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Cholbi E, Espí J, Ventura A, Ramos D, Ramos M, Luis M, Moreno E, Moreno M, Beneyto I, Hernández J. Combined Liver–Kidney Transplantation in High Immunologic Risk Recipients: Kidney Graft Evolution. Transplant Proc 2022; 54:2475-2478. [DOI: 10.1016/j.transproceed.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/01/2022] [Indexed: 11/18/2022]
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Rossi AP, Alloway RR, Hildeman D, Woodle ES. Plasma cell biology: Foundations for targeted therapeutic development in transplantation. Immunol Rev 2021; 303:168-186. [PMID: 34254320 DOI: 10.1111/imr.13011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients with end-stage organ disease. Over the past 70 years, tremendous progress has been made in solid organ transplantation, particularly in T-cell-targeted immunosuppression and organ allocation systems. However, humoral alloimmune responses remain a major challenge to progress. Patients with preexisting antibodies to human leukocyte antigen (HLA) are at significant disadvantages in regard to receiving a well-matched organ, moreover, those who develop anti-HLA antibodies after transplantation face a significant foreshortening of renal allograft survival. Historical therapies to desensitize patients prior to transplantation or to treat posttransplant AMR have had limited effectiveness, likely because they do not significantly reduce antibody levels, as plasma cells, the source of antibody production, remain largely unaffected. Herein, we will discuss the significance of plasma cells in transplantation, aspects of their biology as potential therapeutic targets, clinical challenges in developing strategies to target plasma cells in transplantation, and lastly, novel approaches that have potential to advance the field.
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Affiliation(s)
- Amy P Rossi
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - David Hildeman
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Xu X, Li X, Gu X, Zhang B, Tian W, Han H, Sun P, Du C, Wang H. Prolongation of Cardiac Allograft Survival by Endometrial Regenerative Cells: Focusing on B-Cell Responses. Stem Cells Transl Med 2016; 6:778-787. [PMID: 28297571 PMCID: PMC5442781 DOI: 10.5966/sctm.2016-0206] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 08/01/2016] [Indexed: 12/16/2022] Open
Abstract
Endometrial regenerative cells (ERCs) have been recently evaluated as an attractive candidate source for emerging stem cell therapies in immunosuppression, but their role in immunoregulation is not fully understood. The present study was designed to investigate their effects, especially on B-cell responses in heart transplantation. In this study, ERCs were noninvasively obtained from menstrual blood. Heart transplantation was performed between C57BL/6 (H-2b ) donor mice and BALB/c (H-2d ) recipients. B-cell activation and antibody levels were determined using fluorescence-activated cell sorting, enzyme-linked immunosorbent assay and ELISpot. In this study, we demonstrated that ERCs negatively regulated B-cell maturation and activation in vitro without affecting their viability. ERC treatment prolonged cardiac allograft survival in mice, which was correlated with a decrease in IgM and IgG deposition and circulating antidonor antibodies, as well as with reduction in frequencies of antidonor antibody-secreting CD19+ B cells. In addition, upon ex vivo stimulation, B cells from ERC-treated heart transplant recipients had impaired proliferation capacity and produced less IgM and IgG antibody. Moreover, ERC treatment of mice receiving ovalbumin (OVA)-aluminum hydroxide vaccine resulted in significant lower numbers of anti-OVA IgG antibody-secreting splenic B cells and lower anti-OVA antibody titres. Our results indicate that therapeutic effects of ERCs may be attributed at least in part by their B-cell suppression and humoral response inhibition, suggesting the potential use of ERCs for attenuating antibody-mediated allograft rejection. Stem Cells Translational Medicine 2017;6:778-787.
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Affiliation(s)
- Xiaoxi Xu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xiaochun Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xiangying Gu
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Bai Zhang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Weijun Tian
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Hongqiu Han
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Peng Sun
- Department of General Surgery, Affiliated Hospital of Weifang Medical University, Shandong, People’s Republic of China
| | - Caigan Du
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hao Wang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin General Surgery Institute, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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Klein H, Schanz U, Hivelin M, Waldner M, Koljonen V, Guggenheim M, Giovanoli P, Gorantla V, Fehr T, Plock J. Sensitization and desensitization of burn patients as potential candidates for vascularized composite allotransplantation. Burns 2016; 42:246-57. [DOI: 10.1016/j.burns.2015.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/25/2015] [Indexed: 12/26/2022]
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Long-term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation: A Comparative Analysis. Transplant Proc 2015; 47:1720-6. [DOI: 10.1016/j.transproceed.2015.05.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/27/2015] [Indexed: 12/30/2022]
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6
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Milongo D, Vieu G, Blavy S, Del Bello A, Sallusto F, Rostaing L, Kamar N, Congy-Jolivet N. Interference of therapeutic antibodies used in desensitization protocols on lymphocytotoxicity crossmatch results. Transpl Immunol 2015; 32:151-5. [PMID: 25936347 DOI: 10.1016/j.trim.2015.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Therapeutic antibodies used to desensitize patients awaiting a human leukocyte antigen (HLA) or ABO-mismatched graft are suspected to interfere with the lymphocytotoxicity crossmatch (LCT-XM) test when they are present in the tested sera because of their potential ability to activate or inhibit the complement. METHODS The most frequent therapeutic antibodies (Abs) used in desensitization protocols (intravenous immunoglobulins, rituximab, basiliximab, eculizumab, antithymocyte globulin) were added to a negative- or a positive-control serum at various concentrations, and tested in vitro in a LCT-XM test. RESULTS Rituximab turned the LCT-XM positive on B cells at 0.2 μg/mL and antithymocyte globulin turned the LCT-XM positive with T and B cells at 20 μg/mL and 200 μg/mL, respectively. Treatment with dithiothreitol sera, supplemented with rituximab (0.2 and 2 μg/mL) and antithymocyte globulins (20 and 200 μg/mL), partially or totally reduced this positive interference. Intravenous immunoglobulin, eculizumab, and basiliximab did not trigger any interference with the negative control serum. In a positive LCT-XM, eculizumab did not annihilate activation of the rabbit complement. Intravenous immunoglobulins (25 g/L) could partially or totally reduced lysis score of positive crossmatch with weak lysis scores. CONCLUSION If eculizumab within the serum did not annihilate rabbit complement activation and basiliximab did not interfere with the crossmatch reaction, treatments based on rituximab, antithymocyte globulin and intravenous immunoglobulins need to be taken into account when interpreting a positive or negative crossmatch test.
