Early experience with two-dose daclizumab in the prevention of acute rejection in cardiac transplantation

A randomized controlled trial of daclizumab versus anti-thymocyte globulin induction for heart transplantation

Background

The purpose of this study was to test the efficacy and safety of daclizumab (DZM) versus anti-thymocyte globulin (ATG) as a component of induction therapy in heart transplant recipients.

Methods

Thirty heart transplant patients were randomized to receive either ATG or DZM during induction therapy. Patients in the DZM group received an initial dose of 2 mg/kg intravenous (IV) at the time of transplant and 1 mg/kg IV on postoperative day 4.

Discussion

Recipient, donor, and intraoperative variables did not differ significantly between groups. The cost of induction therapy, total drug cost, and hospital ward costs were significantly less for the DZM group. Average absolute lymphocyte and platelet counts were significantly higher in the DZM group. There were no significant differences in the incidence of rejection, infection, malignancy, or steroid-induced diabetes. One year survival was excellent in both groups (87%, P = 0.1). Daclizumab is a safe component of induction therapy in heart transplantation.

Interleukin-2 receptor blockade with humanized monoclonal antibody for solid organ transplantation

IMPORTANCE OF THE FIELD

Induction therapy has reduced the incidence of acute rejection compared with historical standards. The potency of currently available induction immunosuppression is not without risk and should be carefully considered. Induction with daclizumab, an IL-2 receptor antagonist, has been used safely and effectively for over 10 years across different transplant types. As a result of daclizumab use, transplant centers are able to implement steroid-sparing or calcineurin minimization protocols. Unfortunately, the manufacturing costs have resulted in withdrawal of this agent from the market reducing the options for patients undergoing transplantation.

AREAS COVERED IN THIS REVIEW

This review will update the reader on recently published daclizumab studies in adult solid organ transplant recipients, focusing on comparative studies with other induction agents.

WHAT THE READER WILL GAIN

This paper will provide a summary of comparative studies between daclizumab and other induction therapies focusing on their efficacy and safety.

TAKE HOME MESSAGE

Novel applications, such as long-term use in combination with calcineurin-inhibitor dose reduction and its value in the treatment of acute or chronic rejection have yet to be explored. Since daclizumab has been withdrawn from the market, future IL-2 receptor blockade will have to be achieved with basiliximab, which is a chimeric, monoclonal antibody directed against the same epitope.

Daclizumab

Daclizumab is a humanized monoclonal antibody which binds to the IL-2 receptor on activated lymphocytes and blocks the production of IL-2. Its use is well established in solid organ transplantation as induction therapy, especially in high-risk patients where reduction or delayed dose of standard immunosuppression would be beneficial. It has been used effectively in both 2-dose and 5-dose regimens in conjunction with other standard immunosuppressive agents. The incidence of acute rejection appears reduced without increasing the rates of infection or post-transplant lympho-proliferative disorders. The agent is generally well tolerated in adults and children and there is no need for additional monitoring. Daclizumab has also been used outside the transplant arena in a variety of immune-mediated diseases with limited success.

Two-Dose Daclizumab, Tacrolimus, Mycophenolate Mofetil, and Steroid-Free Regimen in De Novo Cardiac Transplant Recipients: Early Experience

BACKGROUND

Tacrolimus (TAC) with mycophenolate mofetil (MMF) and a steroid-free regimen seems to have good efficacy in preventing acute rejection in cardiac transplant recipients, although concern exists about nephrotoxicity. Induction therapy with Daclizumab seems to give protection without side effects. Data are lacking about the outcome of 2-dose Daclizumab+TAC+MMF and a steroid-free regimen.

MATERIALS AND METHODS

We retrospectively reviewed 28 consecutive de novo heart transplantations performed at a single center between January 2001 and June 2006. Patients received induction therapy with 2-dose Daclizumab. Maintenance immunosuppression included TAC, MMF, and prednisone during the first 6 months. The endpoints were the incidence of acute rejection, patient and graft survival, and clinical tolerability.

RESULTS

Among 28 patients of mean age 57 +/- 9 years, 2 subjects (7%) died in the perioperative period due to infections. The mean follow-up was 2.8 +/- 1.5 years. There were no late deaths. Six patients experienced acute rejection (International Society of Heart and Lung Transplantation [ISHLT] >or=3A) that required treatment during the first 3 months. At follow-up, only 3 patients (>or=3A) required treatment. Mean creatinine level increased from 1.08 +/- 0.37 at baseline to 1.08 +/- 0.41 at 1 year (n = 23; P = not significant [NS]) to 1.39 +/- 0.68 (n = 13; P < .05) at 4 years, 1.65 +/- 0.51 (n = 8; P < .05) at 5 years. No patient required replacement therapy.

CONCLUSIONS

A steroid-free protocol with 2-dose Daclizumab induction therapy and maintenance with TAC and MMF seemed to be safe to prevent acute rejection. Creatinine levels were slightly but significantly increased.

Induction Therapy in Lung Transplantation: Initial Single-Center Experience Comparing Daclizumab and Antithymocyte Globulin

Acute and chronic rejection remain unresolved problems after lung transplantation, despite heavy multidrug immunosuppression. Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed antithymocyte globulin (ATG) or daclizumab as adjuncts to reduce the incidence of rejection episodes.

METHODS

We performed a controlled clinical trial of the two therapies to evaluate differences in postoperative rejection, infection, bronchiolitis obliterans syndrome (BOS) and host survival. Twenty-five consecutive lung transplant patients received ATG (n = 12; group 1) or daclizumab (n = 13; group 2) as an induction agent. The groups showed similar demographics and immunosuppression protocols, differ only in induction agent.

