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Jallah BP, Kuypers DRJ. Impact of Immunosenescence in Older Kidney Transplant Recipients: Associated Clinical Outcomes and Possible Risk Stratification for Immunosuppression Reduction. Drugs Aging 2024; 41:219-238. [PMID: 38386164 DOI: 10.1007/s40266-024-01100-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/23/2024]
Abstract
The number of older individuals receiving a kidney transplant as replacement therapy has significantly increased in the past decades and this increase is expected to continue. Older patients have a lower rate of acute rejection but an increased incidence of death with a functioning graft. Several factors, including an increased incidence of infections, post-transplant malignancy and cardiovascular comorbidity and mortality, contribute to this increased risk. Notwithstanding, kidney transplantation is still the best form of kidney replacement therapy in all patients with chronic kidney disease, including in older individuals. The best form of immunosuppression and the optimal dose of these medications in older recipients remains a topic of discussion. Pharmacological studies have usually excluded older patients and when included, patients were highly selected and their numbers insignificant to draw a reasonable conclusion. The reduced incidence of acute rejection in older recipients has largely been attributed to immunosenescence. Immunosenescence refers to the aging of the innate and adaptive immunity, accumulating in phenotypic and functional changes. These changes influences the response of the immune system to new challenges. In older individuals, immunosenescence is associated with increased susceptibility to infectious pathogens, a decreased response after vaccinations, increased risk of malignancies and cardiovascular morbidity and mortality. Chronic kidney disease is associated with premature immunosenescent changes, and these are independent of aging. The immunosenescent state is associated with low-grade sterile inflammation termed inflammaging. This chronic low-grade inflammation triggers a compensatory immunosuppressive state to avoid further tissue damage, leaving older individuals with chronic kidney disease in an immune-impaired state before kidney transplantation. Immunosuppression after transplantation may further enhance progression of this immunosenescent state. This review covers the role of immunosenescence in older kidney transplant recipients and it details present knowledge of the changes in chronic kidney disease and after transplantation. The impact of immunosuppression on the progression and complications of an immunosenescent state are discussed, and the future direction of a possible clinical implementation of immunosenescence to individualize/reduce immunosuppression in older recipients is laid out.
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Affiliation(s)
- Borefore P Jallah
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium.
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2
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Wiebe C, Balshaw R, Gibson IW, Ho J, Shaw J, Karpinski M, Trachtenberg A, Pochinco D, Goldberg A, Birk P, Pinsk M, Rush DN, Nickerson PW. A rational approach to guide cost-effective de novo donor-specific antibody surveillance with tacrolimus immunosuppression. Am J Transplant 2023; 23:1882-1892. [PMID: 37543094 DOI: 10.1016/j.ajt.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
De novo donor-specific antibody (dnDSA) after renal transplantation has been shown to correlate with antibody-mediated rejection and allograft loss. However, the lack of proven interventions and the time and cost associated with annual screening for dnDSA are difficult to justify for all recipients. We studied a well-characterized consecutive cohort (n = 949) with over 15 years of prospective dnDSA surveillance to identify risk factors that would help institute a resource-responsible surveillance strategy. Younger recipient age and HLA-DR/DQ molecular mismatch were independent predictors of dnDSA development. Combining both risk factors into recipient age molecular mismatch categories, we found that 52% of recipients could be categorized as low-risk for dnDSA development (median subclinical dnDSA-free survival at 5 and 10 years, 98% and 97%, respectively). After adjustment, multivariate correlates of dnDSA development included tacrolimus versus cyclosporin maintenance immunosuppression (hazard ratio [HR], 0.37; 95% CI, 0.2-0.6; P < .0001) and recipient age molecular mismatch category: intermediate versus low (HR, 2.48; 95% CI, 1.5-4.2; P = .0007), high versus intermediate (HR, 2.56; 95% CI, 1.6-4.2; P = .0002), and high versus low (HR, 6.36; 95% CI, 3.7-10.8; P < .00001). When combined, recipient age and HLA-DR/DQ molecular mismatch provide a novel data-driven approach to reduce testing by >50% while selecting those most likely to benefit from dnDSA surveillance.
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Affiliation(s)
- Chris Wiebe
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada.
| | - Rob Balshaw
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ian W Gibson
- Shared Health Services Manitoba, Winnipeg, Manitoba, Canada; Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Jamie Shaw
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Karpinski
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aaron Trachtenberg
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Aviva Goldberg
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia Birk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maury Pinsk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David N Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
| | - Peter W Nickerson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Shared Health Services Manitoba, Winnipeg, Manitoba, Canada
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3
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Betjes MGH, De Weerd A. Lowering maintenance immune suppression in elderly kidney transplant recipients; connecting the immunological and clinical dots. Front Med (Lausanne) 2023; 10:1215167. [PMID: 37502354 PMCID: PMC10368955 DOI: 10.3389/fmed.2023.1215167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023] Open
Abstract
The management of long-term immune suppressive medication in kidney transplant recipients is a poorly explored field in the area of transplant medicine. In particular, older recipients are at an increased risk for side effects and have an exponentially increased risk of infection-related death. In contrast, an aged immune system decreases the risk of acute T-cell-mediated rejection in older recipients. Recent advances in alloimmunity research have shown a rapid and substantial decline in polyfunctional, high-risk CD4+ T cells post-transplantation. This lowers the direct alloreactivity responsible for T-cell-mediated rejection, also known as donor-specific hyporesponsiveness. Chronic antibody-mediated rejection (c-aABMR) is the most frequent cause of kidney graft loss in the long term. However, in older adults, c-aABMR as a cause of graft loss is outnumbered by death with a functioning graft. In addition, DSA development and a diagnosis of c-aABMR plateau ~10 years after transplantation, resulting in a very low risk for rejection thereafter. The intensity of immune suppression regimes could likely be reduced accordingly, but trials in this area are scarce. Tacrolimus monotherapy for 1 year after transplantation seems feasible in older kidney transplant recipients with standard immunological risk, showing the expected benefits of fewer infections and better vaccination responses.
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Hendriks SH, Heidt S, Schulz AR, de Fijter JW, Reinders MEJ, Koning F, van Kooten C. Peripheral Blood Immune Cell Composition After Autologous MSC Infusion in Kidney Transplantation Recipients. Transpl Int 2023; 36:11329. [PMID: 37426430 PMCID: PMC10326287 DOI: 10.3389/ti.2023.11329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
Tacrolimus is the backbone of immunosuppressive agents to prevent transplant rejection. Paradoxically, tacrolimus is nephrotoxic, causing irreversible tubulointerstitial damage. Therefore, infusion of mesenchymal stromal cells (MSC) 6 and 7 weeks post-transplantation was assessed to facilitate withdrawal of tacrolimus in the randomized phase II TRITON trial. Here, we performed detailed analysis of the peripheral blood immune composition using mass cytometry to assess potential effects of MSC therapy on the immune system. We developed two metal-conjugated antibody panels containing 40 antibodies each. PBMC samples from 21 MSC-treated patients and 13 controls, obtained pre-transplant and at 24 and 52 weeks post-transplantation, were analyzed. In the MSC group at 24 weeks, 17 CD4+ T cell clusters were increased of which 14 Th2-like clusters and three Th1/Th2-like clusters, as well as CD4+FoxP3+ Tregs. Additionally, five B cell clusters were increased, representing either class switched memory B cells or proliferating B cells. At 52 weeks, CCR7+CD38+ mature B cells were decreased. Finally, eight Tc1 (effector) memory cytotoxic T cell clusters were increased. Our work provides a comprehensive account of the peripheral blood immune cell composition in kidney transplant recipients after MSC therapy and tacrolimus withdrawal. These results may help improving therapeutic strategies using MSCs with the aim to reduce the use of calcineurin inhibitors. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02057965.
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Affiliation(s)
- Sanne H. Hendriks
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Axel R. Schulz
- German Rheumatism Research Center (DRFZ), Berlin, Germany
| | - Johan W. de Fijter
- Department of Internal Medicine (Nephrology) and Transplant Center, Leiden University Medical Center, Leiden, Netherlands
| | - Marlies E. J. Reinders
- Department of Internal Medicine (Nephrology) and Transplant Center, Leiden University Medical Center, Leiden, Netherlands
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus MC Transplant Institute, Erasmus University Medical Center, Leiden, Netherlands
| | - Frits Koning
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Cees van Kooten
- Department of Internal Medicine (Nephrology) and Transplant Center, Leiden University Medical Center, Leiden, Netherlands
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Cañamero L, Benito-Hernández A, González E, Escagedo C, Rodríguez-Vidriales M, García-Saiz MDM, Valero R, Belmar L, de Cos MA, Francia MV, Ruiz JC, Rodrigo E. Torque Teno Virus Load Predicts Opportunistic Infections after Kidney Transplantation but Is Not Associated with Maintenance Immunosuppression Exposure. Biomedicines 2023; 11:biomedicines11051410. [PMID: 37239081 DOI: 10.3390/biomedicines11051410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Measuring the non-pathogenic Torque Teno Virus (TTV) load allows assessing the net immunosuppressive state after kidney transplantation (KTx). Currently, it is not known how exposure to maintenance immunosuppression affects TTV load. We hypothesized that TTV load is associated with the exposure to mycophenolic acid (MPA) and tacrolimus. We performed a prospective study including 54 consecutive KTx. Blood TTV load was measured by an in-house PCR at months 1 and 3. Together with doses and trough blood levels of tacrolimus and MPA, we calculated the coefficient of variability (CV), time in therapeutic range (TTR) and concentration/dose ratio (C/D) of tacrolimus, and the MPA-area under the curve (AUC-MPA) at the third month. TTV load at the first and third month discriminated those patients at risk of developing opportunistic infections between months 1 and 3 (AUC-ROC 0.723, 95%CI 0.559-0.905, p = 0.023) and between months 3 and 6 (AUC-ROC 0.778, 95%CI 0.599-0.957, p = 0.028), respectively, but not those at risk of acute rejection. TTV load did not relate to mean tacrolimus blood level, CV, TTR, C/D and AUC-MPA. To conclude, although TTV is a useful marker of net immunosuppressive status after KTx, it is not related to exposure to maintenance immunosuppression.