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Affiliation(s)
- David Milongo
- Department of Nephrology and Organ Transplantation, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France.
| | - Guillaume Vieu
- Laboratoire d'immunologie, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France; Laboratoire d'Immunogénétique Moléculaire, EA 3034, Université Toulouse III Paul-Sabatier, 118 Route de Narbonne, 31062 Toulouse, France.
| | - Sarah Blavy
- Laboratoire d'immunologie, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France.
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France.
| | - Federico Sallusto
- Department of Urology, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France.
| | - Lionel Rostaing
- Department of Nephrology and Organ Transplantation, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France; Université Toulouse III Paul-Sabatier, 118 Route de Narbonne, 31062 Toulouse, France.
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France; Université Toulouse III Paul-Sabatier, 118 Route de Narbonne, 31062 Toulouse, France.
| | - Nicolas Congy-Jolivet
- Laboratoire d'immunologie, CHU Rangueil, 1 Avenue du Professeur Jean Poulhes, 31059 Toulouse, France; Laboratoire d'Immunogénétique Moléculaire, EA 3034, Université Toulouse III Paul-Sabatier, 118 Route de Narbonne, 31062 Toulouse, France.
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Zschiedrich S, Kramer-Zucker A, Jänigen B, Seidl M, Emmerich F, Pisarski P, Huber TB. An update on ABO-incompatible kidney transplantation. Transpl Int 2014; 28:387-97. [PMID: 25387763 DOI: 10.1111/tri.12485] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/25/2014] [Accepted: 11/06/2014] [Indexed: 01/21/2023]
Abstract
ABO-incompatible kidney transplantation is nowadays a well-established procedure to expand living donor transplantation to blood group incompatible donor/recipient constellations. In the last two decades, transplantation protocols evolved to more specific isohaemagglutinin elimination techniques and established competent antirejection protection protocols without the need of splenectomy. ABOi kidney transplantation associated accommodation despite isohaemagglutinin reappearance, C4d positivity of peritubular capillaries as well as the increased incidence of bleeding complications is currently under intense investigation. However, most recent data show excellent graft survival rates equivalent to ABO-compatible kidney transplantation outcome.
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Effect of a Proteasome Inhibitor Plus Steroids on HLA Antibodies in Sensitized Patients Awaiting a Renal Transplant. Transplantation 2014; 97:946-52. [DOI: 10.1097/01.tp.0000438207.42465.40] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abu Jawdeh BG, Cuffy MC, Alloway RR, Shields AR, Woodle ES. Desensitization in kidney transplantation: review and future perspectives. Clin Transplant 2014; 28:494-507. [DOI: 10.1111/ctr.12335] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Bassam G. Abu Jawdeh
- Division of Nephrology; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Madison C. Cuffy
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Rita R. Alloway
- Division of Nephrology; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Adele Rike Shields
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - E. Steve Woodle
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
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Liu A, Bernard M. Pharmaceutical costs of desensitization therapy in patients awaiting lung transplantation in France. BioDrugs 2013; 28:55-61. [PMID: 23912421 DOI: 10.1007/s40259-013-0054-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Based on solid experience in renal transplant, new treatments aiming to decrease anti-human leukocyte antigen (HLA) antibodies in patients awaiting lung transplant have recently been developed. The off-label use of high-dose intravenous polyvalent immunoglobulins (IVIg) and/or plasmapheresis changes the economical weight of pharmaceutical cost before lung transplantation. OBJECTIVE Our objective was to assess the budgetary impact of pharmaceutical costs of desensitization therapy. METHODS Two observational studies were conducted in 2009 and 2010 at the Bichat Claude Bernard (BCB) hospital in France. The first assessed the real pharmaceutical costs, and identified cost drivers, of desensitized (D+) patients awaiting lung transplantation. The second compared pharmaceutical and clinical data between D+ and non-treated (D-) patients. RESULTS The major cost drivers were IVIg, representing 89.7 % of pharmaceutical costs. The real cost of drugs was €4,392 ± 647 per hospitalization. Mean hospitalization and annual pharmaceutical costs per patient were significantly higher for D+ than for D- patients (€6,972 vs. 2,925 and €13,074 vs. 399). D+ patients had a significantly higher average number of annual hospitalizations than did D- patients. Total IVIg costs represented 98 % of the pharmaceutical costs for desensitization stays. Pharmaceutical costs represented 40 % of total hospitalization costs for D+ versus only 7 % for D-. CONCLUSION New desensitization protocols can help to manage the immunological hurdle of anti-donor antibodies in lung transplantation. They are expensive and not yet correctly covered by national health insurance, as they are supported by hospital budgets. A medico-economical evaluation of IVIg use in this indication seems necessary.
