1
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Fulchiero R, Galea L, Hewlett J, Savant JD, Lopez S, Amaral S, Viteri B. Bortezomib for antibody-mediated rejection of kidney transplant in youth: Associations with donor-specific antibody. Pediatr Transplant 2024; 28:e14774. [PMID: 38808699 PMCID: PMC11189613 DOI: 10.1111/petr.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Antibody-mediated rejection is one of the most significant risk factors for allograft dysfunction and failure in children and adolescents with kidney transplants, yet optimal treatment remains unidentified. To date, there are mixed findings regarding the use of Bortezomib, a plasma cell apoptosis inducer, as an adjunct therapy in the treatment of antibody-mediated rejection. METHODS In a retrospective single center study, we reviewed the efficacy and tolerability of bortezomib as adjunct therapy for treatment-refractory antibody-mediated rejection. RESULTS Six patients with a median age of 14.6 years (range 6.9-20.1 years) received bortezomib at a mean of 71 months (range 15-83 months) post-kidney transplant. Four patients experienced decline in estimated glomerular filtration rate (eGFR) from 4% to 42%. One patient started bortezomib while on hemodialysis and did not recover graft function, and another patient progressed to hemodialysis 6 months after receiving bortezomib. Although DSA did not completely resolve, there was a statistically significant decline in DSA MFI pre and 12-months post-BZ (p = .012, paired t-test) for the subjects who were not on dialysis at the time of bortezomib. Chronic Allograft Damage Index (CADI) score of ≥3 was seen in all six subjects at their biopsy prior to therapy. No adverse effects were reported. CONCLUSIONS Bortezomib was well tolerated and resulted in improvements in MFI of DSA among four pediatric subjects without allograft failure, although no effects were observed on eGFR trajectory. Further studies are needed to clarify whether earlier intervention with bortezomib could prevent renal failure progression.
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Affiliation(s)
- Rosanna Fulchiero
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Nephrology Division, Inova Children's Hospital, Falls Church, Virginia, USA
| | - Lauren Galea
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Hewlett
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan D Savant
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sonya Lopez
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sandra Amaral
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernarda Viteri
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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3
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Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
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4
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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5
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Liao X, Chang E, Tang X, Watanabe I, Zhang R, Jeong HW, Adams RH, Jain MK. Cardiac macrophages regulate isoproterenol-induced Takotsubo-like cardiomyopathy. JCI Insight 2022; 7:156236. [PMID: 35132957 PMCID: PMC8855841 DOI: 10.1172/jci.insight.156236] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/15/2021] [Indexed: 12/24/2022] Open
Abstract
Takotsubo syndrome (TTS) is an acute, stress-induced cardiomyopathy that occurs predominantly in women after extreme physical and/or emotional stress. To date, our understanding of the molecular basis for TTS remains unknown and, consequently, specific therapies are lacking. Myocardial infiltration of monocytes and macrophages in TTS has been documented in clinical studies. However, the functional importance of these findings remains poorly understood. Here, we show that a single high dose of isoproterenol (ISO) in mice induced a TTS-like cardiomyopathy phenotype characterized by female predominance, severe cardiac dysfunction, and robust myocardial infiltration of macrophages. Single-cell RNA-Seq studies of myocardial immune cells revealed that TTS-like cardiomyopathy is associated with complex activation of innate and adaptive immune cells in the heart, and macrophages were identified as the dominant immune cells. Global macrophage depletion (via clodronate liposome administration) or blockade of macrophage infiltration (via a CCR2 antagonist or in CCR2-KO mice) resulted in recovery of cardiac dysfunction in ISO-challenged mice. In addition, damping myeloid cell activation by HIF1α deficiency or exposure to the immunomodulatory agent bortezomib ameliorated ISO-induced cardiac dysfunction. Collectively, our findings identify macrophages as a critical regulator of TTS pathogenesis that can be targeted for therapeutic gain.
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Affiliation(s)
- Xudong Liao
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Eugene Chang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Xinmiao Tang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ippei Watanabe
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rongli Zhang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Hyun-Woo Jeong
- Max Planck Institute for Molecular Biomedicine, Department of Tissue Morphogenesis, Münster, Germany
| | - Ralf H Adams
- Max Planck Institute for Molecular Biomedicine, Department of Tissue Morphogenesis, Münster, Germany
| | - Mukesh K Jain
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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6
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Anti-HLA immunization of patients qualified for lung transplantation – Single center study. Transpl Immunol 2022; 71:101553. [DOI: 10.1016/j.trim.2022.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022]
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7
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Kitamura H, Tanigawa T, Kuzumoto T, Nadatani Y, Otani K, Fukunaga S, Hosomi S, Tanaka F, Kamata N, Nagami Y, Taira K, Uematsu S, Watanabe T, Fujiwara Y. Interferon-α exerts proinflammatory properties in experimental radiation-induced esophagitis: Possible involvement of plasmacytoid dendritic cells. Life Sci 2022; 289:120215. [PMID: 34890590 DOI: 10.1016/j.lfs.2021.120215] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022]
Abstract
AIMS Radiation-induced esophagitis, experienced during radiation therapy for lung cancer and head and neck cancer, is a major dose-limiting side effect of the treatment. This study aimed to elucidate the role of interferon-α (IFN-α) in radiation-induced esophagitis. MAIN METHODS C57BL/6 mice were exposed to 10 and 25Gy of single thoracic irradiation. Esophageal mucosal damage and inflammatory reactions were assessed for 5 days after irradiation. KEY FINDINGS Irradiation induced esophagitis, characterized by reduction in the thickness of epithelial layer, upregulation of proinflammatory cytokines and chemokines, infiltration of inflammatory cells into the esophageal mucosa, and apoptosis of epithelial cells. Irradiation upregulated the level of gene expression for IFN-α in the esophageal tissue, and the neutralizing antibody against IFN-α ameliorated radiation-induced esophageal mucosal damage, while administration of IFN-α receptor agonist (RO8191) had an inverse effect. Depletion of plasmacytoid dendritic cells (pDCs) by anti-CD317 antibody or pharmacological inactivation with bortezomib suppressed radiation-induced mucosal inflammation and damage, accompanied by decrease in IFN-α expression level. SIGNIFICANCE These findings suggest that IFN-α and pDCs exert proinflammatory properties in the pathophysiology of radiation-induced esophagitis.
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Affiliation(s)
- Hiroyuki Kitamura
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Gastroenterology, Osaka City Juso Hospital, Osaka, Japan.
| | - Takuya Kuzumoto
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuji Nadatani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Uematsu
- Department of Immunology and Genomics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Premier Preventive Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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8
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Olaso D, Manook M, Moris D, Knechtle S, Kwun J. Optimal Immunosuppression Strategy in the Sensitized Kidney Transplant Recipient. J Clin Med 2021; 10:3656. [PMID: 34441950 PMCID: PMC8396983 DOI: 10.3390/jcm10163656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with previous sensitization events against anti-human leukocyte antigens (HLA) often have circulating anti-HLA antibodies. Following organ transplantation, sensitized patients have higher rates of antibody-mediated rejection (AMR) compared to those who are non-sensitized. More stringent donor matching is required for these patients, which results in a reduced donor pool and increased time on the waitlist. Current approaches for sensitized patients focus on reducing preformed antibodies that preclude transplantation; however, this type of desensitization does not modulate the primed immune response in sensitized patients. Thus, an optimized maintenance immunosuppressive regimen is necessary for highly sensitized patients, which may be distinct from non-sensitized patients. In this review, we will discuss the currently available therapeutic options for induction, maintenance, and adjuvant immunosuppression for sensitized patients.