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Affiliation(s)
- Lucía Cañamero
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Adalberto Benito-Hernández
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Elena González
- Immunopathology Group, Immunology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Clara Escagedo
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - María Rodríguez-Vidriales
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - María Del Mar García-Saiz
- Clinical Pharmacology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Rosalía Valero
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Lara Belmar
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - María Angeles de Cos
- Clinical Pharmacology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - María Victoria Francia
- Infectious Diseases and Clinical Microbiology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39011 Santander, Spain
| | - Juan Carlos Ruiz
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
| | - Emilio Rodrigo
- Immunopathology Group, Nephrology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39012 Santander, Spain
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Galvez C, Boza P, González M, Hormazabal C, Encina M, Azócar M, Castañeda LE, Rojo A, Ceballos ML, Krall P. Evaluation of limited-sampling strategies to calculate AUC(0–24) and the role of CYP3A5 in Chilean pediatric kidney recipients using extended-release tacrolimus. Front Pharmacol 2023; 14:1044050. [PMID: 36998611 PMCID: PMC10043346 DOI: 10.3389/fphar.2023.1044050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Kidney transplantation (KTx) requires immunosuppressive drugs such as Tacrolimus (TAC) which is mainly metabolized by CYP3A5. TAC is routinely monitored by trough levels (C0) although it has not shown to be a reliable marker. The area-under-curve (AUC) is a more realistic measure of drug exposure, but sampling is challenging in pediatric patients. Limited-sampling strategies (LSS) have been developed to estimate AUC. Herein, we aimed to determine AUC(0–24) and CYP3A5 genotype in Chilean pediatric kidney recipients using extended-release TAC, to evaluate different LSS-AUC(0–24) formulas and dose requirements.Patients and methods: We analyzed pediatric kidney recipients using different extended-release TAC brands to determine their trapezoidal AUC(0–24) and CYP3A5 genotypes (SNP rs776746). Daily TAC dose (TAC-D mg/kg) and AUC(0–24) normalized by dose were compared between CYP3A5 expressors (*1/*1 and *1/*3) and non-expressors (*3/*3). We evaluated the single and combined time-points to identify the best LSS-AUC(0–24) model. We compared the performance of this model with two pediatric LSS-AUC(0–24) equations for clinical validation.Results: Fifty-one pharmacokinetic profiles were obtained from kidney recipients (age 13.1 ± 2.9 years). When normalizing AUC(0–24) by TAC-D significant differences were found between CYP3A5 expressors and non-expressors (1701.9 vs. 2718.1 ng*h/mL/mg/kg, p < 0.05). C0 had a poor fit with AUC(0–24) (r2 = 0.5011). The model which included C0, C1 and C4, showed the best performance to predict LSS-AUC(0–24) (r2 = 0.8765) and yielded the lowest precision error (7.1% ± 6.4%) with the lowest fraction (9.8%) of deviated AUC(0–24), in comparison to other LSS equations.Conclusion: Estimation of LSS-AUC(0–24) with 3 time-points is an advisable and clinically useful option for pediatric kidney recipients using extended-release TAC to provide better guidance of decisions if toxicity or drug inefficacy is suspected. The different CYP3A5 genotypes associated with variable dose requirements reinforce considering genotyping before KTx. Further multi-centric studies with admixed cohorts are needed to determine the short- and long-term clinical benefits.
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Affiliation(s)
- Carla Galvez
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Pía Boza
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Mariluz González
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Catalina Hormazabal
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Marlene Encina
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Manuel Azócar
- Servicio de Farmacia Clínica, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Luis E. Castañeda
- Programa de Genética Humana, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Angélica Rojo
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - María Luisa Ceballos
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- *Correspondence: María Luisa Ceballos, ; Paola Krall,
| | - Paola Krall
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- Instituto de Medicina, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
- *Correspondence: María Luisa Ceballos, ; Paola Krall,
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7
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Danger R, Le Berre L, Cadoux M, Kerleau C, Papuchon E, Mai HL, Nguyen TVH, Guérif P, Morelon E, Thaunat O, Legendre C, Anglicheau D, Lefaucheur C, Couzi L, Del Bello A, Kamar N, Le Quintrec M, Goutaudier V, Renaudin K, Giral M, Brouard S. Subclinical rejection-free diagnostic after kidney transplantation using blood gene expression. Kidney Int 2023; 103:1167-1179. [PMID: 36990211 DOI: 10.1016/j.kint.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/16/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
We previously established a six-gene-based blood score associated with operational tolerance in kidney transplantation which was decreased in patients developing anti-HLA donor-specific antibodies (DSA). Herein, we aimed to confirm that this score is associated with immunological events and risk of rejection. We measured this using quantitative PCR (qPCR) and NanoString methods from an independent multicenter cohort of 588 kidney transplant recipients with paired blood samples and biopsies at one year after transplantation validating its association with pre-existing and de novo DSA. From 441 patients with protocol biopsy, there was a significant decrease of the score of tolerance in 45 patients with biopsy-proven subclinical rejection (SCR), a major threat associated with pejorative allograft outcomes that prompted an SCR score refinement. This refinement used only two genes, AKR1C3 and TCL1A, and four clinical parameters (previous experience of rejection, previous transplantation, sex of recipient and tacrolimus uptake). This refined SCR score was able to identify patients unlikely to develop SCR with a C-statistic of 0.864 and a negative predictive value of 98.3%. The SCR score was validated in an external laboratory, with two methods (qPCR and NanoString), and on 447 patients from an independent and multicenter cohort. Moreover, this score allowed reclassifying patients with discrepancies between the DSA presence and the histological diagnosis of antibody mediated rejection unlike kidney function. Thus, our refined SCR score could improve detection of SCR for closer and noninvasive monitoring, allowing early treatment of SCR lesions notably for patients DSA-positive and during lowering of immunosuppressive treatment.
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Affiliation(s)
- Richard Danger
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France.
| | - Ludmilla Le Berre
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Marion Cadoux
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Clarisse Kerleau
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuelle Papuchon
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France
| | - Hoa Le Mai
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Thi-Van-Ha Nguyen
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Pierrick Guérif
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, INSERM UMR S970, Université Paris Cité, Kidney Transplant Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis, and Apheresis, CHU Bordeaux, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Moglie Le Quintrec
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Lapeyronie, Montpellier, France
| | - Valentin Goutaudier
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France; Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Karine Renaudin
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; CHU Nantes, Service d'Anatomie et Cytologie Pathologiques, Nantes, France
| | - Magali Giral
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France
| | - Sophie Brouard
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France.
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8
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Bezstarosti S, Meziyerh S, Reinders MEJ, Voogt-Bakker K, Groeneweg KE, Roelen DL, Kers J, de Fijter JW, Heidt S. HLA-DQ eplet mismatch load may identify kidney transplant patients eligible for tacrolimus withdrawal without donor-specific antibody formation after mesenchymal stromal cell therapy. HLA 2023. [PMID: 36841928 DOI: 10.1111/tan.15008] [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: 10/17/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Recently, the randomized phase-II Triton study demonstrated that mesenchymal stromal cell (MSC) therapy facilitated early tacrolimus withdrawal in living donor kidney transplant recipients. The current sub-study analyzed formation of de novo donor-specific HLA antibodies (dnDSA) in the context of the degree of HLA eplet mismatches. At the time of protocol biopsy at 6 months, 7/29 patients (24%) in the MSC group and 1/27 patient (3.7%) in the control group had developed dnDSA. In the MSC group, all dnDSA were anti-HLA-DQ; two patients had anti-DQ alone and five patients combined with anti-class I, HLA-DR or -DP. Despite excess dnDSA formation in the MSC-arm of the study, the evolution of eGFR (CKD-EPI) and proteinuria were comparable 2 years posttransplant. All dnDSA were complement-binding and three patients had antibody-mediated rejection in the protocol biopsy, but overall rejection episodes were not increased. Everolimus had to be discontinued in nine patients because of toxicity, and tacrolimus was reintroduced in six patients because of dnDSA formation. The HLA-DQ eplet mismatch load independently associated with dnDSA (adjusted hazard ratio = 1.07 per eplet mismatch, p = 0.008). A threshold of ≥11 HLA-DQ eplet mismatches predicted subsequent dnDSA in all 11 patients in the MSC group, but specificity was low (44%). Further research is warranted to explore HLA molecular mismatch load as a biomarker to guide personalized maintenance immunosuppression in kidney transplantation.
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Affiliation(s)
- Suzanne Bezstarosti
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands.,Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Soufian Meziyerh
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Kim Voogt-Bakker
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Koen E Groeneweg
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesper Kers
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Van 't Hoff Institute for Molecular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands.,Eurotransplant Reference Laboratory, Leiden, The Netherlands
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9
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McGovern KE, Sonar SA, Watanabe M, Coplen CP, Bradshaw CM, Nikolich JŽ. The aging of the immune system and its implications for transplantation. GeroScience 2023:10.1007/s11357-022-00720-2. [PMID: 36626019 PMCID: PMC9838392 DOI: 10.1007/s11357-022-00720-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
By the last third of life, most mammals, including humans, exhibit a decline in immune cell numbers, immune organ structure, and immune defense of the organism, commonly known as immunosenescence. This decline leads to clinical manifestations of increased susceptibility to infections, particularly those caused by emerging and reemerging microorganisms, which can reach staggering levels-infection with SARS-CoV-2 has been 270-fold more lethal to older adults over 80 years of age, compared to their 18-39-year-old counterparts. However, while this would be expected to be beneficial to situations where hyporeactivity of the immune system may be desirable, this is not always the case. Here, we discuss the cellular and molecular underpinnings of immunosenescence as they pertain to outcomes of solid organ and hematopoietic transplantation.
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Affiliation(s)
- Kathryn E McGovern
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
- BIO5 Institute, University of Arizona, Tucson, AZ, USA
| | - Sandip A Sonar
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Makiko Watanabe
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christopher P Coplen
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christine M Bradshaw
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Janko Ž Nikolich
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA.
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA.
- BIO5 Institute, University of Arizona, Tucson, AZ, USA.
- The Aegis Consortium for Pandemic-free Future, University of Arizona Health Sciences, University of Arizona, Tucson, 85719, USA.
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10
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Kervella D, Blancho G. New immunosuppressive agents in transplantation. Presse Med 2022; 51:104142. [PMID: 36252821 DOI: 10.1016/j.lpm.2022.104142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immunosuppressive agents have enabled the development of allogenic transplantation during the last 40 years, allowing considerable improvement in graft survival. However, several issues remain such as the nephrotoxicity of calcineurin inhibitors, the cornerstone of immunosuppressive regimens and/or the higher risk of opportunistic infections and cancers. Most immunosuppressive agents target T cell activation and may not be efficient enough to prevent allo-immunization in the long term. Finally, antibody mediated rejection due to donor specific antibodies strongly affects allograft survival. Many drugs have been tested in the last decades, but very few have come to clinical use. The most recent one is CTLA4-Ig (belatacept), a costimulation blockade molecule that targets the second signal of T cell activation and is associated with a better long term kidney function than calcineurin inhibitors, despite an increased risk of acute cellular rejection. The research of new maintenance long-term immunosuppressive agents focuses on costimulation blockade. Agents inhibiting CD40-CD40 ligand interaction may enable a good control of both T cells and B cells responses. Anti-CD28 antibodies may promote regulatory T cells. Agents targeting this costimulation pathways are currently evaluated in clinical trials. Immunosuppressive agents for ABMR treatment are scarce since anti-CD20 agent rituximab and proteasome inhibitor bortezomib have failed to demonstrate an interest in ABMR. New drugs focusing on antibodies removal (imlifidase), B cell and plasmablasts (anti-IL-6/IL-6R, anti-CD38…) and complement inhibition are in the pipeline, with the challenge of their evaluation in such a heterogeneous pathology.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France.