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Affiliation(s)
- Annaë Liu
- Department of Pharmacy, Bichat Claude Bernard Hospital, AP-HP, 146 rue Henri Huchard, 75877, Paris Cedex 18, France
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Park KT, Jung CW, Kim MG. Update on the Treatment of Acute and Chronic Antibody-mediated Rejection. KOREAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.4285/jkstn.2013.27.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kwan-Tae Park
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Cheol-Woong Jung
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Myung-Gyu Kim
- Department of Nephrology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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12
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Combined heart and liver transplantation: protection of the cardiac graft from antibody rejection by initial liver implantation. Transplantation 2013; 95:e2-4. [PMID: 23325010 DOI: 10.1097/tp.0b013e318277226d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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Kim SM, Oh JS, Sin YH, Kim JK, Park JI, Huh K, Kim YJ. A Case of Acute Antibody-Mediated Rejection Developed after Pretreatment with Rituximab and Plasma Exchange in a Highly-Sensitized Recipient with a Deceased Donor Kidney. KOREAN JOURNAL OF TRANSPLANTATION 2012. [DOI: 10.4285/jkstn.2012.26.2.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seong Min Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joon Seok Oh
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Hun Sin
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Jong In Park
- Department of Laboratory Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Kill Huh
- Department of General Surgery, Bong Seng Memorial Hospital, Busan, Korea
| | - Yong Jin Kim
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
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Non-human leukocyte antigen antibodies reactive with endothelial cells could be involved in early loss of renal allografts. Transplant Proc 2011; 43:1345-8. [PMID: 21620126 DOI: 10.1016/j.transproceed.2011.03.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Preformed donor-specific human leukocyte antigen (HLA) antibodies have been associated with allograft dysfunction and failure. However, recipients of HLA-identical kidneys can develop acute humoral rejection, implicating putative pathogenic antibodies that are directed against non-HLA antigens. We investigated the presence of endothelial cell-reactive antibodies in 11 patients who experienced early loss of their transplanted kidneys owing to humoral rejection and 1 loss from renal venal thrombosis. We examined the potential efficacy of intravenous immunoglobulin to block the binding of these antibodies, as previously suggested for anti-HLA antibodies.
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Levine MH, Abt PL. Treatment options and strategies for antibody mediated rejection after renal transplantation. Semin Immunol 2011; 24:136-42. [PMID: 21940179 DOI: 10.1016/j.smim.2011.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 08/24/2011] [Indexed: 12/17/2022]
Abstract
Antibody mediated rejection is a significant clinical problem encountered in a subset of renal transplant recipients. This type of rejection has a variable pathogenesis from the presence of donor specific antibodies with no overt disease to immediate hyperacute rejection and many variations between. Antibody mediated rejection is more common in human leukocyte antigen sensitized patients. In general, transplant graft survival after antibody mediated rejection is jeopardized, with less than 50% graft survival 5 years after this diagnosis. A variety of agents have been utilized singly and in combinations to treat antibody mediated rejection with differing results and significant research efforts are being placed on developing new targets for intervention. These same agents have been used in desensitization protocols with some success. In this review, we describe the biology of antibody mediated rejection, review the available agents to treat this form of rejection, and highlight areas of ongoing and future research into this difficult clinical problem.
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Affiliation(s)
- Matthew H Levine
- University of Pennsylvania, Transplant Surgery, Philadelphia, PA 19104, USA.
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Garonzik Wang JM, Montgomery RA, Kucirka LM, Berger JC, Warren DS, Segev DL. Incompatible live-donor kidney transplantation in the United States: results of a national survey. Clin J Am Soc Nephrol 2011; 6:2041-6. [PMID: 21784826 DOI: 10.2215/cjn.02940311] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of incompatible kidney transplantation (IKT) is growing as a response to the organ shortage and the increase in sensitization among candidates. However, recent regulatory mandates possibly threaten IKT, and the potential effect of these mandates cannot be estimated because dissemination of this modality remains unknown. The goal of this study was to better understand practice patterns of IKT in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Directors from all 187 unique active adult kidney transplant programs were queried about transplantation across the following antibody barriers: positive Luminex, negative flow crossmatch (PLNF); positive flow, negative cytotoxic crossmatch (PFNC); positive cytotoxic crossmatch (PCC); and ABO incompatible (ABOi). RESULTS Responses from 125 centers represented 84% of the live-donor transplant volume in the United States. Barriers of PLNF, PFNC, PCC, and ABOi are being crossed in 70%, 51%, 18%, and 24%, respectively, of transplant centers that responded. Desensitization was performed in 58% of PLNF, 76% of PFNC, 100% of PCC, and 80% of ABOi using plasmapheresis and low-dose intravenous Ig (IVIg) in 71% to 83% and high-dose IVIg in 29% to 46%. CONCLUSIONS A higher proportion of centers perform IKT than might be inferred from the literature. The rapid dissemination of these protocols despite adequate evidence of a clear advantage of IKT transplants argues for the creation of a national registry and randomized studies.
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Affiliation(s)
- Jacqueline M Garonzik Wang
- Transplant Surgery, Johns Hopkins Medical Institutions, 720 Rutland Avenue, Ross 771B, Baltimore, MD 21205, USA
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Brick C, Atouf O, Benseffaj N, Essakalli M. [Rejection of kidney graft: mechanism and prevention]. Nephrol Ther 2011; 7:18-26. [PMID: 21227764 DOI: 10.1016/j.nephro.2010.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 09/28/2010] [Accepted: 10/10/2010] [Indexed: 11/19/2022]
Abstract
Rejection occurs after the introduction of a genetically different graft, in a recipient. Nowadays, it is still a major obstacle in renal transplantation and reflects a normal protective immune response of a recipient against a foreign antigen. Involving many mechanisms of the innate and adaptive immunity, this reaction results in renal parenchymal lesions witch may progress to graft destruction and loss of its function. Several ways are currently used to reduce the action of the immune system and consequently reduce the risk of rejection. After a presentation of the main actors and the sequence of events leading to rejection, we will describe the strategy used by antirejection teams' transplantation. We will successively consider the prevention (pre-transplant immunological assessment, preventive immunosuppressive therapy), the monitoring (search for antibodies, biopsies) and the treatment.
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Affiliation(s)
- Chehrazade Brick
- Unité d'immunologie, service de transfusion sanguine et d'hémovigilance de l'hôpital Ibn Sina, CHU de Rabat, Rabat, Maroc.