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Affiliation(s)
| | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (D.O.); (M.M.); (D.M.)
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (D.O.); (M.M.); (D.M.)
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9
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Karafin MS, Schumacher C, Zhang J, Simpson P, Johnson ST, Pierce KL. Human leukocyte antigen (HLA)-incompatible mean fluorescence intensity-selected platelet products have corrected count increments similar to HLA antigen-matched platelets. Transfusion 2021; 61:2307-2316. [PMID: 34075590 DOI: 10.1111/trf.16430] [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: 10/29/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Donor specific antibody sum mean fluorescence intensity (MFI) values have been successfully used in transplant medicine to assess risk for organ rejection. However, little is known regarding whether MFI values could be similarly used to aid in platelet product selection. We have developed a novel protocol where MFI values are used to offer human leukocyte antigen (HLA)-incompatible platelet products when HLA antigen-matched products are not available. We aimed to evaluate the efficacy of this protocol. METHODS We performed a 4-year retrospective chart review for all patients who received at least one MFI-selected platelet product. A corrected count increment (CCI) was calculated for each transfusion event. A mixed effects model was used to investigate the association between CCIs for MFI-selected, HLA antigen matched, and random donor platelet transfusions. A random effects expectation-maximization regression tree was used to define the extent to which other patient variables, such as age, sex, and diagnosis impacted the CCI for each platelet transfusion. RESULTS Twenty highly HLA alloimmunized patients received a total of 591 platelets. MFI-selected platelet (low MFI) transfusions had a significantly higher median CCI 0-6 hour post-transfusion (13,559, interquartile range [IQR]: 8275-18,736) compared to random donor platelets (2121, IQR: 0-10,368, p < 0.0001). There was no significant difference in median CCI between HLA antigen matched and MFI selected platelet transfusions (p = 0.2). Mixed effects and regression modeling revealed that MFI-selected platelet products had a significantly higher CCI than non-matched platelets, even when accounting for other significant patient variables. CONCLUSION MFI-selected HLA-incompatible platelet products could provide a comparable alternative to traditional HLA antigen-matched platelet products.
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Affiliation(s)
- Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Jian Zhang
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa Simpson
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Susan T Johnson
- Diagnostic Laboratories, Versiti Wisconsin, Milwaukee, Wisconsin, USA
| | - Karen L Pierce
- Diagnostic Laboratories, Versiti Wisconsin, Milwaukee, Wisconsin, USA
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10
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Reducing Donor-specific Antibody During Acute Rejection Diminishes Long-term Renal Allograft Loss: Comparison of Early and Late Rejection. Transplantation 2021; 104:2403-2414. [PMID: 32000256 DOI: 10.1097/tp.0000000000003145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reduction in donor-specific antibody (DSA) has been associated with improved renal allograft survival after antibody-mediated rejection (AMR). These observations have not been separately analyzed for early and late AMR and mixed acute rejection (MAR). The purpose of this study was to evaluate long-term responses to proteasome inhibitor-based therapy for 4 rejection phenotypes and to determine factors that predict allograft survival. METHODS Retrospective cohort study evaluating renal transplant recipients with first AMR episodes treated with proteasome inhibitor-based therapy from January 2005 to July 2015. RESULTS A total of 108 patients were included in the analysis. Immunodominant DSA reduction at 14 days differed significantly (early AMR 79.6%, early MAR 54.7%, late AMR 23.4%, late MAR 21.1%, P < 0.001). Death-censored graft survival (DCGS) differed at 3 years postrejection (early AMR 88.3% versus early MAR 77.8% versus late AMR 56.7% versus late MAR 54.9%, P = 0.02). Multivariate analysis revealed that immunodominant DSA reduction > 50% at 14 days was associated with improved DCGS (odds ratio, 0.12, 95% CI, 0.02-0.52, P = 0.01). CONCLUSIONS In summary, significant differences exist across rejection phenotypes with respect to histological and DSA responses. The data suggest that DSA reduction may be associated with improved DCGS in both early and late AMR.
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11
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Kolonko A, Słabiak-Błaż N, Karkoszka H, Więcek A, Piecha G. The Preliminary Results of Bortezomib Used as A Primary Treatment for An Early Acute Antibody-Mediated Rejection after Kidney Transplantation-A Single-Center Case Series. J Clin Med 2020; 9:jcm9020529. [PMID: 32075220 PMCID: PMC7074248 DOI: 10.3390/jcm9020529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/06/2020] [Accepted: 02/12/2020] [Indexed: 01/10/2023] Open
Abstract
Proteasome inhibitor bortezomib has been used in the treatment of refractory cases of acute and chronic antibody-mediated rejection (AMR) in kidney transplant recipients. However, its efficacy and safety as a primary treatment for early AMR has been scarcely investigated. We herein present our preliminary experience with bortezomib- and plasmapheresis-based primary treatment for early AMR. Thirteen patients transplanted between October 2015 and September 2019 were treated (starting at median 19th post-transplant day) with bortezomib/plasmapheresis protocol for early biopsy-proven AMR. Twelve out of thirteen patients received 4 doses and one patient recieved 3 doses of bortezomib (1.3 mg/m2 per dose). In 11/13 patients, 4–7 concomitant plasmapheresis sessions were performed, with or without intravenous immunoglobulin (IVIG). Of note, rituximab was not used in all study patients. The kidney graft and patient survival were 100%. The mean 3-month estimated glomerular filtration rate (eGFR) was 55.3 (95%CI: 44.9–65.8) mL/min/1.73m2, 8/13 patients completed 12-month follow-up with mean eGFR 60.4 (45.4–75.4) mL/min/1.73m2, and 6/13 patients completed a 24-month follow-up period with mean eGFR 73.9 (56.7–91.1) mL/min/1.73m2. Neutropenia < 1 G/L was observed in one patient, third or fourth grade thrombocytopenia in two patients, and eleven patients needed a blood transfusion (median: 2 units/patient). The mid-term results of a primary bortezomib-based treatment for kidney AMR showed its non-inferiority as compared to preceding regimens and acceptable safety. However, our data should be validated in a multicenter randomized trial.
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12
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Tremblay S, Driscoll JJ, Rike-Shields A, Hildeman DA, Alloway RR, Girnita AL, Brailey PA, Woodle ES. A prospective, iterative, adaptive trial of carfilzomib-based desensitization. Am J Transplant 2020; 20:411-421. [PMID: 31550069 PMCID: PMC7872208 DOI: 10.1111/ajt.15613] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/01/2019] [Accepted: 08/29/2019] [Indexed: 01/25/2023]
Abstract
Proteasome inhibitor-based strategies hold promise in transplant but have yielded varying results. Carfilzomib, a second-generation proteasome inhibitor, may possess advantages over bortezomib, the first-generation proteasome inhibitors. The purpose of this study was to evaluate the safety, toxicity, and preliminary efficacy of carfilzomib in highly HLA-sensitized kidney transplant candidates. Renal transplant candidates received escalating doses of carfilzomib followed by plasmapheresis (group A) or an identical regimen with additional plasmapheresis once weekly before carfilzomib dosing. Thirteen participants received carfilzomib, which was well tolerated with most adverse events classified as low grade. The safety profile was similar to bortezomib desensitization; however, neurotoxicity was not observed with carfilzomib. Toxicity resulted in permanent dose reduction in 1 participant but caused no withdrawals or deaths. HLA antibodies were substantially reduced with carfilzomib alone, and median maximal immunodominant antibody reduction was 72.8% (69.8% for group A, P = .031, 80.1% for group B, P = .938). After depletion, rebound occurred rapidly and antibody levels returned to baseline between days 81 and 141. Bone marrow studies revealed that approximately 69.2% of plasma cells were depleted after carfilzomib monotherapy. Carfilzomib monotherapy-based desensitization provides an acceptable safety and toxicity profile while leading to significant bone marrow plasma cell depletion and anti-HLA antibody reduction.
