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Han JL, Zimmerer JM, Zeng Q, Chaudhari S, Satoskar A, Abdel-Rasoul M, Uwase H, Breuer CK, Bumgardner GL. Antibody-Suppressor CXCR5+CD8+ T Cells Are More Potent Regulators of Humoral Alloimmunity after Kidney Transplant in Mice Compared to CD4+ Regulatory T Cells. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:1504-1518. [PMID: 38517294 PMCID: PMC11047759 DOI: 10.4049/jimmunol.2300289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
Adoptive cell therapy (ACT), especially with CD4+ regulatory T cells (CD4+ Tregs), is an emerging therapeutic strategy to minimize immunosuppression and promote long-term allograft acceptance, although much research remains to realize its potential. In this study, we investigated the potency of novel Ab-suppressor CXCR5+CD8+ T cells (CD8+ TAb-supp) in comparison with conventional CD25highFoxp3+CD4+ Tregs for suppression of humoral alloimmunity in a murine kidney transplant (KTx) model of Ab-mediated rejection (AMR). We examined quantity of peripheral blood, splenic and graft-infiltrating CD8+ TAb-supp, and CD4+ Tregs in KTx recipients and found that high alloantibody-producing CCR5 knockout KTx recipients have significantly fewer post-transplant peripheral blood and splenic CD8+ TAb-supp, as well as fewer splenic and graft-infiltrating CD4+ Tregs compared with wild-type KTx recipients. ACT with alloprimed CXCR5+CD8+ T cells reduced alloantibody titer, splenic alloprimed germinal center (GC) B cell quantity, and improved AMR histology in CCR5 knockout KTx recipients. ACT with alloprimed CD4+ Treg cells improved AMR histology without significantly inhibiting alloantibody production or the quantity of splenic alloprimed GC B cells. Studies with TCR transgenic mice confirmed Ag specificity of CD8+ TAb-supp-mediated effector function. In wild-type recipients, CD8 depletion significantly increased alloantibody titer, GC B cells, and severity of AMR pathology compared with isotype-treated controls. Anti-CD25 mAb treatment also resulted in increased but less pronounced effect on alloantibody titer, quantity of GC B cells, and AMR pathology than CD8 depletion. To our knowledge, this is the first report that CD8+ TAb-supp cells are more potent regulators of humoral alloimmunity than CD4+ Treg cells.
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Affiliation(s)
- Jing L. Han
- Department of Surgery, Comprehensive Transplant Center, and the College of Medicine, The Ohio State University, Columbus, OH
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH
| | - Jason M. Zimmerer
- Department of Surgery, Comprehensive Transplant Center, and the College of Medicine, The Ohio State University, Columbus, OH
| | - Qiang Zeng
- Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Sachi Chaudhari
- Department of Surgery, Comprehensive Transplant Center, and the College of Medicine, The Ohio State University, Columbus, OH
| | - Anjali Satoskar
- Department of Pathology, The Ohio State University, Columbus, OH
| | | | - Hope Uwase
- Department of Surgery, Comprehensive Transplant Center, and the College of Medicine, The Ohio State University, Columbus, OH
| | - Christopher K. Breuer
- Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Ginny L. Bumgardner
- Department of Surgery, Comprehensive Transplant Center, and the College of Medicine, The Ohio State University, Columbus, OH
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Vo A, Ammerman N, Jordan SC. Advances in desensitization for human leukocyte antigen incompatible kidney transplantation. Curr Opin Organ Transplant 2024; 29:104-120. [PMID: 38088373 DOI: 10.1097/mot.0000000000001131] [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: 03/08/2024]
Abstract
PURPOSE OF REVIEW Human leukocyte antigen (HLA) sensitization is a major barrier to kidney transplantation induced by exposure to alloantigens through pregnancy, blood product exposure and previous transplantations. Desensitization strategies are undertaken to improve the chances of finding compatible organ offers. Standard approaches to desensitization include the use of plasmapheresis/low dose intravenous immunoglobulin (IVIG) or high dose IVIG plus anti-CD20. However, current methods to reduce HLA antibodies are not always successful, especially in those with calculated panel reactive antibody 99-100%. RECENT FINDINGS Newer desensitization strategies such as imlifidase [immunoglobulin G (IgG) endopeptidase] rapidly inactivates IgG molecules and creates an "antibody-free zone", representing an important advancement in desensitization. However, pathogenic antibodies rebound, increasing allograft injury that is not addressed by imlifidase. Here, use of anti-IL-6R (tocilizumab) or anti-interleukin-6 (clazakizumab) could offer long-term control of B-memory and plasma cell DSA responses to limit graft injury. Agents aimed at long-lived plasma cells (anti-CD38 and anti-BCMAxCD3) could reduce or eliminate HLA-producing plasma cells from marrow niches. Other agents such as complement inhibitors and novel agents inhibiting the Fc neonatal receptor (FcRn) mediated IgG recycling will likely find important roles in desensitization. SUMMARY Use of these agents alone or in combination will likely improve the efficacy and durability of desensitization therapies, improving access to kidney transplantation for immunologically disadvantaged patients.
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Affiliation(s)
- Ashley Vo
- Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California, USA
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Huang CL, Fu XY, Feng Y, Li XK, Sun Y, Mao XL, Li SW. Relationship between the microenvironment and survival in kidney transplantation: a bibliometric analysis from 2013 to 2023. Front Immunol 2024; 15:1379742. [PMID: 38596670 PMCID: PMC11002143 DOI: 10.3389/fimmu.2024.1379742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024] Open
Abstract
Background Kidney transplantation is considered the most effective treatment for end-stage renal failure. Recent studies have shown that the significance of the immune microenvironment after kidney transplantation in determining prognosis of patients. Therefore, this study aimed to conduct a bibliometric analysis to provide an overview of the knowledge structure and research trends regarding the immune microenvironment and survival in kidney transplantation. Methods Our search included relevant publications from 2013 to 2023 retrieved from the Web of Science core repository and finally included 865 articles. To perform the bibliometric analysis, we utilized tools such as VOSviewer, CiteSpace, and the R package "bibliometrix". The analysis focused on various aspects, including country, author, year, topic, reference, and keyword clustering. Results Based on the inclusion criteria, a total of 865 articles were found, with a trend of steady increase. China and the United States were the countries with the most publications. Nanjing Medical University was the most productive institution. High-frequency keywords were clustered into 6 areas, including kidney transplantation, transforming growth factor β, macrophage, antibody-mediated rejection, necrosis factor alpha, and dysfunction. Antibody mediated rejection (2019-2023) was the main area of research in recent years. Conclusion This groundbreaking bibliometric study comprehensively summarizes the research trends and advances related to the immune microenvironment and survival after kidney transplantation. It identifies recent frontiers of research and highlights promising directions for future studies, potentially offering fresh perspectives to scholars in the field.