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Incompatible kidney transplantation: lessons from a decade of desensitization and paired kidney exchange. Immunol Res 2010; 47:257-64. [PMID: 20087679 DOI: 10.1007/s12026-009-8157-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Human leukocyte antigen (HLA) sensitization and ABO incompatibility continue to pose significant barriers to further expansion of live donor renal transplantation. However, the recent development of effective desensitization protocols and creative paired donation strategies demonstrates that the presence of circulating donor HLA-specific antibodies and the use of ABO incompatible organs should no longer be considered contraindications for renal transplantation. It is estimated that as many as 6,000 patients on the kidney transplant waiting list have incompatible living donors and could benefit from these treatments. Furthermore, as our understanding of these treatment modalities has improved, it is now possible to predict whether desensitization, kidney paired donation or a combination of both will provide an individual patient with their best chance for successful renal transplantation.
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Jordan SC, Reinsmoen N, Peng A, Lai CH, Cao K, Villicana R, Toyoda M, Kahwaji J, Vo AA. Advances in diagnosing and managing antibody-mediated rejection. Pediatr Nephrol 2010; 25:2035-45; quiz 2045-8. [PMID: 20077121 PMCID: PMC2923704 DOI: 10.1007/s00467-009-1386-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 10/05/2009] [Accepted: 11/02/2009] [Indexed: 02/07/2023]
Abstract
Antibody-mediated rejection (AMR) is a unique, significant, and often severe form of allograft rejection that is not amenable to treatment with standard immunosuppressive medications. Significant advances have occurred in our ability to predict patients at risk for, and to diagnose, AMR. These advances include the development of newer anti-human leukocyte antigen (HLA)-antibody detection techniques and assays for non-HLA antibodies associated with AMR. The pathophysiology of AMR suggests a prime role for antibodies, B cells and plasma cells, but other effector molecules, especially the complement system, point to potential targets that could modify the AMR process. An emerging and potentially larger problem is the development of chronic AMR (CAMR) resulting from de novo donor-specific anti-HLA antibodies (DSA) that emerge more than 100 days posttransplantation. Therapeutic options include: (1) High-dose intravenously administered immunoglobulin (IVIG), which has many potential benefits. (2) The use of IVIG+rituximab (anti-CD20, anti-B cell). (3) The combination of plasmapheresis (PP)+low-dose IVIG with or without rituximab. Data support the efficacy of all of the above approaches. Newer approaches to treating AMR include using the proteosome inhibitor (bortezomib), which induces apoptosis in plasma cells, and eculizumab (anti-C5, anticomplement monoclonal antibody).
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Affiliation(s)
- Stanley C Jordan
- The Transplant Immunotherapy Program, Comprehensive Transplant Center, Los Angeles, CA 90048, USA.
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Intravenous immunoglobulins promote skin allograft acceptance by triggering functional activation of CD4+Foxp3+ T cells. Transplantation 2010; 89:1446-55. [PMID: 20463648 DOI: 10.1097/tp.0b013e3181dd6bf1] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Intravenous immunoglobulins (IVIg) therapy is effective as a treatment for T-cell-mediated immune diseases, but whether and how IVIg suppress allogeneic T-cell responses is largely unknown. METHODS In vitro, human CD4(+), CD4(+)CD25(-), or CD4(+)CD25(+) T cells were stimulated with allogeneic antigen-presenting cells (APCs), and mouse CBA/Ca (H2(k)) CD4(+) or CD4(+)CD25(-) T cells were stimulated with C57BL/10 (H2(b)) splenocytes, in the presence or absence of IVIg. Proliferation, binding of IVIg, expression of activation markers, and ZAP70-phosphorylation were determined. In vivo, 1x10(5) CD4(+) or CD4(+)CD25(-) T cells of CBA/Ca mice were adoptively transferred into CBA/RAG1(-/-) mice, which were 1 day later transplanted with skin grafts of C57BL/10 mice. IVIg was administered intravenously and skin graft survival was determined. RESULTS IVIg bound to the surface of human and mouse CD4(+)Foxp3(+) regulatory T cells (Tregs). IVIg binding resulted in functional activation of Tregs, as detected by increased expression of surface activation markers, enhanced ZAP70-phosphorylation, and increased capacity to suppress allogeneic T-cell proliferation. IVIg inhibited allogeneic T-cell proliferation in the presence of Tregs, but this effect was abrogated on selective depletion of CD25(+) cells from responder T cells. IVIg prevented T-cell-mediated rejection of fully mismatched skin grafts in CBA/RAG1(-/-) mice reconstituted with CD4(+) T cells, but this effect was lost on selective depletion of CD4(+)CD25(+) cells from transferred T cells, indicating that IVIg induced dominant allograft protection mediated by Tregs. CONCLUSIONS Our data show that IVIg suppress allogeneic T-cell responses by direct activation of Tregs. IVIg treatment, which has been proven safe, may have therapeutic potential in tolerance-inducing strategies in transplant medicine.
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Use of intravenous immune globulin and rituximab for desensitization of highly HLA-sensitized patients awaiting kidney transplantation. Transplantation 2010; 89:1095-102. [PMID: 20110854 DOI: 10.1097/tp.0b013e3181d21e7f] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND.: We have shown that high-dose intravenous immune globulin (IVIG; 2 g/kg x2 doses)+rituximab (1 g x2 doses) was effective in lowering anti-human leukocyte antigen (HLA) antibodies and improving rates of transplantation. The aim of this report was to evaluate the efficacy of IVIG+rituximab on reduction of anti-HLA antibodies to a level that was permissive for living donor (LD) or deceased donor (DD) transplantation without incurring the risk of antibody-mediated rejection and immediate graft loss. METHODS.: From July 2006 to February 2009, 76 HLA-sensitized (HS) patients who met strict sensitization criteria received kidney transplants after desensitization using IVIG 2 g/kg (days 1 and 30)+rituximab (1 g, day 15). Parameters evaluated included rates of transplantation, previous transplants, panel reactive antibodies, donor specific antibody, crossmatches (CMXs), patient and graft survival, acute rejection, serum creatinines, and infections. RESULTS.: Seventy-six HS CMX treated patients (31 LD/45 DD) were transplanted. For LD and DD recipients, significant reductions were seen in T-cell flow cytometry CMXs from pretreatment (T cell 183.5+/-98.4 mean channel shifts (MCS) for LD and 162.8+/-41 MCS for DD) to time of transplant (T cell 68.2+/-58 MCS for LD [P<0.00006] and 125+/-49 for DD [P=0.05]), respectively. Time on wait list for DD recipients was reduced from 95+/-46 months to 4.2+/-4.5 months after treatment. Twenty-eight patients (37%) experienced acute rejection (29% C4d/8% C4d). Patient and graft survival up to 24 months was 95% and 84%, respectively. The mean serum creatinines, at 12 and 24 months were 1.5+/-1.1 and 1.3+/-0.3 mg/dL, respectively. Viral infections were seen in six patients. CONCLUSIONS.: IVIG and rituximab seems to offer significant benefits in reduction of anti-HLA antibodies allowing improved rates of transplantation for HS patients, especially those awaiting DD, with acceptable antibody-mediated rejection and survival rates at 24 months.
