorim
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Manel Solé
- Department of Pathology, Hospital Clinic, Barcelona, Spain
| | - José Ríos
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Frederic Cofán
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Pedro Ventura-Aguiar
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - David Cucchiari
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - Ignacio Revuelta
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Eduard Palou
- Department of Immunology, Hospital Clinic, Barcelona, Spain
| | - Josep M Campistol
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Federico Oppenheimer
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain. .,Red de Investigación Renal (REDinREN), Madrid, Spain.
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain. .,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain. .,Red de Investigación Renal (REDinREN), Madrid, Spain.
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15
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Mella A, Gallo E, Messina M, Caorsi C, Amoroso A, Gontero P, Verri A, Maletta F, Barreca A, Fop F, Biancone L. Treatment with plasmapheresis, immunoglobulins and rituximab for chronic-active antibody-mediated rejection in kidney transplantation: Clinical, immunological and pathological results. World J Transplant 2018; 8:178-187. [PMID: 30211026 PMCID: PMC6134268 DOI: 10.5500/wjt.v8.i5.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/14/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the role of a therapeutic regimen with plasma exchange, intravenous immunoglobulins and rituximab in chronic-active antibody-mediated rejection (cAMR) settings.
METHODS We compared 21 kidney transplant recipients (KTRs) with a diagnosis of cAMR in a retrospective case-control analysis: nine KTRs treated with plasmapheresis, intravenous immunoglobulins and rituximab (PE-IVIG-RTX group) vs 12 patients (control group) not treated with antibody-targeted therapies. We examined kidney survival and functional outcomes 24 mo after diagnosis. Histological features and donor-specific antibody (DSA) characteristics (MFI and C1q-fixing ability) were also investigated.
RESULTS No difference in graft survival between the two groups was noted: three out of nine patients in the PE-IVIG-RTX group (33.3%) and 4/12 in the control group (33.3%) experienced loss of allograft function at a median time after diagnosis of 14 mo (min 12-max 18) and 15 mo (min 7-max 22), respectively. Kidney functional tests and proteinuria 24 mo after cAMR diagnosis were also similar in both groups. Only microvascular inflammation (glomerulitis + peritubular capillaritis score) was significantly reduced after PE-IVIG-RTX in seven out of eight patients (87.5%) in the PE-IVIG-RTX group (median score 3 in pre-treatment biopsy vs 1.5 in post-treatment biopsy; P = 0.047), without any impact on kidney survival and/or DSA characteristics. No functional or histological parameter at diagnosis was predictive of clinical outcome.
CONCLUSION Our data showed no difference in the two year post-treatment outcome of kidney grafts treated with PE-IVIG-RTX for cAMR diagnosis, however there were notable improvements in microvascular inflammation in post-therapy protocol biopsies. Further studies, especially involving innovative therapeutic approaches, are required to improve the management and long-term results of this severe condition.
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Affiliation(s)
- Alberto Mella
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Ester Gallo
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Maria Messina
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Cristiana Caorsi
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Antonio Amoroso
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Aldo Verri
- Division of Vascular Surgery, Department of Thoracic-Vascular Surgery, Città della Salute e della Scienza Hospital, Turin 10126, Italy
| | - Francesca Maletta
- Division of Pathology Transplantation, Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Antonella Barreca
- Division of Pathology Transplantation, Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Fabrizio Fop
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Luigi Biancone
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
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16
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Cioni M, Nocera A, Tagliamacco A, Basso S, Innocente A, Fontana I, Magnasco A, Trivelli A, Klersy C, Gurrado A, Ramondetta M, Boghen S, Catenacci L, Verrina E, Garibotto G, Ghiggeri GM, Cardillo M, Ginevri F, Comoli P. Failure to remove de novo donor-specific HLA antibodies is influenced by antibody properties and identifies kidney recipients with late antibody-mediated rejection destined to graft loss - a retrospective study. Transpl Int 2018; 32:38-48. [PMID: 30076765 DOI: 10.1111/tri.13325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 12/15/2022]
Abstract
Current research is focusing on identifying bioclinical parameters for risk stratification of renal allograft loss, largely due to antibody-mediated rejection (AMR). We retrospectively investigated graft outcome predictors in 24 unsensitized pediatric kidney recipients developing HLA de novo donor-specific antibodies (dnDSAs), and treated for late AMR with plasmapheresis + low-dose IVIG + Rituximab or high-dose IVIG + Rituximab. Renal function and DSA properties were assessed before and longitudinally post treatment. The estimated GFR (eGFR) decline after treatment was dependent on a negative % eGFR variation in the year preceding treatment (P = 0.021) but not on eGFR at treatment (P = 0.74). At a median follow-up of 36 months from AMR diagnosis, 10 patients lost their graft. Altered eGFR (P < 0.001) and presence of C3d-binding DSAs (P = 0.005) at treatment, and failure to remove DSAs (P = 0.01) were negatively associated with graft survival in the univariable analysis. Given the relevance of DSA removal for therapeutic success, we analyzed antibody properties dictating resistance to anti-humoral treatment. In the multivariable analysis, C3d-binding ability (P < 0.05), but not C1q-binding, and high mean fluorescence intensity (P < 0.05) were independent factors characterizing DSAs scarcely susceptible to removal. The poor prognosis of late AMR is related to deterioration of graft function prior to treatment and failure to remove C3d binding and/or high-MFI DSAs.
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Affiliation(s)
- Michela Cioni
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Arcangelo Nocera
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Augusto Tagliamacco
- Clinical Nephrology Unit and Transplant Coordination Unit, Policlinico San Martino, Genova, Italy
| | - Sabrina Basso
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Annalisa Innocente
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Iris Fontana
- Vascular and Endovascular Unit and Kidney Transplant Surgery Unit, Policlinico San Martino, Genova, Italy
| | - Alberto Magnasco
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Antonella Trivelli
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Catherine Klersy
- Biometry and Statistics Service, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Antonella Gurrado
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Miriam Ramondetta
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Stella Boghen
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Laura Catenacci
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Enrico Verrina
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giacomo Garibotto
- Clinical Nephrology Unit, University of Genova and Policlinico San Martino, Genova, Italy
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Massimo Cardillo
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Fabrizio Ginevri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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17
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Khalil MAM, Khalil MAU, Khan TFT, Tan J. Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians. J Transplant 2018; 2018:9429265. [PMID: 30155279 PMCID: PMC6093016 DOI: 10.1155/2018/9429265] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 06/04/2018] [Accepted: 06/25/2018] [Indexed: 12/14/2022] Open
Abstract
Drug-induced hematological cytopenia is common in kidney transplantation. Various cytopenia including leucopenia (neutropenia), thrombocytopenia, and anemia can occur in kidney transplant recipients. Persistent severe leucopenia or neutropenia can lead to opportunistic infections of various etiologies. On the contrary, reducing or stopping immunosuppressive medications in these events can provoke a rejection. Transplant clinicians are often faced with the delicate dilemma of balancing cytopenia and rejection from adjustments of immunosuppressive regimen. Differentials of drug-induced cytopenia are wide. Identification of culprit medication and subsequent modification is also challenging. In this review, we will discuss individual drug implicated in causing cytopenia and correlate it with corresponding literature evidence.
