1
|
Ahmadpoor P, Moranne O. Manipulating the complement system via Therapeutic plasmapheresis: Is there any therapeutic role? J Clin Apher 2022; 37:529-530. [PMID: 35913036 DOI: 10.1002/jca.22001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Pedram Ahmadpoor
- Service Nephrologie Dialyse Apherese, Hopital Universitaire de Nimes, Nimes, France
| | - Olivier Moranne
- Service Nephrologie Dialyse Apherese, Hopital Universitaire de Nimes, Nimes, France.,IDESP UMR INSERM, Montpellier, France
| |
Collapse
|
2
|
Maritati F, Bini C, Cuna V, Tondolo F, Lerario S, Grandinetti V, Busutti M, Corradetti V, La Manna G, Comai G. Current Perspectives in ABO-Incompatible Kidney Transplant. J Inflamm Res 2022; 15:3095-3103. [PMID: 35642217 PMCID: PMC9148605 DOI: 10.2147/jir.s360460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/17/2022] [Indexed: 12/22/2022] Open
Abstract
For a long time, ABO incompatible living donor kidney transplantation has been considered contraindicated, due to the presence of isohemagglutinins, natural antibodies reacting with non-self ABO antigens. However, as the demand for kidney transplantation is constantly growing, methods to expand the donor pool have become increasingly important. Thus, in the last decades, specific desensitization strategies for ABOi transplantation have been developed. Nowadays, these regimens consist of transient removal of preformed anti-A or anti-B antibodies by using plasmapheresis or immunoadsorption and B-cell immunity modulation by CD20+ cells depletion with rituximab, in association with maintenance immunosuppression including corticosteroids, tacrolimus and mycophenolate mofetil. The outcome in ABOi kidney transplantation have markedly improved over the years. In fact, although randomized trials are still lacking, recent meta analysis has revealed that there is no difference in terms of graft and patient's survival between ABOi and ABO compatible kidney transplant, even in the long term. However, many concerns still exist, because ABOi kidney transplantation is associated with an increased risk of bleeding and infectious complications, partly related to the effects of extracorporeal treatments and the strong immunosuppression. Thus, a continuous improvement in desensitization strategies, with the aim of minimize the immunosuppressive burden, on the basis of immune pathogenesis, antibodies titers and/or ABO blood group, is warranted. In this review, we discuss the main immune mechanisms involved in ABOi kidney transplantation, the pathogenesis of tolerance and the desensitization regimens, including immunoadsorption and plasmapheresis and the immunosuppressive protocol. Finally, we provide an overview on outcome and future perspectives in ABOi kidney transplant.
Collapse
Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Lerario
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Grandinetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| |
Collapse
|
3
|
Mohamed M, Sweeney T, Alkhader D, Nassar M, Alqassieh A, Lakhdar S, Nso N, Fülöp T, Daoud A, Soliman KM. ABO incompatibility in renal transplantation. World J Transplant 2021; 11:388-399. [PMID: 34631470 PMCID: PMC8465511 DOI: 10.5500/wjt.v11.i9.388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/19/2021] [Accepted: 09/01/2021] [Indexed: 02/06/2023] Open
Abstract
ABO blood group incompatibility (ABO-I) was historically considered an absolute contraindication to kidney transplantation due to the significant risk of acute antibody-mediated rejection and early graft loss. Nevertheless, the urge to minimize the gap between the candidates’ number on the waitlist for kidney transplants and the available kidney donors encourage investigation into finding ways to use organs from ABO-I kidney donors, especially in the era of using more potent immunosuppression therapies. This review aims to discuss a general overview of ABO-I kidney transplantation and the different protocols adopted by some transplant centers to meaningfully overcome this barrier.