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Affiliation(s)
- Simon Tremblay
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - James J. Driscoll
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
- University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Adele Rike-Shields
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
- The Christ Hospital, Cincinnati, Ohio
| | | | - Rita R. Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alin L. Girnita
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
- Transplantation Immunology Division, Hoxworth Blood Center, Cincinnati, Ohio
| | - Paul A. Brailey
- Transplantation Immunology Division, Hoxworth Blood Center, Cincinnati, Ohio
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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13
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Gundlapalli S, Bande S, Mulpuru V. Plasma cell-rich rejection – The enigma revisited: Case report. INDIAN JOURNAL OF TRANSPLANTATION 2020. [DOI: 10.4103/ijot.ijot_76_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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14
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Kim DG, Lee J, Park Y, Kim MS, Jeong HJ, Kim SI, Kim YS, Kim BS, Huh KH. Transplant outcomes in positive complement-dependent cytotoxicity- versus flow cytometry-crossmatch kidney transplant recipients after successful desensitization: a retrospective study. BMC Nephrol 2019; 20:456. [PMID: 31818254 PMCID: PMC6902609 DOI: 10.1186/s12882-019-1625-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the obvious survival benefit compared to that among waitlist patients, outcomes of positive crossmatch kidney transplantation (KT) are generally inferior to those of human leukocyte antigen (HLA)-compatible KT. This study aimed to compare the outcomes of positive complement-dependent cytotoxicity (CDC) crossmatch (CDC + FC+) and positive flow cytometric crossmatch (CDC-FC+) with those of HLA-compatible KT (CDC-FC-) after successful desensitization. METHODS We retrospectively analyzed 330 eligible patients who underwent KTs between June 2011 and August 2017: CDC-FC- (n = 274), CDC-FC+ (n = 39), and CDC + FC+ (n = 17). Desensitization protocol targeting donor-specific antibody (DSA) involved plasmapheresis, intravenous immunoglobulin (IVIG), and rituximab with/without bortezomib for positive-crossmatch KT. RESULTS Death-censored graft survival and patient survival were not different among the three groups. The median estimated glomerular filtration rate was significantly lower in the CDC + FC+ group than in the compatible group at 6 months (P < 0.001) and 2 years (P = 0.020). Biopsy-proven rejection within 1 year of CDC-FC-, CDC-FC+, and CDC + FC+ were 15.3, 28.2, and 47.0%, respectively. Urinary tract infections (P < 0.001), Pneumocystis jirovecii pneumonia (P < 0.001), and cytomegalovirus viremia (P < 0.001) were more frequent in CDC-FC+ and CDC + FC+ than in CDC-FC-. CONCLUSIONS This study showed that similar graft and patient survival was achieved in CDC-FC+ and CDC + FC+ KT compared with CDC-FC- through DSA-targeted desensitization despite the higher incidence of rejection and infection than that in compatible KT.
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Affiliation(s)
- Deok Gie Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Younhee Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Joo Jeong
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea. .,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.
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15
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Salvadori M, Tsalouchos A. Therapeutic apheresis in kidney transplantation: An updated review. World J Transplant 2019; 9:103-122. [PMID: 31750088 PMCID: PMC6851502 DOI: 10.5500/wjt.v9.i6.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased- or living- donor transplantation. Postoperatively, additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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16
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Su H, Zhang CY, Lin JH, Hammes HP, Zhang C. The Role of Long-Lived Plasma Cells in Antibody-Mediated Rejection of Kidney Transplantation: An Update. KIDNEY DISEASES 2019; 5:211-219. [PMID: 31768378 DOI: 10.1159/000501460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/12/2019] [Indexed: 12/26/2022]
Abstract
Background Antibody-mediated rejection (ABMR) following kidney transplant is closely associated with poor prognosis of the recipients. Long-lived plasma cells (LLPCs) produce alloantibodies as long as life time and play a crucial role in ABMR. Summary LLPCs generate from germinal centers and reside in survival niches in the bone marrow as well as the inflamed tissues. They are the main and long-term source of the antibodies. LLPCs mediate ABMR via the generation of preformed antibodies in sensitized patients and de novo antibodies after transplantation. They have been acknowledged as the leading causes of ABMR; however, LLPCs are insensitive to traditional immunosuppressive therapy that removes B cells. Strategies targeting LLPCs, such as antithymocyte globulin, proteasome inhibitors as well as monoclonal antibodies, are promising methods to persistently and thoroughly clear the entire PC pool. Key Message LLPCs play an important role in ABMR by producing alloantibodies continually, and targeting LLPCs might be a novel and effective approach against ABMR.
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Affiliation(s)
- Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Yun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ji-Hong Lin
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hans-Peter Hammes
- 5th Medical Department, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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17
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Burghuber CK, Manook M, Ezekian B, Gibby AC, Leopardi FV, Song M, Jenks J, Saccoccio F, Permar S, Farris AB, Iwakoshi NN, Kwun J, Knechtle SJ. Dual targeting: Combining costimulation blockade and bortezomib to permit kidney transplantation in sensitized recipients. Am J Transplant 2019; 19:724-736. [PMID: 30102844 PMCID: PMC7185755 DOI: 10.1111/ajt.15067] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 01/25/2023]
Abstract
Previous evidence suggests that a homeostatic germinal center (GC) response may limit bortezomib desensitization therapy. We evaluated the combination of costimulation blockade with bortezomib in a sensitized non-human primate kidney transplant model. Sensitized animals were treated with bortezomib, belatacept, and anti-CD40 mAb twice weekly for a month (n = 6) and compared to control animals (n = 7). Desensitization therapy-mediated DSA reductions approached statistical significance (P = .07) and significantly diminished bone marrow PCs, lymph node follicular helper T cells, and memory B cell proliferation. Graft survival was prolonged in the desensitization group (P = .073). All control animals (n = 6) experienced graft loss due to antibody-mediated rejection (AMR) after kidney transplantation, compared to one desensitized animal (1/5). Overall, histological AMR scores were significantly lower in the treatment group (n = 5) compared to control (P = .020). However, CMV disease was common in the desensitized group (3/5). Desensitized animals were sacrificed after long-term follow-up with functioning grafts. Dual targeting of both plasma cells and upstream GC responses successfully prolongs graft survival in a sensitized NHP model despite significant infectious complications and drug toxicity. Further work is planned to dissect underlying mechanisms, and explore safety concerns.
