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Oliveras L, Coloma A, Lloberas N, Lino L, Favà A, Manonelles A, Codina S, Couceiro C, Melilli E, Sharif A, Hecking M, Guthoff M, Cruzado JM, Pascual J, Montero N. Immunosuppressive drug combinations after kidney transplantation and post-transplant diabetes: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100856. [PMID: 38723582 DOI: 10.1016/j.trre.2024.100856] [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: 03/11/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 06/16/2024]
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent complication after kidney transplantation (KT). This systematic review investigated the effect of different immunosuppressive regimens on the risk of PTDM. We performed a systematic literature search in MEDLINE and CENTRAL for randomized controlled trials (RCTs) that included KT recipients with any immunosuppression and reported PTDM outcomes up to 1 October 2023. The analysis included 125 RCTs. We found no differences in PTDM risk within induction therapies. In de novo KT, there was an increased risk of developing PTDM with tacrolimus versus cyclosporin (RR 1.71, 95%CI [1.38-2.11]). No differences were observed between tacrolimus+mammalian target of rapamycin inhibitor (mTORi) and tacrolimus+MMF/MPA, but there was a tendency towards a higher risk of PTDM in the cyclosporin+mTORi group (RR 1.42, 95%CI [0.99-2.04]). Conversion from cyclosporin to an mTORi increased PTDM risk (RR 1.89, 95%CI [1.18-3.03]). De novo belatacept compared with a calcineurin inhibitor resulted in 50% lower risk of PTDM (RR 0.50, 95%CI [0.32-0.79]). Steroid avoidance resulted in 31% lower PTDM risk (RR 0.69, 95%CI [0.57-0.83]), whereas steroid withdrawal resulted in no differences. Immunosuppression should be decided on an individual basis, carefully weighing the risk of future PTDM and rejection.
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Affiliation(s)
- Laia Oliveras
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Ana Coloma
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain
| | - Nuria Lloberas
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Luis Lino
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain
| | - Alexandre Favà
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain
| | - Anna Manonelles
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Sergi Codina
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Carlos Couceiro
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Edoardo Melilli
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, University of Tübingen, Tübingen, Germany; Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
| | - Josep M Cruzado
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Julio Pascual
- Hospital 12 de Octubre, Nephrology Department, Madrid, Spain.
| | - Nuria Montero
- Hospital Universitari de Bellvitge, Nephrology Department. L'Hospitalet de Llobregat, Spain; Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain.
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Brook MO, Hennessy C, Hester J, Hammad S, Alzhrani A, Rombach I, Dutton S, Lombardi G, Wood KJ, Friend P, Harden PN, Issa F. Late Treatment With Autologous Expanded Regulatory T-cell Therapy After Alemtuzumab Induction Is Safe and Facilitates Immunosuppression Minimization in Living Donor Renal Transplantation. Transplantation 2024:00007890-990000000-00784. [PMID: 38845088 DOI: 10.1097/tp.0000000000005065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
BACKGROUND The TWO Study (Transplantation Without Overimmunosuppression) aimed to investigate a novel approach to regulatory T-cell (Treg) therapy in renal transplant patients, using a delayed infusion protocol at 6 mo posttransplant to promote a Treg-skewed lymphocyte repopulation after alemtuzumab induction. We hypothesized that this would allow safe weaning of immunosuppression to tacrolimus alone. The COVID-19 pandemic led to the suspension of alemtuzumab use, and therefore, we report the unique cohort of 7 patients who underwent the original randomized controlled trial protocol. This study presents a unique insight into Treg therapy combined with alemtuzumab and is therefore an important proof of concept for studies in other diseases that are considering lymphodepletion. METHODS Living donor kidney transplant recipients were randomized to receive autologous polyclonal Treg at week 26 posttransplantation, coupled with weaning doses of tacrolimus, (Treg therapy arm) or standard immunosuppression alone (tacrolimus and mycophenolate mofetil). Primary outcomes were patient survival and rejection-free survival. RESULTS Successful cell manufacturing and cryopreservation until the 6-mo infusion were achieved. Patient and transplant survival was 100%. Acute rejection-free survival was 100% in the Treg-treated group at 18 mo after transplantation. Although alemtuzumab caused a profound depletion of all lymphocytes, including Treg, after cell therapy infusion, there was a transient increase in peripheral Treg numbers. CONCLUSIONS The study establishes that delayed autologous Treg therapy is both feasible and safe, even 12 mo after cell production. The findings present a new treatment protocol for Treg therapy, potentially expanding its applications to other indications.