Collapse
Affiliation(s)
- Mahmoud Mohamed
- Department of Medicine, North Mississippi Medical Center, Tupelo, MS 38804, United States
| | - Tara Sweeney
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Duaa Alkhader
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health and Hospitals, Queens, New York, NY 11432, United States
| | - Ahmed Alqassieh
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Sofia Lakhdar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health and Hospitals, Queens, New York, NY 11432, United States
| | - Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health and Hospitals, Queens, New York, NY 11432, United States
| | - Tibor Fülöp
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ahmed Daoud
- Department of Medicine, Kasr Alainy Medical School, Cairo University, Cairo 11562, Egypt
| | - Karim M Soliman
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| |
Collapse
|
4
|
Cen M, Wang R, Kong W, Deng H, Lei W, Chen J. ABO-incompatible living kidney transplantation. Clin Transplant 2020; 34:e14050. [PMID: 32713064 DOI: 10.1111/ctr.14050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022]
Abstract
ABO-incompatible living kidney transplantation is nowadays a routine procedure to expand living donor pool. The past decades have seen the evolution of desensitization protocol and immunosuppression regimen. Despite increased bleeding events, infectious complications, and rejection episodes reported in some studies, favorable graft and patient survival rate are now achieved, regardless of various protocols among transplant centers. Several issues such as the usage of rituximab and standardization of blood group antibody titration remain to be settled. The deposition of C4d is no longer the histopathologic hallmark of antibody-mediated rejection, which have inspired innovative strategies of peripheral molecular screening and the improvement of histological diagnosis of AMR (antibody-mediated rejection). The better understanding of the underlying mechanism might facilitate the distinction and therapeutic schemes of AMR.
Collapse
Affiliation(s)
- Menger Cen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weiwei Kong
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Deng
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenhua Lei
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
5
|
Salvadori M, Tsalouchos A. Current protocols and outcomes of ABO-incompatible kidney transplantation. World J Transplant 2020; 10:191-205. [PMID: 32844095 PMCID: PMC7416363 DOI: 10.5500/wjt.v10.i7.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
One of the principal obstacles in transplantation from living donors is that approximately 30% are immunologically incompatible because of the presence in the recipient of antibodies directed against the human leukocyte antigen system of the donor or because of the incompatibility of the ABO system. The aim of this review is to describe the more recent data from the literature on the different protocols used and the clinical outcomes of ABO-incompatible kidney transplantation. Two different strategies are used to overcome these barriers: desensitization of the recipient to remove the antibodies and to prevent their rebound after transplantation and the exchange of organs between two or more pairs. The largest part of this review is dedicated to describing the techniques of desensitization. Even if the first reports of successful renal transplantation between ABO-incompatible pairs have been published by 1980, the number of ABO-incompatible transplants increased substantially in this century because of our improved knowledge of the immune system and the availability of new drugs. Rituximab has substantially replaced splenectomy. The technique of apheresis has improved and more recently a tailored desensitization proved to be the more efficient strategy avoiding an excess of immunosuppression with the related side effects. Recent reports document outcomes for such transplantation similar to the outcomes of standard transplantation.
Collapse
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
| |
Collapse
|
6
|
Uchida J, Kosoku A, Naganuma T, Tanaka T, Nakatani T. Latest insights on ABO-incompatible living-donor renal transplantation. Int J Urol 2019; 27:30-38. [PMID: 31522462 PMCID: PMC7004137 DOI: 10.1111/iju.14109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
This review summarizes the latest insights on ABO‐incompatible living‐donor renal transplantation. Desensitization protocols and clinical outcomes were investigated, and a comparison was made with kidney‐paired donation, which is not permitted in Japan for ethical reasons. Although renal transplantation is greatly beneficial for most patients with end‐stage kidney disease, many of these patients must remain on dialysis therapy for extended periods due to the scarcity of organs from deceased donors. ABO blood type incompatibility was once believed to be a contraindication to renal transplantation due to the increased risk for antibody‐mediated rejection and early graft loss attributable to isoagglutinins. Recently, pretransplant desensitization strategies, such as removal of isoagglutinins and antibody‐producing cells, have achieved successful outcomes, although it remains unclear whether graft survival and patient morbidity are equivalent to those for ABO‐compatible renal transplantation. The present review suggested that ABO‐incompatible living‐donor renal transplantation might be a favorable radical renal replacement therapy for patients with end‐stage kidney disease.