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Affiliation(s)
- Christopher K. Burghuber
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Division of Vascular Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Brian Ezekian
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Adriana C. Gibby
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | - Frank V. Leopardi
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Minqing Song
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Jennifer Jenks
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Frances Saccoccio
- Pediatric Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
- Pediatric Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Alton B. Farris
- Department of Pathology, Emory School of Medicine, Atlanta, GA, USA
| | - Neal N. Iwakoshi
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | - Jean Kwun
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Stuart J. Knechtle
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
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18
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Abbas K, Mubarak M, Zafar MN, Musharraf W, Imam M, Aziz T, Rizvi AH. Management of Plasma Cell-Rich Acute Rejection in Living-Related Kidney Transplant: Role of Proteasome Inhibitor. EXP CLIN TRANSPLANT 2019. [PMID: 29534661 DOI: 10.6002/ect.2017.0154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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19
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Pinelli DF, Zachary AA, Friedewald JJ, Gjertson DW, Evans MA, Chatroop EN, Leffell MS, Vo AA, Jordan SC, Montgomery RA, Tambur AR. Prognostic tools to assess candidacy for and efficacy of antibody-removal therapy. Am J Transplant 2019; 19:381-390. [PMID: 29981209 DOI: 10.1111/ajt.15007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/20/2018] [Accepted: 07/01/2018] [Indexed: 01/25/2023]
Abstract
Currently, the ability to predict or monitor the efficacy of HLA antibody-removal therapies is deficient. We previously reported that titration studies are a consistent and accurate means of assessing antibody strength. To test whether titration studies can also predict which patients are better candidates for desensitization, we studied 38 patients from 3 centers (29 receiving plasmapheresis/low-dose intravenous immunoglobulin [IVIg]; 9 patients receiving high-dose IVIg). For patients undergoing plasmapheresis/low-dose IVIg, antibody titer reduction correlated with number of treatment cycles for both class I and II antibodies but only up to approximately 4 cycles. Reduction in titer slowed with additional cycles, suggesting a limit to the efficacy of this approach. Furthermore, initial titer (predesensitization) can guide the selection of candidates for successful antibody-removal treatment. In our experience, patients with antibodies at an initial titer >1:512 could not be reduced to the goal of a negative lymphocyte crossmatch, corresponding to a 1:16 titer, despite a significant increase in the number of treatment cycles. Change in mean fluorescence intensity (MFI) value did not correlate with success of treatment if initial MFI values were >10 000, likely due to single antigen bead saturation. Overall, we present a potential prognostic tool to predict candidacy and a monitoring tool to assess efficacy of desensitization treatment.
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Affiliation(s)
- David F Pinelli
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Andrea A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John J Friedewald
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Gjertson
- Division of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, CA, USA
| | - Michelle A Evans
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Erik N Chatroop
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Mary S Leffell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashley A Vo
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Robert A Montgomery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anat R Tambur
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
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20
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Immunoproteasome inhibition induces plasma cell apoptosis and preserves kidney allografts by activating the unfolded protein response and suppressing plasma cell survival factors. Kidney Int 2019; 95:611-623. [PMID: 30685098 DOI: 10.1016/j.kint.2018.10.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/06/2018] [Accepted: 10/04/2018] [Indexed: 02/06/2023]
Abstract
Chronic antibody-mediated rejection is the leading cause of allograft dysfunction and loss after kidney transplantation, and current immunosuppressive regimens fail to target the plasma cells that produce alloantibodies. We previously showed that treatment with the immunoproteasome inhibitor ONX 0914 prevented the expansion of plasma cells and prevented chronic allograft nephropathy and organ failure after kidney transplantation in rats, but the mechanism has remained elusive. In the current study, we confirmed a long-term reduction in alloantibody production and improvements in allograft histology in rats treated with ONX 0914 or with the broad-spectrum proteasome inhibitor bortezomib. Plasma cells from allotransplanted rats expressed immunoproteasomes at high levels. Immunoproteasome inhibition with ONX 0914 led to ubiquitin-conjugate accumulation, activation of the unfolded protein response, and induction of apoptosis in plasma cells. In addition, ONX 0914 suppressed the expression of adhesion molecules (VLA-4 and LFA-1), plasma cell survival factors (APRIL and IL-6), and IFN-γ-inducible chemokines in bone marrow, while the APRIL receptor BCMA, the IL-6 receptor, and the chemokine receptors CXCR4 and CXCR3 were down-regulated on plasma cells. Taken together, immunoproteasome inhibition blocked alloantibody production by inducing apoptosis of plasma cells through activating the unfolded protein response and suppressing plasma cell survival factors in the bone marrow.
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21
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Other Forms of Immunosuppression. KIDNEY TRANSPLANTATION - PRINCIPLES AND PRACTICE 2019. [PMCID: PMC7152196 DOI: 10.1016/b978-0-323-53186-3.00020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Slatinska J, Slavcev A, Honsova E, Hruba P, Kratochvilova I, Rohal T, Viklicky O. Efficacy and safety of BORTEZOMIB treatment for refractory acute antibody-mediated rejection-a pilot study. HLA 2018; 92 Suppl 2:47-50. [DOI: 10.1111/tan.13387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/15/2018] [Accepted: 08/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Janka Slatinska
- Department of Nephrology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Antonij Slavcev
- Department of Immunogenetics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Eva Honsova
- Department of Clinical and Transplantation Pathology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Petra Hruba
- Transplant Laboratory; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Iva Kratochvilova
- Department of Immunogenetics; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Tomas Rohal
- Department of Nephrology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
- Transplant Laboratory; Institute for Clinical and Experimental Medicine; Prague Czech Republic
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23
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On the role of the immunoproteasome in transplant rejection. Immunogenetics 2018; 71:263-271. [PMID: 30220008 DOI: 10.1007/s00251-018-1084-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
The immunoproteasome is expressed in cells of hematopoietic origin and is induced during inflammation by IFN-γ. Targeting the immunoproteasome with selective inhibitors has been shown to be therapeutically effective in pre-clinical models for autoimmune diseases, colitis-associated cancer formation, and transplantation. Immunoproteasome inhibition prevents activation and proliferation of lymphocytes, lowers MHC class I cell surface expression, reduces the expression of cytokines of activated immune cells, and curtails T helper 1 and 17 cell differentiation. This might explain the in vivo efficacy of immunoproteasome inhibition in different pre-clinical disease models for autoimmunity, cancer, and transplantation. In this review, we summarize the effect of immunoproteasome inhibition in different animal models for transplantation.