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Affiliation(s)
- Matthew O Brook
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
| | - Conor Hennessy
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
| | - Joanna Hester
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
| | - Salim Hammad
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Science, King's College London, London, United Kingdom
| | - Alaa Alzhrani
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
| | - Ines Rombach
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Science, King's College London, London, United Kingdom
| | - Susan Dutton
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - Giovanna Lombardi
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Science, King's College London, London, United Kingdom
| | - Kathryn J Wood
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
| | - Peter Friend
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Paul N Harden
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Fadi Issa
- Translational Research Immunology Group, University of Oxford, Oxford, United Kingdom
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Engen RM, Bartosh SM. Long-term outcomes of two-dose alemtuzumab induction in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14753. [PMID: 38623881 DOI: 10.1111/petr.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Alemtuzumab is a lymphocyte depleting agent used for induction in kidney transplant, but long-term information on its use in pediatric recipients remains sparse. METHODS We performed a single-center retrospective cohort study of 57 pediatric kidney transplant recipients receiving alemtuzumab 20 mg/m2/dose ×2 doses for induction immunosuppression. All patients underwent surveillance biopsies, and 91.3% underwent steroid withdrawal by day 4 post-transplant. Outcomes of interest included graft survival, development of donor specific antibodies (DSA), incidence of viremia and PTLD, and duration of lymphopenia. RESULTS Median follow-up time was 7.9 years (IQR 5-13.6 years). Median graft survival was 16.5 years (95% CI 11.6-unknown). DSA developed in 36.5% at a median of 944 days (IQR 252-2113 days). Incidences of BK polyomavirus DNAemia (BKPyV-DNAemia), CMV DNAemia, and EBV DNAemia were 38.6%, 22.8%, and 14%, respectively; one patient developed PTLD at 13.3 years post-transplant. Median duration of lymphopenia was 365 days (IQR 168-713 days); 19.3% of patients remained lymphopenic at 3 years post-transplant. There was no association between duration of lymphopenia and graft survival, rejection, DSA detection, or viremia. CONCLUSIONS A two-dose alemtuzumab induction protocol can have excellent outcomes with a steroid-free maintenance immunosuppression regimen. More comprehensive, multicenter, comparative studies of pediatric kidney transplant are needed to improve long-term outcomes.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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4
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Nimmo A, Latimer N, Oniscu GC, Ravanan R, Taylor DM, Fotheringham J. Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening. Transpl Int 2022; 35:10105. [PMID: 35832035 PMCID: PMC9271574 DOI: 10.3389/ti.2022.10105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
Inferring causality from observational studies is difficult due to inherent differences in patient characteristics between treated and untreated groups. The randomised controlled trial is the gold standard study design as the random allocation of individuals to treatment and control arms should result in an equal distribution of known and unknown prognostic factors at baseline. However, it is not always ethically or practically possible to perform such a study in the field of transplantation. Propensity score and instrumental variable techniques have theoretical advantages over conventional multivariable regression methods and are increasingly being used within observational studies to reduce the risk of confounding bias. An understanding of these techniques is required to critically appraise the literature. We provide an overview of propensity score and instrumental variable techniques for transplant clinicians, describing their principles, assumptions, strengths, and weaknesses. We discuss the different patient populations included in analyses and how to interpret results. We illustrate these points using data from the Access to Transplant and Transplant Outcome Measures study examining the association between pre-transplant cardiac screening in kidney transplant recipients and post-transplant cardiac events.