Collapse
Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Kosoku
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihide Naganuma
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Tanaka
- Department of Urology, Suita Municipal Hospital, Suita, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
7
|
Defendi F, Malvezzi P, Eskandary F, Cesbron JY, Rostaing L, Böhmig GA, Dumestre-Pérard C. Effects of immunoadsorption combined with membrane filtration on complement markers - results of a randomized, controlled, crossover study. Transpl Int 2019; 32:876-883. [PMID: 30901502 DOI: 10.1111/tri.13431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/05/2019] [Accepted: 03/19/2019] [Indexed: 12/24/2022]
Abstract
The complement system has been implicated in several kidney diseases, such as antibody-mediated rejection after kidney transplantation. Antibody-depletion techniques allow successful ABO- and/or HLA-incompatible transplantation. Considering the IgG removal, the use of semi-selective immunoadsorption (IA) has been advocated. However, because of results on incomplete IgM depletion, the adjunctive use of membrane filtration (MF) has been proposed to enhance the removal of macromolecules and to interfere with complement activation. This secondary endpoint analysis of a recently published randomized, controlled, cross-over trial was designed to investigate the effect of combined treatment IA + MF compared to IA alone on complement depletion. Two treatment sequences, a single session of IA + MF followed by IA (and vice versa), were analyzed with regard to C5b-9, properdin, and mannose-binding lectin (MBL) levels. Neither IA alone nor IA + MF provoked complement activation as demonstrated by stable low levels of C5b-9 after the procedure as compared to the previous. The combined treatment substantially lowered properdin (77% vs. 26% reduction, P < 0.0001) as well as MBL concentrations (81% vs. 11% reduction, P < 0.0001). Recovery of properdin and MBL levels appears to be longer after IA alone compared to IA + MF. Depletion of properdin and MBL levels may have potential clinical implications in the setting of kidney transplantation.
Collapse
Affiliation(s)
- Federica Defendi
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire (CHU) Grenoble-Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jean-Yves Cesbron
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire (CHU) Grenoble-Alpes, Grenoble, France.,BNI TIMC-IMAG, UMR5525, CNRS-Université Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Chantal Dumestre-Pérard
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire (CHU) Grenoble-Alpes, Grenoble, France.,BNI TIMC-IMAG, UMR5525, CNRS-Université Grenoble Alpes, Grenoble, France
| |
Collapse
|
8
|
Sethi SK, Bansal SB, Wadhwani N, Tiwari A, Arora D, Sharma R, Nandwani A, Yadav DK, Mahapatra AK, Jain M, Jha P, Ghosh P, Bhan A, Dhaliwal M, Raghunathan V, Kher V. Pediatric ABO-incompatible kidney transplantation: Evolving with the advancing apheresis technology: A single-center experience. Pediatr Transplant 2018; 22:e13138. [PMID: 29380556 DOI: 10.1111/petr.13138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/11/2022]
Abstract
Recent literature has endorsed favorable outcomes following ABOi kidney transplantation in pediatric population. Nevertheless, reluctance to pursue an ABOi still remains pervasive. This could be ascribed to various legitimate reasons, namely less extensive pediatric ABOi data, technical difficulties encountered during PP, cost restraints, and concerns regarding higher rates of antibody-mediated rejection, infectious complications, and post-transplant lymphoproliferative disorder as compared to adults. However, given the similar excellent outcomes of both ABOi and ABOc kidney transplantation, clinicians should consider this option sooner if a compatible donor or swap is not available. Here, we describe the outcomes of three pediatric ABOi performed at our institute in India (from 2014 till now), wherein distinct apheresis modalities had been employed in each desensitization protocol, and our techniques evolved with advancing science in apheresis. This case series includes India's first published pediatric ABO-incompatible transplant (Case 2) and the youngest child to undergo ABO-incompatible renal transplant in SAARC nations (Case 3).
