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Banno T, Hirai T, Oki R, Yagisawa T, Unagami K, Kanzawa T, Omoto K, Shimizu T, Ishida H, Takagi T. Higher Donor Age and Severe Microvascular Inflammation Are Risk Factors for Chronic Rejection After Treatment of Active Antibody-Mediated Rejection. Transpl Int 2024; 37:11960. [PMID: 38371907 PMCID: PMC10869508 DOI: 10.3389/ti.2024.11960] [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: 08/24/2023] [Accepted: 01/10/2024] [Indexed: 02/20/2024]
Abstract
Recent developments in intensive desensitization protocols have enabled kidney transplantation in human leukocyte antigen (HLA)-sensitized recipients. However, cases of active antibody-mediated rejection (AABMR), when they occur, are difficult to manage, graft failure being the worst-case scenario. We aimed to assess the impact of our desensitization and AABMR treatment regimen and identify risk factors for disease progression. Among 849 patients who underwent living-donor kidney transplantation between 2014 and 2021 at our institution, 59 were diagnosed with AABMR within 1 year after transplantation. All patients received combination therapy consisting of steroid pulse therapy, intravenous immunoglobulin, rituximab, and plasmapheresis. Multivariable analysis revealed unrelated donors and preformed donor-specific antibodies as independent risk factors for AABMR. Five-year death-censored graft survival rate was not significantly different between patients with and without AABMR although 27 of 59 patients with AABMR developed chronic AABMR (CABMR) during the study period. Multivariate Cox proportional hazard regression analysis revealed that a donor age greater than 59 years and microvascular inflammation (MVI) score (g + ptc) ≥4 at AABMR diagnosis were independent risk factors for CABMR. Our combination therapy ameliorated AABMR; however, further treatment options should be considered to prevent CABMR, especially in patients with old donors and severe MVI.
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Affiliation(s)
- Taro Banno
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Rikako Oki
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Takafumi Yagisawa
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Tomokazu Shimizu
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women’s Medical University Hospital, Tokyo, Japan
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Schmitz R, Manook M, Fitch Z, Anwar I, DeLaura I, Olaso D, Choi A, Yoon J, Bae Y, Song M, Farris AB, Kwun J, Knechtle S. Belatacept and carfilzomib-based treatment for antibody-mediated rejection in a sensitized nonhuman primate kidney transplantation model. FRONTIERS IN TRANSPLANTATION 2023; 2:1230393. [PMID: 38993898 PMCID: PMC11235304 DOI: 10.3389/frtra.2023.1230393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/22/2023] [Indexed: 07/13/2024]
Abstract
Introduction One-third of HLA-incompatible kidney transplant recipients experience antibody mediated rejection (AMR) with limited treatment options. This study describes a novel treatment strategy for AMR consisting of proteasome inhibition and costimulation blockade with or without complement inhibition in a nonhuman primate model of kidney transplantation. Methods All rhesus macaques in the present study were sensitized to maximally MHC-mismatched donors by two sequential skin transplants prior to kidney transplant from the same donor. All primates received induction therapy with rhesus-specific ATG (rhATG) and were maintained on various immunosuppressive regimens. Primates were monitored postoperatively for signs of acute AMR, which was defined as worsening kidney function resistant to high dose steroid rescue therapy, and a rise in serum donor-specific antibody (DSA) levels. Kidney biopsies were performed to confirm AMR using Banff criteria. AMR treatment consisted of carfilzomib and belatacept for a maximum of four weeks with or without complement inhibitor. Results Treatment with carfilzomib and belatacept was well tolerated and no treatment-specific side effects were observed. After initiation of treatment, we observed a reduction of class I and class II DSA in all primates. Most importantly, primates had improved kidney function evident by reduced serum creatinine and BUN as well as increased urine output. A four-week treatment was able to extend graft survival by up to two months. Discussion In summary, combined carfilzomib and belatacept effectively treated AMR in our highly sensitized nonhuman primate model, resulting in normalization of renal function and prolonged allograft survival. This regimen may translate into clinical practice to improve outcomes of patients experiencing AMR.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Miriam Manook
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Zachary Fitch
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Imran Anwar
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Isabel DeLaura
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Danae Olaso
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Ashley Choi
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Janghoon Yoon
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Yeeun Bae
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Mingqing Song
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Stuart Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
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Alasfar S, Kodali L, Schinstock CA. Current Therapies in Kidney Transplant Rejection. J Clin Med 2023; 12:4927. [PMID: 37568328 PMCID: PMC10419508 DOI: 10.3390/jcm12154927] [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: 06/19/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Despite significant advancements in immunosuppressive therapies, kidney transplant rejection continues to pose a substantial challenge, impacting the long-term survival of grafts. This article provides an overview of the diagnosis, current therapies, and management strategies for acute T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). TCMR is diagnosed through histological examination of kidney biopsy samples, which reveal the infiltration of mononuclear cells into the allograft tissue. Corticosteroids serve as the primary treatment for TCMR, while severe or steroid-resistant cases may require T-cell-depleting agents, like Thymoglobulin. ABMR occurs due to the binding of antibodies to graft endothelial cells. The most common treatment for ABMR is plasmapheresis, although its efficacy is still a subject of debate. Other current therapies, such as intravenous immunoglobulins, anti-CD20 antibodies, complement inhibitors, and proteasome inhibitors, are also utilized to varying degrees, but their efficacy remains questionable. Management decisions for ABMR depend on the timing of the rejection episode and the presence of chronic changes. In managing both TCMR and ABMR, it is crucial to optimize immunosuppression and address adherence. However, further research is needed to explore newer therapeutics and evaluate their efficacy.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Lavanya Kodali
- Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
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Mylonas KS, Soukouli I, Avgerinos DV, Boletis JN. Current immunosuppression strategies in pediatric heart transplant. Immunotherapy 2022; 14:663-667. [PMID: 35510326 DOI: 10.2217/imt-2021-0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Ioanna Soukouli
- Department of Nephrology & Renal Transplantation, Laiko General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - John N Boletis
- Department of Nephrology & Renal Transplantation, Laiko General Hospital, National & Kapodistrian University of Athens, Athens, Greece
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5
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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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6
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Parlakpinar H, Gunata M. Transplantation and immunosuppression: a review of novel transplant-related immunosuppressant drugs. Immunopharmacol Immunotoxicol 2021; 43:651-665. [PMID: 34415233 DOI: 10.1080/08923973.2021.1966033] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunosuppressive drugs used in the transplantation period are generally defined as induction and maintenance therapy. The use of immunosuppressants, which are particularly useful and have fewer side effects, decreased both mortality and morbidity. Many drugs such as steroids, calcineurin inhibitors (cyclosporine-A, tacrolimus), antimetabolites (mycophenolate mofetil, azathioprine), and mTOR inhibitors (sirolimus, everolimus) are used as immunosuppressive agents. Although immunosuppressant drugs cause many side effects such as hypertension, infection, and hyperlipidemia, they are the agents that should be used to prevent organ rejection. This shows the importance of individualized drug use. The optimal immunosuppressive therapy post-transplant is not established. Therefore, discovering less toxic but more potent new agents is of great importance, and new experimental and clinical studies are needed in this regard.Our review discussed the mechanism of immunosuppressants, new agents' discovery, and current therapeutic protocols in the transplantation.
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Affiliation(s)
- Hakan Parlakpinar
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Mehmet Gunata
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
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7
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Reese SR, Wilson NA, Huang Y, Ptak L, Degner KR, Xiang D, Redfield RR, Zhong W, Panzer SE. B-cell Deficiency Attenuates Transplant Glomerulopathy in a Rat Model of Chronic Active Antibody-mediated Rejection. Transplantation 2021; 105:1516-1529. [PMID: 33273321 PMCID: PMC8106694 DOI: 10.1097/tp.0000000000003530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transplant glomerulopathy (TG) is a pathological feature of chronic active antibody-mediated rejection (cAMR) and is associated with renal allograft failure. The specific role of B cells in the pathogenesis of TG is unclear. METHODS We used a minor mismatched rat kidney transplant model with B cell-deficient recipients, generated by clustered regularly interspaced short palindromic repeats/Cas9 technology, to investigate the impact of B-cell depletion on the pathogenesis of TG. We hypothesized that B-cell deficiency would prevent TG in the rat kidney transplant model of cAMR. Treatment groups included syngeneic, allogeneic, sensitized allogeneic, and B cell-deficient allogeneic transplant recipients. RESULTS B cell-deficient recipients demonstrated reduced TG lesions, decreased microvascular inflammation, reduced allograft infiltrating macrophages, and reduced interferon gamma transcripts within the allograft. Allograft transcript levels of interferon gamma, monocyte chemoattractant protein-1, and interleukin-1β correlated with numbers of intragraft macrophages. B cell-deficient recipients lacked circulating donor-specific antibodies and had an increased splenic regulatory T-cell population. CONCLUSIONS In this model of cAMR, B-cell depletion attenuated the development of TG with effects on T cell and innate immunity.