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Affiliation(s)
- Ailish Nimmo
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
- *Correspondence: Ailish Nimmo,
| | - Nicholas Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Gabriel C. Oniscu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Rommel Ravanan
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Dominic M. Taylor
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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5
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Cooper M, Schnitzler M, Nilubol C, Wang W, Wu Z, Nordyke RJ. Costs in the Year Following Deceased Donor Kidney Transplantation: Relationships With Renal Function and Graft Failure. Transpl Int 2022; 35:10422. [PMID: 35692736 PMCID: PMC9184448 DOI: 10.3389/ti.2022.10422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
Relationships between renal function and medical costs for deceased donor kidney transplant recipients are not fully quantified post-transplant. We describe these relationships with renal function measured by estimated glomerular filtration rate (eGFR) and graft failure. The United States Renal Data System identified adults receiving single-organ deceased donor kidneys 2012–2015. Inpatient, outpatient, other facility costs and eGFRs at discharge, 6 and 12 months were included. A time-history of costs was constructed for graft failures and monthly costs in the first year post-transplant were compared to those without failure. The cohort of 24,021 deceased donor recipients had a 2.4% graft failure rate in the first year. Total medical costs exhibit strong trends with eGFR. Recipients with 6-month eGFRs of 30–59 ml/min/1.73m2 have total costs 48% lower than those <30 ml/min/1.73m2. For recipients with graft failure monthly costs begin to rise 3–4 months prior to failure, with incremental costs of over $38,000 during the month of failure. Mean annual total incremental costs of graft failure are over $150,000. Total costs post-transplant are strongly correlated with eGFR. Graft failure in the first year is an expensive, months-long process. Further reductions in early graft failures could yield significant human and economic benefits.
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Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, United States
| | - Mark Schnitzler
- School of Medicine, Saint Louis University, St. Louis, MO, United States
| | - Chanigan Nilubol
- Medstar Georgetown Transplant Institute, Washington, DC, United States
| | | | - Zheng Wu
- Genesis Research, Hoboken, NJ, United States
| | - Robert J. Nordyke
- Beta6 Consulting Group, Los Angeles, CA, United States
- *Correspondence: Robert J. Nordyke, , orcid.org/0000-0003-2424-7852
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Hilbrands L, Budde K, Bellini MI, Diekmann F, Furian L, Grinyó J, Heemann U, Hesselink DA, Loupy A, Oberbauer R, Pengel L, Reinders M, Schneeberger S, Naesens M. Allograft Function as Endpoint for Clinical Trials in Kidney Transplantation. Transpl Int 2022; 35:10139. [PMID: 35669976 PMCID: PMC9163811 DOI: 10.3389/ti.2022.10139] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
Clinical study endpoints that assess the efficacy of interventions in patients with chronic renal insufficiency can be adopted for use in kidney transplantation trials, given the pathophysiological similarities between both conditions. Kidney dysfunction is reflected in the glomerular filtration rate (GFR), and although a predefined (e.g., 50%) reduction in GFR was recommended as an endpoint by the European Medicines Agency (EMA) in 2016, many other endpoints are also included in clinical trials. End-stage renal disease is strongly associated with a change in estimated (e)GFR, and eGFR trajectories or slopes are increasingly used as endpoints in clinical intervention trials in chronic kidney disease (CKD). Similar approaches could be considered for clinical trials in kidney transplantation, although several factors should be taken into account. The present Consensus Report was developed from documentation produced by the European Society for Organ Transplantation (ESOT) as part of a Broad Scientific Advice request that ESOT submitted to the EMA in 2020. This paper provides a contemporary discussion of primary endpoints used in clinical trials involving CKD, including proteinuria and albuminuria, and evaluates the validity of these concepts as endpoints for clinical trials in kidney transplantation.
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Affiliation(s)
- Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, University of Padua, Padua, Italy
| | - Josep Grinyó
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Dennis A. Hesselink
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
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Brook MO, Hester J, Petchey W, Rombach I, Dutton S, Bottomley MJ, Black J, Abdul-Wahab S, Bushell A, Lombardi G, Wood K, Friend P, Harden P, Issa F. Transplantation Without Overimmunosuppression (TWO) study protocol: a phase 2b randomised controlled single-centre trial of regulatory T cell therapy to facilitate immunosuppression reduction in living donor kidney transplant recipients. BMJ Open 2022; 12:e061864. [PMID: 35428650 PMCID: PMC9014059 DOI: 10.1136/bmjopen-2022-061864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Regulatory T cell (Treg) therapy has been demonstrated to facilitate long-term allograft survival in preclinical models of transplantation and may permit reduction of immunosuppression and its associated complications in the clinical setting. Phase 1 clinical trials have shown Treg therapy to be safe and feasible in clinical practice. Here we describe a protocol for the TWO study, a phase 2b randomised control trial of Treg therapy in living donor kidney transplant recipients that will confirm safety and explore efficacy of this novel treatment strategy. METHODS AND ANALYSIS 60 patients will be randomised on a 1:1 basis to Treg therapy (TR001) or standard clinical care (control). Patients in the TR001 arm will receive an infusion of autologous polyclonal ex vivo expanded Tregs 5 days after transplantation instead of standard monoclonal antibody induction. Maintenance immunosuppression will be reduced over the course of the post-transplant period to low-dose tacrolimus monotherapy. Control participants will receive a standard basiliximab-based immunosuppression regimen with long-term tacrolimus and mycophenolate mofetil immunosuppression. The primary endpoint is biopsy proven acute rejection over 18 months; secondary endpoints include immunosuppression burden, chronic graft dysfunction and drug-related complications. ETHICS AND DISSEMINATION Ethical approval has been provided by the National Health Service Health Research Authority South Central-Oxford A Research Ethics Committee (reference 18/SC/0054). The study also received authorisation from the UK Medicines and Healthcare products Regulatory Agency and is being run in accordance with the principles of Good Clinical Practice, in collaboration with the registered trials unit Oxford Clinical Trials Research Unit. Results from the TWO study will be published in peer-reviewed scientific/medical journals and presented at scientific/clinical symposia and congresses. TRIAL REGISTRATION NUMBER ISRCTN: 11038572; Pre-results.