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Affiliation(s)
- Chun-Lian Huang
- Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Xin-Yu Fu
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Yi Feng
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Xiao-Kang Li
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yi Sun
- MRL Global Medical Affairs, MSD China, Shanghai, China
| | - Xin-Li Mao
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
- Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Shao-Wei Li
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Linhai, Zhejiang, China
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
- Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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Han JL, Zimmerer JM, Zeng Q, Chaudhari S, Hart M, Satoskar AA, Abdel-Rasoul M, Breuer CK, Bumgardner GL. CXCR5 + CD8 + T Cell-mediated Suppression of Humoral Alloimmunity and AMR in Mice Is Optimized With mTOR and Impaired With Calcineurin Inhibition. Transplantation 2024; 108:679-692. [PMID: 37872660 PMCID: PMC10922067 DOI: 10.1097/tp.0000000000004828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Adoptive cellular therapy (ACT) with antibody-suppressor CXCR5 + CD8 + T cells (CD8 + T Ab-supp ) inhibits alloantibody production, antibody-mediated rejection (AMR), and prolongs graft survival in multiple transplant mouse models. However, it is not known how conventional immunosuppressive agents impact the efficacy of CD8 + T Ab-supp ACT. METHODS We investigated the efficacy of CD8 + T Ab-supp cell ACT when combined with calcineurin inhibitor (CNi) or mammalian target of rapamycin inhibitor (mTORi) in a murine model of kidney transplant. RESULTS ACT-mediated decrease in germinal center B cells, posttransplant alloantibody titer, and amelioration of AMR in high alloantibody-producing CCR5 knockout kidney transplant recipients were impaired when ACT was combined with CNi and enhanced when combined with mTORi. CNi (but not mTORi) reduced ACT-mediated in vivo cytotoxicity of IgG + B cells and was associated with increased quantity of germinal center B cells. Neither CNi nor mTORi treatment impacted the expression of cytotoxic effector molecules (FasL, Lamp1, perforin, granzyme B) by CD8 + T Ab-supp after ACT. Concurrent treatment with CNi (but not mTORi) reduced in vivo proliferation of CD8 + T Ab-supp after ACT. The increase in quantity of splenic CD44 + CXCR5 + CD8 + T cells that occurs after ACT was reduced by concurrent treatment with CNi but not by concurrent treatment with mTORi (dose-dependent). CONCLUSIONS Impaired efficacy of ACT by CNi is attributed to reduced persistence and/or expansion of CD8 + T Ab-supp cells after ACT. In contrast, concurrent immunosuppression with mTORi preserves CD8 + T Ab-supp cells quantity, in vivo proliferation, and in vivo cytotoxic effector function after ACT and enhances suppression of humoral alloimmunity and AMR.
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Affiliation(s)
- Jing L. Han
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
- Comprehensive Transplant Center, The Ohio State University, Columbus, OH
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH
| | - Jason M. Zimmerer
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
- Comprehensive Transplant Center, The Ohio State University, Columbus, OH
| | - Qiang Zeng
- Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Sachi Chaudhari
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
- Comprehensive Transplant Center, The Ohio State University, Columbus, OH
| | - Madison Hart
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
- Comprehensive Transplant Center, The Ohio State University, Columbus, OH
| | | | | | | | - Ginny L. Bumgardner
- Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
- Comprehensive Transplant Center, The Ohio State University, Columbus, OH
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Abuazzam F, Dubrawka C, Abdulhadi T, Amurao G, Alrata L, Yaseen Alsabbagh D, Alomar O, Alhamad T. Emerging Therapies for Antibody-Mediated Rejection in Kidney Transplantation. J Clin Med 2023; 12:4916. [PMID: 37568318 PMCID: PMC10419906 DOI: 10.3390/jcm12154916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite the advances in immunosuppressive medications, antibody-mediated rejection (AMR) continues to be a major cause of kidney allograft failure and remains a barrier to improving long-term allograft survival. Recently, there have been significant advances in the understanding of the pathophysiological process of AMR, along with the development of new therapeutic options. Additionally, surveillance protocols with donor-derived cell-free DNA and gene profile testing have been established, leading to the early detection of AMR. A multitude of clinical trials are ongoing, opening numerous opportunities for improving outcome in kidney transplant recipients. In this brief review, we discuss the emerging therapies for managing both active and chronic active AMR and highlight the ongoing clinical trials.
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Affiliation(s)
- Farah Abuazzam
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Casey Dubrawka
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO 63110, USA;
| | - Tarek Abdulhadi
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Gwendolyn Amurao
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Louai Alrata
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Dema Yaseen Alsabbagh
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Omar Alomar
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
| | - Tarek Alhamad
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (F.A.); (T.A.); (G.A.); (L.A.); (D.Y.A.); (O.A.)
- Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO 63110, USA
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van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
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Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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Habibabady Z, McGrath G, Kinoshita K, Maenaka A, Ikechukwu I, Elias GF, Zaletel T, Rosales I, Hara H, Pierson RN, Cooper DKC. Antibody-mediated rejection in xenotransplantation: Can it be prevented or reversed? Xenotransplantation 2023; 30:e12816. [PMID: 37548030 PMCID: PMC11101061 DOI: 10.1111/xen.12816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Antibody-mediated rejection (AMR) is the commonest cause of failure of a pig graft after transplantation into an immunosuppressed nonhuman primate (NHP). The incidence of AMR compared to acute cellular rejection is much higher in xenotransplantation (46% vs. 7%) than in allotransplantation (3% vs. 63%) in NHPs. Although AMR in an allograft can often be reversed, to our knowledge there is no report of its successful reversal in a pig xenograft. As there is less experience in preventing or reversing AMR in models of xenotransplantation, the results of studies in patients with allografts provide more information. These include (i) depletion or neutralization of serum anti-donor antibodies, (ii) inhibition of complement activation, (iii) therapies targeting B or plasma cells, and (iv) anti-inflammatory therapy. Depletion or neutralization of anti-pig antibody, for example, by plasmapheresis, is effective in depleting antibodies, but they recover within days. IgG-degrading enzymes do not deplete IgM. Despite the expression of human complement-regulatory proteins on the pig graft, inhibition of systemic complement activation may be necessary, particularly if AMR is to be reversed. Potential therapies include (i) inhibition of complement activation (e.g., by IVIg, C1 INH, or an anti-C5 antibody), but some complement inhibitors are not effective in NHPs, for example, eculizumab. Possible B cell-targeted therapies include (i) B cell depletion, (ii) plasma cell depletion, (iii) modulation of B cell activation, and (iv) enhancing the generation of regulatory B and/or T cells. Among anti-inflammatory agents, anti-IL6R mAb and TNF blockers are increasingly being tested in xenotransplantation models, but with no definitive evidence that they reverse AMR. Increasing attention should be directed toward testing combinations of the above therapies. We suggest that treatment with a systemic complement inhibitor is likely to be most effective, possibly combined with anti-inflammatory agents (if these are not already being administered). Ultimately, it may require further genetic engineering of the organ-source pig to resolve the problem entirely, for example, knockout or knockdown of SLA, and/or expression of PD-L1, HLA E, and/or HLA-G.
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Affiliation(s)
- Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gannon McGrath
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ileka Ikechukwu
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela F. Elias
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tjasa Zaletel
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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Zhang Y, He J, Yang Z, Zheng H, Deng H, Luo Z, Sun Q, Sun Q. Preventative effect of TSPO ligands on mixed antibody-mediated rejection through a Mitochondria-mediated metabolic disorder. J Transl Med 2023; 21:295. [PMID: 37131248 PMCID: PMC10152746 DOI: 10.1186/s12967-023-04134-2] [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: 02/13/2023] [Accepted: 04/13/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Immune-mediated rejection was the major cause of graft dysfunction. Although the advances in immunosuppressive agents have markedly reduced the incidence of T-cell-mediated rejection after transplantation. However, the incidence of antibody-mediated rejection (AMR) remains high. Donor-specific antibodies (DSAs) were considered the major mediators of allograft loss. Previously, we showed that treatment with 18-kDa translocator protein (TSPO) ligands inhibited the differentiation and effector functions of T cells and reduced the rejection observed after allogeneic skin transplantation in mice. This study we further investigate the effect of TSPO ligands on B cells and DSAs production in the recipients of mixed-AMR model. METHODS In vitro, we explored the effect of treatment with TSPO ligands on the activation, proliferation, and antibody production of B cells. Further, we established a heart-transplantation mixed-AMR model in rats. This model was treated with the TSPO ligands, FGIN1-27 or Ro5-4864, to investigate the role of ligands in preventing transplant rejection and DSAs production in vivo. As TSPO was the mitochondrial membrane transporters, we then investigated the TSPO ligands effect on mitochondrial-related metabolic ability of B cells as well as expression of downstream proteins. RESULTS In vitro studies, treatment with TSPO ligands inhibited the differentiation of B cells into CD138+CD27+ plasma cells; reduced antibodies, IgG and IgM, secretion of B cells; and suppressed the B cell activation and proliferation. In the mixed-AMR rat model, treatment with FGIN1-27 or Ro5-4864 attenuated DSA-mediated cardiac-allograft injury, prolonged graft survival, and reduced the numbers of B cells, including IgG+ secreting B cells, T cells and macrophages infiltrating in grafts. For the further mechanism exploration, treatment with TSPO ligands inhibited the metabolic ability of B cells by downregulating expression of pyruvate dehydrogenase kinase 1 and proteins in complexes I, II, and IV of the electron transport chain. CONCLUSIONS We clarified the mechanism of action of TSPO ligands on B-cell functions and provided new ideas and drug targets for the clinical treatment of postoperative AMR.
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Affiliation(s)
- Yannan Zhang
- Medical Research Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jiannan He
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhe Yang
- Department of Urology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Haofeng Zheng
- Division of kidney Transplantation, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 2nd road Zhongshan, Yuexiu District, Guangzhou, 510080, China
| | - Haoxiang Deng
- Division of kidney Transplantation, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 2nd road Zhongshan, Yuexiu District, Guangzhou, 510080, China
| | - Zihuan Luo
- Division of kidney Transplantation, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 2nd road Zhongshan, Yuexiu District, Guangzhou, 510080, China
| | - Qipeng Sun
- Division of kidney Transplantation, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 2nd road Zhongshan, Yuexiu District, Guangzhou, 510080, China
| | - Qiquan Sun
- Medical Research Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
- Division of kidney Transplantation, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 2nd road Zhongshan, Yuexiu District, Guangzhou, 510080, China.