Collapse
Affiliation(s)
- Sidharth Kumar Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Shyam Bihari Bansal
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Nikita Wadhwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Aseem Tiwari
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Arora
- Blood Transfusion Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Reetesh Sharma
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Ashish Nandwani
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Dinesh Kumar Yadav
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Amit Kumar Mahapatra
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Manish Jain
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Pranaw Jha
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Prasun Ghosh
- Urology Department, Medanta, The Medicity Hospital, Gurgaon, India
| | - Anil Bhan
- Cardiothoracic Surgery, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maninder Dhaliwal
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Veena Raghunathan
- Pediatric Critical Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Vijay Kher
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| |
Collapse
|
9
|
Timsit MO, Kleinclauss F, Mamzer Bruneel M, Thuret R. Le donneur vivant de rein. Prog Urol 2016; 26:940-963. [DOI: 10.1016/j.purol.2016.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 08/29/2016] [Accepted: 09/01/2016] [Indexed: 01/10/2023]
|
10
|
Rostaing L, Allal A, Del Bello A, Sallusto F, Esposito L, Doumerc N, Debiol B, Delas A, Game X, Kamar N. Treatment of large plasma volumes using specific immunoadsorption to desensitize ABO-incompatible kidney-transplant candidates. J Nephropathol 2016; 5:90-7. [PMID: 27540536 PMCID: PMC4961822 DOI: 10.15171/jnp.2016.17] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/14/2016] [Indexed: 12/11/2022] Open
Abstract
Background
ABO-incompatible (ABOi) kidney-transplantation has very good long-term results, i.e. similar to those observed for living-kidney ABO-compatible transplantation. This is because patients are desensitized at pretransplant using apheresis and rituximab therapy, with tacrolimus-based immunosuppression.
Objectives
To assess the efficacy of a single, pretransplant (Day –1), specific immunoadsorption session using Glycosorb® columns (anti-A or anti-B; Glycorex Sweden) to treat large volumes of plasma (up to 18 L).
Patients and Methods
Prospective single-center study evaluating 12 consecutive patients (6 males), aged 40 (23–59) years. Incompatibilities were A into 0 (8), B into 0 (3), and AB into 0 (1). Pretransplant desensitization relied on rituximab (D–30), tacrolimus, mycophenolic acid, and steroids (all started on D–13), and a single session of specific immunoadsorption on D–1. Immunoadsorption was coupled in tandem with a hemodialysis session.
Results
Overall, 15 L (11–18) of plasma were treated per patient, i.e., 0.2 (0.11–0.36 L/kg). Isoagglutinin titers were 1/16 (1/5–1/64) before the procedure, decreasing after 6 hours to 1/5 (1/1–1/16 P = 0.008), and to 1/2 (1/1–1/8; P = 0.05) at completion of the session. The next day, i.e., the day of transplantation, there was no rebound of isoagglutinins [1/4 (1/1–1/5); P = ns]. The procedure was well tolerated with no side-effects and no significant changes in hemoglobin level, platelet counts, fibrinogen, or albumin levels.
Conclusions
For ABOi kidney-transplantation, a single, longer, specific immunoadsorption session was very efficient at 1-day pre-transplantation with no rebound. These results should be confirmed when isoagglutinin titers are higher (≥120).