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Affiliation(s)
- Matthew Oliver Brook
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joanna Hester
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - William Petchey
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Matthew James Bottomley
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joanna Black
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Seetha Abdul-Wahab
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre GMP unit, Guy's Hospital, London, UK
| | - Andrew Bushell
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Giovanna Lombardi
- NIHR Biomedical Research Centre GMP unit, Guy's Hospital, London, UK
- Peter Gorer Department of Immunobiology, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Kathryn Wood
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Peter Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Harden
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fadi Issa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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8
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Thymoglobulin versus Alemtuzumab versus Basiliximab Kidney Transplantation from Donors After Circulatory Death. Kidney Int Rep 2022; 7:732-740. [PMID: 35497810 PMCID: PMC9039467 DOI: 10.1016/j.ekir.2022.01.1042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The Campath, Calcineurin inhibitor (CNI) reduction, and Chronic allograft nephropathy (3C), a study comparing alemtuzumab versus basiliximab induction immunosuppression in kidney transplants, has found lower acute rejection rate with alemtuzumab but same graft survival. The aim of the current study is to evaluate the effect of induction immunosuppression (thymoglobulin, alemtuzumab, basiliximab) on the outcome of kidneys of donors after circulatory death (DCD). Methods Data of the 274 DCD patients of the 3C obtained from the sponsor were compounded with the 140 DCD patients who received thymoglobulin in a single center with the same entry criteria as the 3C, giving 414 patients on 3 induction regimes. Results There were more male donors (P < 0.05) and human leukocyte antigen and DR mismatched patients in the thymoglobulin group (P < 0.001). Death-censored graft survival at 6 months was 98.6% in the thymoglobulin, 95.5% in the alemtuzumab (P = 0.08), and 95.7% in the basiliximab group (P = 0.09) and at 2 years 97.9% versus 94.8% (P = 0.13, hazard ratio [HR] 2.8, 95% CI 0.7–10.9) versus 94.3% (P = 0.06, HR 3.5, 95% CI 0.9–13.6), respectively. The 2-year overall graft survival was 95% in the thymoglobulin versus 88% in the alemtuzumab (unadjusted P = 0.038, adjusted HR 2.4, 95% CI 0.99–5.9) and 91.4% in the basiliximab group (P = 0.21). The 2-year patient survival was numerically less in the alemtuzumab compared with the thymoglobulin group (91.8% vs. 97.1%, P = 0.052, HR 2.90, 95% CI 0.93–9.2). Acute rejection was 17% in the basiliximab, 4.3% in the thymoglobulin, and 6% in the alemtuzumab group (P < 0.001). Conclusion In DCD transplants, thymoglobulin induction may provide advantage over alemtuzumab in patient survival and the same advantage as alemtuzumab over basiliximab in terms of acute rejection. Differing maintenance immunosuppression may contribute to the difference found.