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Affiliation(s)
| | | | - Taqi F. Taufeeq Khan
- King Salman Armed Forces Hospital, Tabuk King Abdul Aziz Rd., Tabuk 47512, Saudi Arabia
| | - Jackson Tan
- RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
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18
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Moreso F, Crespo M, Ruiz JC, Torres A, Gutierrez-Dalmau A, Osuna A, Perelló M, Pascual J, Torres IB, Redondo-Pachón D, Rodrigo E, Lopez-Hoyos M, Seron D. Treatment of chronic antibody mediated rejection with intravenous immunoglobulins and rituximab: A multicenter, prospective, randomized, double-blind clinical trial. Am J Transplant 2018; 18:927-935. [PMID: 28949089 DOI: 10.1111/ajt.14520] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 09/13/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
There are no approved treatments for chronic antibody mediated rejection (ABMR). We conducted a multicenter, prospective, randomized, placebo-controlled, double-blind clinical trial to evaluate efficacy and safety of intravenous immunoglobulins (IVIG) combined with rituximab (RTX) (EudraCT 2010-023746-67). Patients with transplant glomerulopathy and anti-HLA donor-specific antibodies (DSA) were eligible. Patients with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73m2 and/or severe interstitial fibrosis/tubular atrophy were excluded. Patients were randomized to receive IVIG (4 doses of 0.5 g/kg) and RTX (375 mg/m2 ) or a wrapped isovolumetric saline infusion. Primary efficacy variable was the decline of eGFR at one year. Secondary efficacy variables included evolution of proteinuria, renal lesions, and DSA at 1 year. The planned sample size was 25 patients per group. During 2012-2015, 25 patients were randomized (13 to the treatment and 12 to the placebo group). The planned patient enrollment was not achieved because of budgetary constraints and slow patient recruitment. There were no differences between the treatment and placebo groups in eGFR decline (-4.2 ± 14.4 vs. -6.6 ± 12.0 mL/min per 1.73 m2 , P-value = .475), increase of proteinuria (+0.9 ± 2.1 vs. +0.9 ± 2.1 g/day, P-value = .378), Banff scores at one year and MFI of the immunodominant DSA. Safety was similar between groups. These data suggest that the combination of IVIG and RTX is not useful in patients displaying transplant glomerulopathy and DSA.
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Affiliation(s)
- Francesc Moreso
- Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Juan C Ruiz
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, La Laguna, Spain
| | | | - Antonio Osuna
- Nephrology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Manel Perelló
- Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Irina B Torres
- Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Marcos Lopez-Hoyos
- Immunology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Daniel Seron
- Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Guerra MAR, Naini BV, Scapa JV, Reed EF, Busuttil RW, Cheng EY, Farmer DG, Vargas JH, Venick RS, McDiarmid SV, Wozniak LJ. Obliterative portal venopathy: A histopathologic finding associated with chronic antibody-mediated rejection in pediatric liver allografts. Pediatr Transplant 2018; 22. [PMID: 29363222 DOI: 10.1111/petr.13124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 12/11/2022]
Abstract
The significance of post-transplant HLA DSA and chronic AMR in LT is an emerging field of study. Although OPV has previously been described as a histopathologic finding in DSA-positive adult LT recipients, it was not included in the recent Banff criteria for chronic AMR. Our aim was to describe the association between OPV and chronic AMR in pediatric LT recipients. A retrospective review of 67 liver biopsies performed between November 2014 and April 2016 in 45 pediatric LT recipients identified four patients with OPV. Clinical status, liver biochemistry, the presence of DSA, and available non-HLA antibody testing, as well as histopathologic features of chronic AMR, were assessed. All four patients with OPV had class II DSA and histopathologic features of chronic AMR based on the Banff criteria. Two patients were noted to have non-HLA antibodies. Three patients are undergoing treatment with IVIG but have persistent DSA. Two patients have graft failure and are awaiting retransplantation. In conclusion, OPV is a histopathologic finding associated with chronic AMR in pediatric LT recipients. Further studies are needed to elucidate whether OPV is reversible and/or amenable to medical therapy.
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Affiliation(s)
- Marjorie-Anne R Guerra
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Bita V Naini
- Pathology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jason V Scapa
- Pathology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elaine F Reed
- Pathology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Transplant Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elaine Y Cheng
- Transplant Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Douglas G Farmer
- Transplant Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jorge H Vargas
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert S Venick
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,Transplant Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sue V McDiarmid
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,Transplant Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Laura J Wozniak
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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20
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Reflections on the usefulness of extracorporeal photopheresis in renal transplant rejection: A concise review of the involved mechanisms and therapeutic perspectives. Transfus Apher Sci 2018; 57:115-117. [PMID: 29477942 DOI: 10.1016/j.transci.2018.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal rejection clinically represents a major cause of graft dysfunction and sadly the loss of the renal transplant. This is despite the considerable progress in immunosuppressive therapy. It is strongly believed that the complex immunologic network underlying the response against major histocompatibility molecules (MHC) is responsible for rejection, an unresolved issue that is, in part, not inhibited by the current prophylactic and therapeutic strategies. Extracorporeal photopheresis (ECP) is an effective cell therapy approach that was successfully used in immunomodulating heart rejection, acute and chronic GvHD, lung rejection and some selected autoimmune diseases. In this concise report we provide a brief review on the mechanisms of action and the use of ECP in acute and chronic renal allograft rejection.
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21
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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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22
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Regulatory B cells: the cutting edge of immune tolerance in kidney transplantation. Cell Death Dis 2018; 9:109. [PMID: 29371592 PMCID: PMC5833552 DOI: 10.1038/s41419-017-0152-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 12/20/2022]
Abstract
Kidney transplantation is the optimal treatment for end-stage renal diseases. Although great improvement has been achieved, immune tolerance is still the Holy Grail that every organ transplant practitioner pursues. The role of B cells in transplantation has long been considered simply to serve as precursors of plasma cells, which produce alloantibodies and induce antibody-mediated rejection. Recent research indicates that a specialized subset of B cells plays an important role in immune regulation, which has been well demonstrated in autoimmune diseases, infections, and cancers. This category of regulatory B cells (Bregs) differs from conventional B cells, and they may help develop a novel immunomodulatory therapeutic strategy to achieve immune tolerance in transplantation. Here, we review the latest evidence regarding phenotypes, functions, and effectors of Bregs and discuss their diverse effects on kidney transplantation.