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Intracellular IFNγ production in CD3 negative cells exposed to allo-antigens is an indicator of prior sensitization. Transpl Immunol 2010; 22:121-7. [DOI: 10.1016/j.trim.2009.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 11/16/2009] [Indexed: 11/21/2022]
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Varma PP, Hooda AK, Kumar A, Singh L. Highly successful and low-cost desensitization regime for sensitized living donor renal transplant recipients. Ren Fail 2010; 31:533-7. [PMID: 19839846 DOI: 10.1080/08860220903001861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
10-30% of dialysis population awaiting renal transplantation is sensitized. Present desensitization protocols use intravenous immune globulins, rituximab, and plasmapheresis in various combinations; however, these regimens are unaffordable by many in developing countries. We tried desensitization with mycophenolate mofetil and plasmapheresis. Methods. Patients with high PRA titre (> or =50%) or positive crossmatch (>10%) were treated with MMF for a month before proposed transplant and were given five sittings of plasmapheresis. Results. 11 of 12 patients had normalization of PRA/crossmatch with this regimen and were successfully transplanted. One patient lost the graft due to graft vein thrombosis, and two patients died within three months after transplant due to septicemia and pulmonary embolism, respectively, with a functioning graft. No patient, including the two who died, developed clinical rejection over a mean follow-up of 10 months (range 1-16 months). Mean serum creatinine at last follow up was 1.1 mg/dL (range 0.9-1.3 mg/dL). Conclusions. Though the number of patients studied is small, we feel that highly sensitized patients awaiting living donor renal transplant should be tried on this simple and cost-effective regime before transplant. The more aggressive and expensive approaches incorporating IVIg and rituximab should be used only if this relatively low-cost regime is unsuccessful.
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Affiliation(s)
- Prem P Varma
- Army Hospital (R&R), Delhi Cantt, New Delhi, 110010, India
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Is Indoleamine 2,3-Dioxygenase Important for Graft Acceptance in Highly Sensitized Patients After Combined Auxiliary Liver-Kidney Transplantation? Transplantation 2009; 88:911-9. [DOI: 10.1097/tp.0b013e3181b72e49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Gozdowska J, Urbanowicz A, Perkowska-Ptasinska A, Michalska K, Chmura A, Szmidt J, Durlik M. Use of High-Dose Human Immune Globulin in Highly Sensitized Patients on the Kidney Transplant Waiting List: One Center's Experience. Transplant Proc 2009; 41:2997-3001. [DOI: 10.1016/j.transproceed.2009.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lobashevsky A, Manwaring J, Travis M, Nord B, Higgins N, Serov Y, Arnoff T, Hommel-Berrey G, Goggins W, Taber T, Carter C, Smith D, Wozniak T, O'Donnell J, Turrentine M. Effect of desensitization in solid organ transplant recipients depends on some cytokines genes polymorphism. Transpl Immunol 2009; 21:169-78. [DOI: 10.1016/j.trim.2009.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/12/2009] [Accepted: 03/16/2009] [Indexed: 10/20/2022]
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28
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Zhou SM, Tian J, Sun R, Shi WF, Peng ZG, Zou X. Lymphocytic HLA-A mRNA is a reliable indicator of acute rejection in renal transplantation. Transplant Proc 2008; 40:3384-9. [PMID: 19100395 DOI: 10.1016/j.transproceed.2008.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 06/23/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rejection in renal transplantation is the most frequent event causing transplant failure. It is important to identify parameters to predict rejection, which are helpful in a timely fashion. METHODS Fifty-nine renal transplant recipients were divided into two groups: group 1 (stable renal function) and group 2 (acute rejection episodes). The levels of HLA-A mRNA in peripheral blood lymphocytes (both pre- and posttransplantation) were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) with glucose-6-phosphate dehydrogenase (G6PDH) as an internal reference. The TEST software was used to analyze the relative expressions of HLA-A mRNA. RESULTS There was no statistical significance between features of the two groups pretransplant versus normal controls. Posttransplant, the HLA-A mRNA levels decreased significantly compared to those of pretransplant and normal control individuals. The levels of HLA-A mRNA among the 10 patients with acute rejection episodes were significantly increased. There was no significant change in the lymphocyte populations in the early stage of an acute rejection episode compared with the prerejection value. CONCLUSION HLA-A mRNA expression was strongly correlated with immune status. The HLA-A mRNA levels may provide an effective and reliable indicator to predict acute rejection episodes in renal transplantation.
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Affiliation(s)
- S M Zhou
- Department of Urinary Surgery, Liaocheng People's Hospital, Liaocheng, Shandong Province, China
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Abstract
The rate of access to transplantation of hyperimmunized patients has improved thanks to a modification of the organ allocation rule in 2002 and the initiation of the Acceptable Mismatch program. Transplantation of immunized patients must be now preceded by a fine description of the characteristics of pretransplantation immunization using sensitive techniques and by an indispensable clinical and biological discussion to choose the best transplantation strategy, taking into account the risk/benefit balance for the patient of each strategy. Whichever transplantation strategy is adopted, immunosuppression should be adapted to the immunological status of the patient, often using the new therapeutic strategies (IVIg, rituximab, plasma exchange) with a specific follow-up, notably for anti-HLA antibodies, checking their evolution post treatment.