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Affiliation(s)
- Shannon R. Reese
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Nancy A. Wilson
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Yabing Huang
- Department of Pathology, Renmin Hospital of Wuhan University, China
| | - Lucille Ptak
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenna R. Degner
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Ding Xiang
- Department of Organ Transplantation, Xiangya Hospital, Central South University, China
| | - Robert R. Redfield
- Department of Surgery, Division of Transplant Surgery, University of Wisconsin, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI, United States
| | - Sarah E. Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
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8
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Perrottet N, Fernández-Ruiz M, Binet I, Dickenmann M, Dahdal S, Hadaya K, Müller T, Schaub S, Koller M, Rotman S, Moll S, Hopfer H, Venetz JP, Aubert V, Bühler L, Steiger J, Manuel O, Pascual M, Golshayan D. Infectious complications and graft outcome following treatment of acute antibody-mediated rejection after kidney transplantation: A nationwide cohort study. PLoS One 2021; 16:e0250829. [PMID: 33930037 PMCID: PMC8087104 DOI: 10.1371/journal.pone.0250829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/15/2021] [Indexed: 01/13/2023] Open
Abstract
Acute antibody-mediated rejection (AMR) remains a challenge after kidney transplantation (KT). As there is no clear-cut treatment recommendation, accurate information on current therapeutic strategies in real-life practice is needed. KT recipients from the multicenter Swiss Transplant Cohort Study treated for acute AMR during the first post-transplant year were included retrospectively. We aimed at describing the anti-rejection protocols used routinely, as well as patient and graft outcomes, with focus on infectious complications. Overall, 65/1669 (3.9%) KT recipients were treated for 75 episodes of acute AMR. In addition to corticosteroid boluses, most common therapies included plasmapheresis (56.0%), intravenous immunoglobulins (IVIg) (38.7%), rituximab (25.3%), and antithymocyte globulin (22.7%). At least one infectious complication occurred within 6 months from AMR treatment in 63.6% of patients. Plasmapheresis increased the risk of overall (hazard ratio [HR]: 2.89; P-value = 0.002) and opportunistic infection (HR: 5.32; P-value = 0.033). IVIg exerted a protective effect for bacterial infection (HR: 0.29; P-value = 0.053). The recovery of renal function was complete at 3 months after AMR treatment in 67% of episodes. One-year death-censored graft survival was 90.9%. Four patients (6.2%) died during the first year (two due to severe infection). In this nationwide cohort we found significant heterogeneity in therapeutic approaches for acute AMR. Infectious complications were common, particularly among KT recipients receiving plasmapheresis.
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Affiliation(s)
- Nancy Perrottet
- Service of Pharmacy, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Mario Fernández-Ruiz
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Isabelle Binet
- Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St Gallen, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Suzan Dahdal
- Division of Nephrology, Hypertension and Clinical Pharmacology, Inselspital Bern, Bern, Switzerland
| | - Karine Hadaya
- Division of Nephrology and Division of Transplantation, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Müller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Koller
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Samuel Rotman
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Solange Moll
- Division of Clinical Pathology, Department of Pathology and Immunology, Geneva University Hospitals, Geneva, Switzerland
| | - Helmut Hopfer
- Pathology Institute, University Hospital Basel, Basel, Switzerland
| | - Jean-Pierre Venetz
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Léo Bühler
- Visceral and Transplant Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Jurg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Oriol Manuel
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Service of Infectious Diseases, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Dela Golshayan
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- * E-mail:
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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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10
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Yoshinaga K, Araki M, Wada K, Maruyama Y, Mitsui Y, Sadahira T, Kubota R, Nishimura S, Kobayashi Y, Takeuchi H, Tanabe K, Kitagawa M, Morinaga H, Uchida HA, Kitamura S, Sugiyama H, Wada J, Watanabe M, Watanabe T, Nasu Y. Low-dose rituximab induction therapy is effective in immunological high-risk renal transplantation without increasing cytomegalovirus infection. Int J Urol 2020; 27:1136-1142. [PMID: 33012030 DOI: 10.1111/iju.14382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyze the effect and impact of low-dose rituximab induction therapy on cytomegalovirus infection in living-donor renal transplantation. METHODS A total of 92 recipients undergoing living-donor renal transplantation at Okayama University Hospital from May 2009 to August 2018 were evaluated retrospectively. Indications for preoperative rituximab (200 mg/body) were the following: (i) ABO major mismatch; (ii) ABO minor mismatch; (iii) donor-specific anti-human leukocyte antigen antibody-positive; and (iv) focal segmental glomerulosclerosis. We excluded four recipients who were followed <3 months, five who received >200 mg/body rituximab and seven who received prophylactic therapy for cytomegalovirus. RESULTS There were 59 patients in the rituximab group and 17 in the non-rituximab group. Groups differed significantly in age (median age 53 vs 37 years, respectively; P = 0.04), but not in sex (male 64% vs 65%, P = 1.00), focal segmental glomerulosclerosis (3% vs 0%, P = 1.00) or percentage of cytomegalovirus-seronegative recipients of renal allografts from cytomegalovirus-seropositive donors (12% vs 18%, P = 0.68). The estimated glomerular filtration rate did not differ significantly between groups until 24 months after transplantation. Cytomegalovirus clinical symptoms (10% vs 24%, P = 0.22), including fever ≥38°C (5% vs 12%, P = 0.31) and gastrointestinal symptoms (5% vs 12%, P = 0.31), and the 5-year survival rates of death-censored graft loss (90% vs 83%, P = 0.43) did not differ significantly between groups. CONCLUSIONS Low-dose rituximab induction therapy is effective in immunological high-risk recipients without increasing cytomegalovirus infection in the absence of valganciclovir prophylaxis.
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Affiliation(s)
- Kasumi Yoshinaga
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Motoo Araki
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Koichiro Wada
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yuki Maruyama
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yosuke Mitsui
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Takuya Sadahira
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Risa Kubota
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shingo Nishimura
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasuyuki Kobayashi
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hidemi Takeuchi
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Katsuyuki Tanabe
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masashi Kitagawa
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiroshi Morinaga
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Haruhito Adam Uchida
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shinji Kitamura
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Jun Wada
- Department of, Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masami Watanabe
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Toyohiko Watanabe
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasutomo Nasu
- Departments of, Department of, Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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11
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Monitoring of Donor-specific Anti-HLA Antibodies and Management of Immunosuppression in Kidney Transplant Recipients: An Evidence-based Expert Paper. Transplantation 2020; 104:S1-S12. [DOI: 10.1097/tp.0000000000003270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:33/3/e00035-19. [PMID: 32522746 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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13
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Kincaide E, Hitchman K, Hall R, Yamaguchi I, Ding Y, Crowther B. Impact of active antibody-mediated rejection treatment on donor-specific antibodies in pediatric kidney transplant recipients. Pediatr Transplant 2019; 23:e13590. [PMID: 31617318 DOI: 10.1111/petr.13590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/17/2019] [Accepted: 09/01/2019] [Indexed: 01/06/2023]
Abstract
AMR is a major cause of graft loss after kidney transplantation. We evaluated a retrospective cohort of 13 pediatric kidney transplant patients diagnosed with active AMR. All 13 patients were treated with plasmapheresis (PP), IVIg, and rituximab. Anti-HLA DSAs were measured at the time of transplantation, AMR diagnosis, 30 days post-rejection treatment, 90 days post-rejection treatment, and 24 ± 12 months post-AMR. A total of 68 DSAs were identified from 13 patients at the time of active AMR diagnosis. The primary objective of this study was to differentiate treatment response rates between class I and class II anti-HLA DSA post-AMR treatment. Overall, DSAs were significantly reduced at 30 days, and the reduction was sustained at 90 days post-treatment, even for class II anti-HLA and strongly positive DSAs. A significant difference between class I and class II anti-HLA DSA was observed at 30 days; however, between class significance was lost at 90-day follow-up due to continued class II anti-HLA DSA treatment response. Low DSA strength was predictive of treatment response. eGFR demonstrated significant improvement 90 days after AMR diagnosis compared to the initial value at the time of AMR, and the effect was sustained for 12 months. These results suggest that the AMR treatment is effective in pediatric kidney transplant recipients with an early diagnosis of active AMR across both class I and class II anti-HLA DSAs.