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Chu Z, Zou W, Xu Y, Sun Q, Zhao Y. The regulatory roles of B cell subsets in transplantation. Expert Rev Clin Immunol 2018; 14:115-125. [PMID: 29338551 DOI: 10.1080/1744666x.2018.1426461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Zhulang Chu
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Department of Pathology, Beijing University of Chinese Medicine, Beijing, China
| | - Weilong Zou
- Surgery of Transplant and Hepatopancrobiliary, The General Hospital of Chinese People’s Armed Police Forces, Beijing, China
| | - Yanan Xu
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
| | - Qiquan Sun
- Department of Renal Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yong Zhao
- State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
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24
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Abstract
Donor-specific antibodies have become an established biomarker predicting antibody-mediated rejection. Antibody-mediated rejection is the leading cause of graft loss after kidney transplant. There are several phenotypes of antibody-mediated rejection along post-transplant course that are determined by the timing and extent of humoral response and the various characteristics of donor-specific antibodies, such as antigen classes, specificity, antibody strength, IgG subclasses, and complement binding capacity. Preformed donor-specific antibodies in sensitized patients can trigger hyperacute rejection, accelerated acute rejection, and early acute antibody-mediated rejection. De novo donor-specific antibodies are associated with late acute antibody-mediated rejection, chronic antibody-mediated rejection, and transplant glomerulopathy. The pathogeneses of antibody-mediated rejection include not only complement-dependent cytotoxicity, but also complement-independent pathways of antibody-mediated cellular cytotoxicity and direct endothelial activation and proliferation. The novel assay for complement binding capacity has improved our ability to predict antibody-mediated rejection phenotypes. C1q binding donor-specific antibodies are closely associated with acute antibody-mediated rejection, more severe graft injuries, and early graft failure, whereas C1q nonbinding donor-specific antibodies correlate with subclinical or chronic antibody-mediated rejection and late graft loss. IgG subclasses have various abilities to activate complement and recruit effector cells through the Fc receptor. Complement binding IgG3 donor-specific antibodies are frequently associated with acute antibody-mediated rejection and severe graft injury, whereas noncomplement binding IgG4 donor-specific antibodies are more correlated with subclinical or chronic antibody-mediated rejection and transplant glomerulopathy. Our in-depth knowledge of complex characteristics of donor-specific antibodies can stratify the patient's immunologic risk, can predict distinct phenotypes of antibody-mediated rejection, and hopefully, will guide our clinical practice to improve the transplant outcomes.
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Affiliation(s)
- Rubin Zhang
- Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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25
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[THE USE OF BORTEZOMIB FOR THE TREATMENT OF CHRONIC ANTIBODY MEDIATED REJECTION AFTER KIDNEY TRANSPLANTATION]. Nihon Hinyokika Gakkai Zasshi 2018; 109:68-73. [PMID: 31006744 DOI: 10.5980/jpnjurol.109.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
(Backgrounds) The efficacy of bortezomib for chronic antibody mediated rejection (CAMR) after kidney transplantation is still obscure. (Materials and methods) CAMR were persisted in 5 recipients who were treated with plasma exchange, low dose of IVIG, steroid pulse therapy, and rituximab. 1.3 mg/m2 of bortezomib was administered on days 1, 4, 8, 11. Serum creatinine (sCr) levels, anti-HLA antibodies, and histology were analyzed. (Results) Stable sCr levels were obtained in 3 out of 5 recipients. No one lost renal graft function during follow-up periods. Anti-HLA class I antibodies were significantly decreased after bortezomib treatment, however anti-HLA class II antibodies were not changed. Histology showed no improvement at 6 months after bortezomib administration. Two recipients whose sCr levels increased during follow-up had already had interstitial fibrosis and tubular atrophy (IF/TA) in histology before bortezomib treatment. (Conclusions) The use of bortezomib after IF/TA could be detected in histology may not contribute to stabilize renal graft function in CAMR.
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26
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Abstract
Background There is limited information on treatment strategies and monitoring strategies for late antibody-mediated rejection (ABMR) after kidney transplantation. Methods In this observational and nonrandomized study, we compared 78 patients diagnosed with late ABMR (>3 months after transplant) who were treated with standard of care steroids/IVIG (n = 38) ± rituximab (n = 40) at our center between March 1, 2013 and December 31, 2016. All patients had follow-up biopsy and donor-specific antibodies (DSA) monitoring within 3 to 12 weeks. Results Patients had biopsy 7.3 ± 7 years after transplant and were followed for 15.9 ± 9.6 months after ABMR was diagnosed. Both treatment strategies were associated with a significant decline in DSA, microvascular inflammation (peritubular capillaritis + glomerulitis), and C4d Banff scores. In univariate regression analyses, rituximab, estimated glomerular filtration rate (eGFR), Banff i, t, v, chronicity (interstitial fibrosis + tubular atrophy + fibrous intimal thickening + allograft glomerulopathy) scores on the first biopsy, and eGFR and Banff v score on follow-up biopsy were associated with graft loss. Multivariate analyses retained only rituximab (hazard ratio, 0.23; 95% confidence interval, 0.06-0.84; P = 0.03) and eGFR at follow-up biopsy (0.84; 95% confidence interval, 0.76-0.92; P < 0.001) as significant predictors of graft loss. Kaplan-Meier analyses demonstrated that the benefit associated with rituximab was apparent after 1 year (15% vs 32% graft loss, P = 0.02). Conclusion Treatment of late ABMR with steroids/IVIG ± rituximab was effective in reducing DSA and microcirculation inflammation. The addition of rituximab was associated with better graft survival. Follow-up biopsies could be considered in the management of acute rejection to monitor the effect of therapy. Randomized studies on the best therapeutic options for ABMR are needed.