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24
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Nakano R, Ohira M, Ishiyama K, Ide K, Kobayashi T, Tahara H, Shimizu S, Arihiro K, Imamura M, Chayama K, Tanaka Y, Ohdan H. Acute Graft Rejection and Formation of De Novo Donor-Specific Antibodies Triggered by Low Cyclosporine Levels and Interferon Therapy for Recurrent Hepatitis C Infection After Liver Transplantation: A Case Report. Transplant Proc 2018; 49:1634-1638. [PMID: 28838454 DOI: 10.1016/j.transproceed.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/13/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND We report a case of acute rejection of a liver graft, together with the occurrence of de novo donor-specific antibodies (DSAs), in a 53-year-old Japanese man who had undergone deceased-donor liver transplantation. METHODS The graft rejection was triggered by low cyclosporine levels and pegylated interferon treatment for the recurrence of hepatitis C virus (HCV) infection 18 months after transplantation. Although the graft was ABO-compatible, pre-formed DSA B51 was detected; therefore, total plasma exchange was performed and intravenous rituximab (500 mg/body) was administered before transplantation. RESULTS DSA was absent 6 months after transplantation. HCV recurrence was treated with pegylated interferon-α-2a. Renal function deteriorated with this anti-HCV therapy, with serum cyclosporine levels decreasing to 50 ng/mL. A rapid virologic response was achieved, but liver function deteriorated after 3 months of anti-HCV therapy, with histologic evidence of acute cellular rejection and formation of de novo DSAs. Anti-thymocyte globulin was administered for 5 days, which led to immediate improvement in liver function. However, renal function declined, warranting hemodialysis. The patient recovered 2 months after acute rejection, although de novo DSAs persisted. CONCLUSIONS Careful immunologic monitoring may be required for patients receiving interferon therapy for HCV infection to maintain sufficient blood levels of immunosuppressive agents and to prevent acute liver graft rejection.
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Affiliation(s)
- R Nakano
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - M Ohira
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - K Ishiyama
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Ide
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - T Kobayashi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - H Tahara
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - S Shimizu
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Arihiro
- Department of Pathology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - M Imamura
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - K Chayama
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Y Tanaka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - H Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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25
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Lauro A, Oltean M, Marino IR. Chronic Rejection After Intestinal Transplant: Where Are We in Order to Avert It? Dig Dis Sci 2018; 63:551-562. [PMID: 29327261 DOI: 10.1007/s10620-018-4909-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/02/2018] [Indexed: 12/18/2022]
Abstract
Chronic rejection affects the long-term survival of all solid organ transplants and, among intestinal allografts, occurs in up to 10% of the recipients. The insidious clinical evolution of the chronic allograft enteropathy, the absence of noninvasive biomarkers, and the late endoscopic findings delay its diagnosis. No pharmacological approach has been proven effective, and allograft removal nowadays still represents the only available therapy. The inclusion of the liver in the visceral allograft appears to be the only intervention affecting the development of chronic rejection, as revealed by large-center studies and registry reports. A significant body of evidence emerged from the experimental setting and provided essential knowledge on the complex mechanisms behind the development of chronic allograft enteropathy. More recently, donor-specific antibodies have been suggested as an early, key element in the natural history of chronic allograft enteropathy and several novel approaches, tackling the antibody-mediated graft injury, have gained acceptance in clinical settings and are believed to impact on chronic rejection. The inclusion of a liver allograft is advocated when re-transplanting a sensitized recipient, due to its protective effect against humoral immunity. Multicenter trials are required to understand and tackle chronic rejection, and find the therapeutic answer to this clinical dilemma.
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Affiliation(s)
- Augusto Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy.
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ignazio R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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26
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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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27
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32 Doses of Bortezomib for Desensitization Is Not Well Tolerated and Is Associated With Only Modest Reductions in Anti-HLA Antibody. Transplantation 2017; 101:1222-1227. [PMID: 27379560 DOI: 10.1097/tp.0000000000001330] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously showed that bortezomib (BTZ) partially depletes plasma cells, yet has limited efficacy for desensitization in kidney transplant candidates when up to 16 doses is given. METHODS This study aimed to determine the safety and efficacy of 32 doses of BTZ (1.3 mg/m of body surface area) in 10 highly sensitized kidney transplant candidates with alloantibodies against their intended living donor. RESULTS Dose reduction was needed in 2 patients and 2 others completely discontinued therapy for adverse events. Anti-HLA antibodies mean fluorescence intensity (MFI) values were stable prior to BTZ (P = 0.96) but decreased after therapy (mean decrease of 1916 [SE, 425] MFI, P < 0.01). No patient developed a negative crossmatch against their original intended donor, and the calculated panel-reactive antibodies based on MFI of 2000, 4000, and 8000 was unchanged in all patients. CONCLUSIONS These data suggest that 32 doses of BTZ monotherapy was not well tolerated and resulted in only a modest reduction in anti-HLA antibodies.
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28
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Parolin M, Vidal E. Complications of therapeutic apheresis in pediatric kidney transplantation. Transfus Apher Sci 2017; 56:510-514. [PMID: 28760487 DOI: 10.1016/j.transci.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In the setting of kidney transplantation, therapeutic apheresis (TA) is employed both for pre-intervention procedures and during the post-transplant period. In pediatric nephrology units, TA is usually performed as a therapeutic plasma exchange (TPE) with dialysis equipment, and using non-plasma replacement fluids. In children undergoing kidney transplantation, complications of TPE are mainly related to its depletive properties combined with the iatrogenic immunodeficiency status of the patient. Moreover, the use of small central venous catheters and the equipment standardized for adults can increase the risk of adverse events. Focusing on these preconditions, TA in kidney-transplanted children should be performed in specialized centers with specific protocols and a trained staff.
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Affiliation(s)
- Mattia Parolin
- Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy
| | - Enrico Vidal
- Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy.
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29
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No prolongation of skin allograft survival by immunoproteasome inhibition in mice. Mol Immunol 2017; 88:32-37. [DOI: 10.1016/j.molimm.2017.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/18/2017] [Accepted: 05/25/2017] [Indexed: 01/03/2023]
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30
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Yamamoto T, Watarai Y, Takeda A, Tsujita M, Hiramitsu T, Goto N, Narumi S, Katayama A, Morozumi K, Uchida K, Kobayashi T. De Novo Anti-HLA DSA Characteristics and Subclinical Antibody-Mediated Kidney Allograft Injury. Transplantation 2017; 100:2194-202. [PMID: 26636737 DOI: 10.1097/tp.0000000000001012] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unclear whether all donor-specific antibodies (DSA) can cause chronic antibody-mediated rejection (AMR). Subclinical stage before manifestation of renal dysfunction may be a critical period for reversing AMR. The aim of our study was to identify factors related to the development of subclinical AMR and to clarify the characteristics of de novo DSA. METHODS Eight hundred ninety-nine renal transplants were screened for HLA antibody. De novo DSA were detected in 95 patients. Forty-three patients without renal dysfunction who underwent renal biopsies were enrolled in this study. Eighteen patients (41.9%) were diagnosed with biopsy-proven subclinical AMR and treated with plasmapheresis and rituximab-based therapy, whereas 25 showed no findings of AMR. RESULTS Significant subclinical AMR-related factors were younger recipients, history of acute T cell-mediated rejection and DSA class II, especially DR-associated DSA. Mean fluorescence intensity (MFI) values of DR-DSA were significantly higher, whereas DQ-DSA was not different between subclinical AMR and no AMR. The ΔMFI (>50%), DSA-MFI values greater than 3000, and C1q binding DSA were also significant subclinical AMR-related factors (P < 0.05). Among 18 patients treated for subclinical AMR, 8 patients (44.4%) obtained over 50% reduction of DSA-MFI and/or improvement or no deterioration of pathological findings. In contrast, 25 patients without subclinical AMR did not show renal dysfunction clinically. Moreover, all of the 8 patients with rebiopsy after 2 years continued to demonstrate no AMR. CONCLUSIONS About 40% of patients with de novo DSA demonstrated biopsy-proven subclinical AMR, leading to progressive graft injury. To validate the intervention and treatment for de novo DSA-positive patients without renal dysfunction, further study is necessary.