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Affiliation(s)
- Elisabeth Kincaide
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,University Transplant Center, University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kelley Hitchman
- University Transplant Center, University Health System, San Antonio, TX, USA.,Histocompatibility and Immunogenetics Laboratory, University Health System, San Antonio, TX, USA.,Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Reed Hall
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,University Transplant Center, University Health System, San Antonio, TX, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Ikuyo Yamaguchi
- University Transplant Center, University Health System, San Antonio, TX, USA.,Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Yanli Ding
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Health, Aurora, CO, USA.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
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14
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Salvadori M, Tsalouchos A. Therapeutic apheresis in kidney transplantation: An updated review. World J Transplant 2019; 9:103-122. [PMID: 31750088 PMCID: PMC6851502 DOI: 10.5500/wjt.v9.i6.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased- or living- donor transplantation. Postoperatively, additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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15
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The Treatment of Antibody-Mediated Rejection in Kidney Transplantation: An Updated Systematic Review and Meta-Analysis. Transplantation 2018; 102:557-568. [PMID: 29315141 DOI: 10.1097/tp.0000000000002049] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current treatments for antibody-mediated rejection (AMR) in kidney transplantation are based on low-quality data from a small number of controlled trials. Novel agents targeting B cells, plasma cells, and the complement system have featured in recent studies of AMR. METHODS We conducted a systematic review and meta-analysis of controlled trials in kidney transplant recipients using Medline, EMBASE, and CENTRAL from inception to February 2017. RESULTS Of 14 380 citations, we identified 21 studies, including 10 randomized controlled trials, involving 751 participants. Since the last systematic review conducted in 2011, we found nine additional studies evaluating plasmapheresis + intravenous immunoglobulin (IVIG) (two), rituximab (two), bortezomib (two), C1 inhibitor (two), and eculizumab (one). Risk of bias was serious or unclear overall and evidence quality was low for the majority of treatment strategies. Sufficient RCTs for pooled analysis were available only for antibody removal, and here there was no significant difference between groups for graft survival (HR 0.76; 95% CI 0.35-1.63; P = 0.475). Studies showed important heterogeneity in treatments, definition of AMR, quality, and follow-up. Plasmapheresis and IVIG were used as standard-of-care in recent studies, and to this combination, rituximab seemed to add little or no benefit. Insufficient data are available to assess the efficacy of bortezomib and complement inhibitors. CONCLUSION Newer studies evaluating rituximab showed little or no difference to early graft survival, and the efficacy of bortezomib and complement inhibitors for the treatment of AMR remains unclear. Despite the evidence uncertainty, plasmapheresis and IVIG have become standard-of-care for the treatment of acute AMR.
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16
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Bajpai NK, Bajpayee A, Charan J, Pareek P, Elhence P, Kirubakaran R. Interventions for treating antibody-mediated acute rejection in kidney transplant recipients. Hippokratia 2018. [DOI: 10.1002/14651858.cd013033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nitin K Bajpai
- All India Institute of Medical Sciences (AIIMS); Department of Nephrology; Jodhpur Rajasthan India 342005
| | - Archana Bajpayee
- All India Institute of Medical Sciences (AIIMS); Department of Transfusion Medicine & Blood Bank; Basni Phase II Jodhpur Rajasthan India 342005
| | - Jaykaran Charan
- All India Institute of Medical Sciences (AIIMS); Department of Pharmacology; Basni Phase II Jodhpur Rajasthan India 342005
| | - Puneet Pareek
- All India Institute of Medical Sciences (AIIMS); Department of Radiation Oncology; Basni Phase II Jodhpur Rajasthan India 342005
| | - Poonam Elhence
- All India Institute of Medical Sciences (AIIMS); Department of Pathology; Basni Phase II Jodhpur Rajasthan India 342005
| | - Richard Kirubakaran
- Christian Medical College; Cochrane South Asia, Prof. BV Moses Centre for Evidence-Informed Health Care and Health Policy; Carman Block II Floor CMC Campus, Bagayam Vellore India 632002
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17
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Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. De novo glomerular diseases after renal transplantation: How is it different from recurrent glomerular diseases? World J Transplant 2017; 7:285-300. [PMID: 29312858 PMCID: PMC5743866 DOI: 10.5500/wjt.v7.i6.285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/31/2017] [Accepted: 11/10/2017] [Indexed: 02/05/2023] Open
Abstract
The glomerular diseases after renal transplantation can occur de novo, i.e., with no relation to the native kidney disease, or more frequently occur as a recurrence of the original disease in the native kidney. There may not be any difference in clinical features and histological pattern between de novo glomerular disease and recurrence of original glomerular disease. However, structural alterations in transplanted kidney add to dilemma in diagnosis. These changes in architecture of histopathology can happen due to: (1) exposure to the immunosuppression specifically the calcineurin inhibitors (CNI); (2) in vascular and tubulointerstitial alterations as a result of antibody mediated or cell-mediated immunological onslaught; (3) post-transplant viral infections; (4) ischemia-reperfusion injury; and (5) hyperfiltration injury. The pathogenesis of the de novo glomerular diseases differs with each type. Stimulation of B-cell clones with subsequent production of the monoclonal IgG, particularly IgG3 subtype that has higher affinity to the negatively charged glomerular tissue, is suggested to be included in PGNMID pathogenesis. De novo membranous nephropathy can be seen after exposure to the cryptogenic podocyte antigens. The role of the toxic effects of CNI including tissue fibrosis and the hemodynamic alterations may be involved in the de novo FSGS pathophysiology. The well-known deleterious effects of HCV infection and its relation to MPGN disease are frequently reported. The new concepts have emerged that demonstrate the role of dysregulation of alternative complement pathway in evolution of MPGN that led to classifying into two subgroups, immune complex mediated MPGN and complement-mediated MPGN. The latter comprises of the dense deposit disease and the C3 GN disease. De novo C3 disease is rather rare. Prognosis of de novo diseases varies with each type and their management continues to be empirical to a large extent.
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Affiliation(s)
- Fedaey Abbas
- Department of Nephrology, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
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18
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Treatment of Acute Antibody-Mediated Renal Allograft Rejection With Cyclophosphamide. Transplantation 2017; 101:2545-2552. [DOI: 10.1097/tp.0000000000001617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Gubensek J, Buturovic-Ponikvar J, Kandus A, Arnol M, Lindic J, Kovac D, Rigler AA, Romozi K, Ponikvar R. Treatment of Antibody-Mediated Rejection After Kidney Transplantation - 10 Years' Experience With Apheresis at a Single Center. Ther Apher Dial 2017; 20:240-5. [PMID: 27312908 DOI: 10.1111/1744-9987.12430] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 12/28/2022]
Abstract
Antibody-mediated rejection (AMR) is a major cause of kidney graft failure. We aimed to analyze treatment and outcome of AMR in a national cohort of 75 biopsy-proven acute (43 patients, 57%) or chronic active (32 patients, 43%) AMR episodes between 2000 and 2015. The mean patients' age was 46 ± 16 years, the majority was treated with plasma exchange, 4% received immunoadsorption and 7% received both. The majority received pulse methylprednisolone and low-dose CMV hyperimmune globulin, 20% received bortezomib and 13% rituximab. Concomitant infection was treated in 40% of patients. The immediate treatment outcome was successful in 91%, the 1- and 3-year graft survival rates were 71% and 57%, while 3-year patient survival was 97%. Chronic active AMR was associated with worse graft survival than acute AMR (log rank P = 0.06). To conclude, intensive treatment with apheresis and additional immunosuppression was effective in reversing AMR, but long-term graft survival remains markedly decreased, especially in chronic active AMR.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Aljosa Kandus
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jelka Lindic
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Damjan Kovac
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Ales Rigler
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Karmen Romozi
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rafael Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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20
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Macklin PS, Morris PJ, Knight SR. A systematic review of the use of rituximab for the treatment of antibody-mediated renal transplant rejection. Transplant Rev (Orlando) 2017; 31:87-95. [DOI: 10.1016/j.trre.2017.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 01/27/2023]
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21
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Merhi B, Patel N, Bayliss G, Henriksen KJ, Gohh R. Proliferative glomerulonephritis with monoclonal IgG deposits in two kidney allografts successfully treated with rituximab. Clin Kidney J 2017; 10:405-410. [PMID: 28616219 PMCID: PMC5466084 DOI: 10.1093/ckj/sfx001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/29/2016] [Indexed: 01/20/2023] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin G deposit (PGNMID), a recently described pathologic entity in native kidneys, has been recognized in kidney transplant patients, where it can present as either recurrent or de novo disease. There is no definitive treatment to date, in either population. Here, we present two cases of PGNMID in kidney allografts that illustrate the challenges of diagnostic approach and highlight the allograft outcome after treatment with rituximab as a potential treatment of this condition.