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9
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Zeng J, Zhong Q, Feng X, Li L, Feng S, Fan Y, Song T, Huang Z, Wang X, Lin T. Conversion From Calcineurin Inhibitors to Mammalian Target of Rapamycin Inhibitors in Kidney Transplant Recipients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Immunol 2021; 12:663602. [PMID: 34539621 PMCID: PMC8446650 DOI: 10.3389/fimmu.2021.663602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023] Open
Abstract
Background A systematic review and meta-analysis were performed to investigate the efficacy and safety of conversion from calcineurin inhibitors (CNIs) to mammalian target of rapamycin inhibitors (mTORi) in kidney transplant recipients (KTRs). Methods MEDLINE, EMBASE, PubMed, and Cochrane Library were searched to identify randomized controlled trials (RCTs) that compared the continuation of CNI with conversion to mTORi therapy. Results Twenty-nine RCTs (5,747 KTRs) were included in our analysis. Meta-analysis of the glomerular filtration rate (SMD 0.20; 95%CI 0.10-0.31; P<0.01) and malignancy (RR 0.74; 95%CI 0.55-0.99; P=0.04) demonstrated a significant advantage of mTORi conversion over CNI continuation. However, the risk of acute rejection (RR 1.58; 95%CI 1.22-2.04; P<0.01), infection (RR 1.55; 95%CI 1.01-1.31; P=0.04), proteinuria (RR 1.87; 95%CI 1.34-2.59; P<0.01), leukopenia (RR 1.56; 95%CI 1.27-1.91; P<0.01), acne (RR 6.43; 95%CI 3.43-12.04; P<0.01), and mouth ulcer (RR 11.70; 95%CI 6.18-22.17; P<0.01) were higher in the mTORi group. More patients in the conversion group had to discontinue study medication (RR 2.52; 95%CI 1.75-3.63; P<0.01). There was no significant difference between the two groups with regard to death, graft loss, diabetes, chronic allograft nephropathy, and interstitial fibrosis/tubular atrophy. Conclusions Posttransplant patients have a better graft function and lower incidence of malignancy after conversion from CNI to mTORi therapy. However, this conversion strategy may be prevented by the higher drug discontinuation rate due to mTORi-associated adverse events, such as more acute rejection, infection, proteinuria, leukopenia, acne, and mouth ulcer, indicating that conversion therapy may only be a treatment option in selected patients.
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Affiliation(s)
- Jun Zeng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Zhong
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaobing Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Linde Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shijian Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Fan
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Turun Song
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhongli Huang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xianding Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Lin
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.,Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
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10
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Zhang L, Lai X, Guo Y, Ma J, Fang J, Li G, Xu L, Yin W, Chen Z. Autologous bone marrow-derived mesenchymal stem cells for interstitial fibrosis and tubular atrophy: a pilot study. Ren Fail 2021; 43:1266-1275. [PMID: 34493167 PMCID: PMC8425735 DOI: 10.1080/0886022x.2021.1968432] [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] [Indexed: 11/25/2022] Open
Abstract
Background Mesenchymal stem cells (MSCs)-based therapy has shown promising results for renal injury. In this study, the efficacy and safety of autologous bone marrow-derived mesenchymal stem cells (BM-MSCs) in treating nonspecific interstitial fibrosis and tubular atrophy (IFTA) were evaluated. Methods From March 2011 to January 2013, 11 renal transplanted patients with IFTA were recruited. At baseline, patients were given one intra-arterial infusion of BM-MSCs; 7 days and 1 month later, another two intravenous infusions of cells were followed. Serum creatinine, creatinine clearance rate, and serum cystatin-C at baseline and 7 days, 1 month, 3 months, 6 months, and 12 months after the intra-arterial infusion of BM-MSCs were used to assess renal function. At baseline and 6 months, histological examination based on hematoxylin-eosin, Masson’s trichrome and periodic acid-Schiff staining and immunohistochemistry for transforming growth factor β1 (TGF-β1) and connective tissue growth factor (CTGF) was performed. Adverse events were recorded to evaluate the safety of BM-MSCs treatment. Results At 12 months, the renal function of 6 patients (54.5%) was improved, 3 (27.3%) were stable and 2 (18.2%) were worsened. At 6 months, the mean IFTA scores of all participators were similar with the baseline (1.73 ± 0.41 vs.1.50 ± 0.0.77, p = 0.242); however, it was significantly decreased when only 6 patients with improved renal function were analyzed (1.67 ± 0.41 vs. 1.08 ± 0.20, p = 0.013). Besides, decreased expression of TGF-β1 and CTGF were also observed at 6 months. During 1 year follow-up period, only two minor complications including infection and allergy were observed. Conclusion Our results demonstrated that autologous BM-MSCs are safe and beneficial for IFTA patients. Abbreviations: MSCs: mesenchymal stem cells; BM-MSCs: marrow-derived mesenchymal stem cells; IFTA: interstitial fibrosis and tubular atrophy; CAN: chronic allograft nephropathy; CNIs: calcineurin inhibitors; Scr: serum creatinine; CCr: creatinine clearance rate; Cys-C: cystatin-C; TGF-β1: transforming growth factor β1; CTGF: connective tissue growth factor
