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Takada Y, Tanabe T, Sasaki H, Tsujimoto T, Hotta K, Okada K, Shiono Y, Minami K, Tanaka H, Harada H. Kidney donor age of 50 years or above is a risk factor for calcineurin inhibitor-induced nephrotoxicity. Clin Transplant 2024; 38:e15196. [PMID: 37975424 DOI: 10.1111/ctr.15196] [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: 03/27/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Calcineurin inhibitor (CNI)-induced nephrotoxicity (CNI-T) is a post-transplantation complication that leads to graft dysfunction. Older-donor kidney grafts may be susceptible to chronic CNI exposure because of long-term arteriolar damage. The primary aim of this study was to examine the CNI-T incidence and time-course changes in the graft function according to donor age. METHODS We included 334 kidney transplant recipients. CNI-T was defined by Banff arteriolar hyaline thickening scores of ≥2 based on allograft protocol biopsy. Depending on donor age, participants were divided into the D > 70 (≥70 years), D60 (60-69 years), D50 (50-59 years), and D < 49: (≤49 years) groups. We investigated the extent to which CNI-T affected the transplanted kidney function. Patients who did not develop CNI-T during the study period were included in the non-CNI-T group; the remaining were grouped into the CNI-T group. RESULTS The CNI-T incidence was higher in donors aged >50 years. Compared to D < 49, the CNI-T risk was 1.86 times higher in D50 and 2.9 times higher in D > 70. Furthermore, the CNI-T group exhibited a significantly lower graft function 10 years after transplantation. CONCLUSION CNI-T incidence increases in donors aged ≥50 years and affects renal function after 10 years.
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Affiliation(s)
- Yusuke Takada
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Tatsu Tanabe
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hajime Sasaki
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Takashi Tsujimoto
- Department of Pharmacy, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Kazufumi Okada
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yutaka Shiono
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Keita Minami
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hiroshi Tanaka
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hiroshi Harada
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
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2
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McGovern KE, Sonar SA, Watanabe M, Coplen CP, Bradshaw CM, Nikolich JŽ. The aging of the immune system and its implications for transplantation. GeroScience 2023:10.1007/s11357-022-00720-2. [PMID: 36626019 PMCID: PMC9838392 DOI: 10.1007/s11357-022-00720-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
By the last third of life, most mammals, including humans, exhibit a decline in immune cell numbers, immune organ structure, and immune defense of the organism, commonly known as immunosenescence. This decline leads to clinical manifestations of increased susceptibility to infections, particularly those caused by emerging and reemerging microorganisms, which can reach staggering levels-infection with SARS-CoV-2 has been 270-fold more lethal to older adults over 80 years of age, compared to their 18-39-year-old counterparts. However, while this would be expected to be beneficial to situations where hyporeactivity of the immune system may be desirable, this is not always the case. Here, we discuss the cellular and molecular underpinnings of immunosenescence as they pertain to outcomes of solid organ and hematopoietic transplantation.
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Affiliation(s)
- Kathryn E McGovern
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
- BIO5 Institute, University of Arizona, Tucson, AZ, USA
| | - Sandip A Sonar
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Makiko Watanabe
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christopher P Coplen
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christine M Bradshaw
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Janko Ž Nikolich
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA.
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA.
- BIO5 Institute, University of Arizona, Tucson, AZ, USA.
- The Aegis Consortium for Pandemic-free Future, University of Arizona Health Sciences, University of Arizona, Tucson, 85719, USA.