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Affiliation(s)
- Basma Merhi
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Alpert Medical School, Brown University, Providence, RI, USA
| | | | - George Bayliss
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Alpert Medical School, Brown University, Providence, RI, USA
| | | | - Reginald Gohh
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Alpert Medical School, Brown University, Providence, RI, USA
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22
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Yeung MY, Gabardi S, Sayegh MH. Use of polyclonal/monoclonal antibody therapies in transplantation. Expert Opin Biol Ther 2017; 17:339-352. [PMID: 28092486 DOI: 10.1080/14712598.2017.1283400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION For over thirty years, antibody (mAb)-based therapies have been a standard component of transplant immunosuppression, and yet much remains to be learned in order for us to truly harness their therapeutic capabilities. Current mAbs used in transplant directly target and destroy graft-destructive immune cells, interrupt cytokine and costimulation-dependent T and B cell activation, and prevent down-stream complement activation. Areas covered: This review summarizes our current approaches to using antibody-based therapies to prevent and treat allograft rejection. It also provides examples of promising novel mAb therapies, and discusses the potential for future mAb development in transplantation. Expert opinion: The broad capability of antibodies, in parallel with our growing ability to synthetically modulate them, offers exciting opportunities to develop better biologic therapeutics. In order to do so, we must further our understanding about the basic biology underlying allograft rejection, and gain better appreciation of how characteristics of therapeutic antibodies affect their efficacy.
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Affiliation(s)
- Melissa Y Yeung
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States
| | - Steven Gabardi
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States
| | - Mohamed H Sayegh
- a Transplantation Research Center, Renal Division , Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts , United States.,b Faculty of Medicine, Professor of Medicine and Immunology , American University of Beirut , Beirut , Lebanon
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23
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Garces JC, Giusti S, Staffeld-Coit C, Bohorquez H, Cohen AJ, Loss GE. Antibody-Mediated Rejection: A Review. Ochsner J 2017; 17:46-55. [PMID: 28331448 PMCID: PMC5349636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection. METHODS We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies. RESULTS Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody). CONCLUSION AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.
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Affiliation(s)
- Jorge Carlos Garces
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Sixto Giusti
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Catherine Staffeld-Coit
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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24
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Acute antibody-mediated rejection in kidney transplant recipients. Transplant Rev (Orlando) 2017; 31:47-54. [DOI: 10.1016/j.trre.2016.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 10/05/2016] [Indexed: 01/10/2023]
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25
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Marinaki S, Boletis J. Immune Renal Injury: Similarities and Differences Between Glomerular Diseases and Transplantation. BANTAO JOURNAL 2016. [DOI: 10.1515/bj-2015-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Glomerular diseases and renal transplantation are the main fields in nephrology in which the immune system plays a prevalent role. They have for long been considered as independent conditions due to the prominent role of autoimmunity in glomerular diseases and of alloimmunity in renal transplantation.
Moreover, histologic features differ between glomerular diseases and transplantation: in glomerular diseases, histologic damage involves primarily the glomeruli and secondarily the tubulointerstitium and small vessels, whereas in transplantation, allograft injury comprises primarily the tubulointerstitium and vessels and to a lesser degree the glomeruli.
However, recent research has shown that the pathogenetic mechanisms in both conditions share common pathways and that there is cross-reaction between innate and adaptive immunity as well as between auto- and alloimmunity [1].
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Affiliation(s)
- Smaragdi Marinaki
- Nephrology Clinic & Renal Transplantation Unit, National and Kapodistrian University of Athens, Greece
| | - John Boletis
- Nephrology Clinic & Renal Transplantation Unit, National and Kapodistrian University of Athens, Greece
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Kinetic analysis of changes in T- and B-lymphocytes after anti-CD20 treatment in renal pathology. Immunobiology 2016; 222:620-630. [PMID: 27986304 DOI: 10.1016/j.imbio.2016.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/14/2016] [Accepted: 11/15/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The main objective of this study is to describe qualitatively and quantitatively the different immune lymphocyte phenotypes of patients with renal disease after treatment with anti-CD20. MATERIAL AND METHODS Two cohorts of transplanted and autoimmune kidney patients were compared: (1) Those who began treatment with Rituximab, matched (for sex, age and general clinical parameters) with (2) Non-treated control kidney patients. Different analyses were performed: (A) B-lymphocyte subpopulations; (B) T-cell subpopulations; (C) serum levels of BAFF, APRIL, Rituximab and anti-Rituximab; (D) rs396991 polymorphism of CD16a and at different time points for each type of analysis: (i) at baseline, (ii) day 15, (iii) at three and (iv) six months post-antiCD20. RESULTS (A) A depletion of all B cell subsets analysed was observed preferentially decreasing the CD40+memory B-cells, switched memory cells and plasmablasts. (B) A significant decreased percentage of CD4+T-lymphocytes was observed. A significant decrease of the percentage of memory T-cells and an increase in naïve T-cells was also observed. (C) A significant increase for APRIL was observed, as well as a positive correlation between the APRIL levels, and the differential of B-cells. (D) The presence of CD16a Valine-variant induced greater changes in the variations of total T-cell and T-naïve subpopulations. CONCLUSION Our results highlight that the treatment of renal disease with Rituximab affects T-cells, particularly naïve/memory balance, while APRIL could be also a secondary marker of this treatment. The sequential analysis of phenotypic alterations of B- and T-cells could help patient management, although further studies to identify periods of remission or clinical relapse are warranted.
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Trivin C, Tran A, Moulin B, Choukroun G, Gatault P, Courivaud C, Augusto JF, Ficheux M, Vigneau C, Thervet E, Karras A. Infectious complications of a rituximab-based immunosuppressive regimen in patients with glomerular disease. Clin Kidney J 2016; 10:461-469. [PMID: 28852482 PMCID: PMC5570029 DOI: 10.1093/ckj/sfw101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/24/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent years have seen increasing use of rituximab (RTX) for various types of primary and secondary glomerulopathies. However, there are no studies that specifically address the risk of infection related to this agent in patients with these conditions. METHODS We reviewed the outcomes of all patients who received RTX therapy for glomerular disease between June 2000 and October 2011 in eight French nephrology departments. Each case was analysed for survival, cause of death if a non-survivor and/or the presence of infectious complications, including severe or opportunistic infection occurring within the 12 months following RTX infusion. RESULTS Among 98 patients treated with RTX, 25 presented with at least one infection. We report an infection rate of 21.6 per 100 patient-years. Five patients died within 12 months following an RTX infusion, of whom four also presented with an infection. The median interval between the last RTX infusion and the first infectious episode was 2.1 months (interquartile range 0.5-5.1). Most infections were bacterial (79%) and pneumonia was the most frequent infection reported (27%). The presence of diabetes mellitus (P = 0.006), the cumulative RTX dose (P = 0.01) and the concomitant use of azathioprine (P = 0.03) were identified as independent risk factors. Renal failure was significantly associated with an increased infection risk by bivariate analysis (P = 0.03) and was almost significant by multivariate analysis (P = 0.05). Nephrotic syndrome did not further increase the risk of infection and/or death. CONCLUSION The risk of infection after RTX-based immunosuppression among patients with glomerulopathy must be considered and patients should receive close monitoring and appropriate infection prophylaxis, especially in those with diabetes and high-dose RTX regimens.