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Affiliation(s)
- Lei Zhang
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Xingqiang Lai
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Yuhe Guo
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Junjie Ma
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Jiali Fang
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Guanghui Li
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Lu Xu
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Wei Yin
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
| | - Zheng Chen
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou Medical University/The Second Clinical Medicine School of Guangzhou Medical University, Guangzhou, China
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11
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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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12
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Tsai H, Zeng X, Liu L, Xin S, Wu Y, Xu Z, Zhang H, Liu G, Bi Z, Su D, Yang M, Tao Y, Wang C, Zhao J, Eriksson JE, Deng W, Cheng F, Chen H. NF45/NF90-mediated rDNA transcription provides a novel target for immunosuppressant development. EMBO Mol Med 2021; 13:e12834. [PMID: 33555115 PMCID: PMC7933818 DOI: 10.15252/emmm.202012834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/26/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Herein, we demonstrate that NFAT, a key regulator of the immune response, translocates from cytoplasm to nucleolus and interacts with NF45/NF90 complex to collaboratively promote rDNA transcription via triggering the directly binding of NF45/NF90 to the ARRE2-like sequences in rDNA promoter upon T-cell activation in vitro. The elevated pre-rRNA level of T cells is also observed in both mouse heart or skin transplantation models and in kidney transplanted patients. Importantly, T-cell activation can be significantly suppressed by inhibiting NF45/NF90-dependent rDNA transcription. Amazingly, CX5461, a rDNA transcription-specific inhibitor, outperformed FK506, the most commonly used immunosuppressant, both in terms of potency and off-target activity (i.e., toxicity), as demonstrated by a series of skin and heart allograft models. Collectively, this reveals NF45/NF90-mediated rDNA transcription as a novel signaling pathway essential for T-cell activation and as a new target for the development of safe and effective immunosuppressants.
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Affiliation(s)
- Hsiang‐i Tsai
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Xiaobin Zeng
- Center Lab of Longhua Branch and Department of Infectious DiseaseShenzhen People's Hospital2 Clinical Medical College of Jinan UniversityShenzhenChina
- Guangdong Provincial Key Laboratory of Regional Immunity and DiseasesMedicine School of Shenzhen UniversityShenzhenChina
| | - Longshan Liu
- Organ Transplant CentermThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Shengchang Xin
- State Key Laboratory of Coordination ChemistryInstitute of Chemistry and Biomedical SciencesSchool of Life SciencesNanjing UniversityNanjingChina
| | - Yingyi Wu
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Zhanxue Xu
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Huanxi Zhang
- Organ Transplant CentermThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Gan Liu
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Zirong Bi
- Organ Transplant CentermThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Dandan Su
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Min Yang
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Yijing Tao
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Changxi Wang
- Organ Transplant CentermThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Jing Zhao
- State Key Laboratory of Coordination ChemistryInstitute of Chemistry and Biomedical SciencesSchool of Life SciencesNanjing UniversityNanjingChina
| | - John E Eriksson
- Cell BiologyBiosciencesFaculty of Science and EngineeringÅbo Akademi UniversityTurkuFinland
- Turku Centre for BiotechnologyUniversity of Turku and Åbo Akademi UniversityTurkuFinland
| | - Wenbin Deng
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Fang Cheng
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
| | - Hongbo Chen
- School of Pharmaceutical Sciences (Shenzhen)Sun Yat‐Sen UniversityShenzhenChina
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13
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Long-Term Infectious and Noninfectious Outcomes of Monthly Alemtuzumab as a Calcineurin Inhibitor- and Steroid-Free Regimen for Pancreas Transplant Recipients. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:8883183. [PMID: 33101558 PMCID: PMC7569440 DOI: 10.1155/2020/8883183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