Collapse
Affiliation(s)
- Lionel Rostaing
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France ; Université Toulouse III Paul Sabatier, Toulouse, France
| | - Asma Allal
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Federico Sallusto
- Department of Urology, Andrology, and Transplantation, CHU Rangueil, Toulouse, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Nicolas Doumerc
- Department of Urology, Andrology, and Transplantation, CHU Rangueil, Toulouse, France
| | - Bénédicte Debiol
- Etablissement Français du Sang de Midi-Pyrénées, CHU Purpan, Toulouse, France
| | - Audrey Delas
- Laboratory of Histopathology, CHU Rangueil, Toulouse, France
| | - Xavier Game
- Université Toulouse III Paul Sabatier, Toulouse, France ; Department of Urology, Andrology, and Transplantation, CHU Rangueil, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France ; Université Toulouse III Paul Sabatier, Toulouse, France ; INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| |
Collapse
|
11
|
From orphan drugs to adopted therapies: Advancing C3-targeted intervention to the clinical stage. Immunobiology 2016; 221:1046-57. [PMID: 27353192 DOI: 10.1016/j.imbio.2016.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 01/23/2023]
Abstract
Complement dysregulation is increasingly recognized as an important pathogenic driver in a number of clinical disorders. Complement-triggered pathways intertwine with key inflammatory and tissue destructive processes that can either increase the risk of disease or exacerbate pathology in acute or chronic conditions. The launch of the first complement-targeted drugs in the clinic has undeniably stirred the field of complement therapeutic design, providing new insights into complement's contribution to disease pathogenesis and also helping to leverage a more personalized, comprehensive approach to patient management. In this regard, a rapidly expanding toolbox of complement therapeutics is being developed to address unmet clinical needs in several immune-mediated and inflammatory diseases. Elegant approaches employing both surface-directed and fluid-phase inhibitors have exploited diverse components of the complement cascade as putative points of therapeutic intervention. Targeting C3, the central hub of the system, has proven to be a promising strategy for developing biologics as well as small-molecule inhibitors with clinical potential. Complement modulation at the level of C3 has recently shown promise in preclinical primate models, opening up new avenues for therapeutic intervention in both acute and chronic indications fueled by uncontrolled C3 turnover. This review highlights recent developments in the field of complement therapeutics, focusing on C3-directed inhibitors and alternative pathway (AP) regulator-based approaches. Translational perspectives and considerations are discussed, particularly with regard to the structure-guided drug optimization and clinical advancement of a new generation of C3-targeted peptidic inhibitors.
Collapse
|
12
|
Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
Collapse
Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
Kidney transplantation across the ABO blood group barrier was long considered a contraindication for transplantation, but in an effort to increase donor pools, specific regimens for ABO-incompatible (ABOi) transplantation have been developed. These regimens are now widely used as an integral part of the available treatment options. Various desensitization protocols, commonly based on transient depletion of preformed anti-A and/or anti-B antibodies and modulation of B-cell immunity, enable excellent transplant outcomes, even in the long-term. Nevertheless, the molecular mechanisms behind transplant acceptance facilitated by a short course of anti-humoral treatment are still incompletely understood. With the evolution of efficient clinical programmes, tailoring of recipient preconditioning based on individual donor-recipient blood type combinations and the levels of pretransplant anti-A/B antibodies has become possible. In the context of low antibody titres and/or donor A2 phenotype, immunomodulation and/or apheresis might be dispensable. A concern still exists, however, that ABOi kidney transplantation is associated with an increased risk of surgical and infectious complications, partly owing to the effects of extracorporeal treatment and intensified immunosuppression. Nevertheless, a continuous improvement in desensitization strategies, with the aim of minimizing the immunosuppressive burden, might pave the way to clinical outcomes that are comparable to those achieved in ABO-compatible transplantation.