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Affiliation(s)
- C Antoine
- Service de Néphrologie et de transplantation rénale, Hôpital Saint-Louis, 1, avenue Claude Vellefaux, 75010 Paris, France.
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Vo AA, Lukovsky M, Toyoda M, Wang J, Reinsmoen NL, Lai CH, Peng A, Villicana R, Jordan SC. Rituximab and intravenous immune globulin for desensitization during renal transplantation. N Engl J Med 2008; 359:242-51. [PMID: 18635429 DOI: 10.1056/nejmoa0707894] [Citation(s) in RCA: 496] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Few options for transplantation currently exist for patients highly sensitized to HLA. This exploratory, open-label, phase 1-2, single-center study examined whether intravenous immune globulin plus rituximab could reduce anti-HLA antibody levels and improve transplantation rates. METHODS Between September 2005 and May 2007, a total of 20 highly sensitized patients (with a mean [+/-SD] T-cell panel-reactive antibody level, determined by use of the complement-dependent cytotoxicity assay, of 77+/-19% or with donor-specific antibodies) were enrolled and received treatment with intravenous immune globulin and rituximab. We recorded rates of transplantation, panel-reactive antibody levels, cross-matching results at the time of transplantation, survival of patients and grafts, acute rejection episodes, serum creatinine values, adverse events and serious adverse events, and immunologic factors. RESULTS The mean panel-reactive antibody level was 44+/-30% after the second infusion of intravenous immune globulin (P<0.001 for the comparison with the pretreatment level). At study entry, the mean time on dialysis among recipients of a transplant from a deceased donor was 144+/-89 months (range, 60 to 324). However, the time to transplantation after desensitization was 5+/-6 months (range, 2 to 18). Sixteen of the 20 patients (80%) received a transplant. At 12 months, the mean serum creatinine level was 1.5+/-1.1 mg per deciliter (133+/-97 micromol per liter), and the mean survival rates of patients and grafts were 100% and 94%, respectively. There were no infusion-related adverse events or serious adverse events during the study. Long-term monitoring for infectious complications and neurologic problems revealed no unanticipated events. CONCLUSIONS These findings suggest that the combination of intravenous immune globulin and rituximab may prove effective as a desensitization regimen for patients awaiting a transplant from either a living donor or a deceased donor. Larger and longer trials are needed to evaluate the clinical efficacy and safety of this approach. (ClinicalTrials.gov number, NCT00642655.)
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MESH Headings
- Adult
- Antibodies/blood
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antigens, CD19/blood
- Antigens, CD20/immunology
- Creatinine/blood
- Desensitization, Immunologic/methods
- Drug Therapy, Combination
- Female
- Graft Rejection/epidemiology
- HLA Antigens/immunology
- Humans
- Immunoglobulins, Intravenous/adverse effects
- Immunoglobulins, Intravenous/therapeutic use
- Immunologic Factors/adverse effects
- Immunologic Factors/therapeutic use
- Immunosuppression Therapy/methods
- Kidney Transplantation/immunology
- Male
- Middle Aged
- Rituximab
- Survival Rate
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Affiliation(s)
- Ashley A Vo
- Comprehensive Transplant Center, Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles 90048, USA.
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Faenza A, Fuga G, Bertelli R, Scolari M, Buscaroli A, Stefoni S. Hyperimmunized Patients Awaiting Cadaveric Kidney Graft: Is There a Quick Desensitization Possible? Transplant Proc 2008; 40:1833-8. [DOI: 10.1016/j.transproceed.2008.05.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tha-In T, Metselaar HJ, Tilanus HW, Groothuismink ZMA, Kuipers EJ, de Man RA, Kwekkeboom J. Intravenous immunoglobulins suppress T-cell priming by modulating the bidirectional interaction between dendritic cells and natural killer cells. Blood 2007; 110:3253-62. [PMID: 17673603 DOI: 10.1182/blood-2007-03-077057] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractThe modes of action of intravenous immunoglobulins (IVIgs) in exerting their immunomodulatory properties are broad and not fully understood. IVIgs can modulate the function of various immune cells, including suppressing the capacity of dendritic cells (DCs) to stimulate T cells. In the present study, we showed that DCs matured in the presence of IVIgs (IVIg-DCs) activated NK cells, and increased their interferon-γ production and degranulation. The activated NK cells induced apoptosis of the majority of IVIg-DCs. In consequence, only in the presence of NK cells, IVIg-DCs were 4-fold impaired in their T-cell priming capacity. This was due to NK-cell–mediated antibody-dependent cellular cytotoxicity (ADCC) to IVIg-DCs, probably induced by IgG multimers, which could be abrogated by blockade of CD16 on NK cells. Furthermore, IVIg-DCs down-regulated the expression of NKp30 and KIR receptors, and induced the generation of CD56brightCD16−CCR7+ lymph node–type NK cells. Our results identify a novel pathway, in which IVIgs induce ADCC of mature DCs by NK cells, which downsizes the antigen-presenting pool and inhibits T-cell priming. By influencing the interaction between DCs and NK cells, IVIgs modulate the ability of the innate immunity to trigger T-cell activation, a mechanism that can “cool down” the immune system at times of activation.