Multiple doses of alemtuzumab for immunosuppressive therapy of patients with hematologic malignancies and hematopoietic stem cell transplant have been associated with a high rate of infection. In transplantation, limited alemtuzumab dosing has been successfully used as induction immunosuppression. The effect of multiple doses of alemtuzumab, used as maintenance therapy to minimize steroid and/or calcineurin inhibitor toxicity in solid organ transplant recipients, is unknown. We evaluated the infectious and noninfectious outcomes of 179 pancreas transplant recipients treated with alemtuzumab for induction and maintenance therapy (extended alemtuzumab exposure (EAE)) from 2/28/2003 through 8/31/2005, compared with 159 pancreas transplant recipients with standard induction and maintenance (SIM) therapy performed before (1/1/2002 until 12/31/2002) and after (1/1/2006 until 12/31/2006) the implementation of EAE. EAE was associated with higher risk of overall infections (hazard ratio (HR) 1.33 (1.06–1.66), P=0.01), bacterial infections (HR 1.33 (1.05–1.67), P=0.02), fungal infections (HR 1.86 (1.28–2.71), P < 0.01), and cytomegalovirus infections (HR 2.29 (1.39–3.77), P < 0.01). In addition, EAE was associated with higher risk of acute cellular rejection (HR 2.09 (1.46–2.99), P < 0.01). In conclusion, while a limited alemtuzumab dosing is safe and effective for induction therapy in pancreas transplantation, EAE combined with steroid and calcineurin minimization is associated with a high risk of infectious complications and acute cellular rejection.
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14
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Gupta S, Cortazar FB, Riella LV, Leaf DE. Immune Checkpoint Inhibitor Nephrotoxicity: Update 2020. KIDNEY360 2020; 1:130-140. [PMID: 35372904 PMCID: PMC8809100 DOI: 10.34067/kid.0000852019] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Immune checkpoint inhibitors (ICPIs) have transformed the landscape of oncology, but are associated with a variety of autoimmune adverse events, including AKI. ICPI-associated AKI (ICPI-AKI) is emerging as an increasingly frequent cause of AKI in patients with cancer, and poses unique diagnostic and management challenges to clinicians who care for these patients. In this review, we describe the incidence and risk factors for ICPI-AKI, including proton pump inhibitor use, CKD, and combination immunotherapy. We discuss the limitations of the various definitions used for ICPI-AKI in prior studies, and propose a novel classification system (definite, probable, and possible ICPI-AKI) that recognizes the diagnostic uncertainty inherent in many cases. We discuss the key clinicopathologic features and treatment strategies for ICPI-AKI, including the role of kidney biopsy versus empirical treatment with steroids. We also explore the under-studied area of ICPI use in the setting of solid organ transplantation, where nephrologists and oncologists must balance the risk of rejection versus treating the underlying malignancy. Finally, we summarize existing data on the role of ICPI rechallenge after an episode of ICPI-AKI.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frank B. Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York; and
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Leonardo V. Riella
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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15
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Bang JB, Oh CK, Ju MK, Kim SJ, Yu HC, Lee SH. Clinical Study of Standard- vs Reduced-Dose Tacrolimus Combined With Generic Mycophenolate Mofetil in De Novo Kidney Transplantation: A Prospective Randomized Trial. Transplant Proc 2020; 52:133-139. [PMID: 31898939 DOI: 10.1016/j.transproceed.2019.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The lowering of calcineurin inhibitor exposure is possibly considered as the proper strategy to prevent calcineurin inhibitor-induced nephrotoxicity in kidney transplant. This clinical study was designed to compare the efficacy and tolerability of reduced-dose tacrolimus with standard-dose mycophenolate mofetil (MMF) vs standard-dose tacrolimus with reduced-dose MMF. METHODS A prospective, multicenter, open-label, randomized, and parallel-group clinical trial was conducted at 4 transplant centers in Korea. A total sample size was 108, and eligible patients were randomly assigned in a 1:1 ratio to either reduced-dose tacrolimus with standard-dose MMF (the study group) or standard-dose tacrolimus with reduced-dose MMF (the control group) for 6 months in de novo kidney transplant recipients. Graft function, the incidence of efficacy failure, and adverse events were compared. RESULTS The mean estimated glomerular filtration rate at 6 months post-transplantation was 69.83 ± 16.68 mL/min/1.73 m2 in the study group and 69.92 ± 17.55 mL/min/1.73 m2 in the control group (P > .05). The overall incidence of biopsy-proven acute rejection was 3.64% (n = 2) in the study group, compared to 3.77% (n = 2) in the control group (P > .05). There was no graft loss, death, or loss of follow-up in either group. CONCLUSION In conclusion, the results suggest that tacrolimus minimization with standard-dose MMF provides adequate immunosuppression with proper renal function and similar rate of incidence of acute rejection compared with the regimen including standard-dose tacrolimus with reduced-dose MMF.