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27
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Mulley WR, Huang LL, Ramessur Chandran S, Longano A, Amos LAR, Polkinghorne KR, Nikolic-Paterson DJ, Kanellis J. Long-term graft survival in patients with chronic antibody-mediated rejection with persistent peritubular capillaritis treated with intravenous immunoglobulin and rituximab. Clin Transplant 2017. [DOI: 10.1111/ctr.13037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- William R. Mulley
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Louis L. Huang
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
| | - Sharmila Ramessur Chandran
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Anthony Longano
- Department of Anatomical Pathology; Monash Medical Centre; Clayton Vic. Australia
| | - Liv A. R. Amos
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Prahran Vic. Australia
| | - David J. Nikolic-Paterson
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
| | - John Kanellis
- Department of Nephrology; Monash Medical Centre; Clayton Vic. Australia
- Department of Medicine; Centre for Inflammatory Diseases; Monash University; Clayton Vic. Australia
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28
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Katsuma A, Yamakawa T, Nakada Y, Yamamoto I, Yokoo T. Histopathological findings in transplanted kidneys. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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29
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Riella LV, Djamali A, Pascual J. Chronic allograft injury: Mechanisms and potential treatment targets. Transplant Rev (Orlando) 2017; 31:1-9. [DOI: 10.1016/j.trre.2016.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/05/2023]
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30
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Garces JC, Giusti S, Staffeld-Coit C, Bohorquez H, Cohen AJ, Loss GE. Antibody-Mediated Rejection: A Review. Ochsner J 2017; 17:46-55. [PMID: 28331448 PMCID: PMC5349636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection. METHODS We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies. RESULTS Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody). CONCLUSION AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.
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Affiliation(s)
- Jorge Carlos Garces
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Sixto Giusti
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Catherine Staffeld-Coit
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Graft dysfunction in chronic antibody-mediated rejection correlates with B-cell-dependent indirect antidonor alloresponses and autocrine regulation of interferon-γ production by Th1 cells. Kidney Int 2016; 91:477-492. [PMID: 27988211 PMCID: PMC5258815 DOI: 10.1016/j.kint.2016.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/19/2016] [Accepted: 10/06/2016] [Indexed: 12/22/2022]
Abstract
Chronic antibody-mediated rejection, a common cause of renal transplant failure, has a variable clinical phenotype. Understanding why some with chronic antibody-mediated rejection progress slowly may help develop more effective therapies. B lymphocytes act as antigen-presenting cells for in vitro indirect antidonor interferon-γ production in chronic antibody-mediated rejection, but many patients retain the ability to regulate these responses. Here we test whether particular patterns of T and B cell antidonor response associate with the variability of graft dysfunction in chronic antibody-mediated rejection. Our results confirm that dynamic changes in indirect antidonor CD4+ T-cell responses correlate with changes in estimated glomerular filtration rates, independent of other factors. Graft dysfunction progressed rapidly in patients who developed unregulated B-cell–driven interferon-γ production. However, conversion to a regulated or nonreactive pattern, which could be achieved by optimization of immunosuppression, associated with stabilization of graft function. Functional regulation by B cells appeared to activate an interleukin-10 autocrine pathway in CD4+ T cells that, in turn, impacted on antigen-specific responses. Thus, our data significantly enhance the understanding of graft dysfunction associated with chronic antibody-mediated rejection and provide the foundation for strategies to prolong renal allograft survival, based on regulation of interferon-γ production.
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32
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Kiberd BA, Miller A, Martin S, Tennankore KK. De Novo Donor-Specific Human Leukocyte Antigen Antibody Screening in Kidney Transplant Recipients After the First Year Posttransplantation: A Medical Decision Analysis. Am J Transplant 2016; 16:3212-3219. [PMID: 27106124 DOI: 10.1111/ajt.13838] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/24/2016] [Accepted: 04/14/2016] [Indexed: 01/25/2023]
Abstract
Screening for de novo donor-specific antibodies (dnDSA) in stable kidney transplant recipients is routine practice in some centers. Patients with DSA are at increased risk of graft loss and early intervention may improve outcomes. However, the costs and benefits of dnDSA surveillance are unknown. A medical decision analysis to examine a screening strategy was developed for kidney transplant recipients who had stable graft function and were DSA negative 1 year posttransplant. In the base case, a modest 25% reduction in graft loss in dnDSA-positive patients treated with increased immunosuppression resulted in 0.04618 quality-adjusted years (QALYs) gained. However, benefits from reduced graft loss were eliminated if there was a small increased risk of death from added therapy. The incremental cost effectiveness was marginal at approximately $120 000-250 000 per QALY, but could be more or less favorable depending on several key variables such as efficacy of treatment, screening costs, incidence rate of subclinical dnDSA, and patient survival. Screening performed the best in patients with lower mortality rates and higher baseline incidence rates of dnDSA. Further study is warranted to gather the necessary high-quality evidence to justify screening.
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Affiliation(s)
- B A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - A Miller
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S Martin
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K K Tennankore
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Thaunat O, Koenig A, Leibler C, Grimbert P. Effect of Immunosuppressive Drugs on Humoral Allosensitization after Kidney Transplant. J Am Soc Nephrol 2016; 27:1890-900. [PMID: 26872489 DOI: 10.1681/asn.2015070781] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The negative effect of donor-specific antibodies on the success of solid transplant is now clearly established. However, the lack of effective treatment to prevent the development of antibody-mediated lesions deepens the need for clinicians to focus on primary prevention of de novo humoral allosensitization. Among the factors associated with the risk of developing de novo donor-specific antibodies, therapeutic immunosuppression is the most obvious parameter in which improvement is possible. Beyond compliance and the overall depth of immunosuppression, it is likely that the nature of the drugs is also crucial. Here, we provide an overview of the molecular effect of the various immunosuppressive drugs on B cell biology. Clinical data related to the effect of these drugs on de novo humoral allosensitization are also examined, providing a platform from which clinicians can optimize immunosuppression for prevention of de novo donor-specific antibody generation at the individual level.
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Affiliation(s)
- Olivier Thaunat
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, INSERM UMR1111, Université de Lyon, Lyon, France; and
| | - Alice Koenig
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, INSERM UMR1111, Université de Lyon, Lyon, France; and
| | - Claire Leibler
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation, INSERM U955, Université Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation, INSERM U955, Université Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, Creteil, France
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Durand J, Chiffoleau E. B cells with regulatory properties in transplantation tolerance. World J Transplant 2015; 5:196-208. [PMID: 26722647 PMCID: PMC4689930 DOI: 10.5500/wjt.v5.i4.196] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/19/2015] [Accepted: 09/30/2015] [Indexed: 02/05/2023] Open
Abstract
Induction of tolerance remains a major goal in transplantation. Indeed, despite potent immunosuppression, chronic rejection is still a real problem in transplantation. The humoral response is an important mediator of chronic rejection, and numerous strategies have been developed to target either B cells or plasma cells. However, the use of anti-CD20 therapy has highlighted the beneficial role of subpopulation of B cells, termed regulatory B cells. These cells have been characterized mainly in mice models of auto-immune diseases but emerging literature suggests their role in graft tolerance in transplantation. Regulatory B cells seem to be induced following inflammation to restrain excessive response. Different phenotypes of regulatory B cells have been described and are functional at various differentiation steps from immature to plasma cells. These cells act by multiple mechanisms such as secretion of immuno-suppressive cytokines interleukin-10 (IL-10) or IL-35, cytotoxicity, expression of inhibitory receptors or by secretion of non-inflammatory antibodies. Better characterization of the development, phenotype and mode of action of these cells seems urgent to develop novel approaches to manipulate the different B cell subsets and the response to the graft in a clinical setting.