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Affiliation(s)
- Claire Trivin
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Antoine Tran
- Pediatric Emergency, Hopitaux pediatrique CHU Nice Lenval, France
| | - Bruno Moulin
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, France
| | | | | | - Cécile Courivaud
- Nephrology, Dialysis and Renal Transplantation, CHU Saint Jacques, Besançon, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, France.,University of Angers, INSERM, U892-CRCNA, France
| | | | - Cécile Vigneau
- Service de Néphrologie, CHU Rennes, France.,Université Rennes 1, CNRS UMR 6290 equipe Kyca, France
| | - Eric Thervet
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
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Rituximab in Combination With Bortezomib, Plasmapheresis, and High-Dose IVIG to Treat Antibody-Mediated Renal Allograft Rejection. Transplant Direct 2016; 2:e91. [PMID: 27819032 PMCID: PMC5083001 DOI: 10.1097/txd.0000000000000604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 01/21/2023] Open
Abstract
Background Current treatment strategies for antibody-mediated renal allograft rejection (AMR) are not sufficiently effective. In most centers, “standard of care” treatment includes plasmapheresis (PPH) and IVIG preparations. Since several years, modern therapeutics targeting B cells and plasma cells have become available. We investigated, whether combined administration of rituximab and bortezomib in addition to PPH and high-dose IVIG is useful. Methods Between November 2011 and January 2013, we treated 10 consecutive patients with biopsy-proven AMR with rituximab (500 mg), bortezomib (4× 1.3 mg/m2), PPH (6×), and high-dose IVIG (1.5 g/kg) (group A). This group was compared with a group of 11 consecutive patients treated with an identical regimen without rituximab between July 2010 and November 2011 (group B). Results Median follow-up was 41(33-46) months in group A and 55(47-63) months in group B. At 40 months after treatment, graft survival was 60% in group A and 64% in group B, respectively (P = 0.87). Before and after treatment, serum creatinine, estimated glomerular filtration rate, and proteinuria were not different between groups. A significant reduction in donor-specific HLA antibody mean fluorescence intensity was observed in group A (25.2%, P = 0.046) and B (38.3%, P = 0.01) at 3 months posttreatment. In group A, more patients suffered from side effects compared with group B (infections: 70% vs 18%, P = 0.02). Conclusions The addition of rituximab to bortezomib, PPH, and high-dose IVIG did not further improve graft survival. Instead, we observed an increase of side effects. Therefore, combined administration of bortezomib and rituximab in addition to PPH and IVIG should be regarded with caution.
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Ahmadi F, Dashti-Khavidaki S, Khatami MR, Lessan-Pezeshki M, Khalili H, Khosravi M. Rituximab-Related Late-Onset Neutropenia in Kidney Transplant Recipients Treated for Antibody-Mediated Acute Rejection. EXP CLIN TRANSPLANT 2016; 15:414-419. [PMID: 27796249 DOI: 10.6002/ect.2016.0027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Kidney transplant is a new area for use of rituximab, which is being used to treat acute antibody-mediated rejection or as an induction agent in ABO- or HLA-incompatible grafts. We report on late-onset neutropenia in rituximab-treated kidney transplant recipients with antibody-mediated rejection. MATERIALS AND METHODS This observational prospective study was performed on kidney transplant recipients with clinically suspicious or biopsy-proven antibody-mediated rejection treated with plasmapheresis plus intravenous immunoglobulin with (cases) or without (controls) rituximab. RESULTS Compared with none of the controls, 4 of 6 patients (66.7%) in the rituximab-treated group experienced late-onset neutropenia 35 to 93 days after the last dose of rituximab. The course of neutropenia was complicated by endocarditis in 1 patient, resulting in his death just because of a lack of valvular surgery. CONCLUSIONS Increased use of rituximab to treat antibody-mediated rejection among kidney transplant recipients requires attention to its late-onset adverse event, neutropenia. Although asymptomatic in some patients, kidney transplant recipients treated concomitantly with plasmapheresis and mycophenolate mofetil are predisposed to hypogammaglobulinemia, and monitoring of patients for infections is required.
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Affiliation(s)
- Fatemeh Ahmadi
- From the Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Kleinclauss F, Frontczak A, Terrier N, Thuret R, Timsit MO. [Immunology and immunosuppression in kidney transplantation. ABO and HLA incompatible kidney transplantation]. Prog Urol 2016; 26:977-992. [PMID: 27670824 DOI: 10.1016/j.purol.2016.08.015] [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: 07/15/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To perform a state of the art about immunological features in renal transplantation, immunosuppressive drugs and their mechanisms of action and immunologically high risk transplantations such as ABO and HLA-incompatible transplantation. MATERIAL AND METHODS An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "allogenic response; allograft; immunosuppression; ABO incompatible transplantation; donor specific antibodies; HLA incompatible; desensitization; kidney transplantation". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 4717 articles. After reading titles and abstracts, 141 were included in the text, based on their relevance. RESULTS The considerable step in comprehension and knowledge allogeneic response this last few years allowed a better used of immunosuppression and the discover of news immunosuppressive drugs. In the first part of this article, the allogeneic response will be described. The different classes of immunosuppressive drugs will be presented and the actual management of immunosuppression will be discussed. Eventually, the modalities and results of immunologically high-risk transplantations such as ABO and HLA incompatible transplantations will be reported. CONCLUSIONS The knowledge and the control of allogeneic response to allogeneic graft allowed the development of renal transplantation.
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Affiliation(s)
- F Kleinclauss
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France.
| | - A Frontczak
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France
| | - N Terrier
- Service d'urologie et transplantation rénale, CHU de Grenoble, 38700 Grenoble, France
| | - R Thuret
- Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34000 Montpellier, France
| | - M-O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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Khan SA, Al-Riyami D, Al-Mula Abed YW, Mohammed S, Al-Riyami M, Al-Lawati NM. Successful Salvage Treatment of Resistant Acute Antibody-Mediated Kidney Transplant Rejection with Eculizumab. Sultan Qaboos Univ Med J 2016; 16:e371-4. [PMID: 27606122 DOI: 10.18295/squmj.2016.16.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/24/2015] [Accepted: 06/02/2016] [Indexed: 12/17/2022] Open
Abstract
Antibody-mediated rejection (ABMR) jeopardises short- and long-term transplant survival and remains a challenge in the field of organ transplantation. We report the first use of the anticomplement agent eculizumab in Oman in the treatment of a 61-year-old female patient with ABMR following a living unrelated kidney transplant. The patient was admitted to the Sultan Qaboos University Hospital in Muscat, Oman, in 2013 on the eighth day post-transplantation with serum creatinine (Cr) levels of 400 µmol/L which continued to rise, necessitating haemodialysis. A biopsy indicated ABMR with acute cellular rejection. No improvement was observed following standard ABMR treatment and she continued to require dialysis. Five doses of eculizumab were administered over six weeks with a subsequent dramatic improvement in renal function. The patient became dialysis-free with serum Cr levels of 119 µmol/L within four months. This case report indicates that eculizumab is a promising agent in the treatment of ABMR.