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Affiliation(s)
- Thanyalak Tha-In
- Department of Gastroenterology and Hepatology, Erasmus Medical Center-University Medical Center, 3015 CE Rotterdam, The Netherlands
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36
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Desensitization protocols for crossing human leukocyte antigen and ABO incompatible barriers. Curr Opin Organ Transplant 2007. [DOI: 10.1097/mot.0b013e3282703903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Feingold B, Bowman P, Zeevi A, Girnita AL, Quivers ES, Miller SA, Webber SA. Survival in Allosensitized Children After Listing for Cardiac Transplantation. J Heart Lung Transplant 2007; 26:565-71. [PMID: 17543778 DOI: 10.1016/j.healun.2007.03.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Revised: 02/11/2007] [Accepted: 03/12/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Little is known about the effect of pre-transplant alloantibody in the pediatric cardiac transplant population. METHODS All cardiac listings (n = 298) at Children's Hospital of Pittsburgh from January 1990 through February 2006 were reviewed to determine the impact of allosensitization on transplantation outcomes. Analysis focused on: (1) wait list outcomes; (2) survival from the time of listing, regardless of subsequent transplantation; (3) post-transplant graft and patient survival; and (4) post-transplant freedom from graft vasculopathy. Institutional policy required a negative, prospective crossmatch for candidates with panel-reactive antibody >20%. RESULTS Alloantibody data were available for 252 (85%) listings. Median time to transplantation was greater for sensitized vs non-sensitized subjects (2.7 months vs 1.3 months; p = 0.02). At 1 year after listing, sensitized subjects had a higher incidence of death (22% vs 8.4%; p = 0.055). Survival at all time-points after listing (regardless of transplantation) was worse for sensitized subjects (p = 0.04). Although no statistically significant differences in post-transplant graft or patient survival were noted, pre-transplant allosensitization was associated with decreased freedom from graft vasculopathy (hazard ratio [HR] 2.76, 95% confidence interval [CI] 1.18 to 6.45; p = 0.019). CONCLUSIONS A policy requiring a negative, prospective crossmatch for highly sensitized candidates is associated with longer wait list time and higher mortality after listing. The development of graft vasculopathy appears to be influenced by the presence of pre-transplant alloantibody.
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Affiliation(s)
- Brian Feingold
- Division of Pediatric Cardiology and Cardiopulmonary Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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38
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Anglicheau D, Loupy A, Suberbielle C, Zuber J, Patey N, Noël LH, Cavalcanti R, Le Quintrec M, Audat F, Méjean A, Martinez F, Mamzer-Bruneel MF, Thervet E, Legendre C. Posttransplant prophylactic intravenous immunoglobulin in kidney transplant patients at high immunological risk: a pilot study. Am J Transplant 2007; 7:1185-92. [PMID: 17359509 DOI: 10.1111/j.1600-6143.2007.01752.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effects of posttransplant prophylactic intravenous immunoglobulin (IVIg) were investigated in renal transplant recipients at high immunological risk. Thirty-eight deceased-donor kidney transplant recipients with previous positive complement-dependent cytotoxicity crossmatch (n=30), and/or donor-specific anti-HLA antibodies (n=14) were recruited. IVIg (2 g/kg) was administrated on days 0, 21, 42 and 63 with quadruple immunosuppression. Biopsy-proven acute cellular and humoral rejection rates at month 12 were 18% and 10%, respectively. Glomerulitis was observed in 31% and 60% of patients at months 3 and 12, respectively, while allograft glomerulopathy rose from 3% at month 3 to 28% at 12 months. Interstitial fibrosis/tubular atrophy increased from 18% at day 0 to 51% and 72% at months 3 and 12 (p<0.0001). GFR was 50 +/- 17 mL/min/1.73 m(2) and 48 +/- 17 mL/min/1.73 m(2) at 3 and 12 months. PRA decreased significantly after IVIg (class I: from 18 +/- 27% to 5 +/- 12%, p<0.01; class II: from 25 +/- 30% to 7 +/- 16%, p<0.001). Patient and graft survival were 97% and 95%, respectively and no graft was lost due to rejection (mean follow-up 25 months). In conclusion, prophylactic IVIg in high-immunological risk patients is associated with good one-year outcomes, with adequate GFR and a profound decrease in PRA level, but a significant increase in allograft nephropathy.
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Affiliation(s)
- D Anglicheau
- Service de Transplantation Rénale et de Soins Intensifs, Hôpital Necker, APHP, Paris, F-75015 France.
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39
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Zachary AA, Montgomery RA, Jordan SC, Reinsmoen NL, Claas FHJ, Reed EF. 14th International HLA and Immunogenetics Workshop: Report on understanding antibodies in transplantation. ACTA ACUST UNITED AC 2007; 69 Suppl 1:160-73. [PMID: 17445194 DOI: 10.1111/j.1399-0039.2006.00764.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A session of the 14 International Histocompatibility Workshop brought together experts representing the major clinical protocols, clinical research, and basic research dealing with overcoming the barrier of alloantibody in transplantation and in understanding the mechanisms by which those antibodies exert their effect on a transplanted organ. This report is an integration of the presentations of those scientists.
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Affiliation(s)
- A A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205-2222, USA.
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40
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Locke JE, Zachary AA, Haas M, Melancon JK, Warren DS, Simpkins CE, Segev DL, Montgomery RA. The utility of splenectomy as rescue treatment for severe acute antibody mediated rejection. Am J Transplant 2007; 7:842-6. [PMID: 17391127 DOI: 10.1111/j.1600-6143.2006.01709.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) after desensitization for a positive crossmatch (+XM) live donor renal transplant can be severe and result in sudden onset oliguria and loss of the allograft. Attempts to rescue these kidneys using plasmapheresis (PP) and IVIg may be ineffective due to the magnitude of antibody burden that must be controlled to prevent renal thrombosis or cortical necrosis. We review our experience using splenectomy combined with PP/IVIg as rescue therapy for patients experiencing an acute deterioration in renal function and a rise in donor-specific antibody within the first posttransplant week after desensitization for a +XM. Five patients underwent immediate splenectomy followed by PP/IVIg and had return of allograft function within 48 h of the procedure. Emergent splenectomy followed by PP/IVIg may be an effective treatment for reversing severe AMR.