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Tse GH, Johnston CJC, Kluth D, Gray M, Gray D, Hughes J, Marson LP. Intrarenal B Cell Cytokines Promote Transplant Fibrosis and Tubular Atrophy. Am J Transplant 2015; 15:3067-80. [PMID: 26211786 DOI: 10.1111/ajt.13393] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 04/28/2015] [Accepted: 05/23/2015] [Indexed: 01/25/2023]
Abstract
Renal transplantation is the optimum treatment for end-stage renal failure. B cells have been identified in chronic allograft damage (CAD) and associated with the development of tertiary lymphoid tissue within the human renal allograft. We performed renal transplantation in mice to model CAD and identified B cells forming tertiary lymphoid tissue with germinal centers. Intra-allograft B220(+) B cells comprised of IgM(high) CD23(-) B cells, IgM(lo) CD23(+) B cells, and IgM(lo) CD23(-) B cells with elevated expression of CD86. Depletion of B cells with anti-CD20 was associated with an improvement in CAD but only when administered after transplantation and not before. Isolated intra-allograft B cells were cultured and shown to synthesize multiple cytokines, the most abundant of these were GRO-α (CXCL1), RANTES (CCL5), IL-6 and MCP-1 (CCL2). Tubular loss was observed with T cell accumulation within the allograft and development of interstitial fibrosis, whilst type III collagen deposition was observed in areas of F4/80(+) macrophages and PDGFR-β(+) and transgelin(+) fibroblasts, all of which were reduced by B cell depletion. We have shown that intra-allograft B cells are key mediators of CAD. B cells possibly contribute to CAD by intra-allograft secretion of cytokines and chemokines.
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Affiliation(s)
- G H Tse
- Medical Research Council/University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - C J C Johnston
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - D Kluth
- Medical Research Council/University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - M Gray
- Medical Research Council/University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - D Gray
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - J Hughes
- Medical Research Council/University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - L P Marson
- Medical Research Council/University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, United Kingdom
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Grenda R, Jarmużek W, Rubik J, Migdał M, Pronicki M. Fatal rituximab-associated lung injury syndrome in a patient treated with rituximab for recurrence of post-transplant nephrotic syndrome. Pediatr Transplant 2015; 19:E115-20. [PMID: 25929598 DOI: 10.1111/petr.12481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Rituximab (anti-B CD20 ab.) in recently widely used in renal transplantation. CASE HISTORY A 10-yr-old patient with end-stage renal failure due to multidrug-resistant NS was transplanted with renal graft from deceased donor and presented immediate recurrence of NS. PF was started on day 3 and patient received MP pulses, however with no effect. Rituximab (4 × 375 mg/m(2)) was administered. Chest radiographs taken at that time were normal. Partial remission was achieved and the patient was discharged in good condition. Sequential recurrence appeared two wk afterward. Twelve sessions of PF were performed and six pulses of MP were given, effecting a partial remission. Three months after the last dose of rituximab, patient was admitted with increasing respiratory failure, requiring mechanical ventilation. Infectious background, including CMV, BKV, mycoplasma, and pneumocystis, was not confirmed. The patient was treated with MP pulses, IVIG, and a variety of antibiotics. Ground-glass opacity was confirmed on lung CT images. Respiratory failure worsened, despite aggressive ventilation and patient passed away after three wk at ICU. A destruction of alveolar epithelium and extended pulmonary fibrosis was confirmed in the autopsy report. The case represents a fatal RALI.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Wioletta Jarmużek
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marek Migdał
- Intensive Care Unit, Department of Anesthesiology and Intensive Care, The Children's Memorial Health Institute, Warsaw, Poland
| | - Maciej Pronicki
- Department of Pathology, The Children's Memorial Health Institute, Warsaw, Poland
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Bestard O, Sarwal MM. Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression. Pediatr Nephrol 2015; 30:397-403. [PMID: 25503324 DOI: 10.1007/s00467-014-3020-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibody-mediated rejection (ABMR) is a recognized cause of late kidney allograft loss. Although ABMR may occur despite appropriate chronic immunosuppressive therapy, non-adherence both facilitates and accelerates the activation of the effector phase of the humoral immune response against the donor tissue, leading in turn to progressive kidney allograft rejection. Given the poor efficacy of rescue therapies for both acute and chronic late ABMR, establishing appropriate preventive strategies at different times before and after transplantation is a critical management goal. CASE-DIAGNOSIS/TREATMENT In this report, we discuss the differential diagnoses and management of ABMR based on the clinical case report of a young kidney transplant recipient with progressive ABMR due to poor immunosuppressive adherence. In the absence of sensitive and specific non-invasive monitoring tools for alloimmune activation, the clinical dilemma in the management of the adolescent patient lies in differentiating between suboptimal prescribed immunosuppression and deliberate non-adherence to adequate immunosuppression dosing. Despite the advent of therapies to reduce ABMR injury, the graft is destined for untimely functional loss. CONCLUSIONS New biomarkers and tools for the accurate characterization of alloimmune risk before and after transplantation, and serial testing for de novo changes in circulating donor-specific alloantibodies, are urgently needed to support the delivery of optimized immunosuppression exposure.
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Affiliation(s)
- Oriol Bestard
- Renal Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona, Spain,
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Woodle ES, Rothstein DM. Clinical implications of basic science discoveries: janus resurrected--two faces of B cell and plasma cell biology. Am J Transplant 2015; 15:39-43. [PMID: 25382283 DOI: 10.1111/ajt.13028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 09/17/2014] [Accepted: 09/20/2014] [Indexed: 01/25/2023]
Abstract
B cells play a complex role in the immune response. In addition to giving rise to plasma cells (PCs) and promoting T cell responses via antigen presentation, they perform immunoregulatory functions. This knowledge has created concerns regarding nonspecific B cell depletional therapy because of the potential to paradoxically augment immune responses. Recent studies now indicate that PCs have immune functions beyond immunoglobulin synthesis. Evidence for a new role for PCs as potent regulatory cells (via IL-10 and IL-35 production) is discussed including the implications for PC-targeted therapies currently being developed for clinical transplantation.