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9
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Reichart B, Cooper DKC, Längin M, Tönjes RR, Pierson RN, Wolf E. Cardiac xenotransplantation: from concept to clinic. Cardiovasc Res 2023; 118:3499-3516. [PMID: 36461918 PMCID: PMC9897693 DOI: 10.1093/cvr/cvac180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
For many patients with terminal/advanced cardiac failure, heart transplantation is the most effective, durable treatment option, and offers the best prospects for a high quality of life. The number of potentially life-saving donated human organs is far fewer than the population who could benefit from a new heart, resulting in increasing numbers of patients awaiting replacement of their failing heart, high waitlist mortality, and frequent reliance on interim mechanical support for many of those deemed among the best candidates but who are deteriorating as they wait. Currently, mechanical assist devices supporting left ventricular or biventricular heart function are the only alternative to heart transplant that is in clinical use. Unfortunately, the complication rate with mechanical assistance remains high despite advances in device design and patient selection and management, and the quality of life of the patients even with good outcomes is only moderately improved. Cardiac xenotransplantation from genetically multi-modified (GM) organ-source pigs is an emerging new option as demonstrated by the consistent long-term success of heterotopic (non-life-supporting) abdominal and life-supporting orthotopic porcine heart transplantation in baboons, and by a recent 'compassionate use' transplant of the heart from a GM pig with 10 modifications into a terminally ill patient who survived for 2 months. In this review, we discuss pig heart xenotransplantation as a concept, including pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental overgrowth of the heart, as well as GM strategies in pigs to prevent or minimize these problems. Additional topics discussed include relevant results of heterotopic and orthotopic heart transplantation experiments in the pig-to-baboon model, microbiological and virologic safety concepts, and efficacy requirements for initiating formal clinical trials. An adequate regulatory and ethical framework as well as stringent criteria for the selection of patients will be critical for the safe clinical development of cardiac xenotransplantation, which we expect will be clinically tested during the next few years.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Centre for Experimental Medicine, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - Ralf R Tönjes
- Division of Medical Biotechnology, Paul-Ehrlich-Institute, Langen 63225, Germany
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Eckhard Wolf
- Gene Centre and Centre for Innovative Medical Models (CiMM), Ludwig-Maximilians-Universität München, Munich 81377, Germany
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10
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Eskandari SK, Gaya da Costa M, Faria B, Petr V, Azzi JR, Berger SP, Seelen MAJ, Damman J, Poppelaars F. An interleukin 6-based genetic risk score strengthened with interleukin 10 polymorphisms associated with long-term kidney allograft outcomes. Am J Transplant 2022; 22 Suppl 4:45-57. [PMID: 36453708 PMCID: PMC10107952 DOI: 10.1111/ajt.17212] [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: 08/15/2022] [Revised: 10/03/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022]
Abstract
Of all kidney transplants, half are still lost in the first decade after transplantation. Here, using genetics, we probed whether interleukin 6 (IL-6) could be a target in kidney transplantation to improve graft survival. Additionally, we investigated if a genetic risk score (GRS) based on IL6 and IL10 variants could improve prognostication of graft loss. In a prospective cohort study, DNA of 1271 donor-recipient kidney transplant pairs was analyzed for the presence of IL6, IL6R, IL10, IL10RA, and IL10RB variants. These polymorphisms and their GRS were then associated with 15-year death-censored allograft survival. The C|C-genotype of the IL6 polymorphism in donor kidneys and the combined C|C-genotype in donor-recipient pairs were both associated with a reduced risk of graft loss (p = .043 and p = .042, respectively). Additionally, the GRS based on IL6, IL6R, IL10, IL10RA, and IL10RB variants was independently associated with the risk of graft loss (HR 1.53, 95%-CI [1.32-1.84]; p < .001). Notably, the GRS improved risk stratification and prediction of graft loss beyond the level of contemporary clinical markers. Our findings reveal the merits of a polygenic IL-6-based risk score strengthened with IL-10- polymorphisms for the prognostication and risk stratification of late graft failure in kidney transplantation.
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Affiliation(s)
- Siawosh K Eskandari
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mariana Gaya da Costa
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bernardo Faria
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Nephrology R&D Group, Institute for Research and Innovation in Health (i3S), São João University Hospital Center, University of Porto, Porto, Portugal
| | - Vojtech Petr
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jamil R Azzi
- Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stefan P Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marc A J Seelen
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jeffrey Damman
- Department of Pathology, Erasmus University Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Felix Poppelaars
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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11
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Lynch TJ, Ahlers BA, Swatek AM, Ievlev V, Pai AC, Brooks L, Tang Y, Evans IA, Meyerholz DK, Engelhardt JF, Parekh KR. Ferret Lung Transplantation Models Differential Lymphoid Aggregate Morphology Between Restrictive and Obstructive Forms of Chronic Lung Allograft Dysfunction. Transplantation 2022; 106:1974-1989. [PMID: 35442232 PMCID: PMC9529760 DOI: 10.1097/tp.0000000000004148] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Long-term survival after lung transplantation remains limited by chronic lung allograft dysfunction (CLAD). CLAD has 2 histologic phenotypes, namely obliterative bronchiolitis (OB) and restrictive alveolar fibroelastosis (AFE), which have distinct clinical presentations, pathologies, and outcomes. Understanding of OB versus AFE pathogenesis would improve with better animal models. METHODS We utilized a ferret orthotopic single-lung transplantation model to characterize allograft fibrosis as a histologic measure of CLAD. Native lobes and "No CLAD" allografts lacking aberrant histology were used as controls. We used morphometric analysis to evaluate the size and abundance of B-cell aggregates and tertiary lymphoid organs (TLOs) and their cell composition. Quantitative RNA expression of 47 target genes was performed simultaneously using a custom QuantiGene Plex Assay. RESULTS Ferret lung allografts develop the full spectrum of human CLAD histology including OB and AFE subtypes. While both OB and AFE allografts developed TLOs, TLO size and number were greater with AFE histology. More activated germinal center cells marked by B-cell lymphoma 6 Transcription Repressor, (B-cell lymphoma 6) expression and fewer cells expressing forkhead box P3 correlated with AFE, congruent with greater diffuse immunoglobulin, plasma cell abundance, and complement 4d staining. Furthermore, forkhead box P3 RNA induction was significant in OB allografts specifically. RNA expression changes were seen in native lobes of animals with AFE but not OB when compared with No CLAD native lobes. CONCLUSIONS The orthotopic ferret single-lung transplant model provides unique opportunities to better understand factors that dispose allografts to OB versus AFE. This will help develop potential immunomodulatory therapies and antifibrotic approaches for lung transplant patients.