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Affiliation(s)
- Takayuki Yamamoto
- 1 Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan. 2 Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan. 3 Department of Transplant Surgery, Masuko Memorial Hospital, Nagoya, Japan. 4 Department of Nephrology, Masuko Memorial Hospital, Nagoya, Japan. 5 Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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Kizilbash S, Claes D, Ashoor I, Chen A, Jandeska S, Matar RB, Misurac J, Sherbotie J, Twombley K, Verghese P. Bortezomib in the treatment of antibody-mediated rejection in pediatric kidney transplant recipients: A multicenter Midwest Pediatric Nephrology Consortium study. Pediatr Transplant 2017; 21. [PMID: 28092129 DOI: 10.1111/petr.12873] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/18/2023]
Abstract
Antibody-mediated rejection leads to allograft loss after kidney transplantation. Bortezomib has been used in adults for the reversal of antibody-mediated rejection; however, pediatric data are limited. This retrospective study was conducted in collaboration with the Midwest Pediatric Nephrology Consortium. Pediatric kidney transplant recipients who received bortezomib for biopsy-proven antibody-mediated rejection between 2008 and 2015 were included. The objective was to characterize the use of bortezomib in pediatric kidney transplant recipients. Thirty-three patients received bortezomib for antibody-mediated rejection at nine pediatric kidney transplant centers. Ninety percent of patients received intravenous immunoglobulin, 78% received plasmapheresis, and 78% received rituximab. After a median follow-up of 15 months, 65% of patients had a functioning graft. The estimated glomerular filtration rate improved or stabilized in 61% and 36% of patients at 3 and 12 months post-bortezomib, respectively. The estimated glomerular filtration rate at diagnosis significantly predicted estimated glomerular filtration rate at 12 months after adjusting for chronic histologic changes (P .001). Fifty-six percent of patients showed an at least 25% reduction in the mean fluorescence intensity of the immune-dominant donor-specific antibody, 1-3 months after the first dose of bortezomib. Non-life-threatening side effects were documented in 21 of 33 patients. Pediatric kidney transplant recipients tolerated bortezomib without life-threatening side effects. Bortezomib may stabilize estimated glomerular filtration rate for 3-6 months in pediatric kidney transplant recipients with antibody-mediated rejection.
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Affiliation(s)
| | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Isa Ashoor
- Children's Hospital New Orleans, New Orleans, LA, USA
| | - Ashton Chen
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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32
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De Sousa-Amorim E, Revuelta I, Diekmann F, Cofan F, Lozano M, Cid J, Palou E, Sole M, Campistol JM, Oppenheimer F. Bortezomib for refractory acute antibody-mediated rejection in kidney transplant recipients: A single-centre case series. Nephrology (Carlton) 2017; 21:700-4. [PMID: 26492594 DOI: 10.1111/nep.12659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 11/26/2022]
Abstract
AIM Acute antibody-mediated rejection (ABMR) after kidney transplantation (KT) is associated with poor allograft survival. Current therapies for ABMR are able to deplete B-lymphocytes but do not target plasma cells. Bortezomib is a proteasome inhibitor that can eliminate plasma cells and has demonstrated utility in the treatment of ABMR. METHODS A retrospective study was carried out from 2010 to 2014, including all patients with ABMR refractory to conventional treatment who received bortezomib. Bortezomib (1.3 mg/m(2) ) was administered intravenously on days 1, 4, 8, and 11. Renal function, graft survival, follow-up biopsies, and donor-specific antibodies (DSA) were recorded. RESULTS We identified seven patients. Of these, high immunological risk was found in 6 of 7, preformed DSA were found in 5 of 7, flow cytometry crossmatch was positive in 4 of 7, and desensitization before KTx was provided in 6 of 7 patients. ABMR was diagnosed at a median of 90 days (8-167) post-KT. After bortezomib therapy, renal function improved or stabilized in 5 of 7 patients and progressively deteriorated in 2 of 7, leading to haemodialysis after 7 and 11 months, respectively. Follow-up kidney biopsies showed persistence of ABMR in 2 of 7, chronic active ABMR 3 of 7 and inactive chronic lesions in 2 of 7. DSA titres significantly decreased after treatment (P = 0.028). All patients experienced mild adverse events. After a follow-up of 22 ± 18 months, three grafts were lost (42%) and four remained functioning. CONCLUSION Bortezomib could be useful as an adjuvant therapy for ABMR refractory to conventional treatment with acceptable mid-term outcomes in these severe cases. More research is needed to develop strategies to better preserve graft function after refractory ABMR.
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Affiliation(s)
| | - Ignacio Revuelta
- Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), CRB CELLEX
| | - Fritz Diekmann
- Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), CRB CELLEX
| | | | - Miquel Lozano
- Hemotherapy and Hemostasis, Hospital Clinic Barcelona, Barcelona, Spain
| | - Joan Cid
- Hemotherapy and Hemostasis, Hospital Clinic Barcelona, Barcelona, Spain
| | - Eduard Palou
- Immunology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Manel Sole
- Histopathology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Josep María Campistol
- Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), CRB CELLEX
| | - Federic Oppenheimer
- Nephrology, Hospital Clinic Barcelona, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), CRB CELLEX
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33
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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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34
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Vacha M, Chery G, Hulbert A, Byrns J, Benedetti C, Finlen Copeland CA, Gray A, Onwuemene O, Palmer SM, Snyder LD. Antibody depletion strategy for the treatment of suspected antibody-mediated rejection in lung transplant recipients: Does it work? Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12886] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mary Vacha
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Godefroy Chery
- Department of Medicine; Duke University Hospital; Durham NC USA
| | - Amanda Hulbert
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Jennifer Byrns
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | - Clark Benedetti
- Department of Pharmacy; Duke University Hospital; Durham NC USA
| | | | - Alice Gray
- Department of Medicine; Duke University Hospital; Durham NC USA
| | | | - Scott M. Palmer
- Department of Medicine; Duke University Hospital; Durham NC USA
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35
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Acute antibody-mediated rejection in kidney transplant recipients. Transplant Rev (Orlando) 2017; 31:47-54. [DOI: 10.1016/j.trre.2016.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 10/05/2016] [Indexed: 01/10/2023]
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36
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Prevention and treatment of liver allograft antibody-mediated rejection and the role of the 'two-hit hypothesis'. Curr Opin Organ Transplant 2016; 21:209-18. [PMID: 26918881 DOI: 10.1097/mot.0000000000000275] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The review outlines the diagnosis, prevention strategies, and possible treatment options for acute and chronic antibody-mediated rejection (AMR). RECENT FINDINGS Although rare, severe acute AMR (aAMR) usually occurs in patients with high mean fluorescence intensity despite serial dilutions or high-titer preformed class I donor-specific alloantibodies (DSA). The diagnosis is suspected when allograft dysfunction occurs with DSA, diffuse C4d staining, and a microvascular injury, and may be aided by the aAMR score. However, the incidence of and treatment approach to combined T-cell-mediated rejection (TCMR) with DSA present and some but not all features of AMR is yet to be determined. Chronic liver allograft AMR is characterized by low-grade chronic inflammation and progressive fibrosis with DSA, the chronic AMR (cAMR) score may facilitate diagnosis. The 'two-hit' hypothesis, whereby a coexistent insult upregulates human leukocyte antigen class II target antigens on the microvascular endothelium, may explain why suboptimal donors with lower sensitization levels might suffer from acute AMR and those with chronic complications (e.g., recurrent original disease) might be more susceptible to chronic AMR. Although treatment algorithms are needed, prevention is preferable and at a minimum includes transfusion minimization, and medication adherence. SUMMARY Severe acute AMR is rare but diagnosable, and there is need to determine the incidence of and optimal therapy for less severe combined AMR and TCMR. Chronic AMR is likely more common and of significant relevance to long-term allograft survival improvement. The two-hit hypothesis may help to explain the rarity of both findings and shed insight onto future prevention and treatment strategies.