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11
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Masset C, Dantal J, Soulillou JP, Walencik A, Delbos F, Brouard S, Giral M. Case Report: Long-term observations from the tacrolimus weaning randomized clinical trial depicts the challenging aspects for determination of low-immunological risk patients. Front Immunol 2022; 13:1021481. [PMID: 36518770 PMCID: PMC9744190 DOI: 10.3389/fimmu.2022.1021481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/31/2022] [Indexed: 11/30/2022] Open
Abstract
Whilst calcineurin inhibitors (CNI) are the cornerstone of immunosuppressive maintenance therapy in kidney transplantation, several studies have investigated the safety of CNI withdrawal in order to avoid their numerous side effects. In this context, we performed several years ago a clinical randomized trial evaluating CNI weaning in stable kidney transplant recipients without anti-HLA immunization. The trial was interrupted prematurely due to a high number of de novo DSA (dnDSA) and biopsy proven acute rejection (BPAR) in patients who underwent tacrolimus weaning, resulting in treatment for rejection and resumption of tacrolimus. We report here the long-term outcomes of patients included in this clinical trial. Ten years after randomization, all patients are alive with a functional allograft. They all receive tacrolimus therapy except one with recurrent cutaneous neoplasia issues. Long-term eGFR was comparable between patients of the two randomized groups (46.4 ml/min vs 42.8 ml/min). All dnDSA that occurred during the study period became non-detectable and all rejections episodes were reversed. The retrospective assessment of HLA DQ single molecule epitope mismatching determined that a majority of patients who developed dnDSA after tacrolimus withdrawal would have been considered at high immunological risk. Minimization of immunosuppression remains a challenging objective, mainly because of the issues to properly select very low immunological risk patients. Valuable improvements have been made the last decade regarding evaluation of the allograft rejection notably through the determination of numerous at-risk biomarkers. However, even if the impact of such tools still need to be clarify in clinical routine, they may permit an improvement in patients' selection for immunosuppression minimization without increasing the risk of allograft rejection.
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Affiliation(s)
- Christophe Masset
- Institut de Transplantation Urologie Néphrologie (ITUN), Centre Hospitalo-Universitaire (CHU) Nantes, Nantes, France,Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Jacques Dantal
- Institut de Transplantation Urologie Néphrologie (ITUN), Centre Hospitalo-Universitaire (CHU) Nantes, Nantes, France,Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Jean-Paul Soulillou
- Institut de Transplantation Urologie Néphrologie (ITUN), Centre Hospitalo-Universitaire (CHU) Nantes, Nantes, France,Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Alexandre Walencik
- Laboratoire d’immunologie et HLA Etablissement Français du Sang, Nantes, France
| | - Florent Delbos
- Laboratoire d’immunologie et HLA Etablissement Français du Sang, Nantes, France
| | - Sophie Brouard
- Institut de Transplantation Urologie Néphrologie (ITUN), Centre Hospitalo-Universitaire (CHU) Nantes, Nantes, France,Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France,*Correspondence: Magali Giral, ; Sophie Brouard,
| | - Magali Giral
- Institut de Transplantation Urologie Néphrologie (ITUN), Centre Hospitalo-Universitaire (CHU) Nantes, Nantes, France,Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France,*Correspondence: Magali Giral, ; Sophie Brouard,
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12
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Comparison of Tacrolimus Intra-Patient Variability during 6-12 Months after Kidney Transplantation between CYP3A5 Expressers and Nonexpressers. J Clin Med 2022; 11:jcm11216320. [PMID: 36362548 PMCID: PMC9658797 DOI: 10.3390/jcm11216320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022] Open
Abstract
A high intra-patient variability (IPV) of tacrolimus exposure is associated with poor long-term kidney transplantation outcomes. To assess the influence of cytochrome P450 (CYP) 3A5 genetic polymorphisms on tacrolimus IPV, 188 clinically stable kidney transplant recipients, who had received an immediate-release tacrolimus-based immunosuppressive regimen, were enrolled in this retrospective cohort study. Genotyping of CYP3A5*3 (rs776746) was performed and 110 (58.5%) were identified as CYP3A5 expressers and 78 (41.5%) as nonexpressers. Whole blood tacrolimus concentrations were analyzed by chemiluminescent microparticle immunoassay. Dose-adjusted trough tacrolimus concentrations (C0/D) measured at months 6, 9, and 12 were used to determine IPV. There were no significant differences in the IPV estimated by the coefficient of variation, the IPV calculated by mean absolute deviation method, and the proportions of recipients with the IPV estimated by the coefficient of variation of 30% or more between CYP3A5 expressers and nonexpressers (p = 0.613, 0.686, and 0.954, respectively). Tacrolimus C0/D in CYP3A5 expressers was approximately half of those in nonexpressers, overall (p < 0.001). In both CYP3A5 expressers and nonexpressers, tacrolimus C0/D increased gradually from month 6 to month 12 (p = 0.021). There was no evidence that the CYP3A5 polymorphisms significantly influence tacrolimus IPV during the 6 to 12 months after kidney transplantation.
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13
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de Weerd AE, Fatly ZA, Boer-Verschragen M, Kal-van Gestel JA, Roelen DL, Dieterich M, Betjes MGH. Tacrolimus Monotherapy is Safe in Immunologically Low-Risk Kidney Transplant Recipients: A Randomized-Controlled Pilot Study. Transpl Int 2022; 35:10839. [PMID: 36353052 PMCID: PMC9637544 DOI: 10.3389/ti.2022.10839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/12/2022] [Indexed: 12/02/2022]
Abstract
In this randomized-controlled pilot study, the feasibility and safety of tacrolimus monotherapy in immunologically low-risk kidney transplant recipients was evaluated [NTR4824, www.trialregister.nl]. Low immunological risk was defined as maximal 3 HLA mismatches and the absence of panel reactive antibodies. Six months after transplantation, recipients were randomized if eGFR >30 ml/min, proteinuria <50 mg protein/mmol creatinine, no biopsy-proven rejection after 3 months, and no lymphocyte depleting therapy given. Recipients were randomized to tacrolimus/mycophenolate mofetil (TAC/MMF) or to taper and discontinue MMF at month 9 (TACmono). 79 of the 121 recipients were randomized to either TACmono (n = 38) or TAC/MMF (n = 41). Mean recipient age was 59 years and 59% received a living donor transplant. The median follow-up was 62 months. After randomization, 3 TACmono and 4 TAC/MMF recipients experienced a biopsy-proven rejection. At 5 years follow-up, patient survival was 84% in TACmono versus 76% in TAC/MMF with death-censored graft survival of 97% for both groups and no differences in eGFR and proteinuria. Eleven TACmono recipients had an infectious episode versus 22 TAC/MMF recipients (p < 0.03). Donor-specific anti-HLA antibodies were not detected during follow-up in both groups. Tacrolimus monotherapy in selected immunologically low-risk kidney transplant recipients appears safe and reduces the number of infections.
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Affiliation(s)
- Annelies E. de Weerd
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
- *Correspondence: Annelies E. de Weerd,
| | - Zainab Al Fatly
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Marieken Boer-Verschragen
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Judith A. Kal-van Gestel
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Dave L. Roelen
- Department of Immunology, HLA Laboratory, Leiden University Medical Center, Leiden, Netherlands
| | - Marjolein Dieterich
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Michiel G. H. Betjes
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, Netherlands
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14
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Chong AS, Habal MV. From bench to bedside: reversing established antibody responses and desensitization. Curr Opin Organ Transplant 2022; 27:376-384. [PMID: 35950890 PMCID: PMC9474614 DOI: 10.1097/mot.0000000000001009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Basic transplant immunology has primarily focused on the definition of mechanisms, but an often-stated aspirational goal is to translate basic mechanistic research into future therapy. Pretransplant donor-specific antibodies (DSA) mediate hyperacute as well as early antibody-mediated rejection (AMR), whereas DSA developing late posttransplantation may additionally mediate chronic rejection. Although contemporary immunosuppression effectively prevents early cellular rejection after transplant in nonsensitized patients, it is less effective at controlling preexisting HLA antibody responses or reversing DSA once established, thus underscoring a need for better therapies. RECENT FINDINGS We here review the development of a bench-to-bedside approach involving transient proteasome inhibition to deplete plasma cells, combined with maintenance co-stimulation blockade, with CTLA-4Ig or belatacept, to prevent the generation of new antibody-secreting cells (ASCs). SUMMARY This review discusses how this treatment regimen, which was rationally designed and validated to reverse established DSA responses in mouse models, translated into reversing active AMR in the clinic, as well as desensitizing highly sensitized patients on the transplant waitlist.
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Affiliation(s)
- Anita S. Chong
- Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - Marlena V. Habal
- Department of Medicine, Columbia University College of Medicine, New York, NY, USA
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15
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The effect of the very low dosage diltiazem on tacrolimus exposure very early after kidney transplantation: a randomized controlled trial. Sci Rep 2022; 12:14247. [PMID: 35989346 PMCID: PMC9393165 DOI: 10.1038/s41598-022-18552-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/16/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractThe objective of this study was to assess the effect of the very low dosage of diltiazem on tacrolimus exposure during the first week post-kidney transplantation, among cytochrome P450 (CYP) 3A5 expressers who did not receive diltiazem (EXplb), CYP3A5 expressers who received the very low dose diltiazem (EXdtz), CYP3A5 nonexpressers who did not receive diltiazem (NEplb), and CYP3A5 nonexpressers who received the very low dose diltiazem (NEdtz). Forty kidney recipients who receive tacrolimus-based immunosuppressive regimen were randomly assigned, with stratification on the CYP3A5 genotypes, to receive either diltiazem 30 mg every 12 h or a matched placebo. The observed median dose-adjusted area under the 12-h curve of tacrolimus concentration (AUC/D) at day 7 post-transplantation was lowest in the EXplb group followed by EXdtz, NEplb, and NEdtz at 34.9, 43.6, 49.4, and 71.1 ng*h/mL per mg, respectively. A Kruskal–Wallis test showed a significant difference in the mean ranks of AUC/D among groups. Significant differences between EXplb and NEplb, and between EXplb and NEdtz were demonstrated, whereas no sufficient evidence of significant differences was detected between the other pairs. In conclusion, coadministration of diltiazem 30 mg twice daily may be advantageous for increasing tacrolimus exposure early after kidney transplantation among CYP3A5 expressers.
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16
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Masset C, Gautier-Vargas G, Cantarovich D, Ville S, Dantal J, Delbos F, Walencik A, Kerleau C, Hourmant M, Garandeau C, Meurette A, Giral M, Benotmane I, Caillard S, Blancho G. Occurrence of de novo Donor Specific Antibodies after Covid-19 in kidney transplant recipients is low despite immunosuppression modulation. Kidney Int Rep 2022; 7:983-992. [PMID: 35155848 PMCID: PMC8818557 DOI: 10.1016/j.ekir.2022.01.1072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 02/07/2023] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Christophe Masset
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Correspondence: Christophe Masset, Service de Néphrologie et Immunologie Clinique, 30 bd Jean Monnet, 44093 Nantes Cedex 01, France.
| | - Gabriela Gautier-Vargas
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Diego Cantarovich
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Simon Ville
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Jacques Dantal
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | | | | | - Clarisse Kerleau
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Maryvonne Hourmant
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Claire Garandeau
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Aurélie Meurette
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Magali Giral
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Ilies Benotmane
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Gilles Blancho
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
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17
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Hellemans R, Abramowicz D. Is the failure of recent trials on withdrawal of calcineurin inhibitors due to inadequate mycophenolic acid dosing? J Nephrol 2022; 35:1789-1795. [PMID: 35088366 DOI: 10.1007/s40620-021-01183-y] [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: 09/02/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
Calcineurin inhibitors (CNIs) are the mainstay immunosuppressive therapy after kidney transplantation, despite their side effects. Recently, several randomized controlled trials attempting CNI withdrawal or minimization in stable, low-risk kidney transplant recipients led to an unacceptable risk of acute rejection and de novo HLA antibody formation. In the opinions of many, these trials definitively demonstrated that CNI-free regimens in the context of mycophenolate mofetil (MMF) maintenance are too risky. It can be argued, however, that the investigators failed to optimize the dose of the remaining immunosuppressive therapy. In particular, the potential benefit of MMF dosing based on the targeted mycophenolic acid (MPA) concentration was not taken into account. In this review, we present an overview of the studies on CNI withdrawal, both recent and older, paying specific attention to the MMF dose and elaborating on the possible benefit of MPA monitoring in this setting.