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Affiliation(s)
- Thomas J. Lynch
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Bethany A. Ahlers
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Anthony M. Swatek
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Vitaly Ievlev
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Albert C. Pai
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Leonard Brooks
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Yinghua Tang
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Idil A. Evans
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - David K. Meyerholz
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - John F. Engelhardt
- Department of Anatomy and Cell Biology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Kalpaj R. Parekh
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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12
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Mayer KA, Budde K, Jilma B, Doberer K, Böhmig GA. Emerging drugs for antibody-mediated rejection after kidney transplantation: a focus on phase II & III trials. Expert Opin Emerg Drugs 2022; 27:151-167. [PMID: 35715978 DOI: 10.1080/14728214.2022.2091131] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antibody-mediated rejection (ABMR) is a leading cause of kidney allograft failure. Its therapy continues to be challenge, and no treatment has been approved for the market thus far. AREAS COVERED In this article, we discuss the pathophysiology and phenotypic presentation of ABMR, the current level of evidence to support the use of available therapeutic strategies, and the emergence of tailored drugs now being evaluated in systematic clinical trials. We searched PubMed, Clinicaltrials.gov and Citeline's Pharmaprojects for pertinent information on emerging anti-rejection strategies, laying a focus on phase II and III trials. EXPERT OPINION Currently, we rely on the use of apheresis for alloantibody depletion and intravenous immunoglobulin (referred to as standard of care), preferentially in early active ABMR. Recent systematic trials have questioned the benefits of using the CD20 antibody rituximab or the proteasome inhibitor bortezomib. However, there are now several promising treatment approaches in the pipeline, which are being trialed in phase II and III studies. These include interleukin-6 antagonism, CD38-targeting antibodies, and selective inhibitors of complement. On the basis of the information that has emerged so far, it seems that innovative treatment strategies for clinical use in ABMR may be available within the next 5-10 years.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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13
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Vo AA, Huang E, Ammerman N, Toyoda M, Ge S, Haas M, Zhang X, Peng A, Najjar R, Williamson S, Myers C, Sethi S, Lim K, Choi J, Gillespie M, Tang J, Jordan SC. Clazakizumab for desensitization in highly sensitized patients awaiting transplantation. Am J Transplant 2022; 22:1133-1144. [PMID: 34910841 DOI: 10.1111/ajt.16926] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 12/12/2021] [Accepted: 12/12/2021] [Indexed: 01/25/2023]
Abstract
Alloantibodies are a significant barrier to successful transplantation. While desensitization has emerged, efficacy is limited. Interleukin-6 (IL-6) is an important mediator of inflammation and immune cell activation. Persistent IL-6 production increases the risk for alloantibody production. Here we report our experience with clazakizumab (anti-IL-6) for desensitization of highly HLA-sensitized patients (HS). From March 2018 to September 2020, 20 HS patients were enrolled in an open label pilot study to assess safety and limited efficacy of clazakizumab desensitization. Patients received PLEX, IVIg, and clazakizumab 25 mg monthly X6. If transplanted, graft function, pathology, HLA antibodies and regulatory immune cells were monitored. Transplanted patients received standard immunosuppression and clazakizumab 25 mg monthly posttransplant. Clazakizumab was well tolerated and associated with significant reductions in class I and class II antibodies allowing 18 of 20 patients to receive transplants with no DSA rebound in most. Significant increases in Treg and Breg cells were seen posttransplant. Antibody-mediated rejection occurred in three patients. The mean estimated glomerular filtration rate at 12 months was 58 ± 29 ml/min/1.73 m2 . Clazakizumab was generally safe and associated with significant reductions in HLA alloantibodies and high transplant rates for highly-sensitized patients. However, confirmation of efficacy for desensitization requires assessment in randomized controlled trials.
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Affiliation(s)
- Ashley A Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edmund Huang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Noriko Ammerman
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mieko Toyoda
- Department of Transplant Immunology and Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shili Ge
- Department of Transplant Immunology and Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mark Haas
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaohai Zhang
- Department of HLA & Immunogenetics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Reiad Najjar
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Summer Williamson
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Catherine Myers
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Supreet Sethi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kathlyn Lim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Gillespie
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jacqueline Tang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
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14
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Salvadori M, Tsalouchos A. Innovative immunosuppression in kidney transplantation: A challenge for unmet needs. World J Transplant 2022; 12:27-41. [PMID: 35433332 PMCID: PMC8968476 DOI: 10.5500/wjt.v12.i3.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/27/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the optimal results obtained in kidney transplantation and to the lack of interest of the industries, new innovative drugs in kidney transplantation are difficult to be encountered. The best strategy to find the new drugs recently developed or under development is to search in the sections of kidney transplantation still not completely covered by the drugs on the market. These unmet needs are the prevention of delayed graft function (DGF), the protection of the graft over the long time and the desensitization of preformed anti human leukocyte antigen antibodies and the treatment of the acute antibody-mediated rejection. These needs are particularly relevant due to the expansion of some kind of kidney transplantation as transplantation from non-heart beating donor and in the case of antibody-incompatible grafts. The first are particularly exposed to DGF, the latter need a safe desensitization and a safe treatments of the antibody mediated rejections that often occur. Particular caution is needed in treating these drugs. First, they are described in very recent studies and the follow-up of their effect is of course rather short. Second, some of these drugs are still in an early phase of study, even if in well-conducted randomized controlled trials. Particular caution and a careful check need to be used in trials launched 2 or 3 years ago. Indeed, is always necessary to verify whether the study is still going on or whether and why the study itself was abandoned.
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Affiliation(s)
- Maurizio Salvadori
- Department of Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Division of Nephrology, Santa Maria Annunziata Hospital, Florence 50012, Italy
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15
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Cheung CY, Tang SCW. Personalized immunosuppression after kidney transplantation. Nephrology (Carlton) 2022; 27:475-483. [PMID: 35238110 DOI: 10.1111/nep.14035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Abstract
With advances in immunosuppressive therapy, there have been significant improvements in acute rejection rates and short-term allograft survival in kidney transplant recipients. However, this success has not been translated into long-term benefits by the same magnitude. Optimization of immunosuppression is important to improve the clinical outcome of transplant recipients. It is important to note that each patient has unique attributes and immunosuppression management should not be a one-size-fits-all approach. Elderly transplant patients are less likely to develop acute rejection but more likely to die from infectious and cardiovascular causes than younger patients. For those with post-transplant cancers and BK polyomavirus-associated nephropathy, reduction of immunosuppression can increase the risk of rejection. Therapeutic drug monitoring (TDM) is routinely used for dosage adjustment of several immunosuppressive drugs. It has been hoped that pharmacogenetics can be used to complement TDM in optimizing drug exposure. Among the various drug-genotype pairs being investigated, tacrolimus and CYP3A5 gives the most promising results. Different studies have consistently shown that CYP3A5 expressers require a higher tacrolimus dose and take longer time to achieve target blood tacrolimus levels than nonexpressers. However, for pharmacogenetics to be widely used clinically, further trials are necessary to demonstrate the clinical benefits of genotype-guided dosing such as reduction of rejection and drug-related toxicities. The development of different biomarkers in recent years may help to achieve true personalized therapy in transplant patients.