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Affiliation(s)
- E S Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Hatakeyama S, Fujita T, Murakami R, Suzuki Y, Sugiyama N, Yamamoto H, Okamoto A, Imai A, Tobisawa Y, Yoneyama T, Mori K, Yoneyama T, Hashimoto Y, Koie T, Narumi S, Ohyama C. Outcome comparison of ABO-incompatible kidney transplantation with low-dose rituximab and ABO-compatible kidney transplantation: a single-center experience. Transplant Proc 2014; 46:445-8. [PMID: 24655984 DOI: 10.1016/j.transproceed.2013.09.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The development of immunosuppressive techniques has helped overcome the ABO incompatibility barrier. However, the outcomes of ABO-incompatible (ABOi) kidney transplantation remain a controversial issue with the advent of the anti-CD20 chimeric antibody rituximab. Herein, we report the outcomes of ABOi kidney transplantation with low-dose rituximab. PATIENTS AND METHODS Between June 2006 and April 2013, 42 patients underwent living-related kidney transplantation at our hospital. The patients were divided into 2 groups: ABO-compatible (ABOc; n = 29) and ABOi kidney transplants using low-dose rituximab (100 mg/m(2)) without splenectomy (n = 13). The basic immunosuppression regimen (calcineurin inhibitor [CNI], mycophenolate mofetil [MMF], and steroids) was the same for both groups, except for the use of rituximab and therapeutic apheresis in the ABOi group. We compared post-transplantation renal function, incidents of virus infection, episodes of rejection, and graft survival between the 2 groups. RESULTS In our hospital, 30% of recipients received ABOi kidney transplants. The estimated glomerular filtration rate (eGFR) did not differ between the groups. Rejection episodes confirmed by biopsy in the ABOc and ABOi groups were 8 (28%) and 4 (31%) patients (P = .833), acute antibody-mediated rejection was observed in 1 (3.5%) and 2 (15%) patients (P = .165), and virus infection was observed in 14 (48%) and 3 (23%) patients (P = .252), respectively. The 5-year patient survival rate was 100% in both groups, and the 5-year graft survival rates were 95% for ABOc and 100% for ABOi transplants (P = .527). CONCLUSIONS These results suggest that the outcomes of ABOi kidney transplantation with low-dose rituximab are similar to those of ABOc kidney transplantation. Further study is necessary to address the efficacy and safety of ABOi kidney transplantation.
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Affiliation(s)
- S Hatakeyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - T Fujita
- Department of Cardiology, Respiratory Medicine and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - R Murakami
- Department of Cardiology, Respiratory Medicine and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Y Suzuki
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - N Sugiyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - H Yamamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - A Okamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - A Imai
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Y Tobisawa
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - T Yoneyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - K Mori
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - T Yoneyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Y Hashimoto
- Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - T Koie
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - S Narumi
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Hirosaki, Japan
| | - C Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Kim MG, Kim YJ, Kwon HY, Park HC, Koo TY, Jeong JC, Jeon HJ, Han M, Ahn C, Yang J. Outcomes of combination therapy for chronic antibody-mediated rejection in renal transplantation. Nephrology (Carlton) 2014; 18:820-6. [PMID: 24033843 DOI: 10.1111/nep.12157] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 12/28/2022]
Abstract
AIM Chronic antibody-mediated rejection (CAMR) in renal transplant patients has poor allograft outcomes. However, treatment strategy has not been established yet. Herein, we present short-term outcomes of combination therapy for CAMR. METHODS We identified nine patients with CAMR or suspicious CAMR who were treated with antihumoral therapy from 2010 to 2011 and analyzed their medical records retrospectively. RESULTS Five patients had CAMR, and four patients had suspicious CAMR. Severe transplant glomerulopathy (TG) was observed in seven patients. The estimated glomerular filtration rate (eGFR) was decreased in all patients before treatment. We used three different treatment regimens: (i) high-dose intravenous immunoglobulin (IVIG) and rituximab; (ii) high-dose IVIG, rituximab, and bortezomib; and (iii) plasmapheresis with low-dose IVIG, rituximab and bortezomib. After treatment with one of these three regimens, graft function improved or stabilized in six patients, whereas three patients showed further deterioration of eGFR. The third regimen suppressed deterioration of renal function in all patients. Most patients showed no progression of proteinuria. Infectious complications due to Pneumocystis jirovecii pneumonia and herpes zoster occurred in two patients. CONCLUSION Combination therapy for CAMR might be effective, even in patients with relatively late-stage CAMR.
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Affiliation(s)
- Myung-Gyu Kim
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea; Transplantation Center, Seoul National University Hospital, Seoul, Korea
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41
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Clinical outcome in patients with chronic antibody-mediated rejection treated with and without rituximab and intravenous immunoglobulin combination therapy. Transpl Immunol 2014; 31:140-4. [DOI: 10.1016/j.trim.2014.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/22/2014] [Accepted: 08/22/2014] [Indexed: 01/03/2023]
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42
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High dose intravenous immunoglobulin therapy for donor-specific antibodies in kidney transplant recipients with acute and chronic graft dysfunction. Transplantation 2014; 97:1253-9. [PMID: 24937199 DOI: 10.1097/01.tp.0000443226.74584.03] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postkidney transplant donor-specific antibodies (DSA) have been identified as important contributors to graft loss. Few therapeutic options exist and have been met with limited success. We report outcomes in patients with de novo DSA and graft damage treated with a protocol of high-dose intravenous immunoglobulin (IVIG). METHODS Retrospective analysis of 28 kidney transplant recipients with de novo DSA and graft damage in the form of either chronic graft dysfunction (group 1, n=20) or a recent previous acute antibody-mediated rejection (AMR) episode (group 2, n=8) prescribed a standard regimen of high-dose (5 g/kg) IVIG dosed over 6 months. RESULTS Mean fluorescence intensity (MFI) of 70 total DSA decreased by 12%at the end of treatment (T1, P=0.14) and by 18%at last follow up (T2, P=0.035) compared with treatment initiation (T0) MFI. The most robust effect was seen in class I DSA (37% decrease at T2 versus T0, P=0.05) and in DSA from patients in group 2 (52% decrease at T2 versus T0, P=0.008). Graft function stabilized in patients in group 2 but continued to decline in those in group 1. CONCLUSION High-dose IVIG resulted in modest DSA MFI reductions in patients with previous graft damage, with a larger effect occurring in class I DSA in patients with a previous acute AMR. There was no clinical treatment benefit in patients with ongoing chronic graft damage, whereas high-dose IVIG may reduce the risk of chronic graft dysfunction in those with an acute AMR event.