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Affiliation(s)
- Rachel Hellemans
- Laboratory of Experimental Medicine and Pediatrics, Department of Nephrology, Antwerp University Hospital, University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.
| | - Daniel Abramowicz
- Laboratory of Experimental Medicine and Pediatrics, Department of Nephrology, Antwerp University Hospital, University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
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18
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Garg N, Viney K, Burger J, Hidalgo L, Parajuli S, Aziz F, Mohamed MA, Djamali A, Mandelbrot DA. Factors affecting sensitization following kidney allograft failure. Clin Transplant 2021; 36:e14558. [PMID: 34923658 DOI: 10.1111/ctr.14558] [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: 05/25/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 11/28/2022]
Abstract
Management of immunosuppression in a kidney transplant recipient with a failed allograft is complex; continuation carries infectious and metabolic risks, and discontinuation can lead to sensitization. We evaluated risk factors for sensitization in 89 kidney or simultaneous kidney-pancreas recipients, whose kidney transplant failed after 1/2013 and who were subsequently re-evaluated for kidney transplantation. Among recipients with pre graft failure cPRA <50%, calcineurin inhibitor (CNI) continuation (OR 0.11, p = 0.003) and steroid continuation (OR 0.17, p = 0.04) were associated with significantly lower odds of developing an absolute increase in cPRA of ≥50%. Each additional HLA mismatch was associated with OR of 2.16 (p = 0.02). CNI use was associated with OR of 0.09 (p = 0.001) for increase in cPRA to ≥80% if pre graft failure cPRA was <50%, and OR of 0.08 (p = 0.02) for increase in cPRA to ≥98% if pre graft cPRA was <80%. Anti-metabolites were continued more often among recipients who had a <50% increase (p = 0.006), however the association was lost on multivariate analyses. Weaning off immunosuppression and higher number of HLA mismatches are associated with greater likelihood of sensitization. While both CNI and steroid continuation conferred some protection against increase in cPRA, CNI continuation was the only factor protecting against becoming highly sensitized. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kelley Viney
- HLA laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John Burger
- HLA laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luis Hidalgo
- HLA laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Maha A Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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19
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Lenain R, Maanaoui M, Hamroun A, Larrue R, Van Der Hauwaert C, Gibier JB, Gnemmi V, Gomis S, Labalette M, Broly F, Hennart B, Pottier N, Hazzan M, Cauffiez C, Glowacki F. Impact of Tacrolimus Daily Dose Limitation in Renal Transplant Recipients Expressing CYP3A5: A Retrospective Study. J Pers Med 2021; 11:jpm11101002. [PMID: 34683143 PMCID: PMC8539387 DOI: 10.3390/jpm11101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/25/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022] Open
Abstract
The pharmacokinetic variability of tacrolimus can be partly explained by CYP3A5 activity. Our objective was to evaluate a tacrolimus sparing policy on renal graft outcome according to CYP3A5 6986A>G genetic polymorphism. This retrospective study included 1114 recipients with a median follow-up of 6.3 years. Genotyping of the 6986A>G allelic variant corresponding to CYP3A5*3 was systematically performed. One year after transplantation, tacrolimus blood trough concentration (C0) target range was 5–7 ng/mL. However, daily dose was capped to 0.10 mg/kg/day regardless of the CYP3A5 genotype. A total 208 CYP3A5*1/- patients were included. Despite a higher daily dose, CYP3A5*1/- recipients exhibited lower C0 during follow-up (p < 0.01). Multivariate analysis did not show any significant influence of CYP3A5*1/- genotype (HR = 0.70, 0.46–1.07, p = 0.10) on patient-graft survival. Glomerular Filtration Rate (GFR) decline was significantly lower for the CYP3A5*1/- group (p = 0.02). The CYP3A5*1/- genotype did not significantly impact the risk of biopsy-proven acute rejection (BPAR) (HR = 1.01, 0.68–1.49, p = 0.97) despite significantly lower C0. Based on our experience, a strategy of tacrolimus capping is associated with a better GFR evolution in CYP3A5*1/- recipients without any significant increase of BPAR incidence. Our study raised some issues about specific therapeutic tacrolimus C0 targets for CYP3A5*1/- patients and suggests to set up randomized control studies in this specific population.
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Affiliation(s)
- Rémi Lenain
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
| | - Mehdi Maanaoui
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
| | - Aghilès Hamroun
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
| | - Romain Larrue
- UMR9020-U1277—CANTHER—Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (R.L.); (C.V.D.H.); (N.P.)
- CHU Lille, Service de Toxicologie et Génopathies, F-59000 Lille, France; (F.B.); (B.H.)
| | - Cynthia Van Der Hauwaert
- UMR9020-U1277—CANTHER—Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (R.L.); (C.V.D.H.); (N.P.)
- CHU Lille, Département de la Recherche en Santé, F-59000 Lille, France
| | - Jean-Baptiste Gibier
- CHU Lille, Service d’Anatomo-Pathologie, F-59000 Lille, France; (J.-B.G.); (V.G.)
| | - Viviane Gnemmi
- CHU Lille, Service d’Anatomo-Pathologie, F-59000 Lille, France; (J.-B.G.); (V.G.)
| | - Sébastien Gomis
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
| | - Myriam Labalette
- CHU de Lille, Institut D’Immunologie-HLA, F-59000 Lille, France;
| | - Franck Broly
- CHU Lille, Service de Toxicologie et Génopathies, F-59000 Lille, France; (F.B.); (B.H.)
| | - Benjamin Hennart
- CHU Lille, Service de Toxicologie et Génopathies, F-59000 Lille, France; (F.B.); (B.H.)
| | - Nicolas Pottier
- UMR9020-U1277—CANTHER—Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (R.L.); (C.V.D.H.); (N.P.)
- CHU Lille, Service de Toxicologie et Génopathies, F-59000 Lille, France; (F.B.); (B.H.)
| | - Marc Hazzan
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
| | - Christelle Cauffiez
- UMR9020-U1277—CANTHER—Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (R.L.); (C.V.D.H.); (N.P.)
- Correspondence:
| | - François Glowacki
- CHU Lille, Service de Néphrologie, F-59000 Lille, France; (R.L.); (M.M.); (A.H.); (S.G.); (M.H.); (F.G.)
- UMR9020-U1277—CANTHER—Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (R.L.); (C.V.D.H.); (N.P.)
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20
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21
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Slepicka PF, Yazdanifar M, Bertaina A. Harnessing Mechanisms of Immune Tolerance to Improve Outcomes in Solid Organ Transplantation: A Review. Front Immunol 2021; 12:688460. [PMID: 34177941 PMCID: PMC8222735 DOI: 10.3389/fimmu.2021.688460] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/24/2021] [Indexed: 12/15/2022] Open
Abstract
Survival after solid organ transplantation (SOT) is limited by chronic rejection as well as the need for lifelong immunosuppression and its associated toxicities. Several preclinical and clinical studies have tested methods designed to induce transplantation tolerance without lifelong immune suppression. The limited success of these strategies has led to the development of clinical protocols that combine SOT with other approaches, such as allogeneic hematopoietic stem cell transplantation (HSCT). HSCT prior to SOT facilitates engraftment of donor cells that can drive immune tolerance. Recent innovations in graft manipulation strategies and post-HSCT immune therapy provide further advances in promoting tolerance and improving clinical outcomes. In this review, we discuss conventional and unconventional immunological mechanisms underlying the development of immune tolerance in SOT recipients and how they can inform clinical advances. Specifically, we review the most recent mechanistic studies elucidating which immune regulatory cells dampen cytotoxic immune reactivity while fostering a tolerogenic environment. We further discuss how this understanding of regulatory cells can shape graft engineering and other therapeutic strategies to improve long-term outcomes for patients receiving HSCT and SOT.
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Affiliation(s)
- Priscila Ferreira Slepicka
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mahboubeh Yazdanifar
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Alice Bertaina
- Division of Hematology, Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
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22
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Nickerson PW, Balshaw R, Wiebe C, Ho J, Gibson IW, Bridges ND, Rush DN, Heeger PS. A noninferiority design for a delayed calcineurin inhibitor substitution trial in kidney transplantation. Am J Transplant 2021; 21:1503-1512. [PMID: 32956576 PMCID: PMC8048676 DOI: 10.1111/ajt.16311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/03/2020] [Accepted: 09/04/2020] [Indexed: 01/25/2023]
Abstract
Improving long-term kidney transplant outcomes requires novel treatment strategies, including delayed calcineurin inhibitor (CNI) substitution, tested using informative trial designs. An alternative approach to the usual superiority-based trial is a noninferiority trial design that tests whether an investigational agent is not unacceptably worse than standard of care. An informative noninferiority design, with biopsy-proven acute rejection (BPAR) as the endpoint, requires determination of a prespecified, evidence-based noninferiority margin for BPAR. No such information is available for delayed CNI substitution in kidney transplantation. Herein we analyzed data from recent kidney transplant trials of CNI withdrawal and "real world" CNI- based standard of care, containing subjects with well-documented evidence of immune quiescence at 6 months posttransplant-ideal candidates for delayed CNI substitution. Our analysis indicates an evidence-based noninferiority margin of 13.8% for the United States Food and Drug Administration's composite definition of BPAR between 6 and 24 months posttransplant. Sample size estimation determined that ~225 randomized subjects would be required to evaluate noninferiority for this primary clinical efficacy endpoint, and superiority for a renal function safety endpoint. Our findings provide the basis for future delayed CNI substitution noninferiority trials, thereby increasing the likelihood they will provide clinically implementable results and achieve regulatory approval.