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Affiliation(s)
- Saif A Khan
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Dawood Al-Riyami
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Yasser W Al-Mula Abed
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Saja Mohammed
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Marwa Al-Riyami
- Department of Pathology, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Nabil M Al-Lawati
- Department of Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
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One-year Results of the Effects of Rituximab on Acute Antibody-Mediated Rejection in Renal Transplantation: RITUX ERAH, a Multicenter Double-blind Randomized Placebo-controlled Trial. Transplantation 2016; 100:391-9. [PMID: 26555944 DOI: 10.1097/tp.0000000000000958] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Treatment of acute antibody-mediated rejection (AMR) is based on a combination of plasma exchange (PE), IVIg, corticosteroids (CS), and rituximab, but the place of rituximab is not clearly specified in the absence of randomized trials. METHODS In this phase III, multicenter, double-blind, placebo-controlled trial, we randomly assigned patients with biopsy-proven AMR to receive rituximab (375 mg/m) or placebo at day 5. All patients received PE, IVIg, and CS. The primary endpoint was a composite of graft loss or no improvement in renal function at day 12. RESULTS Among the 38 patients included, at 1 year, no deaths occurred, but 1 graft loss occurred in each group. The primary endpoint frequency was 52.6% (10/19) and 57.9% (11/19) in the rituximab and placebo groups, respectively (P = 0.744). Renal function improved in both groups, as soon as day 12 with no difference in serum creatinine level and proteinuria at 1, 3, 6, and 12 months. Supplementary administration of rituximab and total number of IVIg and PE treatments did not differ between the 2 groups. Both groups showed improved histological features of AMR and Banff scores at 1 and 6 months, with no significant difference between groups but with a trend in favor of the rituximab group. Both groups showed decreased mean fluorescence intensity of donor-specific antibodies as soon as day 12, with no significant difference between them but with a trend in favor of the rituximab group at 12 months. CONCLUSIONS After 1 year of follow-up, we observed no additional effect of rituximab in patients receiving PE, IVIg, and CS for AMR. Nevertheless, our study was underpowered and important differences between groups may have been missed. Complementary trials with long-term follow-up are needed.
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Muduma G, Odeyemi I, Smith-Palmer J, Pollock RF. Review of the Clinical and Economic Burden of Antibody-Mediated Rejection in Renal Transplant Recipients. Adv Ther 2016; 33:345-56. [PMID: 26905265 DOI: 10.1007/s12325-016-0292-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 01/29/2023]
Abstract
UNLABELLED Antibody-mediated rejection (AbMR) is a leading cause of late graft loss in kidney transplant recipients, accounting for up to 60% of late graft failures. AbMR manifests as two distinct phenotypes: the first occurs in the immediate post-transplant period in sensitized patients; the second occurs in the late post-transplant period and has been associated with non-adherence to immunosuppression. The present review summarizes the current treatment options for AbMR, its clinical and economic burden, and approaches for reducing the risk of AbMR. While AbMR is typically refractory to treatment with corticosteroids, there are numerous other approaches focused on removal, inhibition or neutralization of donor-specific antibodies, or inhibition of complement-mediated allograft damage. AbMR treatment is generally expensive with one US study reporting costs of USD 49,000-155,000 per episode. However, leaving AbMR untreated puts patients at high risk of capillaritis, microangiopathy, necrosis and graft failure, which may ultimately result in much greater costs associated with a return to dialysis. Given the barriers to treatment, which include the high cost and the fact that pharmacologic treatments are currently used off-label, prevention of AbMR is important, with improvement in patient adherence to immunosuppression a key strategic approach that may be worthy of further evaluation. FUNDING Astellas Pharma EMEA Limited.
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Teo RZC, Wong G, Russ GR, Lim WH. Cell-mediated and humoral acute vascular rejection and graft loss: A registry study. Nephrology (Carlton) 2016; 21:147-55. [DOI: 10.1111/nep.12577] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel ZC Teo
- Renal Unit; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research; Westmead Hospital; Sydney New South Wales Australia
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
- Centre for Kidney Research; The Children's Hospital at Westmead; Sydney New South Wales Australia
- ANZDATA Registry; Adelaide Australia
| | - Graeme R Russ
- ANZDATA Registry; Adelaide Australia
- Central and Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Wai H Lim
- ANZDATA Registry; Adelaide Australia
- Department of Renal Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
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Affiliation(s)
- S B Bansal
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta Medicity, Gurgaon, Haryana, India
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Surendra M, Raju SB, Raju N, Chandragiri S, Mukku KK, Uppin MS. Rituximab in the treatment of refractory late acute antibody-mediated rejection: Our initial experience. Indian J Nephrol 2016; 26:317-321. [PMID: 27795623 PMCID: PMC5015507 DOI: 10.4103/0971-4065.177207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Antibody-mediated rejection (AMR) is not uncommon after renal transplantation and is harder to handle compared to cell-mediated rejection. When refractory to conventional therapies, rituximab is an attractive option. This study aims to examine the effectiveness of rituximab in refractory late acute AMR. This is a retrospective study involving nine renal transplant recipients. Four doses of rituximab were administered at weekly interval for 4 weeks, at a dose of 375 mg/m2. The mean age of patients was 35.3 ± 7.38 years. The median period between transplantation and graft dysfunction was 30 ± 20 months. Mean serum creatinine at the time of discharge after transplantation and at the time of acute AMR diagnosis was 1.14 ± 0.19 mg/dl and 2.26 ± 0.57 mg/dl, respectively. After standard therapy, it was 2.68 ± 0.62 mg/dl. One patient died of Pseudomonas sepsis and three patients progressed to end-stage renal disease (ESRD). Four biopsies showed significant plasma cell infiltrations. Mean serum creatinine among non-ESRD patients at the end of 1 year progressed from 2.3 ± 0.4 to 3.8 ± 1.2 mg/dl (P value 0.04). eGFR prior to therapy and at the end of 1 year were 34.4 ± 6.18 and 20.8 ± 7.69 ml/min (P value 0.04), respectively. Only one patient showed improvement in graft function in whom donor-specific antibody (DSA) titers showed significant improvement. Rituximab may not be effective in late acute AMR unlike in early acute AMR. Monitoring of DSA has a prognostic role in these patients and plasma cell rich rejection is associated with poor prognosis.
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Affiliation(s)
- M Surendra
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S B Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S Chandragiri
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - K K Mukku
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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Differential Effects of Tacrolimus versus Sirolimus on the Proliferation, Activation and Differentiation of Human B Cells. PLoS One 2015; 10:e0129658. [PMID: 26087255 PMCID: PMC4472515 DOI: 10.1371/journal.pone.0129658] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/11/2015] [Indexed: 01/25/2023] Open
Abstract
The direct effect of immunosuppressive drugs calcineurin inhibitor (Tacrolimus, TAC) and mTOR inhibitor (Sirolimus, SRL) on B cell activation, differentiation and proliferation is not well documented. Purified human B cells from healthy volunteers were stimulated through the B Cell Receptor with Anti-IgM + anti-CD40 + IL21 in the absence / presence of TAC or SRL. A variety of parameters of B cell activity including activation, differentiation, cytokine productions and proliferation were monitored by flow cytometry. SRL at clinically relevant concentrations (6 ng/ml) profoundly inhibited CD19+ B cell proliferation compared to controls whereas TAC at similar concentrations had a minimal effect. CD27+ memory B cells were affected more by SRL than naïve CD27- B cells. SRL effectively blocked B cell differentiation into plasma cells (CD19+CD138+ and Blimp1+/Pax5low cells) even at low dose (2 ng/ml), and totally eliminated them at 6 ng/ml. SRL decreased absolute B cell counts, but the residual responding cells acquired an activated phenotype (CD25+/CD69+) and increased the expression of HLA-DR. SRL-treated stimulated B cells on a per cell basis were able to enhance the proliferation of allogeneic CD4+CD25− T cells and induce a shift toward the Th1 phenotype. Thus, SRL and TAC have different effects on B lymphocytes. These data may provide insights into the clinical use of these two agents in recipients of solid organ transplants.
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Bestard O, Sarwal MM. Antibody-mediated rejection in young kidney transplant recipients: the dilemma of noncompliance and insufficient immunosuppression. Pediatr Nephrol 2015; 30:397-403. [PMID: 25503324 DOI: 10.1007/s00467-014-3020-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibody-mediated rejection (ABMR) is a recognized cause of late kidney allograft loss. Although ABMR may occur despite appropriate chronic immunosuppressive therapy, non-adherence both facilitates and accelerates the activation of the effector phase of the humoral immune response against the donor tissue, leading in turn to progressive kidney allograft rejection. Given the poor efficacy of rescue therapies for both acute and chronic late ABMR, establishing appropriate preventive strategies at different times before and after transplantation is a critical management goal. CASE-DIAGNOSIS/TREATMENT In this report, we discuss the differential diagnoses and management of ABMR based on the clinical case report of a young kidney transplant recipient with progressive ABMR due to poor immunosuppressive adherence. In the absence of sensitive and specific non-invasive monitoring tools for alloimmune activation, the clinical dilemma in the management of the adolescent patient lies in differentiating between suboptimal prescribed immunosuppression and deliberate non-adherence to adequate immunosuppression dosing. Despite the advent of therapies to reduce ABMR injury, the graft is destined for untimely functional loss. CONCLUSIONS New biomarkers and tools for the accurate characterization of alloimmune risk before and after transplantation, and serial testing for de novo changes in circulating donor-specific alloantibodies, are urgently needed to support the delivery of optimized immunosuppression exposure.