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43
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Kim M, Martin ST, Townsend KR, Gabardi S. Antibody-mediated rejection in kidney transplantation: a review of pathophysiology, diagnosis, and treatment options. Pharmacotherapy 2014; 34:733-44. [PMID: 24753207 DOI: 10.1002/phar.1426] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antibody-mediated rejection (AMR), also known as B-cell-mediated or humoral rejection, is a significant complication after kidney transplantation that carries a poor prognosis. Although fewer than 10% of kidney transplant patients experience AMR, as many as 30% of these patients experience graft loss as a consequence. Although AMR is mediated by antibodies against an allograft and results in histologic changes in allograft vasculature that differ from cellular rejection, it has not been recognized as a separate disease process until recently. With an improved understanding about the importance of the development of antibodies against allografts as well as complement activation, significant advances have occurred in the treatment of AMR. The standard of care for AMR includes plasmapheresis and intravenous immunoglobulin that remove and neutralize antibodies, respectively. Agents targeting B cells (rituximab and alemtuzumab), plasma cells (bortezomib), and the complement system (eculizumab) have also been used successfully to treat AMR in kidney transplant recipients. However, the high cost of these medications, their use for unlabeled indications, and a lack of prospective studies evaluating their efficacy and safety limit the routine use of these agents in the treatment of AMR in kidney transplant recipients.
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Affiliation(s)
- Miae Kim
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
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Eskandary F, Bond G, Schwaiger E, Kikic Z, Winzer C, Wahrmann M, Marinova L, Haslacher H, Regele H, Oberbauer R, Böhmig GA. Bortezomib in late antibody-mediated kidney transplant rejection (BORTEJECT Study): study protocol for a randomized controlled trial. Trials 2014; 15:107. [PMID: 24708575 PMCID: PMC4014747 DOI: 10.1186/1745-6215-15-107] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 03/10/2014] [Indexed: 02/07/2023] Open
Abstract
Background Despite major advances in transplant medicine, improvements in long-term kidney allograft survival have not been commensurate with those observed shortly after transplantation. The formation of donor-specific antibodies (DSA) and ongoing antibody-mediated rejection (AMR) processes may critically contribute to late graft loss. However, appropriate treatment for late AMR has not yet been defined. There is accumulating evidence that the proteasome inhibitor bortezomib may substantially affect the function and integrity of alloantibody-secreting plasma cells. The impact of this agent on the course of late AMR has not so far been systematically investigated. Methods/design The BORTEJECT Study is a randomized controlled trial designed to clarify the impact of intravenous bortezomib on the course of late AMR. In this single-center study (nephrological outpatient service, Medical University Vienna) we plan an initial cross-sectional DSA screening of 1,000 kidney transplant recipients (functioning graft at ≥180 days; estimated glomerular filtration rate (eGFR) >20 ml/minute/1.73 m2). DSA-positive recipients will be subjected to kidney allograft biopsy to detect morphological features consistent with AMR. Forty-four patients with biopsy-proven AMR will then be included in a double-blind placebo-controlled intervention trial (1:1 randomization stratified for eGFR and the presence of T-cell-mediated rejection). Patients in the active group will receive two cycles of bortezomib (4 × 1.3 mg/m2 over 2 weeks; 3-month interval between cycles). The primary end point will be the course of eGFR over 24 months (intention-to-treat analysis). The sample size was calculated according to the assumption of a 5 ml/minute/1.73 m2 difference in eGFR slope (per year) between the two groups (alpha: 0.05; power: 0.8). Secondary endpoints will be DSA levels, protein excretion, measured glomerular filtration rate, transplant and patient survival, and the development of acute and chronic morphological lesions in 24-month protocol biopsies. Discussion The impact of anti-humoral treatment on the course of late AMR has not yet been systematically investigated. Based on the hypothesis that proteasome inhibition improves the outcome of DSA-positive late AMR, we suggest that our trial has the potential to provide solid evidence towards the treatment of this type of rejection. Trial registration Clinicaltrials.gov: NCT01873157.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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Salvadori M, Bertoni E. Impact of donor-specific antibodies on the outcomes of kidney graft: Pathophysiology, clinical, therapy. World J Transplant 2014; 4:1-17. [PMID: 24669363 PMCID: PMC3964192 DOI: 10.5500/wjt.v4.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
Allo-antibodies, particularly when donor specific, are one of the most important factors that cause both early and late graft dysfunction. The authors review the current state of the art concerning this important issue in renal transplantation. Many antibodies have been recognized as mediators of renal injury. In particular donor-specific-Human Leukocyte Antigens antibodies appear to play a major role. New techniques, such as solid phase techniques and Luminex, have revealed these antibodies from patient sera. Other new techniques have uncovered alloantibodies and signs of complement activation in renal biopsy specimens. It has been acknowledged that the old concept of chronic renal injury caused by calcineurine inhibitors toxicity should be replaced in many cases by alloantibodies acting against the graft. In addition, the number of patients on waiting lists with preformed anti-human leukocyte antigens (HLA) antibodies is increasing, primarily from patients with a history of renal transplant failure already been sensitized. We should distinguish early and late acute antibody-mediated rejection from chronic antibody-mediated rejection. The latter often manifets late during the course of the post-transplant period and may be difficult to recognize if specific techniques are not applied. Different therapeutic strategies are used to control antibody-induced damage. These strategies may be applied prior to transplantation or, in the case of acute antibody-mediated rejection, after transplantation. Many new drugs are appearing at the horizon; however, these drugs are far from the clinic because they are in phase I-II of clinical trials. Thus the pipeline for the near future appears almost empty.
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46
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Zaza G, Tomei P, Granata S, Boschiero L, Lupo A. Monoclonal antibody therapy and renal transplantation: focus on adverse effects. Toxins (Basel) 2014; 6:869-91. [PMID: 24590384 PMCID: PMC3968366 DOI: 10.3390/toxins6030869] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/07/2014] [Accepted: 02/21/2014] [Indexed: 02/06/2023] Open
Abstract
A series of monoclonal antibodies (mAbs) are commonly utilized in renal transplantation as induction therapy (a period of intense immunosuppression immediately before and following the implant of the allograft), to treat steroid-resistant acute rejections, to decrease the incidence and mitigate effects of delayed graft function, and to allow immunosuppressive minimization. Additionally, in the last few years, their use has been proposed for the treatment of chronic antibody-mediated rejection, a major cause of late renal allograft loss. Although the exact mechanism of immunosuppression and allograft tolerance with any of the currently used induction agents is not completely defined, the majority of these medications are targeted against specific CD proteins on the T or B cells surface (e.g., CD3, CD25, CD52). Moreover, some of them have different mechanisms of action. In particular, eculizumab, interrupting the complement pathway, is a new promising treatment tool for acute graft complications and for post-transplant hemolytic uremic syndrome. While it is clear their utility in renal transplantation, it is also unquestionable that by using these highly potent immunosuppressive agents, the body loses much of its innate ability to mount an adequate immune response, thereby increasing the risk of severe adverse effects (e.g., infections, malignancies, haematological complications). Therefore, it is extremely important for clinicians involved in renal transplantation to know the potential side effects of monoclonal antibodies in order to plan a correct therapeutic strategy minimizing/avoiding the onset and development of severe clinical complications.