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Affiliation(s)
- Peter W. Nickerson
- Department of Internal MedicineMax Rady College of MedicineUniversity of ManitobaWinnipegCanada,Health Sciences CentreShared Health Services ManitobaWinnipegCanada,Department of ImmunologyMax Rady College of MedicineUniversity of ManitobaWinnipegCanada
| | - Robert Balshaw
- George and Fay Yee Centre for Healthcare InnovationUniversity of ManitobaWinnipegCanada
| | - Chris Wiebe
- Department of Internal MedicineMax Rady College of MedicineUniversity of ManitobaWinnipegCanada,Health Sciences CentreShared Health Services ManitobaWinnipegCanada,Department of ImmunologyMax Rady College of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of Internal MedicineMax Rady College of MedicineUniversity of ManitobaWinnipegCanada,Health Sciences CentreShared Health Services ManitobaWinnipegCanada,Department of ImmunologyMax Rady College of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Health Sciences CentreShared Health Services ManitobaWinnipegCanada,Department of PathologyMax Rady College of MedicineUniversity of ManitobaWinnipegCanada
| | - Nancy D. Bridges
- Division of AllergyImmunology and TransplantationNational Institute of Allergy and Infectious DiseaseBethesdaMaryland
| | - David N. Rush
- Department of Internal MedicineMax Rady College of MedicineUniversity of ManitobaWinnipegCanada,Health Sciences CentreShared Health Services ManitobaWinnipegCanada
| | - Peter S. Heeger
- Translational Transplant Research CenterDepartment of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew York
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23
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Sommerer C, Brunet M, Budde K, Millán O, Guirado Perich L, Glander P, Meuer S, Zeier M, Giese T. Monitoring of gene expression in tacrolimus-treated de novo renal allograft recipients facilitates individualized immunosuppression: Results of the IMAGEN study. Br J Clin Pharmacol 2021; 87:3851-3862. [PMID: 33620734 DOI: 10.1111/bcp.14794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/06/2021] [Accepted: 02/13/2021] [Indexed: 12/25/2022] Open
Abstract
AIMS Calcineurin inhibitors (CNI) have a small therapeutic window, and drug monitoring is required. Pharmacokinetic monitoring does not correlate sufficiently with clinical outcome. Therefore, the expression of nuclear factor of activated T cells (NFAT)-regulated genes in the peripheral blood has been suggested as a potentially useful immune monitoring tool to optimize CNI therapy. NFAT-regulated gene expression (RGE) was evaluated in renal allograft recipients as predictive biomarker to detect patients at risk of acute rejection or infections. METHODS NFAT-RGE (interleukin-2, interferon-γ, granular-macrophage colony-stimulating factor) was evaluated by quantitative real-time polymerase chain reaction in whole blood samples at day 7, day 14, month 1, 3, and 6 after transplantation in 64 de novo renal allograft recipients from 3 European centres. Immunosuppression consisted of tacrolimus (Tac), mycophenolic acid, and corticosteroids. RESULTS Tac concentrations (C0 and C1.5) correlated inversely with NFAT-RGE (P < .01). NFAT-RGE showed a high interindividual variability (1-61%). Patients with high residual gene expression (NFAT-RGE ≥30%) were at the increased risk of acute rejection in the following months (35 vs. 5%, P = .02), whereas patients with low residual gene expression (NFAT-RGE <30%) showed a higher incidence of viral complications, especially cytomegalovirus and BK virus replication (52.5 vs. 10%, P = .01). CONCLUSIONS NFAT-RGE was confirmed as a potential noninvasive early predictive biomarker in the immediate post-transplant period to detect patients at risk of acute rejection and infectious complications in Tac-treated renal allograft recipients. Monitoring of NFAT-RGE may provide additional useful information for physicians to achieve individualized Tac treatment.
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Affiliation(s)
- Claudia Sommerer
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, CDB, CIBERehd, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Klemens Budde
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Olga Millán
- Pharmacology and Toxicology Laboratory, CDB, CIBERehd, IDIBAPS, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - Lluis Guirado Perich
- Renal Transplant Unit, Nephrology Department, Fundació Puigvert, Barcelona, Spain
| | - Petra Glander
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Stefan Meuer
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Giese
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
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24
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Cravedi P, Fribourg M, Zhang W, Yi Z, Zaslavsky E, Nudelman G, Anderson L, Hartzell S, Brouard S, Heeger PS. Distinct peripheral blood molecular signature emerges with successful tacrolimus withdrawal in kidney transplant recipients. Am J Transplant 2020; 20:3477-3485. [PMID: 32459070 PMCID: PMC7704683 DOI: 10.1111/ajt.15979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 01/25/2023]
Abstract
Tacrolimus (Tac) is an effective anti-rejection agent in kidney transplantation, but its off-target effects make withdrawal desirable. Although studies indicate that Tac can be safely withdrawn in a subset of kidney transplant recipients, immune mechanisms that underlie successful vs unsuccessful Tac removal are unknown. We performed microarray analyses of peripheral blood mononuclear cells (PBMC) RNA from subjects enrolled in the Clinical Trials in Organ Transplantation-09 study in which we randomized stable kidney transplant recipients to Tac withdrawal or maintenance of standard immunosuppression beginning 6 months after transplant. Eight of 14 subjects attempted but failed withdrawal, while six developed stable graft function for ≥2 years on mycophenolate mofetil plus prednisone. Whereas failed withdrawal upregulated immune activation genes, successful Tac withdrawal was associated with a downregulatory and proapoptotic gene program enriched within T cells. Functional analyses suggested stronger donor-reactive immunity in subjects who failed withdrawal without evidence of regulatory T cell dysfunction. Together, our data from a small, but unique, patient cohort support the conclusion that successful Tac withdrawal is not simply due to absence of donor-reactive immunity but rather is associated with an active immunological process.
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Affiliation(s)
- P. Cravedi
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - M. Fribourg
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - W Zhang
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Z Yi
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - E. Zaslavsky
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - G. Nudelman
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - L. Anderson
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - S. Hartzell
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sophie Brouard
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation etImmunologie, Nantes, France
| | - P. S. Heeger
- Translational Transplant Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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25
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Mannon RB, Armstrong B, Stock PG, Mehta AK, Farris AB, Watson N, Morrison Y, Sarwal M, Sigdel T, Bridges N, Robien M, Newell KA, Larsen CP. Avoidance of CNI and steroids using belatacept-Results of the Clinical Trials in Organ Transplantation 16 trial. Am J Transplant 2020; 20:3599-3608. [PMID: 32558199 PMCID: PMC7710570 DOI: 10.1111/ajt.16152] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 01/25/2023]
Abstract
Immunosuppression devoid of corticosteroids has been investigated to avoid long-term comorbidities. Likewise, alternatives to calcineurin inhibitors have been investigated as a strategy to improve long-term kidney function following transplanion. Costimulatory blockade strategies that include corticosteroids have recently shown promise, despite their higher rates of early acute rejection. We designed a randomized clinical trial utilizing depletional induction therapy to mitigate early rejection risk while limiting calcineurin inhibitors and corticosteroids. This trial, Clinical Trials in Organ Transplantation 16 (CTOT-16), sought to evaluate novel belatacept-based strategies employing tacrolimus and corticosteroid avoidance. Sixty-nine kidney transplant recipients were randomized from 4 US transplant centers comparing a control group of with rabbit antithymocyte globulin (rATG) induction, rapid steroid taper, and maintenance mycophenolate and tacrolimus, to 2 arms using maintenance belatacept. There were no graft losses but there were 2 deaths in the control group. However, the trial was halted early because of rejection in the belatacept treatment groups. Serious adverse events were similar across groups. Although rejection was not uniform in the belatacept maintenance therapy groups, the frequency of rejection limits the practical implementation of this strategy to avoid both calcineurin inhibitors and corticosteroids at this time.
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Affiliation(s)
- Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Aneesh K. Mehta
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA,Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Alton B. Farris
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
| | - Natasha Watson
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Minnie Sarwal
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Tara Sigdel
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - Nancy Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Kenneth A. Newell
- Emory Transplant Center, Emory University School of Medicine, Atlanta GA
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26
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Dujardin A, Chesneau M, Dubois F, Danger R, Bui L, Kerleau C, Guérif P, Brouard S, Dantal J. Clinical and immunological follow-up of very long-term kidney transplant recipients treated with calcineurin inhibitors indicates dual phenotypes. Kidney Int 2020; 99:1418-1429. [PMID: 33137335 DOI: 10.1016/j.kint.2020.09.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
Operationally tolerant kidney transplant recipients harbor an immunological signature, associated with low rejection risk, and focused on B lymphocytes. Here, we investigated whether patients with long-term transplantation and still on immunosuppressive therapy would present such a signature of low immunological rejection risk, compared to more recently transplanted patients. Of 114 kidney transplant recipients enrolled, 38 with more than 25 years of graft survival and stable graft function under calcineurin inhibitors, were matched with two different groups of transplanted patients (10-15 and 5-7 years after transplantation). Three phenotypes associated with low immunological rejection risk (Tfh, B and regulatory T cells), initially found in operationally tolerant kidney transplant recipients, and the composite score of tolerance (combination of six transcriptomic markers, age at transplantation and age at sampling) were analyzed. We found that very long-term patients were characterized by a significantly lower percentage of total B cells, a significantly higher proportion of CD24HiCD38Lo memory B cells, significantly fewer CD24LoCD38Lo naive B cells, and a significantly lower proportion of PD1HiCCR7Lo Tfh lymphocytes than more recently transplanted patients. This phenotype is associated with a positive composite score of tolerance in patients transplanted for more than 25 years. Thus, our study suggests a dual phenotype in very long-term kidney transplanted patients with an immunological profile associated with low rejection risk.
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Affiliation(s)
- Amaury Dujardin
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France; Service de Néphrologie et Immunologie Clinique, CHU Nantes, Nantes Université, ITUN, Nantes, France
| | - Mélanie Chesneau
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France
| | - Florian Dubois
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France
| | - Richard Danger
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France
| | - Linh Bui
- Service de Néphrologie, Centre Hospitalier de Béthune, Bethune Cedex, France
| | - Clarisse Kerleau
- Service de Néphrologie et Immunologie Clinique, CHU Nantes, Nantes Université, ITUN, Nantes, France
| | - Pierrick Guérif
- Service de Néphrologie et Immunologie Clinique, CHU Nantes, Nantes Université, ITUN, Nantes, France
| | - Sophie Brouard
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France; Service de Néphrologie et Immunologie Clinique, CHU Nantes, Nantes Université, ITUN, Nantes, France.
| | - Jacques Dantal
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France; Service de Néphrologie et Immunologie Clinique, CHU Nantes, Nantes Université, ITUN, Nantes, France
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27
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Beckett J, Hester J, Issa F, Shankar S. Regulatory B cells in transplantation: roadmaps to clinic. Transpl Int 2020; 33:1353-1368. [PMID: 32725703 DOI: 10.1111/tri.13706] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/08/2020] [Accepted: 07/23/2020] [Indexed: 12/16/2022]
Abstract
Over the last two decades, an additional and important role for B cells has been established in immune regulation. Preclinical studies demonstrate that regulatory B cells (Breg) can prolong allograft survival in animal models and induce regulatory T cells. Operationally tolerant human kidney transplant recipients demonstrate B-cell-associated gene signatures of immune tolerance, and novel therapeutic agents can induce Bregs in phase I clinical trials in transplantation. Our rapidly expanding appreciation of this novel B-cell subtype has made the road to clinical application a reality. Here, we outline several translational pathways by which Bregs could soon be introduced to the transplant clinic.