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Affiliation(s)
- Chi Yuen Cheung
- Renal Unit, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR
| | - Sydney Chi Wai Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR
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16
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Poppelaars F, Gaya da Costa M, Faria B, Eskandari SK, Damman J, Seelen MA. A functional TGFB1 polymorphism in the donor associates with long-term graft survival after kidney transplantation. Clin Kidney J 2022; 15:278-286. [PMID: 35145642 PMCID: PMC8824786 DOI: 10.1093/ckj/sfab175] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Improvement of long-term outcomes in kidney transplantation remains one of the most pressing challenges, yet drug development is stagnating. Human genetics offers an opportunity for much-needed target validation in transplantation. Conflicting data exist about the effect of transforming growth factor-beta 1 (TGF-β1) on kidney transplant survival, since TGF-β1 has pro-fibrotic and protective effects. We investigated the impact of a recently discovered functional TGFB1 polymorphism on kidney graft survival. Methods We performed an observational cohort study analysing recipient and donor DNA in 1271 kidney transplant pairs from the University Medical Centre Groningen in The Netherlands, and associated a low-producing TGFB1 polymorphism (rs1800472-C > T) with 5-, 10- and 15-year death-censored kidney graft survival. Results Donor genotype frequencies of rs1800472 in TGFB1 differed significantly between patients with and without graft loss (P = 0.014). Additionally, the low-producing TGFB1 polymorphism in the donor was associated with an increased risk of graft loss following kidney transplantation (hazard ratio = 2.12 for the T-allele; 95% confidence interval 1.18–3.79; P = 0.012). The incidence of graft loss within 15 years of follow-up was 16.4% in the CC-genotype group and 31.6% in the CT-genotype group. After adjustment for transplant-related covariates, the association between the TGFB1 polymorphism in the donor and graft loss remained significant. In contrast, there was no association between the TGFB1 polymorphism in the recipient and graft loss. Conclusions Kidney allografts possessing a low-producing TGFB1 polymorphism have a higher risk of late graft loss. Our study adds to a growing body of evidence that TGF-β1 is beneficial, rather than harmful, for kidney transplant survival.
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Affiliation(s)
- Felix Poppelaars
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mariana Gaya da Costa
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bernardo Faria
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Nephrology and Infectious Disease R&D Group, INEB, Institute of Investigation and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Siawosh K Eskandari
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jeffrey Damman
- Department of Pathology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Marc A Seelen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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Evaluation of Clazakizumab (anti-IL-6) in Patients with Treatment-Resistant Chronic Active Antibody Mediated Rejection of Kidney Allografts. Kidney Int Rep 2022; 7:720-731. [PMID: 35497778 PMCID: PMC9039906 DOI: 10.1016/j.ekir.2022.01.1074] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction Interleukin-6 (IL-6) is an important mediator of inflammation and activation of T cells, B cells, and plasma cells. Excessive IL-6 production is linked to human diseases characterized by unregulated antibody production, including alloimmunity, where persistence of donor-specific antibodies (DSAs), chronic active antibody-mediated rejection (cAMR), and graft loss are noted. Here, we report our experience investigating clazakizumab, a novel IL-6 inhibitor, in treating human leukocyte antigen (HLA)-sensitized patients with cAMR. Methods Between February 2018 and January 2019, 10 adults with biopsy-proven cAMR were enrolled in a phase 2, single-center, open-label study. Patients received clazakizumab 25 mg subcutaneously (s.c.) monthly for 12 months, with a 6-month protocol biopsy. Primary end points included patient survival, graft survival, estimated glomerular filtration rate (eGFR), and safety. Secondary end points assessed immune markers (DSAs, IgG, T-regulatory [Treg] cells). At 12 months, stable patients entered a long-term extension (LTE). Results LTE patients received clazakizumab for >2.5 years. Mean eGFRs showed significant declines from −24 months to study initiation (0 months) (52.8 ± 14.6 to 38.11 ± 12.23 ml/min per 1.73 m2, P = 0.03). However, after initiation of clazakizumab, eGFR stabilized at (41.6 ± 14.2 and 38.1 ± 20.3 ml/min per 1.73 m2, at 12 and 24 months, respectively). Banff 2017 analysis of pre- and post-treatment biopsies showed reductions in g+ptc and C4d scores. DSA reductions were seen in most patients. Adverse events (AEs) were minimal, and 2 graft losses occurred, both in patients who discontinued clazakizumab therapy at 6 months and 12 months after study initiation. Conclusion In this small cohort of patients with cAMR, clazakizumab treatment showed a trend toward stabilization of eGFR and reductions in DSA and graft inflammation. No significant safety issues were observed. A randomized, placebo-controlled clinical trial (IMAGINE) of clazakizumab in cAMR treatment is underway (NCT03744910).
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18
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Lasa-Lázaro M, Ramos-Boluda E, Mancebo E, Castro-Panete MJ, González-Sacristán R, Serradilla J, Andrés-Moreno AM, Hernández-Oliveros F, Paz-Artal E, Talayero P. Antibody-removal therapies for de novo DSA in pediatric intestinal recipients: Why, when, and how? A single-center experience. Front Pediatr 2022; 10:1074577. [PMID: 36819192 PMCID: PMC9932897 DOI: 10.3389/fped.2022.1074577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Donor-specific anti-HLA antibodies (DSA) impact negatively on the outcome of intestinal grafts. Although the use of antibody-removal therapies (ART) is becoming more frequent in the last few years, issues regarding their timing and effectiveness remain under discussion. METHODS In the present study, we report our experience with eight ART procedures (based on plasmapheresis, intravenous immunoglobulin, and rituximab) in eight pediatric intestinal and multivisceral transplants with de novo DSA (dnDSA). RESULTS ART were performed when dnDSA appeared in two contexts: (1) concomitant with rejection (acute or chronic) or (2) without rejection or any other clinical symptom. Complete DSA removal was observed in seven out of eight patients, showing an effectiveness of 88%. In the group treated for dnDSA without clinical symptoms, the success rate was 100%, with complete DSA removal and without rejection afterward. A shorter time between DSA detection and ART performance appeared as a significant factor for the success of the therapy (p = 0.0002). DSA against HLA-A and DQ alleles were the most resistant to ART, whereas anti-DR DSA were the most sensitive. In addition, the 8-year allograft survival rate in recipients undergoing ART was similar to that in those without DSA, being significantly lower in non-treated DSA-positive recipients (p = 0.013). CONCLUSION The results confirm the effectiveness of ART in terms of DSA removal and allograft survival and encourage its early use even in the absence of clinical symptoms.