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Affiliation(s)
- Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Luigino Boschiero
- First Surgical Clinic, Kidney Transplantation Center, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
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47
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The effect of combination therapy with rituximab and intravenous immunoglobulin on the progression of chronic antibody mediated rejection in renal transplant recipients. J Immunol Res 2014; 2014:828732. [PMID: 24741626 PMCID: PMC3987969 DOI: 10.1155/2014/828732] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 10/28/2013] [Accepted: 11/11/2013] [Indexed: 12/18/2022] Open
Abstract
The treatment for chronic active antibody-mediated rejection (CAMR) remains controversial. We investigated the efficacy of rituximab (RTX) and intravenous immunoglobulin (IVIg) for CAMR. Eighteen patients with CAMR were treated with RTX (375 mg/m2) and IVIg (0.4 g/kg) for 4 days. The efficacy of RTX/IVIg combination therapy (RIT) was assessed by decline in estimated glomerular filtration rate per month (ΔeGFR) before and after RIT. Patients were divided into responder and nonresponder groups based on decrease and no decrease in ΔeGFR, respectively, and their clinical and histological characteristics were compared. Response rate to RIT was 66.7% (12/18), and overall ΔeGFR decreased significantly to 0.4 ± 1.7 mL·min−1·1.73 m−2 per month 6 months after RIT compared to that observed 6 months before RIT (1.8 ± 1.0, P < 0.05). Clinical and histological features between the 12 responders and the 6 nonresponders were not significantly different, but nonresponders had a significantly higher proteinuria levels at the time of RIT (2.5 ± 2.5 versus 7.0 ± 3.5 protein/creatinine (g/g), P < 0.001). The effect of the RIT on ΔeGFR had dissipated in all patients by 1 year post-RIT. Thus, RIT delayed CAMR progression, and baseline proteinuria level was a prognostic factor for response to RIT.
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Dorling A, Rebollo-Mesa I, Hilton R, Peacock JL, Vaughan R, Gardner L, Danzi G, Baker R, Clark B, Thuraisingham RC, Buckland M, Picton M, Martin S, Borrows R, Briggs D, Horne R, McCrone P, Kelly J, Murphy C. Can a combined screening/treatment programme prevent premature failure of renal transplants due to chronic rejection in patients with HLA antibodies: study protocol for the multicentre randomised controlled OuTSMART trial. Trials 2014; 15:30. [PMID: 24447519 PMCID: PMC3906093 DOI: 10.1186/1745-6215-15-30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 01/06/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Renal transplantation is the best treatment for kidney failure, in terms of length and quality of life and cost-effectiveness. However, most transplants fail after 10 to 12 years, consigning patients back onto dialysis. Damage by the immune system accounts for approximately 50% of failing transplants and it is possible to identify patients at risk by screening for the presence of antibodies against human leukocyte antigens. However, it is not clear how best to treat patients with antibodies. This trial will test a combined screening and treatment protocol in renal transplant recipients. METHODS/DESIGN Recipients>1 year post-transplantation, aged 18 to 70 with an estimated glomerular filtration rate>30 mL/min will be randomly allocated to blinded or unblinded screening arms, before being screened for the presence of antibodies. In the unblinded arm, test results will be revealed. Those with antibodies will have biomarker-led care, consisting of a change in their anti-rejection drugs to prednisone, tacrolimus and mycophenolate mofetil. In the blinded arm, screening results will be double blinded and all recruits will remain on current therapy (standard care). In both arms, those without antibodies will be retested every 8 months for 3 years. The primary outcome is the 3-year kidney failure rate for the antibody-positive recruits, as measured by initiation of long-term dialysis or re-transplantation, predicted to be approximately 20% in the standard care group but <10% in biomarker-led care. The secondary outcomes include the rate of transplant dysfunction, incidence of infection, cancer and diabetes mellitus, an analysis of adherence with medication and a health economic analysis of the combined screening and treatment protocol. Blood samples will be collected and stored every 4 months and will form the basis of separately funded studies to identify new biomarkers associated with the outcomes. DISCUSSION We have evidence that the biomarker-led care regime will be effective at preventing graft dysfunction and expect this to feed through to graft survival. This trial will confirm the benefit of routine screening and lead to a greater understanding of how to keep kidney transplants working longer. TRIAL REGISTRATION Current Controlled Trials ISRCTN46157828.
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Affiliation(s)
- Anthony Dorling
- MRC Centre for Transplantation, King's College London, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK.
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Zachary AA, Leffell MS. Barriers to successful transplantation of the sensitized patient. Expert Rev Clin Immunol 2014; 6:449-60. [DOI: 10.1586/eci.10.14] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Lee KM, Yeh H, Zhao G, Wei L, O'Connor M, Stott RT, Soohoo J, Dunussi K, Fiorina P, Deng S, Markmann JF, Kim JI. B-cell depletion improves islet allograft survival with anti-CD45RB. Cell Transplant 2014; 23:51-8. [PMID: 23192154 PMCID: PMC3812388 DOI: 10.3727/096368912x658962] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A short course of anti-CD45RB leads to long-term islet allograft survival and donor-specific tolerance in approximately half of immunocompetent mice. We have previously demonstrated that anti-CD45RB antibody-mediated tolerance requires B-cells for cardiac allograft survival. We therefore asked whether B-cells were also required for anti-CD45RB antibody-mediated survival of islets. Unexpectedly, we found that nearly 100% of islet allografts survive long term in B-cell-deficient mice. Similarly, B-cell depletion by anti-CD22/cal augmented anti-CD45RB-mediated tolerance when administered pretransplant, although it had no effect on tolerance induction when administered posttransplant. Our results demonstrate that the role of B-cells in promoting tolerance with anti-CD45RB is graft specific, promoting tolerance in cardiac grafts but resisting tolerance in islet transplantation. These findings may help elucidate the varied action of B-cells in promoting tolerance versus rejection.
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Affiliation(s)
- Kang Mi Lee
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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