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Affiliation(s)
- Joseph Beckett
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Joanna Hester
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Fadi Issa
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Sushma Shankar
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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28
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The TOMATO Study (Tacrolimus Metabolization in Kidney Transplantation): Impact of the Concentration-Dose Ratio on Death-censored Graft Survival. Transplantation 2020; 104:1263-1271. [PMID: 31415035 DOI: 10.1097/tp.0000000000002920] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tacrolimus trough concentrations (mean/variability), as well as concentration-to-dose ratio (C/D ratio), affect kidney allograft outcomes. We investigated the link between the C/D ratio and death-censored kidney graft survival (DCGS). METHODS We performed a retrospective study on 1029 kidney transplant patients (2004-2016) with the following criteria: tacrolimus-based immunosuppression, >1-year graft survival, no initial use of everolimus, and available anti-human leukocyte antigen antibody data. We analyzed the impact of the time-varying C/D ratio on DCGS. Fast metabolizers were defined by a C/D ratio < 1.05. We also investigated the effect of an early (mo 3 to mo 6 post transplantation) C/D ratio below 1.05. Cox survival analyses were performed, adjusting for potential confounders (tacrolimus trough, variability of tacrolimus trough, de novo donor-specific antibody development, cytochrome P450 3A5 genotype, pregraft sensitization, mo 3 glomerular filtration rate). RESULTS Time-varying C/D ratio was significantly associated with DCGS (hazard ratio [HR], 2.35; P < 0.001) in a univariate model, on the full analysis set comprising 1029 patients. In the multivariate time-varying model, based on 666 patients with available cytochrome P450 3A5 genotypes, the effect of the C/D ratio remained significant (HR, 2.26; P = 0.015); even when glomerular filtration rate at month 3 < 30 mL/min/1.73 m (HR, 2.61; P = 0.011), de novo donor-specific antibody development (HR, 4.09; P < 0.001) and continued steroid prescription (HR=2.08, P = 0.014) were taken into account (other covariates, including tacrolimus trough concentrations, were nonsignificant). In the same multivariate model, the effect of early C/D ratio (median at mo 3 and mo 6) remained significantly associated with DCGS (HR, 2.25; P = 0.041). CONCLUSIONS C/D ratio is an independent and early predictor of DCGS. Identification of fast metabolizers could be a strategy to improve graft survival, for example, by optimizing tacrolimus formulation. Mechanistic studies to understand the C/D ratio effect are required.
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30
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Wiebe C, Rush DN, Gibson IW, Pochinco D, Birk PE, Goldberg A, Blydt‐Hansen T, Karpinski M, Shaw J, Ho J, Nickerson PW. Evidence for the alloimmune basis and prognostic significance of Borderline T cell-mediated rejection. Am J Transplant 2020; 20:2499-2508. [PMID: 32185878 PMCID: PMC7496654 DOI: 10.1111/ajt.15860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Prognostic biomarkers of T cell-mediated rejection (TCMR) have not been adequately studied in the modern era. We evaluated 803 renal transplant recipients and correlated HLA-DR/DQ molecular mismatch alloimmune risk categories (low, intermediate, high) with the severity, frequency, and persistence of TCMR. Allograft survival was reduced in recipients with Banff Borderline (hazard ratio [HR] 2.4, P = .003) and Banff ≥ IA TCMR (HR 4.3, P < .0001) including a subset who never developed de novo donor-specific antibodies (P = .002). HLA-DR/DQ molecular mismatch alloimmune risk categories were multivariate correlates of Banff Borderline and Banff ≥ IA TCMR and correlated with the severity and frequency of rejection episodes. Recipient age, HLA-DR/DQ molecular mismatch category, and cyclosporin vs tacrolimus immunosuppression were independent correlates of Banff Borderline and Banff ≥ IA TCMR. In the subset treated with tacrolimus (720/803) recipient age, HLA-DR/DQ molecular mismatch category, and tacrolimus coefficient of variation were independent correlates of TCMR. The correlation of HLA-DR/DQ molecular mismatch category with TCMR, including Borderline, provides evidence for their alloimmune basis. HLA-DR/DQ molecular mismatch may represent a precise prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegCanada
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | | | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Tom Blydt‐Hansen
- Department of PediatricsUniversity of British ColumbiaWinnipegCanada
| | | | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
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31
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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Christakoudi S, Runglall M, Mobillo P, Rebollo-Mesa I, Tsui TL, Nova-Lamperti E, Taube C, Norris S, Kamra Y, Hilton R, Augustine T, Bhandari S, Baker R, Berglund D, Carr S, Game D, Griffin S, Kalra PA, Lewis R, Mark PB, Marks SD, MacPhee I, McKane W, Mohaupt MG, Paz-Artal E, Kon SP, Serón D, Sinha MD, Tucker B, Viklický O, Stahl D, Lechler RI, Lord GM, Hernandez-Fuentes MP. Development and validation of the first consensus gene-expression signature of operational tolerance in kidney transplantation, incorporating adjustment for immunosuppressive drug therapy. EBioMedicine 2020; 58:102899. [PMID: 32707447 PMCID: PMC7374249 DOI: 10.1016/j.ebiom.2020.102899] [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: 05/16/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023] Open
Abstract
Background Kidney transplant recipients (KTRs) with “operational tolerance” (OT) maintain a functioning graft without immunosuppressive (IS) drugs, thus avoiding treatment complications. Nevertheless, IS drugs can influence gene-expression signatures aiming to identify OT among treated KTRs. Methods We compared five published signatures of OT in peripheral blood samples from 18 tolerant, 183 stable, and 34 chronic rejector KTRs, using gene-expression levels with and without adjustment for IS drugs and regularised logistic regression. Findings IS drugs explained up to 50% of the variability in gene-expression and 20–30% of the variability in the probability of OT predicted by signatures without drug adjustment. We present a parsimonious consensus gene-set to identify OT, derived from joint analysis of IS-drug-adjusted expression of five published signature gene-sets. This signature, including CD40, CTLA4, HSD11B1, IGKV4–1, MZB1, NR3C2, and RAB40C genes, showed an area under the curve 0⋅92 (95% confidence interval 0⋅88–0⋅94) in cross-validation and 0⋅97 (0⋅93–1⋅00) in six months follow-up samples. Interpretation We advocate including adjustment for IS drug therapy in the development stage of gene-expression signatures of OT to reduce the risk of capturing features of treatment, which could be lost following IS drug minimisation or withdrawal. Our signature, however, would require further validation in an independent dataset and a biomarker-led trial. Funding FP7-HEALTH-2012-INNOVATION-1 [305147:BIO-DrIM] (SC,IR-M,PM,DSt); MRC [G0801537/ID:88245] (MPH-F); MRC [MR/J006742/1] (IR-M); Guy's&StThomas’ Charity [R080530]&[R090782]; CONICYT-Bicentennial-Becas-Chile (EN-L); EU:FP7/2007–2013 [HEALTH-F5–2010–260687: The ONE Study] (MPH-F); Czech Ministry of Health [NV19–06–00031] (OV); NIHR-BRC Guy's&StThomas' NHS Foundation Trust and KCL (SC); UK Clinical Research Networks [portfolio:7521].
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Affiliation(s)
- Sofia Christakoudi
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; Biostatistics and Health Informatics Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF, UK.
| | - Manohursingh Runglall
- NIHR Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, Great Maze Pond, London SE1 9RT, UK
| | - Paula Mobillo
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK
| | - Irene Rebollo-Mesa
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; Biostatistics and Health Informatics Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Tjir-Li Tsui
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | | | - Catharine Taube
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK
| | - Sonia Norris
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK
| | - Yogesh Kamra
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK
| | - Rachel Hilton
- Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Titus Augustine
- Manchester Royal Infirmary, Oxford Rd, Manchester M13 9WL, UK
| | - Sunil Bhandari
- Hull University Teaching Hospitals NHS Trust, Anlaby Rd, Hull HU3 2JZ, UK
| | - Richard Baker
- St James's University Hospital, Beckett St, Leeds LS9 7TF, UK
| | - David Berglund
- Department of Immunology, Genetics and Pathology, Uppsala University, Rudbecklaboratoriet, 751 85 Uppsala, Sweden
| | - Sue Carr
- Leicester General Hospital, Gwendolen Rd, Leicester LE5 4PW, UK
| | - David Game
- Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Sian Griffin
- Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK
| | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK
| | - Robert Lewis
- Queen Alexandra Hospital, Southwick Hill Rd, Cosham, Portsmouth PO6 3LY, UK
| | - Patrick B Mark
- University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK; University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London WC1N 1EH, UK
| | - Iain MacPhee
- St George's Hospital, Blackshaw Rd, London SW17 0QT, UK & Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London SW17 0RE
| | - William McKane
- Northern General Hospital, Herries Rd, Sheffield S5 7AU, UK
| | - Markus G Mohaupt
- Internal Medicine, Lindenhofgruppe Berne, Switzerland; University of Bern, Berne, Switzerland; School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Estela Paz-Artal
- Department of Immunology and imas12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - Sui Phin Kon
- King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Daniel Serón
- Hospital Universitario Vall d'Hebrón, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Manish D Sinha
- Evelina London Children's Hospital, Westminster Bridge Rd, Lambeth, London SE1 7EH, UK; Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK; King's Health Partners, Guy's Hospital, London SE1 9RT, UK
| | - Beatriz Tucker
- King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Ondrej Viklický
- Transplantační laboratoř, Institut klinické a experimentální medicíny (IKEM), Vídeňská 1958/9, 140 21 Praha 4, Czech Republic
| | - Daniel Stahl
- Biostatistics and Health Informatics Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF, UK
| | - Robert I Lechler
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; King's Health Partners, Guy's Hospital, London SE1 9RT, UK
| | - Graham M Lord
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; NIHR Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, Great Maze Pond, London SE1 9RT, UK; Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Maria P Hernandez-Fuentes
- MRC Centre for Transplantation, King's College London, Great Maze Pond, London SE1 9RT, UK; King's Health Partners, Guy's Hospital, London SE1 9RT, UK
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Dreyer GJ, de Fijter JW. Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching. Front Immunol 2020; 11:359. [PMID: 32226428 PMCID: PMC7080649 DOI: 10.3389/fimmu.2020.00359] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.
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Affiliation(s)
- Geertje J Dreyer
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
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35
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Human leukocyte antigen molecular mismatch to risk stratify kidney transplant recipients. Curr Opin Organ Transplant 2020; 25:8-14. [DOI: 10.1097/mot.0000000000000714] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Long-Term Kidney Transplant Outcomes: Role of Prolonged-Release Tacrolimus. Transplant Proc 2019; 52:102-110. [PMID: 31901329 DOI: 10.1016/j.transproceed.2019.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/02/2019] [Indexed: 01/08/2023]
Abstract
Tacrolimus has significantly improved outcomes for kidney transplant patients and remains the cornerstone of immunosuppressive therapy. While improvements in short-term outcomes in transplantation have been achieved in recent years, maintaining long-term graft survival remains a challenge in kidney transplantation. Minimizing risk factors for poor long-term kidney graft function and survival, and modifying tacrolimus regimens in the early and maintenance phases post-transplantation are essential to maintain long-term kidney transplant outcomes. Tacrolimus has a narrow therapeutic window, resulting in a tightly defined range of optimal drug exposure. Underimmunosuppression is associated with long-term risks, such as the development of donor-specific antibodies and antibody-mediated rejection, with a high possibility of a decline in kidney function and progression to graft failure. Conversely, prolonged overimmunosuppression carries a risk of drug-related adverse events. This review provides an overview of the differences in the formulation, delivery, and pharmacokinetic profiles between immediate- and prolonged-release tacrolimus and evaluates the effect of prolonged-release tacrolimus on the risk factors for poor outcomes in kidney transplantation. Recent evidence is used to provide guidance on target tacrolimus trough levels in the early and maintenance phases post-transplantation, with a view to improving long-term kidney graft function.