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Affiliation(s)
- María Lasa-Lázaro
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Esther Ramos-Boluda
- Unit of Intestinal Rehabilitation and Transplant, University Hospital La Paz, Madrid, Spain
| | - Esther Mancebo
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - María José Castro-Panete
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Javier Serradilla
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Ane Miren Andrés-Moreno
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Francisco Hernández-Oliveros
- Department of Pediatric Surgery, University Hospital La Paz, Madrid, Spain.,IdiPaz Research Institute, University Hospital La Paz, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain.,CIBER de Enfermedades Infecciosas, ISCIII, Madrid, Spain
| | - Paloma Talayero
- Department of Immunology, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
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19
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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20
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Matsuda Y, Watanabe T, Li XK. Approaches for Controlling Antibody-Mediated Allograft Rejection Through Targeting B Cells. Front Immunol 2021; 12:682334. [PMID: 34276669 PMCID: PMC8282180 DOI: 10.3389/fimmu.2021.682334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/17/2021] [Indexed: 01/14/2023] Open
Abstract
Both acute and chronic antibody-mediated allograft rejection (AMR), which are directly mediated by B cells, remain difficult to treat. Long-lived plasma cells (LLPCs) in bone marrow (BM) play a crucial role in the production of the antibodies that induce AMR. However, LLPCs survive through a T cell-independent mechanism and resist conventional immunosuppressive therapy. Desensitization therapy is therefore performed, although it is accompanied by severe side effects and the pathological condition may be at an irreversible stage when these antibodies, which induce AMR development, are detected in the serum. In other words, AMR control requires the development of a diagnostic method that predicts its onset before LLPC differentiation and enables therapeutic intervention and the establishment of humoral immune monitoring methods providing more detailed information, including individual differences in the susceptibility to immunosuppressive agents and the pathological conditions. In this study, we reviewed recent studies related to the direct or indirect involvement of immunocompetent cells in the differentiation of naïve-B cells into LLPCs, the limitations of conventional methods, and the possible development of novel control methods in the context of AMR. This information will significantly contribute to the development of clinical applications for AMR and improve the prognosis of patients who undergo organ transplantation.
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Affiliation(s)
- Yoshiko Matsuda
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Takeshi Watanabe
- Laboratory of Immunology, Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto, Japan
| | - Xiao-Kang Li
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
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21
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Abstract
Purpose of Review IL-6 is a pleiotropic, pro-inflammatory cytokine that plays an integral role in the development of acute and chronic rejection after solid organ transplantation. This article reviews the experimental evidence and current clinical application of IL-6/IL-6 receptor (IL-6R) signaling inhibition for the prevention and treatment of allograft injury. Recent Findings There exists a robust body of evidence linking IL-6 to allograft injury mediated by acute inflammation, adaptive cellular/humoral responses, innate immunity, and fibrosis. IL-6 promotes the acute phase reaction, induces B cell maturation/antibody formation, directs cytotoxic T-cell differentiation, and inhibits regulatory T-cell development. Importantly, blockade of the IL-6/IL-6R signaling pathway has been shown to mitigate its harmful effects in experimental studies, particularly in models of kidney and heart transplant rejection. Currently, available agents for IL-6 signaling inhibition include monoclonal antibodies against IL-6 or IL-6R and janus kinase inhibitors. Recent clinical trials have investigated the use of tocilizumab, an anti-IL-6R mAb, for desensitization and treatment of antibody-mediated rejection (AMR) in kidney transplant recipients, with promising initial results. Further studies are underway investigating the use of alternative agents including clazakizumab, an anti-IL-6 mAb, and application of IL-6 signaling blockade to clinical cardiac transplantation. Summary IL-6/IL-6R signaling inhibition provides a novel therapeutic option for the prevention and treatment of allograft injury. To date, evidence from clinical trials supports the use of IL-6 blockade for desensitization and treatment of AMR in kidney transplant recipients. Ongoing and future clinical trials will further elucidate the role of IL-6 signaling inhibition in other types of solid organ transplantation.
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22
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Manook M, Flores WJ, Schmitz R, Fitch Z, Yoon J, Bae Y, Shaw B, Kirk A, Harnois M, Permar S, Farris AB, Magnani DM, Kwun J, Knechtle S. Measuring the Impact of Targeting FcRn-Mediated IgG Recycling on Donor-Specific Alloantibodies in a Sensitized NHP Model. Front Immunol 2021; 12:660900. [PMID: 34149698 PMCID: PMC8207189 DOI: 10.3389/fimmu.2021.660900] [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: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background In transplantation, plasmapheresis and IVIg provide the mainstay of treatment directed at reducing or removing circulating donor-specific antibody (DSA), yet both have limitations. We sought to test the efficacy of targeting the IgG recycling mechanism of the neonatal Fc receptor (FcRn) using anti-FcRn mAb therapy in a sensitized non-human primate (NHP) model, as a pharmacological means of lowering DSA. Methods Six (6) rhesus macaque monkeys, previously sensitized by skin transplantation, received a single dose of 30mg/kg anti-RhFcRn IV, and effects on total IgG, as well as DSA IgG, were measured, in addition to IgM and protective immunity. Subsequently, 60mg/kg IV was given in the setting of kidney transplantation from skin graft donors. Kidney transplant recipients received RhATG, and tacrolimus, MMF, and steroid for maintenance immunosuppression. Results Circulating total IgG was reduced from a baseline 100% on D0 to 32.0% (mean, SD ± 10.6) on d4 post infusion (p<0.05), while using a DSA assay. T-cell flow cross match (TFXM) was reduced to 40.6±12.5% of baseline, and B-cell FXCM to 52.2±19.3%. Circulating total IgM and DSA IgM were unaffected by treatment. Pathogen-specific antibodies (anti-gB and anti-tetanus toxin IgG) were significantly reduced for 14d post infusion. Post-transplant, circulating IgG responded to anti-FcRn mAb treatment, but DSA increased rapidly. Conclusion Targeting the FcRn-mediated recycling of IgG is an effective means of lowering circulating donor-specific IgG in the sensitized recipient, although in the setting of organ transplantation mechanisms of rapid antibody rise post-transplant remains unaffected.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Walter J Flores
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Robin Schmitz
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Zachary Fitch
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Allan Kirk
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Melissa Harnois
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, United States
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, GA, United States
| | - Diogo M Magnani
- Massbiologics of the University of Massachusetts Medical School, Boston, MA, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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23
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Joher N, Matignon M, Grimbert P. HLA Desensitization in Solid Organ Transplantation: Anti-CD38 to Across the Immunological Barriers. Front Immunol 2021; 12:688301. [PMID: 34093594 PMCID: PMC8173048 DOI: 10.3389/fimmu.2021.688301] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
The presence of anti-human leucocyte antigen (HLA) antibodies in the potential solid organ transplant recipient's blood is one of the main barriers to access to a transplantation. The HLA sensitization is associated with longer waitlist time, antibody mediated rejection and transplant lost leading to increased recipient's morbidity and mortality. However, solid organ transplantation across the HLA immunological barriers have been reported in recipients who were highly sensitized to HLA using desensitization protocols. These desensitization regimens are focused on the reduction of circulating HLA antibodies. Despite those strategies improve rates of transplantation, it remains several limitations including persistent high rejection rate and worse long-term outcomes when compare with non-sensitized recipient population. Currently, interest is growing in the development of new desensitization approaches which, beyond targeting antibodies, would be based on the modulation of alloimmune pathways. Plasma cells appears as an interesting target given their critical role in antibody production. In the last decade, CD38-targeting immunotherapies, such as daratumumab, have been recognized as a key component in the treatment of myeloma by inducing an important plasma cell depletion. This review focuses on an emerging concept based on targeting CD38 to desensitize in the field of transplantation.