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Affiliation(s)
- Oriol Bestard
- Renal Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona, Spain,
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Indicators of treatment responsiveness to rituximab and plasmapheresis in antibody-mediated rejection after kidney transplantation. Transplantation 2015; 99:56-62. [PMID: 25121474 DOI: 10.1097/tp.0000000000000244] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Treatment of patients with antibody-mediated rejection (AMR) after kidney transplantation by rituximab and plasmapheresis is ambiguous. Because of its unknown efficiency and serious side effects, biomarkers, which are predictive for responsiveness to this treatment in AMR patients, are required. METHODS Twenty renal transplant patients were included in this retrospective study. Selection was based on Renal Index Biopsies, classified according to Banff within 3 months before treatment. Patients were categorized into responders (R) and nonresponders (NR) depending on whether they returned to dialysis within 6 months after initiation of rituximab treatment. Clinical, histopathologic (Banff classification) and serologic parameters were compared between both groups by t test, Mann-Whitney U test, or likelihood ratio chi-square test. RESULTS In comparisons between the groups, the R group showed a 1.5-fold higher level of estimated glomerular filtration rate and a fourfold lower level of proteinuria. By contrast, there were no differences in the histologic scores for chronic transplant lesions between the groups. The t and i scores were higher in NRs, whereas Banff-C4d scores of peritubular capillaries were increased in the Rs. Transplant biopsies in the Rs exhibited more CD138+ cell infiltrates. Serologic determination of human leukocyte antigen antibodies showed higher positivity for human leukocyte antigen class II donor-specific antibodies in the R group. No significant differences in other clinical criteria were found. CONCLUSION Increased proteinuria, decreased graft function, and a higher grade of tubulitis and inflammation in AMR are negative predictors for responsiveness to rituximab therapy. Rituximab therapy therefore should be initiated in an early phase of AMR.
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Muduma G, Odeyemi I, Pollock RF. Evaluating the economic implications of non-adherence and antibody-mediated rejection in renal transplant recipients: the role of once-daily tacrolimus in the UK. J Med Econ 2015. [PMID: 26201252 DOI: 10.3111/13696998.2015.1074584] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND AIMS While short-term kidney graft survival has gradually improved over time, improvements in long-term graft survival have been more modest. One key clinical factor limiting improved longer-term outcomes is antibody-mediated rejection (AbMR), the incidence of which appears to be higher in patients who are non-adherent to immunosuppressants. Recent data show that adherence can be improved by reducing pill burden. The aim of the present study was to model the incidence and economic consequences of graft loss and AbMR in patients taking once- vs twice-daily tacrolimus in the UK. METHODS A combined decision tree and Markov model was developed to estimate the incidence of graft failure, AbMR and mortality in renal transplant recipients taking once- vs twice-daily tacrolimus. Underlying rates of graft failure and mortality were derived from UK-specific sources. Proportions of patients adherent to once- vs twice-daily tacrolimus were taken from a recent randomized clinical trial and relative risks of graft failure and AbMR were taken from a prospective, multi-center analysis of 315 patients. Cost data were taken from the British National Formulary and National Health Service reference costs and reported in 2014 pounds sterling. RESULTS Modeling results showed that improved adherence would be associated with reduced incidence of AbMR and graft failure in renal transplant recipients. Based on improvements in adherence resulting from switching from twice-daily to once-daily tacrolimus, the modeling analysis projected cost savings of GBP 4862 per patient over 5 years with Advagraf relative to Prograf, on absolute costs of GBP 40,974 and GBP 45,836, respectively. CONCLUSIONS Using Advagraf in place of Prograf in renal transplant recipients was predicted to be associated with lower pharmacy, dialysis and AbMR treatment costs, with the reduction in AbMR and dialysis costs being driven by improved adherence to the Advagraf regimen and consequent reductions in graft failure and onset of AbMR.
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Affiliation(s)
- G Muduma
- a a Astellas Pharma EMEA Limited , Chertsey , UK
| | - I Odeyemi
- a a Astellas Pharma EMEA Limited , Chertsey , UK
| | - R F Pollock
- b b Ossian Health Economics and Communications , Basel , Switzerland
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Ejaz NS, Alloway RR, Halleck F, Dürr M, Budde K, Woodle ES. Review of bortezomib treatment of antibody-mediated rejection in renal transplantation. Antioxid Redox Signal 2014; 21:2401-18. [PMID: 24635140 DOI: 10.1089/ars.2014.5892] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
SIGNIFICANCE Development of donor-specific antibodies (DSA) after kidney transplantation is associated with reduced allograft survival. A few strategies have been tested in controlled clinical trials for the treatment of antibody-mediated rejection (AMR), and no therapies are approved by regulatory authorities. Thus development of antihumoral therapies that provide prompt elimination of DSA and improve allograft survival is an important goal. RECENT ADVANCES Proteasome inhibitor (PI)-based regimens provide a promising new approach for treating AMR. To date, experiences have been limited to off-label bortezomib use in AMR. Key findings with PI-based therapy are that they provide effective primary and rescue therapy for AMR by prompt reduction in immunodominant DSA and improvements in histologic and renal function. Early and late AMR differ immunologically and in response to PI therapy. Bortezomib-related toxicities in renal transplant recipients are similar to those observed in the multiple myeloma population. CRITICAL ISSUES Although preliminary evidence with PI therapy for AMR is encouraging, the evidence is limited. Larger, prospective, randomized controlled trials with long-term follow up are needed. Advancement in endpoints of clinical trial designs and rigorous clinical trials with more standardized adjunct therapies are also required to explore the risks and benefits of AMR treatment modalities. FUTURE DIRECTIONS In the next few years, new PIs are likely to be introduced and new approaches would be developed for achieving synergy with PIs. The ultimate goal will be to develop a regimen that delivers reliable, rapid, complete, and durable elimination of DSA with an acceptable safety profile.
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Affiliation(s)
- Nicole S Ejaz
- 1 Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
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Yamada C, Ramon DS, Cascalho M, Sung RS, Leichtman AB, Samaniego M, Davenport RD. Efficacy of plasmapheresis on donor-specific antibody reduction by HLA specificity in post-kidney transplant recipients. Transfusion 2014; 55:727-35; quiz 726. [PMID: 25385678 DOI: 10.1111/trf.12923] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/03/2014] [Accepted: 09/10/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Donor-specific antibodies (DSAs) to HLA antigens can cause acute antibody-mediated rejection (AMR) after kidney transplantation (Txp). Therapeutic plasma exchange (TPE) has been used for AMR treatment; however, DSA reduction rates are inconsistent. We investigated DSA reduction rates by HLA specificity and clinical outcome. STUDY DESIGN AND METHODS Sixty-four courses of TPE for 56 kidney Txp recipients with high DSA were investigated. Dates of TPE procedures and Txp, patients' age, sex, race, creatinine (Cr), and mean fluorescent intensity (MFI) of DSA were retrieved. MFI reduction rate after one to three TPE and four to six TPE procedures were calculated by HLA DSA specificity in each patient, and the mean reduction rates were compared. The relationship of TPE treatment, MFI or Cr improvement rate, and graft age was also investigated. RESULTS Patients received a mean 6.0 TPE procedures. Most received intravenous immunoglobulin after TPE and immunosuppressives. Forty-two cases (65.6%) had DSA to HLA Class I and 54 cases (84.4%) to Class II, including 32 cases (50.0%) to both. Mean MFI reduction rates after one to three TPE and four to six TPE procedures were 25.7 and 37.1% in HLA Class I, 25.1 and 34.2% in Class II, and 14.3 and 19.9% in DR51-53. The mean Cr improvements at the end of TPE and 3 and 6 months after TPE were 3.41, -0.37, and -0.72%, respectively. CONCLUSION Six TPE procedures decreased DSA more than three TPE procedures, but reduction rate was lower by the second three TPE procedures than the first three TPE procedures. Although the mean Cr improvement was minimal, the treatment has good potential to stop further deterioration of kidney function. Better Cr improvement rate is correlated with the graft age.