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Mendoza Rojas A, Hesselink DA, van Besouw NM, Baan CC, van Gelder T. Impact of low tacrolimus exposure and high tacrolimus intra-patient variability on the development of de novo anti-HLA donor-specific antibodies in kidney transplant recipients. Expert Rev Clin Immunol 2019; 15:1323-1331. [PMID: 31721605 DOI: 10.1080/1744666x.2020.1693263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: De novo donor-specific antibodies (dnDSA) directed against HLA are a major contributing factor to the chronic deterioration of renal allograft function. Several factors, including the degree of HLA matching, younger recipient age, and past sensitization events have been shown to increase the risk for the development of dnDSA. The development of dnDSA is also strongly associated with modifications in the immunosuppressive regimen, non-adherence, and under-immunosuppression.Areas covered: Tacrolimus is widely used after solid organ transplantation (SOT) and in recent years, both a high intra-patient variability in tacrolimus exposure and low tacrolimus exposure have been found to be associated with a higher risk of dnDSA development in kidney transplant recipients. This article provides an overview of current findings published in the recent 5 years regarding the relationship between tacrolimus exposure and variation therein and the development of dnDSA.Expert opinion: In this review, we describe how combining data on tacrolimus intra-patient variability and mean pre-dose concentration may be an effective tool to identify kidney transplant recipients who are at higher risk of developing dnDSA.
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Affiliation(s)
- Aleixandra Mendoza Rojas
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicole M van Besouw
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
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Salcedo-Herrera S, Pinto Ramirez JL, García-Lopez A, Amaya-Nieto J, Girón-Luque F. Acute Rejection in Kidney Transplantation and Early Beginning of Tacrolimus. Transplant Proc 2019; 51:1758-1762. [PMID: 31399163 DOI: 10.1016/j.transproceed.2019.04.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/05/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although tacrolimus is an effective immunosuppressive drug used for preventing biopsy proven acute rejection (BPAR) in kidney transplanted patients, its nephrotoxicity may compromise renal function and lead to delayed initiation because of its side effects. This study aimed to evaluate the safety of early initiation of tacrolimus in the occurrence of BPAR during the first 90 days post transplant. METHODS We conducted a retrospective cohort study involving 315 patients who underwent kidney transplantation from 2015 to 2017. Comparisons were performed between 2 groups according to whether the start time of tacrolimus therapy was delayed or not delayed. Cox proportional hazards models were used to examine the association between variables and the occurrence of BPAR. RESULTS The incidence of BPAR was 14.9% (n = 47) and it was significantly higher in the delayed group (19.4% vs 6.4%; P = .002). Delayed initiation tacrolimus group was significantly associated with the risk of BPAR (hazard ratio: 2.95; P < .036). The overall mortality rate was 2.5% (n = 8) and there was no association between delayed initiation therapy and death (P = .56). CONCLUSION Our study confirmed that delayed initiation of tacrolimus in patients with delayed graft function is associated with a high risk of BPAR.
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Affiliation(s)
| | | | - Andrea García-Lopez
- Department of Transplantation Research, Colombiana de Trasplantes, Bogotá, Colombia
| | - Javier Amaya-Nieto
- Department of Transplantation Research, Colombiana de Trasplantes, Bogotá, Colombia
| | - Fernando Girón-Luque
- Department of Transplantation Surgery, Colombiana de Trasplantes, Bogotá, Colombia
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Sellberg F, Berglund D, Binder C, Hope J, Fontenot J, Griesemer A, Sykes M, Sachs DH, Berglund E. Pharmacokinetic and pharmacodynamic study of a clinically effective anti-CD2 monoclonal antibody. Scand J Immunol 2019; 91:e12839. [PMID: 31630416 DOI: 10.1111/sji.12839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/22/2022]
Abstract
The humanized IgG1κ monoclonal antibody siplizumab and its rat parent monoclonal IgG2b antibody BTI-322 are directed against the CD2 antigen. Siplizumab is species-specific, reacting with human and chimpanzee cells but not with cells from any other species, including other non-human primates. Because siplizumab treatment has recently shown great potential in clinical transplantation, we now present the results of our previous pharmacokinetic, pharmacodynamic and safety studies of both antibodies. Fourteen chimpanzees received 1-3 doses of 0.143 to 5.0 mg/kg iv The effects were followed with flow cytometry on peripheral lymphocytes and staining of lymph nodes. Side effects were recorded. Serum antibody concentrations were followed. Across the doses, a rapid, transient depletion of CD2, CD3, CD4 and CD8 lymphocytes and NK cells was observed for both antibodies. Immune reconstitution was more rapid for BTI-322 compared to siplizumab. Paracortical lymph node T cell depletion was moderate, estimated at 45% with doses of >0.6 mg/kg. Restoration of lymph node architecture was seen after two weeks to two months for all animals. All four subjects receiving BTI-322 experienced AEs on the first dosing day, while the eight subjects dosed with siplizumab experienced few mild, transient AEs. Infusion with siplizumab and BTI-322 resulted in rapid depletion of CD2+ cells in circulation and tissue. Siplizumab had a longer t1/2 and fewer AEs compared to BTI-322.
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Affiliation(s)
- Felix Sellberg
- Department of Immunology, Genetics and Pathology, Section of Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - David Berglund
- Department of Immunology, Genetics and Pathology, Section of Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Christian Binder
- Department of Immunology, Genetics and Pathology, Section of Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - James Hope
- Independent BioTechnology Consultants, Chicago, IL, USA
| | - Jane Fontenot
- University of Louisiana at Lafayette New Iberia Primate Research Center, New Iberia, LA, USA
| | - Adam Griesemer
- Department of Surgery, Columbia Center for Translational Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Megan Sykes
- Department of Surgery, Columbia Center for Translational Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - David H Sachs
- Department of Surgery, Columbia Center for Translational Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Erik Berglund
- Department of Surgery, Columbia Center for Translational Immunology, Columbia University Medical Center, Columbia University, New York, NY, USA.,Division of Transplantation Surgery, Department of Transplantation Surgery, Karolinska Institute, CLINTEC, Karolinska University Hospital, Stockholm, Sweden
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Cockfield SM, Wilson S, Campbell PM, Cantarovich M, Gangji A, Houde I, Jevnikar AM, Keough‐Ryan TM, Monroy‐Cuadros F, Nickerson PW, Pâquet MR, Ramesh Prasad GV, Senécal L, Shoker A, Wolff J, Howell J, Schwartz JJ, Rush DN. Comparison of the effects of standard vs low-dose prolonged-release tacrolimus with or without ACEi/ARB on the histology and function of renal allografts. Am J Transplant 2019; 19:1730-1744. [PMID: 30582281 PMCID: PMC6590452 DOI: 10.1111/ajt.15225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 01/25/2023]
Abstract
Targeting the renin-angiotensin system and optimizing tacrolimus exposure are both postulated to improve outcomes in renal transplant recipients (RTRs) by preventing interstitial fibrosis/tubular atrophy (IF/TA). In this multicenter, prospective, open-label controlled trial, adult de novo RTRs were randomized in a 2 × 2 design to low- vs standard-dose (LOW vs STD) prolonged-release tacrolimus and to angiotensin-converting enzyme inhibitors/angiotensin II receptor 1 blockers (ACEi/ARBs) vs other antihypertensive therapy (OAHT). There were 2 coprimary endpoints: the prevalence of IF/TA at month 6 and at month 24. IF/TA prevalence was similar for LOW vs STD tacrolimus at month 6 (36.8% vs 39.5%; P = .80) and ACEi/ARBs vs OAHT at month 24 (54.8% vs 58.2%; P = .33). IF/TA progression decreased significantly with LOW vs STD tacrolimus at month 24 (mean [SD] change, +0.42 [1.477] vs +1.10 [1.577]; P = .0039). Across the 4 treatment groups, LOW + ACEi/ARB patients exhibited the lowest mean IF/TA change and, compared with LOW + OAHT patients, experienced significantly delayed time to first T cell-mediated rejection. Renal function was stable from month 1 to month 24 in all treatment groups. No unexpected safety findings were detected. Coupled with LOW tacrolimus dosing, ACEi/ARBs appear to reduce IF/TA progression and delay rejection relative to reduced tacrolimus exposure without renin-angiotensin system blockade. ClinicalTrials.gov identifier: NCT00933231.