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Affiliation(s)
- Nizar Joher
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
| | - Marie Matignon
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
| | - Philippe Grimbert
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Universitaire Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire (Innovative Therapy for Immune Disorders), Créteil, France.,Université Paris Est Créteil UPEC, Institut National de la Santé et de la Recherche Médicale INSERM U955, Institut Mondor de Recherche Biomédicale IMRB, Équipe 21, Créteil, France
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24
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Naciri Bennani H, Daligault M, Noble J, Bardy B, Motte L, Giovannini D, Emprou C, Fiard G, Imerzoukene F, Bourdin A, Masson D, Janbon B, Malvezzi P, Rostaing L, Jouve T. Treatment of antibody-mediated rejection with double-filtration plasmapheresis, low dose IVIg plus rituximab after kidney transplantation. J Clin Apher 2021; 36:584-594. [PMID: 33783868 DOI: 10.1002/jca.21897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 12/19/2022]
Abstract
Antibody-mediated rejection (ABMR) at early or late post-transplantation remains challenging. We performed a single-center single-arm study where four cases of acute ABMR and nine cases of chronic active ABMR (defined by Banff classification) were treated with double-filtration plasmapheresis (two cycles of three consecutive daily sessions with a 4-day gap between). At the end of the third and sixth DFPP sessions, the patients received rituximab 375 mg/m2 . After a median follow-up of 1078 (61-1676) days, kidney-allograft survival was 50%. Before DFPP/rituximab therapy, the median donor-specific alloantibody (DSA) mean fluorescence intensity (MFI) was 9160 (4000-15 400); 45 days (D45) later it had significantly decreased to 7375 (215-18 100) (P = .018). In addition, at one-year (Y1) post-therapy, MFI had decreased further, that is, 4060 (400-7850) (P = .001). In two patients, DSA MFIs decreased and remained below 2000. The slope of estimated glomerular-filtration rate within the 6 months preceding intervention was -1.18 mL/min/month and remained unchanged at -1.29 mL/min/month within the year after intervention. Proteinuria remained unchanged. Baseline Banff scores on repeat allograft biopsies (post-therapy D45, Y1) did not show any improvement. Side-effects were mild to moderate. We conclude that the combined DFPP/rituximab significantly decreased DSAs in ABMR kidney-transplant recipients but did not improve renal function or renal histology at 1-year follow-up.
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Affiliation(s)
- Hamza Naciri Bennani
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Mélanie Daligault
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | | | - Lionel Motte
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Diane Giovannini
- Pathology Department, Grenoble University Hospital, Grenoble, France
| | - Camille Emprou
- Pathology Department, Grenoble University Hospital, Grenoble, France
| | - Gaëlle Fiard
- Department of Urology and Kidney Transplantation, Grenoble University Hospital, Grenoble, France.,Grenoble Alpes University, Grenoble, France
| | - Farida Imerzoukene
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | | | | | - Bénédicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France.,Grenoble Alpes University, Grenoble, France
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France.,Grenoble Alpes University, Grenoble, France
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25
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Imlifidase as a Potential Treatment for Antibody-Mediated Rejection. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00327-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Mayer KA, Doberer K, Eskandary F, Halloran PF, Böhmig GA. New concepts in chronic antibody-mediated kidney allograft rejection: prevention and treatment. Curr Opin Organ Transplant 2021; 26:97-105. [PMID: 33315763 DOI: 10.1097/mot.0000000000000832] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Chronic antibody-mediated rejection (AMR) is a cardinal cause of transplant failure, with currently no proven effective prevention or treatment. The present review will focus on new therapeutic concepts currently under clinical evaluation. RECENT FINDINGS One interesting treatment approach may be interference with interleukin-6 (IL-6) signaling to modulate B-cell immunity and donor-specific antibody (DSA) production. Currently, a large phase III randomized controlled trial is underway to clarify the safety and efficacy of clazakizumab, a high-affinity anti-IL-6 antibody, in chronic AMR. A prevention/treatment strategy may be costimulation blockade using belatacept to interfere with germinal center responses and DSA formation. In a recent uncontrolled study, belatacept conversion was shown to stabilize renal function and dampen AMR activity. Moreover, preliminary clinical results suggest efficacy of CD38 antibodies to deplete plasma and natural killer cells to treat AMR, with anecdotal reports demonstrating at least transient resolution of active rejection. SUMMARY There are promising concepts on the horizon for the prevention and treatment of chronic AMR. The design of adequately powered placebo-controlled trials to clarify the safety and efficacy of such new therapies, however, remains a big challenge, and will rely on the definition of precise surrogate endpoints predicting long-term allograft survival. Mapping the natural history of AMR would greatly help the understanding of who would derive benefits from treatment.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philip F Halloran
- Alberta Transplant Applied Genomics Centre (ATAGC), University of Alberta, Edmonton, AB, Canada
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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