RESULTS

No differences were observed in the immediate postoperative outcomes, such as length of hospitalization, ICU stay, or time on ventilator. There were no significant differences in the number of episodes of acute rejection, freedom from BOS, or infections. Freedom from acute rejection was significantly greater with daclizumab than with ATG (P = .037). The 1-year survival for group 1 was 67% and for group 2, 77% (P = .584).

CONCLUSIONS

Daclizumab constitutes a safe and effective form of induction immunosuppressive therapy. Using a two-dose administration schedule, daclizumab prolonged the time without acute rejection compared to ATG. The differences in the incidence of infectious complications, acute rejection, or BOS as well as the short-term or long-term results were not significantly different. The results of the study justify the further use of daclizumab as an induction agent in patients following lung transplantation.

Induction Therapy With Daclizumab in Heart Transplantation—How Many Doses?

Since their introduction onto the market, interleukin-2 antagonists have been increasingly used by a growing number of transplant units. Their benefits versus OKT3 appear evident, although the optimal dose remains to be established. Our objective was to establish possible differences related to the use of two versus five doses of daclizumab.

MATERIALS AND METHODS

This study evaluated 81 consecutive patients treated with two bolus doses of daclizumab (1 mg/kg) on days 1 and 14 posttransplantation. We excluded retransplantations, pediatric transplantations, and combined transplantations. We compared our series to a previous trial involving the administration of a single bolus dose every 14 days (five boluses in total). Study variables included the number of graft rejections, the number of infections, and the mortality. Statistical analysis was performed using the chi square and Student's t tests. Significance was set at P < .05.

RESULTS

There were no differences between groups in the baseline characteristics of the patients. The number of rejection episodes during the first year was significantly lower among the patients in our series treated with two bolus doses of daclizumab than in the series of patients treated with five bolus doses: 24 (30%) vs 17 (61%) episodes (P = .003). No significant differences were observed for mortality: the group receiving two boluses registered 10 deaths (12%) versus two (7%) in the group receiving five boluses (P = .4), or infection rate: 11 patients (40%) in the group receiving five bolus versus 31 patients (38%) in the group given two bolus doses (P = .9).

CONCLUSIONS

Our results suggested that induction therapy with two doses of daclizumab was at least as effective in preventing rejection as five doses, with no negative effects on patient survival.

Two-dose basiliximab compared with two-dose daclizumab in renal transplantation: a clinical study

BACKGROUND

Addition of the interleukin-2 receptor (IL-2R) antagonists basiliximab or daclizumab to a calcineurin inhibitor-based regimen significantly reduces risk of acute rejection with a tolerability profile similar to a placebo. Use of a truncated two-dose regimen of daclizumab has been reported, but till date, there has been no controlled study of two-dose daclizumab vs. two-dose basiliximab.

METHODS

Deceased-donor renal transplant recipients were randomized to basiliximab (20 mg on days 0 and 4) or daclizumab (50 mg on days 1 and 14) with cyclosporine, mycophenolate mofetil and corticosteroids. Flow cytometry was used to calculate the proportion of CD25(+) T cells in peripheral blood.

RESULTS

Thirty patients were randomized to basiliximab and 28 to daclizumab. There was one patient death in each group, with no other graft losses. By six months, the incidence of biopsy-proven acute rejection was 0% with basiliximab vs. 21.4% with daclizumab (p < 0.05). Three patients in the daclizumab group required OKT3 for steroid-resistant rejection. There were no between-group differences in the incidence of infection. The proportion of CD25(+) T cells declined markedly during the first two wk in both groups, but was significantly lower in the basiliximab group during weeks six to eight.

CONCLUSION

Two doses of basiliximab are more effective than two 1 mg/kg doses of daclizumab in preventing acute rejection in de novo renal transplant patients receiving cyclosporine, mycophenolate mofetil and corticosteroid maintenance therapy. In patients receiving relatively low-level immunosuppression in order to minimize toxicity, basiliximab may be preferable to a truncated daclizumab regimen.

Experience With Single-Dose Daclizumab in the Prevention of Acute Rejection in Heart Transplantation

INTRODUCTION

Daclizumab is a monoclonal antibody that binds to the interleukin-2 receptor. It has been used as induction therapy in heart transplantation with two to five repeated administrations over several weeks. The objective of our study was to estimate the efficacy and safety of induction therapy with only one dose of daclizumab in a consecutive series of patients undergoing heart transplantation.

METHODS

Thirty-two consecutive heart transplants performed since July 2002, who received single-dose daclizumab as induction therapy, were compared with the 30 patients transplanted previously, who received OKT3. In both groups, maintenance immunosuppression included cyclosporine or tacrolimus, mycophenolate mofetil, and corticosteroids. Follow-up time was 1 year.

RESULTS

There were no baseline differences between the two groups regarding age, gender, or etiology. In the group treated with daclizumab there were more diabetics (43% versus 10%, P = .01) and the ischemia time was longer (192 versus 156 minutes, P = .03). During the first posttransplant year, 76% of patients treated with OKT3 and 55% of those treated with daclizumab presented acute rejection > or =3A; 20% and 25%, respectively, presented infections; and 5 (17%) patients in the OKT3 group and 2 (6%) in the group treated with daclizumab died. None of these differences was statistically significant.

CONCLUSIONS

Our experience suggests that induction therapy with a single-dose regimen of daclizumab seems to have an efficacy and safety profile similar to OKT3, and it is easier to administer and has a lower cost than other induction regimens.