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Schrezenmeier E, Rincon-Arevalo H, Jens A, Stefanski AL, Hammett C, Osmanodja B, Koch N, Zukunft B, Beck J, Oellerich M, Proß V, Stahl C, Choi M, Bachmann F, Liefeldt L, Glander P, Schütz E, Bornemann-Kolatzki K, López del Moral C, Schrezenmeier H, Ludwig C, Jahrsdörfer B, Eckardt KU, Lachmann N, Kotsch K, Dörner T, Halleck F, Sattler A, Budde K. Temporary antimetabolite treatment hold boosts SARS-CoV-2 vaccination-specific humoral and cellular immunity in kidney transplant recipients. JCI Insight 2022; 7:e157836. [PMID: 35349490 PMCID: PMC9090237 DOI: 10.1172/jci.insight.157836] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/24/2022] [Indexed: 12/04/2022] Open
Abstract
Transplant recipients exhibit an impaired protective immunity after SARS-CoV-2 vaccination, potentially caused by mycophenolate (MPA) immunosuppression. Recent data from patients with autoimmune disorders suggest that temporary MPA hold might greatly improve booster vaccination outcomes. We applied a fourth dose of SARS-CoV-2 vaccine to 29 kidney transplant recipients during a temporary (5 weeks) MPA/azathioprine hold, who had not mounted a humoral immune response to previous vaccinations. Seroconversion until day 32 after vaccination was observed in 76% of patients, associated with acquisition of virus-neutralizing capacity. Interestingly, 21/25 (84%) calcineurin inhibitor-treated patients responded, but only 1/4 belatacept-treated patients responded. In line with humoral responses, counts and relative frequencies of spike receptor binding domain-specific (RBD-specific) B cells were markedly increased on day 7 after vaccination, with an increase in RBD-specific CD27++CD38+ plasmablasts. Whereas overall proportions of spike-reactive CD4+ T cells remained unaltered after the fourth dose, frequencies were positively correlated with specific IgG levels. Importantly, antigen-specific proliferating Ki67+ and in vivo-activated programmed cell death 1-positive T cells significantly increased after revaccination during MPA hold, whereas cytokine production and memory differentiation remained unaffected. In summary, antimetabolite hold augmented all arms of immunity during booster vaccination. These data suggest further studies of antimetabolite hold in kidney transplant recipients.
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Affiliation(s)
- Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care and
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- BIH Charité Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Hector Rincon-Arevalo
- Department of Nephrology and Medical Intensive Care and
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Rheumatism Research Centre Berlin (DRFZ), Berlin, Germany
- Cellular Immunology and Immunogenetics Group, Faculty of Medicine, Institute of Medical Research, University of Antioquia (UdeA), Medellín, Colombia
| | - Annika Jens
- Department of Nephrology and Medical Intensive Care and
| | - Ana-Luisa Stefanski
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Rheumatism Research Centre Berlin (DRFZ), Berlin, Germany
| | | | | | - Nadine Koch
- Department of Nephrology and Medical Intensive Care and
| | | | - Julia Beck
- Department of Clinical Pharmacology, Universitätsmedizin Göttingen, Göttingen, Germany
- Chronix Biomedical GmbH, Göttingen, Germany
| | - Michael Oellerich
- Department of Clinical Pharmacology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Vanessa Proß
- Department for General and Visceral Surgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carolin Stahl
- Department for General and Visceral Surgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care and
| | | | - Lutz Liefeldt
- Department of Nephrology and Medical Intensive Care and
| | - Petra Glander
- Department of Nephrology and Medical Intensive Care and
| | | | | | | | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg–Hessen and University Hospital Ulm, Ulm, Germany
| | - Carolin Ludwig
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg–Hessen and University Hospital Ulm, Ulm, Germany
| | - Bernd Jahrsdörfer
- Institute of Transfusion Medicine, Ulm University, Ulm, Germany
- Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg–Hessen and University Hospital Ulm, Ulm, Germany
| | | | - Nils Lachmann
- Center for Tumor Medicine, H&I Laboratory, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katja Kotsch
- Department for General and Visceral Surgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Rheumatism Research Centre Berlin (DRFZ), Berlin, Germany
| | | | - Arne Sattler
- Department for General and Visceral Surgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care and