Collapse
|
14
|
The Reuse of Immunoadsorption Columns in ABO-Incompatible Kidney Transplantation Is Efficient: The Swiss Experience. Transplantation 2015; 99:1030-5. [PMID: 25340594 DOI: 10.1097/tp.0000000000000457] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We developed a multicentric Swiss protocol for ABO-incompatible kidney transplantation including immunoadsorption column reuse. The aim of this study was to assess efficacy and safety of immunoadsorption column reuse in ABO-incompatible kidney transplantation. METHODS We performed a multicentric prospective trial including all ABO-incompatible kidney transplantations in Switzerland from 2005 to 2011. Patients received rituximab and standardized immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. Antigen-specific perioperative immunoadsorption was performed. Immunoadsorption columns were reused after restoration. Graft survival, patient survival, kidney function, rejections, number of columns, adverse events after column reuse, and anti-A/anti-B antibody titers were assessed. RESULTS Seventy-one ABO-incompatible patients underwent antigen-specific immunoadsorption and could be transplanted across the blood group barrier. Kaplan-Meier estimates for both, patient-censored and death-censored graft survivals were both 97.2% at 5 years. Allograft function was excellent with a mean estimated glomerular filtration rate of 54 mL per min after 1 year. The median number of pretransplant immunoadsorptions was 5. All centers performed column reuse. A total of 394 immunoadsorption procedures were performed with reused filters. Patient survival, graft survival, and adverse events did not differ when filters were reused. Column reuse resulted in cost savings of 21,458 USD per patient. CONCLUSION We have introduced a national protocol for ABO-incompatible kidney transplantation including immunoadsorption column reuse. Column reuse was efficient and safe.
Collapse
|
15
|
Mastellos DC, Yancopoulou D, Kokkinos P, Huber-Lang M, Hajishengallis G, Biglarnia AR, Lupu F, Nilsson B, Risitano AM, Ricklin D, Lambris JD. Compstatin: a C3-targeted complement inhibitor reaching its prime for bedside intervention. Eur J Clin Invest 2015; 45:423-40. [PMID: 25678219 PMCID: PMC4380746 DOI: 10.1111/eci.12419] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/06/2015] [Indexed: 12/12/2022]
Abstract
There is a growing awareness that complement plays an integral role in human physiology and disease, transcending its traditional perception as an accessory system for pathogen clearance and opsonic cell killing. As the list of pathologies linked to dysregulated complement activation grows longer, it has become clear that targeted modulation of this innate immune system opens new windows of therapeutic opportunity for anti-inflammatory drug design. Indeed, the introduction of the first complement-targeting drugs has reignited a vibrant interest in the clinical translation of complement-based inhibitors. Compstatin was discovered as a cyclic peptide that inhibits complement activation by binding C3 and interfering with convertase formation and C3 cleavage. As the convergence point of all activation pathways and a molecular hub for crosstalk with multiple pathogenic pathways, C3 represents an attractive target for therapeutic modulation of the complement cascade. A multidisciplinary drug optimization effort encompassing rational 'wet' and in silico synthetic approaches and an array of biophysical, structural and analytical tools has culminated in an impressive structure-function refinement of compstatin, yielding a series of analogues that show promise for a wide spectrum of clinical applications. These new derivatives have improved inhibitory potency and pharmacokinetic profiles and show efficacy in clinically relevant primate models of disease. This review provides an up-to-date survey of the drug design effort placed on the compstatin family of C3 inhibitors, highlighting the most promising drug candidates. It also discusses translational challenges in complement drug discovery and peptide drug development and reviews concerns related to systemic C3 interception.
Collapse
Affiliation(s)
- Dimitrios C Mastellos
- Division of Biodiagnostic Sciences and Technologies, INRASTES, National Center for Scientific Research 'Demokritos', Aghia Paraskevi Attikis, Greece
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Biglarnia AR, Ekdahl KN, Nilsson B. Complement Interception Across Humoral Incompatibility in Solid Organ Transplantation: A Clinical Perspective. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 865:211-33. [PMID: 26306452 DOI: 10.1007/978-3-319-18603-0_13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The humoral barrier in transplant biology is the result of preformed donor-specific antibodies (DSAs), directed either against human leukocyte antigens (HLA) or non-HLA antigens such as blood group (ABO) molecules. The term "sensitization" applies to patients carrying these antibodies. Transplantation is widely accepted as a life-saving opportunity for patients with terminal end-organ disease. However, in sensitized patients, transplant outcome is hampered by antibody-mediated rejection (AMR) as a consequence of DSA exposure. Furthermore, sensitized patients have limited access to "matched" organs from the both living and deceased donor pool.Considering the crucial role of the complement system in the pathophysiology of AMR and the availability of complement intervention therapeutics, there is a growing interest in complement-targeting strategies. This review highlights the emerging importance of monitoring and modulation of the complement system in the context of enabling transplantation across humoral incompatibility in sensitized recipients with preformed anti-HLA or natural anti-ABO antibodies. It also discusses the significance of the complement system in the induction of accommodation and further emphasizes current and future perspectives of novel complement therapeutics.