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Affiliation(s)
| | - Sam Wilson
- Astellas Pharma Global DevelopmentNorthbrookIllinois
| | | | | | - Azim Gangji
- St. Joseph's Healthcare HamiltonHamiltonOntarioCanada
| | | | | | | | | | | | | | | | | | | | | | - John Howell
- Astellas Pharma Global Development, Inc.MarkhamOntarioCanada
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41
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Wiebe C, Kosmoliaptsis V, Pochinco D, Gibson IW, Ho J, Birk PE, Goldberg A, Karpinski M, Shaw J, Rush DN, Nickerson PW. HLA-DR/DQ molecular mismatch: A prognostic biomarker for primary alloimmunity. Am J Transplant 2019; 19:1708-1719. [PMID: 30414349 PMCID: PMC6563434 DOI: 10.1111/ajt.15177] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/11/2018] [Accepted: 11/04/2018] [Indexed: 01/25/2023]
Abstract
Alloimmune risk stratification in renal transplantation has lacked the necessary prognostic biomarkers to personalize recipient care or optimize clinical trials. HLA molecular mismatch improves precision compared to traditional antigen mismatch but has not been studied in detail at the individual molecule level. This study evaluated 664 renal transplant recipients and correlated HLA-DR/DQ single molecule eplet mismatch with serologic, histologic, and clinical outcomes. Compared to traditional HLA-DR/DQ whole antigen mismatch, HLA-DR/DQ single molecule eplet mismatch improved the correlation with de novo donor-specific antibody development (area under the curve 0.54 vs 0.84) and allowed recipients to be stratified into low, intermediate, and high alloimmune risk categories. These risk categories were significantly correlated with primary alloimmune events including Banff ≥1A T cell-mediated rejection (P = .0006), HLA-DR/DQ de novo donor-specific antibody development (P < .0001), antibody-mediated rejection (P < .0001), as well as all-cause graft loss (P = .0012) and each of these correlations persisted in multivariate models. Thus, HLA-DR/DQ single molecule eplet mismatch may represent a precise, reproducible, and widely available prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada
| | - Vasilis Kosmoliaptsis
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at the University of CambridgeCambridgeUK,The NIHR Cambridge Biomedical Research CentreCambridgeUK
| | | | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegManitobaCanada,Department of PathologyUniversity of ManitobaWinnipegManitobaCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Department of ImmunologyUniversity of ManitobaWinnipegManitobaCanada
| | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Martin Karpinski
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegManitobaCanada,Shared Health Services ManitobaWinnipegManitobaCanada,Department of ImmunologyUniversity of ManitobaWinnipegManitobaCanada
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42
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Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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43
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Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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44
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Jouve T, Noble J, Rostaing L, Malvezzi P. An update on the safety of tacrolimus in kidney transplant recipients, with a focus on tacrolimus minimization. Expert Opin Drug Saf 2019; 18:285-294. [DOI: 10.1080/14740338.2019.1599858] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
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45
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Tacrolimus Variability: A Cause of Donor-Specific Anti-HLA Antibody Formation in Children. Eur J Drug Metab Pharmacokinet 2019; 44:539-548. [DOI: 10.1007/s13318-019-00544-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
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46
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Girerd S, Schikowski J, Girerd N, Duarte K, Busby H, Gambier N, Ladrière M, Kessler M, Frimat L, Aarnink A. Impact of reduced exposure to calcineurin inhibitors on the development of de novo DSA: a cohort of non-immunized first kidney graft recipients between 2007 and 2014. BMC Nephrol 2018; 19:232. [PMID: 30219043 PMCID: PMC6139146 DOI: 10.1186/s12882-018-1014-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background In low-immunological risk kidney transplant recipients (KTRs), reduced exposure to calcineurin inhibitor (CNI) appears particularly attractive for avoiding adverse events, but may increase the risk of developing de novo Donor Specific Antibodies (dnDSA). Methods CNI exposure was retrospectively analyzed in 247 non-HLA immunized first KTRs by taking into account trough levels (C0) collected during follow-up. Reduced exposure to CNI was defined as follows: C0 less than the lower limit of the international targets for ≥50% of follow-up. Results During a mean follow-up of 5.0 ± 2.0 years, 39 patients (15.8%) developed dnDSA (MFI ≥1000). Patients with DSA were significantly younger (46.6 ± 13.8 vs. 51.7 ± 14.0 years, p = 0.039), received more frequently poorly-matched grafts (59% with 6–8 A-B-DR-DQ HLA mismatches vs. 34.6%, p = 0.016) and had more frequently a reduced exposure to CNI (92.3% vs. 62.0%, p = 0.0002). Reduced exposure to CNI was associated with an increased risk of dnDSA (multivariable HR = 9.77, p = 0.002). Reduced exposure to CNI had no effect on patient survival, graft loss from any cause including death, or post-transplant cancer. Conclusions Even in a low-immunological risk population, reduced exposure to CNI is associated with increased risk of dnDSA. Benefits and risks of under-immunosuppression must be carefully evaluated before deciding on CNI minimization.
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Affiliation(s)
- S Girerd
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France. .,INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
| | - J Schikowski
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - N Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - K Duarte
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - H Busby
- Service d'Anatomie pathologique, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - N Gambier
- Service de Pharmacologie-Toxicologie, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - M Ladrière
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - M Kessler
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - L Frimat
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - A Aarnink
- Laboratoire d'Histocompatibilité, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
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47
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Mannon RB, Askar M, Jackson AM, Newell K, Mengel M. Meeting report of the STAR-Sensitization in Transplantation Assessment of Risk: Naïve Abdominal Transplant Organ subgroup focus on kidney transplantation. Am J Transplant 2018; 18:2120-2134. [PMID: 29943908 DOI: 10.1111/ajt.14977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/30/2018] [Accepted: 05/31/2018] [Indexed: 01/25/2023]
Abstract
The development of de novo donor-specific HLA antibody (dnDSA) is a critical feature contributing to late allograft failure. The complexity of the issue is further complicated by organ-specific differences, detection techniques, reliance of tissue histopathology and changing diagnostic criteria, ineffective therapies, and lack of consensus. To tackle these issues, the Sensitization in Transplantation Assessment of Risk (STAR) 2017 was initiated as a collaboration of the American Society of Transplantation and American Society of Histocompatibility and Immunogenetics consisting of 8 working groups with the goal to provide guidelines on how to assess risk and risk stratify patients based on their potential alloimmune and DSA status. Herein is a summary of discussions by the Naïve Abdominal Working Group, highlighting currently available data and identifying gaps in our knowledge on the development and impact of dnDSA following kidney transplantation.
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Affiliation(s)
- Roslyn B Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Medhat Askar
- Transplant Immunology, Baylor University Medical Center, Dallas, TX, USA
| | - Annette M Jackson
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
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48
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Wiebe C, Ho J, Gibson IW, Rush DN, Nickerson PW. Carpe diem-Time to transition from empiric to precision medicine in kidney transplantation. Am J Transplant 2018; 18:1615-1625. [PMID: 29603637 DOI: 10.1111/ajt.14746] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/13/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
The current immunosuppressive pipeline in kidney transplantation is limited. In part, this is due to excellent one-year allograft outcomes with the current standard of care (ie, calcineurin inhibitor in combination with anti-proliferative agents). Despite this success, a recent Federal government-sponsored systematic review has identified gaps/limits in the evidence of what constitutes optimal calcineurin inhibitor use in the short- and long-term. Moreover, recent empiric approaches to minimize/withdraw/convert from calcineurin inhibitors have come with the price of increased alloreactivity. As the time horizon to replace calcineurin inhibitors on a global scale may be distant, the transplant community should seize the opportunity to develop ways to personalize calcineurin inhibitor immunosuppression to the individual-transitioning from empiricism to precision. The authors argue in this viewpoint that the path to precision will require measures capable of detecting subclinical alloreactivity to define adequacy of immunosuppression, as well as novel genetic analytics to accurately define alloimmune risk at the individual level-both approaches will require validation in clinical trials.
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Affiliation(s)
- Chris Wiebe
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Diagnostic Services of Manitoba, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ian W Gibson
- Diagnostic Services of Manitoba, Winnipeg, MB, Canada.,Department of Pathology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David N Rush
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter W Nickerson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Diagnostic Services of Manitoba, Winnipeg, MB, Canada
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49
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Tambur AR, Campbell P, Claas FH, Feng S, Gebel HM, Jackson AM, Mannon RB, Reed EF, Tinckam K, Askar M, Chandraker A, Chang PP, Colvin M, Demetris AJ, Diamond JM, Dipchand AI, Fairchild RL, Ford ML, Friedewald J, Gill RG, Glotz D, Goldberg H, Hachem R, Knechtle S, Kobashigawa J, Levine DJ, Levitsky J, Mengel M, Milford E, Newell KA, O'Leary JG, Palmer S, Randhawa P, Smith J, Snyder L, Starling RC, Sweet S, Taner T, Taylor CJ, Woodle S, Zeevi A, Nickerson P. Sensitization in Transplantation: Assessment of Risk (STAR) 2017 Working Group Meeting Report. Am J Transplant 2018; 18:1604-1614. [PMID: 29603613 DOI: 10.1111/ajt.14752] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/25/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
The presence of preexisting (memory) or de novo donor-specific HLA antibodies (DSAs) is a known barrier to successful long-term organ transplantation. Yet, despite the fact that laboratory tools and our understanding of histocompatibility have advanced significantly in recent years, the criteria to define presence of a DSA and assign a level of risk for a given DSA vary markedly between centers. A collaborative effort between the American Society for Histocompatibility and Immunogenetics and the American Society of Transplantation provided the logistical support for generating a dedicated multidisciplinary working group, which included experts in histocompatibility as well as kidney, liver, heart, and lung transplantation. The goals were to perform a critical review of biologically driven, state-of-the-art, clinical diagnostics literature and to provide clinical practice recommendations based on expert assessment of quality and strength of evidence. The results of the Sensitization in Transplantation: Assessment of Risk (STAR) meeting are summarized here, providing recommendations on the definition and utilization of HLA diagnostic testing, and a framework for clinical assessment of risk for a memory or a primary alloimmune response. The definitions, recommendations, risk framework, and highlighted gaps in knowledge are intended to spur research that will inform the next STAR Working Group meeting in 2019.
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Affiliation(s)
| | | | - Frans H Claas
- Leiden University Medical Center, Leiden, Netherlands
| | - Sandy Feng
- UCSF Medical Center, San Francisco, California
| | | | | | | | - Elaine F Reed
- UCLA Pathology & Laboratory Medicine, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | - Mandy L Ford
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Ramsey Hachem
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | - Edgar Milford
- Brigham and Women's' Hospital, Boston, Massachusetts
| | | | | | - Scott Palmer
- Duke University School of Medicine, Durham, North Carolina
| | | | - John Smith
- Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Laurie Snyder
- Duke University School of Medicine, Durham, North Carolina
| | | | - Stuart Sweet
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | - Adriana Zeevi
- University of Pittsburg Medical Center, Pittsburgh, Pennsylvania
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50
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Perico N, Casiraghi F, Todeschini M, Cortinovis M, Gotti E, Portalupi V, Mister M, Gaspari F, Villa A, Fiori S, Introna M, Longhi E, Remuzzi G. Long-Term Clinical and Immunological Profile of Kidney Transplant Patients Given Mesenchymal Stromal Cell Immunotherapy. Front Immunol 2018; 9:1359. [PMID: 29963053 PMCID: PMC6014158 DOI: 10.3389/fimmu.2018.01359] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 05/31/2018] [Indexed: 12/11/2022] Open
Abstract
We report here the long-term clinical and immunological results of four living-donor kidney transplant patients given autologous bone marrow-derived mesenchymal stromal cells (MSCs) as part of a phase 1 study focused on the safety and feasibility of this cell therapy. According to study protocols implemented over time, based on initial early safety findings, the patients were given MSC at day 7 posttransplant (n = 2) or at day −1 pretransplant (n = 2) and received induction therapy with basiliximab and low-dose rabbit anti-thymocyte globulin (RATG) or RATG alone, and were maintained on low-dose ciclosporin (CsA)/mycophenolate mofetil (MMF). All MSC-treated patients had stable graft function during the 5- to 7-year follow-up, without increased susceptibility to infections or neoplasm. In three MSC recipients, but not historical control patients, circulating memory CD8+ T cell percentages remained lower than basal, coupled with persistent reduction of ex vivo donor-specific cytotoxicity. Two patients showed a long-lasting increase in the regulatory T cell/memory CD8+ T cell ratio, paralleled by high circulating levels of naïve and transitional B cells. In one of these two patients, CsA was successfully discontinued, and currently the low-dose MMF monotherapy is on the tapering phase. The study shows that MSC therapy is safe in the long term and could promote a pro-tolerogenic environment in selected patients. Extensive immunomonitoring of MSC-treated kidney transplant recipients could help selection of patients for safe withdrawal of maintenance immunosuppressive drugs (NCT00752479 and NCT02012153).
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Affiliation(s)
- Norberto Perico
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | | | - Marta Todeschini
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Monica Cortinovis
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Eliana Gotti
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Valentina Portalupi
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Marilena Mister
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Flavio Gaspari
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Alessandro Villa
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Sonia Fiori
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Martino Introna
- G. Lanzani Laboratory of Cell Therapy, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Elena Longhi
- Laboratory of Transplant Immunology, UOC Coordinamento Trapianti IRCCS Fondazione Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Giuseppe Remuzzi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy.,Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.,L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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