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Yeung MY. Histocompatibility Assessment in Precision Medicine for Transplantation: Towards a Better Match. Semin Nephrol 2022; 42:44-62. [DOI: 10.1016/j.semnephrol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Deng J, Lu Y, He L, Ou J, Xie H. A comparison of mycophenolate mofetil and calcineurin inhibitor as maintenance immunosuppression for kidney transplant recipients: A meta-analysis of randomized controlled trials. Turk J Med Sci 2021; 51:1080-1091. [PMID: 33356028 PMCID: PMC8283438 DOI: 10.3906/sag-1910-156] [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: 10/21/2019] [Accepted: 12/26/2020] [Indexed: 12/02/2022] Open
Abstract
Background/aim We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the comparison and its timing between mycophenolate mofetil (MMF) and calcineurin inhibitor (CNI) as maintenance immunosuppression for kidney transplant recipients. Materials and methods The RCTs of MMF versus CNI as maintenance immunosuppression for kidney transplant recipients were searched from PubMed, Embase, Cochrane Central Register of Controlled Trials (CCRCT), and ClinicalTrials.gov. After screening relevant RCTs, two authors independently assessed the quality of included studies and performed a meta-analysis using RevMan5.3. Relative risk (RR) was used to report dichotomous data, while mean difference (MD) with 95% confidence interval (CI) was used to report continuous outcomes. The analysis was conducted using the random-effect model due to the expected heterogeneity among different studies. Four subgroups were allocated to compare MMF with CNI as maintenance immunosuppression: (1) after 3 months of CNI-based therapy, (2) after 6 months of CNI-based therapy, (3) after 12 months of CNI-based therapy, and (4) in recipients with allograft dysfunction. Results Twelve RCTs with 950 renal transplant recipients were included. This meta-analysis presented the following results upon comparison between MMF and CNI as maintenance immunosuppression for kidney transplant recipients: (1) MMF significantly improved the glomerular filtration rate (GFR) not only in the comparison performed after 3, 6, or 12 months of CNI-based therapy but also in the comparison of recipients with allograft dysfunction, (2) MMF may increase the risk of acute rejection in the comparison performed after 3 months of CNI-based therapy, but no increase was noted in the comparison performed after 6 or 12 months of CNI-based therapy. Conclusion Our present meta-analysis suggested that MMF followed at least 6 months of CNI-based therapy is an effective maintenance immunosuppressive regimen for kidney transplant recipients to improve renal function but not increase rejection.
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Affiliation(s)
- Jin Deng
- Department of Nephrology, the First Affiliated Hospital of University of South China, Hengyang, China
| | - Yi Lu
- Department of Nephrology, the First Affiliated Hospital of University of South China, Hengyang, China
| | - Lihong He
- Department of Diagnostic Ultrasound, the First Hospital of Changsha, Hengyang, China
| | - Jihong Ou
- Department of Diagnostic Ultrasound, the First Hospital of Changsha, Hengyang, China
| | - Hongping Xie
- Department of Health Management, the First Affiliated Hospital of University of South China, Hengyang, China
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6
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El Hennawy HM, Faifi ASA, El Nazer W, Mahedy A, Kamal A, Al Faifi IS, Abdulmalik H, Safar O, Zaitoun MF, Fahmy AE. Calcineurin Inhibitors Nephrotoxicity Prevention Strategies With Stress on Belatacept-Based Rescue Immunotherapy: A Review of the Current Evidence. Transplant Proc 2021; 53:1532-1540. [PMID: 34020797 DOI: 10.1016/j.transproceed.2021.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A traditional narrative review was performed to evaluate clinical studies that have examined the clinical implications, risk factors, and prevention of calcineurin inhibitors (CNIs) nephrotoxicity with stress on a belatacept-based rescue regimen. METHODS The Cochrane Library, PubMed/MEDLINE, EBSCO (Academic Search Ultimate), ProQuest (Central), and Excerpta Medical databases and Google scholar were searched using the keywords (CNI AND Nephrotoxicity prevention) OR ("Calcineurin inhibitor" AND Nephrotoxicity) OR (Tacrolimus AND Nephrotoxicity) OR (Ciclosporin AND Nephrotoxicity) OR (cyclosporine AND Nephrotoxicity) OR (Belatacept) OR (CNI Conversion) for the period from 1990 to 2020. Fifty-five related articles and reviews were found. CONCLUSION A better understanding of the mechanisms underlying calcineurin inhibitor nephrotoxicity could help in the individualization of therapy for and prevention of CNI nephrotoxicity. Identification of high-risk patients for CNI nephrotoxicity before renal transplantation enables better use and selection of immunosuppression with reduced adverse effects and, eventually, successful treatment of the kidney recipients. Belatacept conversion is a good and safe option in patients with deteriorating renal function attributed to CNI nephrotoxicity.