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Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University College of Medicine, Jeonju, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
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16
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Herrington WG, Staplin N, Haynes R. Kidney disease trials for the 21st century: innovations in design and conduct. Nat Rev Nephrol 2019; 16:173-185. [PMID: 31673162 DOI: 10.1038/s41581-019-0212-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Abstract
Compared to other specialties, nephrology has reported relatively few clinical trials, and most of these are too small to detect moderate treatment effects. Consequently, interventions that are commonly used by nephrologists have not been adequately tested and some may be ineffective or harmful. More randomized trials are urgently needed to address important clinical questions in patients with kidney disease. The use of robust surrogate markers may accelerate early-phase drug development. However, scientific innovations in trial conduct developed by other specialties should also be adopted to improve trial quality and enable more, larger trials in kidney disease to be completed in the current era of burdensome regulation and escalating research costs. Examples of such innovations include utilizing routinely collected health-care data and disease-specific registries to identify and invite potential trial participants, and for long-term follow-up; use of prescreening to facilitate rapid recruitment of participants; use of pre-randomization run-in periods to improve participant adherence and assess responses to study interventions prior to randomization; and appropriate use of statistics to monitor studies and analyse their results. Nephrology is well positioned to harness such innovations due to its advanced use of electronic health-care records and the development of disease-specific registries. Adopting a population approach and efficient trial conduct along with challenging unscientific regulation may increase the number of definitive clinical trials in nephrology and improve the care of current and future patients.
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Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK.,Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK. .,Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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17
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Haynes R, Blackwell L, Staplin N, Herrington WG, Emberson J, Judge PK, Storey BC, Landray MJ, Harden PN, Baigent C, Friend P. Campath, calcineurin inhibitor reduction, and chronic allograft nephropathy (the 3C Study) - results of a randomized controlled clinical trial. Am J Transplant 2018; 18:1424-1434. [PMID: 29226570 PMCID: PMC6001618 DOI: 10.1111/ajt.14619] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitors (CNIs, eg, tacrolimus) reduce short-term kidney transplant failure, but chronic nephrotoxicity may contribute to late transplant loss. Elective conversion to inhibitors of the mammalian target of rapamycin (mTOR, eg, sirolimus) pathway might avoid long-term CNI renal damage and improve outcomes. The 3C Study was a pragmatic randomized controlled trial of sequential randomizations between alemtuzumab and basiliximab induction therapy (at the time of surgery) and between tacrolimus and sirolimus maintenance therapy at 6 months posttransplantation. The primary outcome of this analysis was estimated glomerular filtration rate (eGFR) at 18 months after maintenance therapy randomization; 197 patients were assigned sirolimus-based and 197 to tacrolimus-based therapy. Allocation to sirolimus had no significant effect on eGFR at 18 months: baseline-adjusted mean (SEM) eGFR was 53.7 (0.9) mL/min/1.73 m2 in the sirolimus group versus 54.6 (0.9) mL/min/1.73 m2 in the tacrolimus group (P = .50). Biopsy-proven acute rejection (29 [14.7%]) vs 6 [3.0%]; P < .001) and serious infections (defined as opportunistic infections or those requiring hospitalization; 95 [48.2%] vs 70 [35.5%]; P = .008) were more common among participants allocated sirolimus. Compared with tacrolimus-based therapy, sirolimus-based maintenance therapy did not improve transplant function at 18 months after conversion and was associated with significant hazards of rejection and infection. ClinicalTrials.gov identifier NCT01120028 and ISRCTN88894088.
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Affiliation(s)
| | - Richard Haynes
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Lisa Blackwell
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Natalie Staplin
- Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - William G. Herrington
- Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Jonathan Emberson
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Parminder K. Judge
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Benjamin C. Storey
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Martin J. Landray
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Paul N. Harden
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Colin Baigent
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Peter Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
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