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The Influence of Immunosuppressive Agents on the Risk of De Novo Donor-Specific HLA Antibody Production in Solid Organ Transplant Recipients. Transplantation 2016; 100:39-53. [PMID: 26680372 PMCID: PMC4683034 DOI: 10.1097/tp.0000000000000869] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Production of de novo donor-specific antibodies (dnDSA) is a major risk factor for acute and chronic antibody-mediated rejection and graft loss after all solid organ transplantation. In this article, we review the data available on the risk of individual immunosuppressive agents and their ability to prevent dnDSA production. Induction therapy with rabbit antithymocyte globulin may achieve a short-term decrease in dnDSA production in moderately sensitized patients. Rituximab induction may be beneficial in sensitized patients, and in abrogating rebound antibody response in patients undergoing desensitization or treatment for antibody-mediated rejection. Use of bortezomib for induction therapy in at-risk patients is of interest, but the benefits are unproven. In maintenance regimens, nonadherent and previously sensitized patients are not suitable for aggressive weaning protocols, particularly early calcineurin inhibitor withdrawal without lymphocyte-depleting induction. Early conversion to mammalian target of rapamycin inhibitor monotherapy has been reported to increase the risk of dnDSA formation, but a combination of mammalian target of rapamycin inhibitor and reduced-exposure calcineurin inhibitor does not appear to alter the risk. Early steroid therapy withdrawal in standard-risk patients after induction has no known dnDSA penalty. The available data do not demonstrate a consistent effect of mycophenolic acid on dnDSA production. Risk minimization for dnDSA requires monitoring of adherence, appropriate risk stratification, risk-based immunosuppression intensity, and prospective DSA surveillance.
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Current outcomes of chronic active antibody mediated rejection - A large single center retrospective review using the updated BANFF 2013 criteria. Hum Immunol 2016; 77:346-52. [PMID: 26867813 DOI: 10.1016/j.humimm.2016.01.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The updated BANFF 2013 criteria has enabled a more standardized and complete serologic and histopathologic diagnosis of chronic active antibody mediated rejection (cAMR). Little data exists on the outcomes of cAMR since the initiation of this updated criteria. METHODS 123 consecutive patients with biopsy proven cAMR (BANFF 2013) between 2006 and 2012 were identified. RESULTS Patients identified with cAMR were followed for a median of 9.5 (2.7-20.3) years after transplant and 4.3 (0-8.8) years after cAMR. Ninety-four (76%) recipients lost their grafts with a median survival of 1.9 years after diagnosis with cAMR. Mean C4d and allograft glomerulopathy scores were 2.6 ± 0.7 and 2.2 ± 0.8, respectively. 53.2% had class II DSA, 32.2% had both class I and II, and 14.5% had class I DSA only. Chronicity score >8 (HR 2.9, 95% CI 1-8.4, p=0.05), DSA >2500 MFI (HR 2.8, 95% CI 1.1-6.8, p=0.03), Scr >3mg/dL (HR 3.2, 95% CI 1.6-6.3, p=0.001) and UPC >1g/g (HR 2.5, 95% CI 1.4-4.5, p=0.003) were associated with a higher risk of graft loss. CONCLUSIONS cAMR was associated with poor graft survival after diagnosis. Improved therapies and earlier detection strategies are likely needed to improve outcomes of cAMR in kidney transplant recipients.
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39
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King KE, Montgomery RA. Therapeutic plasma exchange for kidney transplantation: the problem of antibody-mediated rejection. Transfusion 2016; 55:696-9. [PMID: 26840785 DOI: 10.1111/trf.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Karen E King
- Hemapheresis and Transfusion Support Service, Department of Pathology
| | - Robert A Montgomery
- Comprehensive Transplant Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
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Gazdic T, Svobodova E, Kubanek M, Kment M, Pagacova L, Viklicky O, Malek I, Kautzner J. Bortezomib-containing regimen for primary treatment of early antibody-mediated cardiac allograft rejection: a case report. Prog Transplant 2015; 25:147-52. [PMID: 26107275 DOI: 10.7182/pit2015934] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Evidence regarding the use of bortezomib-containing schemes in primary treatment of antibody-mediated rejection in heart transplant recipients is scarce. This case report presents the clinical experience with upstream use of bortezomib in primary treatment of early antibody-mediated rejection in an adult heart transplant recipient. Two cycles of bortezomib together with methylprednisolone, immunoadsorption, rituximab, and supplementary doses of intravenous immunoglobulin G reversed signs of heart failure, production of donor-specific antibodies, and findings of antibody-mediated rejection in biopsy. This treatment regimen was tolerated with only mild hematologic toxicity and proved to be successful during a 12-month follow-up. Primary treatment with a bortezomib-containing regimen appears to be a new therapeutic option for severe antibody-mediated rejection in heart transplant recipients. However, the efficacy and safety of this treatment need to be tested in prospective trials.
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Affiliation(s)
- Tomas Gazdic
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Eva Svobodova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milos Kubanek
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martin Kment
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Libuse Pagacova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Malek
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate the effectiveness of bortezomib in the recent literature for the prevention and treatment of kidney transplant rejection. RECENT FINDINGS Several studies have analyzed bortezomib alone and in comparison to more traditional immunosuppressive agents during the last 2 years. If administered prior to transplant or soon thereafter, bortezomib appears to lower donor-specific antibody levels and improves graft survival. Its role as a treatment option for antibody-mediated rejection after transplant remains unclear, with limited evidence supporting its long-term success. SUMMARY Bortezomib appears to be a promising early desensitizing agent in the world of kidney transplantation and high short-term success rates have been observed. However, additional randomized trials would be useful to more conclusively demonstrate its effectiveness and optimal administration time in relation to transplant surgery.
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Abstract
PURPOSE OF REVIEW There are several monoclonal and polyclonal antibodies used in renal transplantation today, this article will discuss several agents, their updates and newer agents. RECENT FINDINGS Antithymocyte globulin and interleukin-2 (IL-2) receptor blocker continue to be used as induction agents. The risk of acute rejection was higher in IL-2 receptor blockers mainly in the first year, but graft survivals were similar in both groups long term. Belatacept is the only approved intravenous maintenance immunosuppressive therapy which provides the benefit of glomerular filtration rate preservation, but it was associated with a higher risk of acute rejection and post-transplant lymphoproliferative disorder. Bortezomib may help decrease donor-specific antibody levels, but there are limited data to support its use for desensitization or rejection. Eculizumab may help in antibody-mediated rejection in some cases but has not shown promising long-term effects in high-risk individuals. Newer agents have been continuously tested for improved efficacy and safety. SUMMARY Transplantation is the standard of care for end-stage renal disease patients, but we still have a long way to go, as we need to improve long-term outcomes. The manipulation of the immune system is a delicate undertaking, with risks of adverse events; therefore, risk versus benefit needs to be carefully evaluated and treatment needs to be individualized.