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Affiliation(s)
- Hany M El Hennawy
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia.
| | - Abdullah S Al Faifi
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Mahedy
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Kamal
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ibrahim S Al Faifi
- Department of Family Medicine, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Hana Abdulmalik
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Omar Safar
- Department of Urology, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Mohammad F Zaitoun
- Department of Pharmacy, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed E Fahmy
- Department of Surgery, Division of Transplantation, North Shore University Hospital, Northwell Health, Manhasset, New York
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Dreyer GJ, de Fijter JW. Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching. Front Immunol 2020; 11:359. [PMID: 32226428 PMCID: PMC7080649 DOI: 10.3389/fimmu.2020.00359] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.
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Affiliation(s)
- Geertje J Dreyer
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
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Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
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Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
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Dugast E, Soulillou JP, Foucher Y, Papuchon E, Guerif P, Paul C, Riochet D, Chesneau M, Cesbron A, Renaudin K, Dantal J, Giral M, Brouard S. Failure of Calcineurin Inhibitor (Tacrolimus) Weaning Randomized Trial in Long-Term Stable Kidney Transplant Recipients. Am J Transplant 2016; 16:3255-3261. [PMID: 27367750 DOI: 10.1111/ajt.13946] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/10/2016] [Accepted: 06/22/2016] [Indexed: 01/25/2023]
Abstract
Long-term renal transplant outcome is limited by side effects of immunosuppressive drugs, particularly calcineurin inhibitor (CNI). We assumed that some patients selected for a "low immunological risk of rejection" could be eligible and benefit from a CNI weaning strategy. We designed a prospective, randomized, multicenter, double-blind placebo-controlled clinical study (Eudract: 2010-019574-33) to analyze the benefit-risk ratio of tacrolimus weaning on highly selected patients (≥4 years of transplantation, normal histology, stable graft function, no anti-HLA immunization). The primary endpoint was improvement of renal function. Fifty-two patients were scheduled in each treatment arm, placebo compared to the CNI maintenance arm. Only 10 patients were eligible and randomized. Five patients were assigned to the placebo arm and five were assigned to the tacrolimus maintenance arm. In the tacrolimus maintenance arm, all patients maintained stable graft function and no immunological events occurred. Contrastingly, in the placebo arm, all five patients had to reintroduce a full dose of tacrolimus since three of them presented an acute rejection episode (one humoral, one mixed, and one borderline) and two displayed anti-HLA antibodies without histological lesion (one donor-specific antibodies [DSA] and one non-DSA). Clearly, tacrolimus withdrawal must be avoided even in long-term highly selective stable kidney recipients.
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Affiliation(s)
- E Dugast
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,Université de Nantes, Faculté de Médecine, Nantes, France
| | - J-P Soulillou
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,Université de Nantes, Faculté de Médecine, Nantes, France
| | - Y Foucher
- Université de Nantes, SPHERE Laboratory EA4275, Nantes, France
| | - E Papuchon
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,CIC Biothérapie, Nantes, France
| | - P Guerif
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,CIC Biothérapie, Nantes, France
| | - C Paul
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France
| | - D Riochet
- Department of Pediatrics, Nantes University Hospital, Nantes, France.,LUNAM University, INSERM, UMR 1064 ITUN, Nantes, France
| | - M Chesneau
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France
| | - A Cesbron
- LabEx Transplantex, Nantes, France.,Etablissement Français du sang, Pays de la Loire, HLA Laboratory, Nantes, France
| | - K Renaudin
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,Université de Nantes, Faculté de Médecine, Nantes, France
| | - J Dantal
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France
| | - M Giral
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France. .,Université de Nantes, Faculté de Médecine, Nantes, France. .,LabEx Transplantex, Nantes, France. .,EU consortium BIO-DrIM (www.biodrim.eu), Berlin, Germany.
| | - S Brouard
- ITUN, CHU de Nantes, INSERM, UMR 1064, Nantes, France.,LabEx Transplantex, Nantes, France.,EU consortium BIO-DrIM (www.biodrim.eu), Berlin, Germany.,LabEx IGO "Immunotherapy Graft Oncology", Nantes, France
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10
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Sawinski D, Trofe-Clark J, Leas B, Uhl S, Tuteja S, Kaczmarek JL, French B, Umscheid CA. Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis. Am J Transplant 2016; 16:2117-38. [PMID: 26990455 DOI: 10.1111/ajt.13710] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/28/2015] [Accepted: 01/07/2016] [Indexed: 01/25/2023]
Abstract
Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.