Collapse
Affiliation(s)
- Ali-Reza Biglarnia
- Surgical Science, Department of Transplantation, Uppsala University Hospital, Uppsala University, Uppsala, Sweden,
| | | | | |
Collapse
|
17
|
Early clinical complications after ABO-incompatible live-donor kidney transplantation: a national study of Medicare-insured recipients. Transplantation 2014; 98:54-65. [PMID: 24978035 DOI: 10.1097/tp.0000000000000029] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Descriptions of the sequelae of ABO-incompatible (ABOi) kidney transplantation are limited to single-center reports, which may lack power to detect important effects. METHODS We examined U.S. Renal Data System registry data to study associations of ABOi live-donor kidney transplantation with clinical complications in a national cohort. Among 14,041 Medicare-insured transplants in 2000 to 2007, 119 non-donor-A2 ABOi transplants were identified. A2-incompatible (n=35) transplants were categorized separately. Infection and hemorrhage events were identified by diagnosis codes on billing claims. Associations of ABO incompatibility with complications were assessed by multivariate Cox regression. RESULTS Recipients of ABOi transplants experienced significantly (P<0.05) higher incidence of wound infections (12.7% vs. 7.3%), pneumonia (7.6% vs. 3.8%), and urinary tract infections (UTIs) or pyelonephritis (24.5% vs. 15.3%) in the first 90 days compared with ABO-compatible recipients. In adjusted models, ABO incompatibility was associated with twice the risk of pneumonia (adjusted hazard ratio [aHR], 2.22; 95% confidence interval [CI], 1.14-4.33) and 56% higher risk of UTIs or pyelonephritis (aHR, 1.56; 95% CI, 1.05-2.30) in the first 90 posttransplantation days, and 3.5 times the relative risk of wound infections in days 91 to 365 (aHR, 3.55; 95% CI, 1.92-6.57). ABOi recipients, 19% of whom underwent pre- or peritransplant splenectomy, experienced twice the adjusted risk of early hemorrhage (aHR, 1.96; 95% CI, 1.19-3.24). A2-incompatible transplantation was associated only with early risk of UTIs or pyelonephritis. CONCLUSION ABOi transplantation offers patients with potential live donors an additional transplant option but with higher risks of infectious and hemorrhagic complications. Awareness of these complications may help improve protocols for the management of ABOi transplantation.
Collapse
|
18
|
Eskandary F, Wahrmann M, Biesenbach P, Sandurkov C, Konig F, Schwaiger E, Perkmann T, Kunig S, Derfler K, Zlabinger GJ, Bohmig GA. ABO antibody and complement depletion by immunoadsorption combined with membrane filtration--a randomized, controlled, cross-over trial. Nephrol Dial Transplant 2013; 29:706-14. [DOI: 10.1093/ndt/gft502] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
|
19
|
Holgersson J, Rydberg L, Breimer ME. Molecular deciphering of the ABO system as a basis for novel diagnostics and therapeutics in ABO incompatible transplantation. Int Rev Immunol 2013; 33:174-94. [PMID: 24350817 DOI: 10.3109/08830185.2013.857408] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In recent years ABO incompatible kidney transplantation (KTx) has become a more or less clinical routine procedure with graft and patient survival similar to those of ABO compatible transplants. Antigen-specific immunoadsorption (IA) for anti-A and anti-B antibody removal constitutes in many centers an important part of the treatment protocol. ABO antibody titration by hemagglutination is guiding the treatment; both if the recipient can be transplanted as well as in cases of suspected rejections if antibody removal should be performed. Despite the overall success of ABO incompatible KTx, there is still room for improvements and an extension of the technology to include other solid organs. Based on an increased understanding of the structural complexity and tissue distribution of ABH antigens and the fine epitope specificity of the ABO antibody repertoire, improved IA matrices and ABO antibody diagnostics should be developed. Furthermore, understanding the molecular mechanisms behind accommodation of ABO incompatible renal allografts could make it possible to induce long-term allograft acceptance also in human leukocyte antigen (HLA) sensitized recipients and, perhaps, also make clinical xenotransplantation possible.