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Abstract
Multiple myeloma is a plasma cell malignancy in which significant advances have been observed during the last 15 years. Our understanding of the disease has been advanced through its molecular characterization. We have also seen improvements in patient care with the development of 2 new classes of active agents, proteasome inhibitors and immunomodulatory drugs (IMiDs), resulting in a significant improvement in overall survival of myeloma patients such that it can now be debated as to whether some subsets of myeloma patients can be cured. However, the advances in our understanding of myeloma biology occurred in parallel with advances in treatment as opposed to being directly informed by the research. Moreover, the molecular characterization of malignant plasma cells would not have predicted the effectiveness of these novel therapies.We hypothesize that proteasome inhibitors and IMiDs are highly active because malignant plasma cells are constrained by many of the characteristics of their normal counterparts and these novel therapies target both normal plasma cell biology and the cancer biology of myeloma. Thus, a better understanding of normal plasma cell biology will likely yield as many actionable targets as mapping the genomic landscape of this disease.
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Pretagostini R, Poli L, Gozzer M, Pettorini L, Garofalo M, Novelli S, Cinti P, Berloco P. Plasmapheresis, Photopheresis, and Endovenous Immunoglobulin in Acute Antibody-mediated Rejection in Kidney Transplantation. Transplant Proc 2015; 47:2142-4. [DOI: 10.1016/j.transproceed.2015.01.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/08/2015] [Accepted: 01/28/2015] [Indexed: 12/01/2022]
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Calcineurin Inhibitor Minimization With Ixazomib, an Investigational Proteasome Inhibitor, for the Prevention of Antibody Mediated Rejection in a Preclinical Model. Transplantation 2015; 99:1785-95. [DOI: 10.1097/tp.0000000000000736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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A Banff Component Scoring-based Histologic Assessment of Bortezomib-based Antibody-mediated Rejection Therapy. Transplantation 2015; 99:1691-9. [DOI: 10.1097/tp.0000000000000694] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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47
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Wongsaroj P, Kahwaji J, Vo A, Jordan SC. Modern approaches to incompatible kidney transplantation. World J Nephrol 2015; 4:354-362. [PMID: 26167458 PMCID: PMC4491925 DOI: 10.5527/wjn.v4.i3.354] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 03/11/2015] [Accepted: 04/07/2015] [Indexed: 02/06/2023] Open
Abstract
The presence of human-leukocyte antigen (HLA)-antibodies and blood group incompatibility remain a large barrier to kidney transplantation leading to increased morbidity and mortality on the transplant waiting list. Over the last decade a number of new approaches were developed to overcome these barriers. Intravenous immunoglobulin (IVIG) remains the backbone of HLA desensitization therapy and has been shown in a prospective, randomized, placebo controlled trial to improve transplantation rates. Excellent outcomes with the addition of rituximab (anti-B cell) to IVIG based desensitization have been achieved. There is limited experience with bortezomib (anti-plasma cell) and eculizumab (complement inhibition) for desensitization. However, these agents may be good adjuncts for patients who are broadly sensitized with strong, complement-fixing HLA antibodies. Excellent short and long-term outcomes have been achieved in ABO incompatible transplantation with the combination of antibody removal, B cell depletion, and pre-transplant immunosuppression. Kidney paired donation has emerged as a reasonable alternative for programs who cannot provide desensitization or in conjunction with desensitization. Future therapies directed toward cytokines that alter B cell proliferation are under investigation.
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Abstract
PURPOSE OF REVIEW In the present review, we aim to describe the state of knowledge concerning antibody-mediated rejection (ABMR) spectrum and diagnosis criteria before analyzing the present and future promising leads regarding ABMR prognosis markers and treatment. RECENT FINDINGS Recent studies regarding complement-binding donor-specific antibodies and the molecular approach highlighted the unmet need for stratification tools for prognosis and treatment inside ABMR disease. SUMMARY ABMR is the leading cause of kidney allograft failure. The recent expansion of its spectrum is related to the paradigm of a continuous process, leading insidiously to a chronic form of ABMR and to the progressive acknowledgement of new entities (such as vascular ABMR, subclinical ABMR, C4d-negative ABMR). Considering the global picture of ABMR, the Banff classification gradually refined the diagnosis criteria so that it now describes a clinically relevant and coherent entity. Nevertheless, if the diagnosis mainly relies on conventional assessment, such as histological findings and circulating donor-specific antibodies, these criteria face serious limitations in terms of stratification of patients at risk of graft loss inside ABMR disease. Recently, new promising tools have emerged in order to identify long-term outcomes at the time of the diagnosis of rejection. In this regard, donor-specific antibodies' complement-fixing ability and the molecular approach contributed significantly. Currently, however, no clinically relevant surrogate marker of treatment efficiency is currently available.
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Sin YH, Kim YJ, Oh JS, Lee JH, Kim SM, Kim JK. Treatment of acute antibody-mediated rejection using bortezomib: a case report. Nephrology (Carlton) 2015; 20 Suppl 2:86-9. [DOI: 10.1111/nep.12459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Yong-Hun Sin
- Division of Nephrology; Department of Internal Medicine; Bong Seng Hospital; Busan Korea
| | - Yong-Jin Kim
- Department of Pathology; Yeungnam University College of Medicine; Daegu Korea
| | - Joon Seok Oh
- Division of Nephrology; Department of Internal Medicine; Bong Seng Hospital; Busan Korea
| | - Jin Ho Lee
- Division of Nephrology; Department of Internal Medicine; Bong Seng Hospital; Busan Korea
| | - Seong Min Kim
- Division of Nephrology; Department of Internal Medicine; Bong Seng Hospital; Busan Korea
| | - Joong Kyung Kim
- Division of Nephrology; Department of Internal Medicine; Bong Seng Hospital; Busan Korea
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Report of the inefficacy of eculizumab in two cases of severe antibody-mediated rejection of renal grafts. Transplantation 2015; 98:1056-9. [PMID: 24839895 DOI: 10.1097/tp.0000000000000184] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute antibody-mediated rejection (AMR) is responsible for up to 20% to 30% of acute rejection after kidney transplantation. New therapeutic agents have recently emerged, such as eculizumab, an anticomplement protein-C5 monoclonal antibody. In the setting of renal transplantation, eculizumab has so far proved effective both for preventive and curative treatments of AMR in sensitized patients and patients diagnosed with severe AMR. Unsuccessful eculizumab treatment has only been reported once in the literature by Stegall et al. (Am J Transplant 2011; 11: 2405). METHODS AND RESULTS We present two cases of AMR resistant to eculizumab after renal transplantation. One patient received the anti-C5 antibody curatively, and the other patient developed AMR while being treated with eculizumab after a relapse of atypical hemolytic uremic syndrome. The peculiarity of these two cases was the absence of C4d deposition in peritubular capillaries as well as the absence of C1q-binding donor-specific anti-human leukocyte antigen alloantibody, as determined retrospectively, suggesting that a complement-independent mechanism underlies the pathogenesis of these AMR. CONCLUSION The use of eculizumab in C4d-negative or C1q-negative AMR does not seem effective.
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