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Affiliation(s)
- D Sawinski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J Trofe-Clark
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - B Leas
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA
| | - S Uhl
- ECRI Institute, Plymouth Meeting, PA
| | - S Tuteja
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - B French
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - C A Umscheid
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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11
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Hricik DE, Formica RN, Nickerson P, Rush D, Fairchild RL, Poggio ED, Gibson IW, Wiebe C, Tinckam K, Bunnapradist S, Samaniego-Picota M, Brennan DC, Schröppel B, Gaber O, Armstrong B, Ikle D, Diop H, Bridges ND, Heeger PS. Adverse Outcomes of Tacrolimus Withdrawal in Immune-Quiescent Kidney Transplant Recipients. J Am Soc Nephrol 2015; 26:3114-22. [PMID: 25925687 DOI: 10.1681/asn.2014121234] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/05/2015] [Indexed: 12/18/2022] Open
Abstract
Concerns about adverse effects of calcineurin inhibitors (CNIs) have prompted development of protocols that minimize their use. Whereas previous CNI withdrawal trials in heterogeneous cohorts showed unacceptable rates of acute rejection (AR), we hypothesized that we could identify individuals capable of tolerating CNI withdrawal by targeting immunologically quiescent kidney transplant recipients. The Clinical Trials in Organ Transplantation-09 Trial was a randomized, prospective study of nonsensitized primary recipients of living donor kidney transplants. Subjects received rabbit antithymocyte globulin, tacrolimus, mycophenolate mofetil, and prednisone. Six months post-transplantation, subjects without de novo donor-specific antibodies (DSAs), AR, or inflammation at protocol biopsy were randomized to wean off or remain on tacrolimus. The intended primary end point was the change in interstitial fibrosis/tubular atrophy score between implantation and 24-month protocol biopsies. Serially collected urine CXCL9 ELISA results were correlated with outcomes. The study was terminated prematurely because of unacceptable rates of AR (4 of 14) and/or de novo DSAs (5 of 14) in the tacrolimus withdrawal arm. Positive urinary CXCL9 predated clinical detection of AR by a median of 15 days. Analyses showed that >16 HLA-DQ epitope mismatches and pretransplant, peripheral blood, donor-reactive IFN-γ ELISPOT assay results correlated with development of DSAs and/or AR on tacrolimus withdrawal. Although data indicate that urinary CXCL9 monitoring, epitope mismatches, and ELISPOT assays are potentially informative, complete CNI withdrawal must be strongly discouraged in kidney transplant recipients who are receiving standard-of-care immunosuppression, including those who are deemed to be immunologically quiescent on the basis of current clinical and laboratory criteria.
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Affiliation(s)
- Donald E Hricik
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Richard N Formica
- Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter Nickerson
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Rush
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert L Fairchild
- Department of Immunology and Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D Poggio
- Department of Immunology and Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ian W Gibson
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chris Wiebe
- College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Tinckam
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suphamai Bunnapradist
- Department of Medicine, University of California at Los Angeles Medical Center, Los Angeles, California
| | | | - Daniel C Brennan
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Bernd Schröppel
- Department of Medicine and Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Weil Cornell Medical College, New York, New York
| | | | | | - Helena Diop
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Nancy D Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter S Heeger
- Department of Medicine and Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York;
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12
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Abstract
Late kidney transplant dysfunction may be a harbinger of graft failure. For many years, calcineurin inhibitor toxicity was felt to be the main cause for graft dysfunction with fibrosis and transplant loss. Recently this idea has come into question. With the observation that peritubular capillary C4d staining in kidney allografts may indicate antibody-mediated injury in conjunction with biopsy study findings, an appreciation for antibody-mediated rejection as a major cause of late graft dysfunction and loss has emerged. Twenty percent to 30% of patients develop de novo donor-specific antibodies after kidney transplantation. There are no US Food and Drug Administration-approved treatments for antibody-mediated rejection, nor have any randomized controlled trials assessed efficacy. Off-label treatment strategies include some combination of plasma exchange, intravenous immunoglobulin, and rituximab. Other approaches, including splenectomy, bortezomib, and eculizumab, have also been tried.
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