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Affiliation(s)
- Chisa Yamada
- Transfusion Medicine Division, Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Daniel S Ramon
- Histocompatibility Lab Division, Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Marilia Cascalho
- Transplant Biology Division, Department of Surgery, Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan
| | - Randall S Sung
- General Surgery Division, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Alan B Leichtman
- Nephrology Division, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milagros Samaniego
- Nephrology Division, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robertson D Davenport
- Transfusion Medicine Division, Department of Pathology, University of Michigan, Ann Arbor, Michigan
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A closer look at rituximab induction on HLA antibody rebound following HLA-incompatible kidney transplantation. Kidney Int 2014; 87:409-16. [PMID: 25054778 PMCID: PMC4305036 DOI: 10.1038/ki.2014.261] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/22/2014] [Accepted: 06/05/2014] [Indexed: 01/15/2023]
Abstract
Rituximab has been used to increase the efficacy of desensitization protocols for HLA incompatible kidney transplantation, however, controlled comparisons have not been reported. Here we examined 256 post-transplant HLA antibody levels in 25 recipients desensitized with or 25 without rituximab induction, to determine the impact of B cell depletion. We found significantly less HLA antibody rebound in the rituximab-treated patients (7% of donor specific antibodies (DSAs) and 33% of non-DSAs) compared to a control cohort desensitized and transplanted without rituximab (32% DSAs and 55% non-DSAs). The magnitude of the increase was significantly larger among patients who did not receive rituximab. Interestingly, in rituximab treated patients, of the 39 HLA antibodies that increased post-transplant, 34 were specific for HLA mismatches present in previous allografts or pregnancies, implying limited efficacy in memory B cell depletion. Compared to controls, rituximab-treated patients had a significantly greater mean reduction in DSA (−2505 versus −292 mean fluorescence intensity), but a similar rate of DSA persistence (52% in rituximab treated and 40% in non-treated recipients). Thus, rituximab induction in HLA incompatible recipients reduced the incidence and magnitude of HLA antibody rebound, but did not impact DSA elimination, antibody mediated rejection, or 5 year allograft survival when compared to recipients desensitized and transplanted without rituximab.
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Kim M, Martin ST, Townsend KR, Gabardi S. Antibody-mediated rejection in kidney transplantation: a review of pathophysiology, diagnosis, and treatment options. Pharmacotherapy 2014; 34:733-44. [PMID: 24753207 DOI: 10.1002/phar.1426] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Antibody-mediated rejection (AMR), also known as B-cell-mediated or humoral rejection, is a significant complication after kidney transplantation that carries a poor prognosis. Although fewer than 10% of kidney transplant patients experience AMR, as many as 30% of these patients experience graft loss as a consequence. Although AMR is mediated by antibodies against an allograft and results in histologic changes in allograft vasculature that differ from cellular rejection, it has not been recognized as a separate disease process until recently. With an improved understanding about the importance of the development of antibodies against allografts as well as complement activation, significant advances have occurred in the treatment of AMR. The standard of care for AMR includes plasmapheresis and intravenous immunoglobulin that remove and neutralize antibodies, respectively. Agents targeting B cells (rituximab and alemtuzumab), plasma cells (bortezomib), and the complement system (eculizumab) have also been used successfully to treat AMR in kidney transplant recipients. However, the high cost of these medications, their use for unlabeled indications, and a lack of prospective studies evaluating their efficacy and safety limit the routine use of these agents in the treatment of AMR in kidney transplant recipients.
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Affiliation(s)
- Miae Kim
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
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Salvadori M, Bertoni E. Impact of donor-specific antibodies on the outcomes of kidney graft: Pathophysiology, clinical, therapy. World J Transplant 2014; 4:1-17. [PMID: 24669363 PMCID: PMC3964192 DOI: 10.5500/wjt.v4.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
Allo-antibodies, particularly when donor specific, are one of the most important factors that cause both early and late graft dysfunction. The authors review the current state of the art concerning this important issue in renal transplantation. Many antibodies have been recognized as mediators of renal injury. In particular donor-specific-Human Leukocyte Antigens antibodies appear to play a major role. New techniques, such as solid phase techniques and Luminex, have revealed these antibodies from patient sera. Other new techniques have uncovered alloantibodies and signs of complement activation in renal biopsy specimens. It has been acknowledged that the old concept of chronic renal injury caused by calcineurine inhibitors toxicity should be replaced in many cases by alloantibodies acting against the graft. In addition, the number of patients on waiting lists with preformed anti-human leukocyte antigens (HLA) antibodies is increasing, primarily from patients with a history of renal transplant failure already been sensitized. We should distinguish early and late acute antibody-mediated rejection from chronic antibody-mediated rejection. The latter often manifets late during the course of the post-transplant period and may be difficult to recognize if specific techniques are not applied. Different therapeutic strategies are used to control antibody-induced damage. These strategies may be applied prior to transplantation or, in the case of acute antibody-mediated rejection, after transplantation. Many new drugs are appearing at the horizon; however, these drugs are far from the clinic because they are in phase I-II of clinical trials. Thus the pipeline for the near future appears almost empty.
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Schinstock C, Stegall MD. Acute Antibody-Mediated Rejection in Renal Transplantation: Current Clinical Management. CURRENT TRANSPLANTATION REPORTS 2014; 1:78-85. [PMID: 27656351 DOI: 10.1007/s40472-014-0012-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute antibody mediated rejection (AMR) is recognized as a major cause of graft loss in renal transplant recipients. Early acute AMR in the first few days after transplantation occurs primarily in sensitized renal transplant recipients with donor-specific alloantibody at the time of transplant and is a relatively "pure" form of acute AMR. Late acute AMR occurs months to years after transplantation and is commonly a mixed cellular and humoral rejection. While there is no consensus regarding optimum treatment, we contend that rational therapeutic approaches are emerging and the acute episode can be managed in most instances. However, new therapies are needed to prevent ongoing chronic injury in these patients.
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Affiliation(s)
| | - Mark D Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
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Zaza G, Tomei P, Granata S, Boschiero L, Lupo A. Monoclonal antibody therapy and renal transplantation: focus on adverse effects. Toxins (Basel) 2014; 6:869-91. [PMID: 24590384 PMCID: PMC3968366 DOI: 10.3390/toxins6030869] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/07/2014] [Accepted: 02/21/2014] [Indexed: 02/06/2023] Open
Abstract
A series of monoclonal antibodies (mAbs) are commonly utilized in renal transplantation as induction therapy (a period of intense immunosuppression immediately before and following the implant of the allograft), to treat steroid-resistant acute rejections, to decrease the incidence and mitigate effects of delayed graft function, and to allow immunosuppressive minimization. Additionally, in the last few years, their use has been proposed for the treatment of chronic antibody-mediated rejection, a major cause of late renal allograft loss. Although the exact mechanism of immunosuppression and allograft tolerance with any of the currently used induction agents is not completely defined, the majority of these medications are targeted against specific CD proteins on the T or B cells surface (e.g., CD3, CD25, CD52). Moreover, some of them have different mechanisms of action. In particular, eculizumab, interrupting the complement pathway, is a new promising treatment tool for acute graft complications and for post-transplant hemolytic uremic syndrome. While it is clear their utility in renal transplantation, it is also unquestionable that by using these highly potent immunosuppressive agents, the body loses much of its innate ability to mount an adequate immune response, thereby increasing the risk of severe adverse effects (e.g., infections, malignancies, haematological complications). Therefore, it is extremely important for clinicians involved in renal transplantation to know the potential side effects of monoclonal antibodies in order to plan a correct therapeutic strategy minimizing/avoiding the onset and development of severe clinical complications.
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Affiliation(s)
- Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Luigino Boschiero
- First Surgical Clinic, Kidney Transplantation Center, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
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