Collapse
Affiliation(s)
- Jan Holgersson
- 1Department of Clinical Chemistry and Transfusion Medicine and
| | | | | |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW A significant number of kidney transplantations in industrialized countries is currently performed over human leukocyte antigen (HLA) or ABO antibody barriers after living donation to encounter the increasing shortage of organs from deceased donors. Although patients with moderate titers of anti-A/B antibodies may easily be desensitized with no negative impact on allograft survival, recipients with high titers and HLA sensitized patients demonstrate a substantial risk for antibody-mediated rejection, limiting long-term outcomes. RECENT FINDINGS The use of powerful desensitization strategies including plasmapheresis and immunoadsorption, extended therapeutic options such as the application of the recently introduced complement inhibitors, and refined antibody detection techniques may further facilitate transplantations, especially in the HLA-sensitized kidney transplant recipient. On the contrary, special strategies such as the Eurotransplant Acceptable Mismatch Program or kidney paired exchange help improving long-term outcomes in these difficult to transplant patients by circumventing the HLA (or ABO) antibody barrier. SUMMARY As compared with waiting for a compatible deceased donor organ, HLA and ABO incompatible transplantations performed in experienced centers have become a reasonable alternative for end-stage kidney disease patients with an incompatible live donor. Whenever possible, however, the transplantation should be performed between ABO compatible donor-recipient pairs in the absence of positive crossmatch results.
Collapse
|
21
|
Chen CK, Dipchand AI. The current state and key issues of pediatric heart transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.1016/j.ijt.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
22
|
Bleeding complications in pediatric ABO-incompatible kidney transplantation. Pediatr Nephrol 2013; 28:327-32. [PMID: 22961637 DOI: 10.1007/s00467-012-2302-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 08/03/2012] [Accepted: 08/06/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND ABO-incompatible renal transplantation (ABOi-RTx) following preconditioning with immunoadsorption (IA) and rituximab is a promising approach to facilitate living-related RTx. However, clinical experience is limited in pediatric patients. METHODS Three patients underwent living-related ABOi-RTx in our center. Preoperative IA was performed six, ten and 11 times in patient one, two and three, respectively, to achieve isoagglutinin titers of ≤1:8 on the day of transplantation; rituximab was administered once. The immunosuppressive regimen further comprised tacrolimus, mycophenolate, methylprednisolone and basiliximab; immunoglobulin G (IgG) was infused on the day of ABOi-RTx. RESULTS All three patients achieved normal renal function within 2-6 days post-RTx. Major postoperative bleeding occurred in two patients, with one requiring repeated blood transfusions and the other a surgical revision 4 h after RTx, despite local citrate anticoagulation use during the preoperative IA procedures in the latter patient. A pyelonephritis-associated increase of the isoagglutinin IgG/IgM titers to 1:64/1:128 led to a biopsy-proven acute humoral rejection in the third patient, which was treated successfully with plasma exchange and methylprednisolone pulses. The estimated glomerular filtration rate at 18, 8 and 23 months post-RTx was 96, 52 and 74 ml/min/1.73 m(2), respectively. CONCLUSIONS ABOi-RTx can successfully be performed in pediatric patients after preconditioning with quadruple immunosuppression, rituximab and IA. Caution is required regarding bleeding complications, which are most likely due to the unspecific binding of coagulation factors during repeated IA.
Collapse
|