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Affiliation(s)
- J E Locke
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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41
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Negi VS, Elluru S, Sibéril S, Graff-Dubois S, Mouthon L, Kazatchkine MD, Lacroix-Desmazes S, Bayry J, Kaveri SV. Intravenous immunoglobulin: an update on the clinical use and mechanisms of action. J Clin Immunol 2007; 27:233-45. [PMID: 17351760 DOI: 10.1007/s10875-007-9088-9] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 02/21/2007] [Indexed: 01/27/2023]
Abstract
Initially used as a replacement therapy for immunodeficiency diseases, intravenous immunoglobulin (IVIg) is now widely used for a number of autoimmune and inflammatory diseases. Considerable progress has been made in understanding the mechanisms by which IVIg exerts immunomodulatory effects in autoimmune and inflammatory disorders. The mechanisms of action of IVIg are complex, involving modulation of expression and function of Fc receptors, interference with activation of complement and the cytokine network and of idiotype network, regulation of cell growth, and effects on the activation, differentiation, and effector functions of dendritic cells, and T and B cells.
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Affiliation(s)
- Vir-Singh Negi
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Olausson M, Mjörnstedt L, Nordén G, Rydberg L, Mölne J, Bäckman L, Friman S. Successful combined partial auxiliary liver and kidney transplantation in highly sensitized cross-match positive recipients. Am J Transplant 2007; 7:130-6. [PMID: 17227562 DOI: 10.1111/j.1600-6143.2006.01592.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Combined liver and renal transplantations can be performed against a positive cross-match, indicating that the liver protects the kidney from the harmful HLA antibodies. This led us to the hypothesis that a partial auxiliary liver graft may have a similar protective effect when performed together with the kidney in highly sensitized patients. Seven patients, with broadly reacting HLA antibodies and positive crossmatches, were transplanted with a partial liver and a kidney from the same donor. In one of the cases a living donor was used. We performed lymphocytotoxic and flow cross-matches before and after the transplantation. Cross-matches turned negative after grafting in five of seven cases. The kidney function was excellent, without rejections, during the follow-up (24-60 months) in these patients. In two cases the cross-match remained positive after transplantation, one with a never-functioning renal graft and the other with an early graft failure, probably due to humoral rejection. A simultaneous transplantation of a partial auxiliary liver graft from the same donor, with the sole purpose of protecting the kidney from harmful lymphocytotoxic antibodies, can be performed successfully despite a positive cross-match and may thus be a new option of treatment for highly sensitized patients waiting for a kidney transplant.
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Affiliation(s)
- M Olausson
- Department of Transplantation and Liver Surgery, Sahlgrenska Universith Hospital, Göteborg, Sweden
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Taylor PA, Ehrhardt MJ, Roforth MM, Swedin JM, Panoskaltsis-Mortari A, Serody JS, Blazar BR. Preformed antibody, not primed T cells, is the initial and major barrier to bone marrow engraftment in allosensitized recipients. Blood 2006; 109:1307-15. [PMID: 17018854 PMCID: PMC1785137 DOI: 10.1182/blood-2006-05-022772] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multiply-transfused individuals are at higher risk for BM rejection. We show that whereas allosensitization resulted in the priming of both cellular and humoral immunity, preformed antibody was the major barrier to engraftment. The generation of cross-reactive alloantibody led to rejection of BM of a different MHC-disparate strain. Imaging studies indicated that antibody-mediated rejection was very rapid (<3 hours) in primed recipients, while T-cell-mediated rejection in nonprimed mice took more than 6 days. Antibody-mediated BM rejection was not due to a defect in BM homing as rejection occurred despite direct intra-BM infusion of donor BM. Rejection was dependent upon host FcR+ cells. BM cells incubated with serum from primed mice were eliminated in nonprimed recipients, indicating that persistent exposure to high-titer antibody was not essential for rejection. High donor engraftment was achieved in a proportion of primed mice by mega-BM cell dose, in vivo T-cell depletion, and high-dose immunoglobulin infusion. The addition of splenectomy to this protocol only modestly added to the efficacy of this combination strategy. These data demonstrate both rapid alloantibody-mediated elimination of BM by host FcR+ cells and priming of host antidonor T cells and suggest a practical strategy to overcome engraftment barriers in primed individuals.
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Affiliation(s)
- Patricia A Taylor
- University of Minnesota Cancer Center, Department of Pediatrics, Minneapolis 55455, USA
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Drakos SG, Kfoury AG, Long JW, Stringham JC, Fuller TC, Nelson KE, Campbell BK, Gilbert EM, Renlund DG. Low-Dose Prophylactic Intravenous Immunoglobulin Does Not Prevent HLA Sensitization in Left Ventricular Assist Device Recipients. Ann Thorac Surg 2006; 82:889-93. [PMID: 16928502 DOI: 10.1016/j.athoracsur.2006.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Revised: 04/01/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of left ventricular assist devices is associated with human leukocyte antigen (HLA) allosensitization. We investigated whether prophylactic treatment with low-dose intravenous immunoglobulin (IVIG), analogous to the use of IgG anti-D (anti-Rh) in preventing Rh immunization, can abrogate HLA allosensitization after left ventricular assist device implantation. METHODS We retrospectively reviewed the data from 84 consecutive heart failure patients who underwent implantation of a left ventricular assist device as a bridge to transplantation. After implantation, panel reactive antibody (PRA) was measured biweekly to assess sensitization (defined by PRA > 10%). Patients who were sensitized before left ventricular assist device implantation were excluded from further analysis (n = 12). Patients who either did not require perioperatively transfusions of cellular blood products or received other immunomodifying regimens were also excluded from further analysis (n = 21). The rest of the patients were divided into two groups based on whether they received IVIG, 10 g daily for 3 days (IVIG group, n = 26; non-IVIG group, n = 25). The decision as to whether patients received IVIG was not randomized but was based on surgeon preference. RESULTS The sensitization rates (expressed as ratio of sensitized patients to total patients at risk) in the two groups were similar at consecutive time points (2, 4, 6, 8, 12, 20 weeks) after left ventricular assist device implantation. Also, mean PRA at the same time points did not differ between the two groups. Overall, 34.6% (9 of 26) of the IVIG group became sensitized during mechanical support, compared with 32% (8 of 25) of the non-IVIG group (p = 1.0). A PRA of 90% or greater (high-degree sensitization) occurred in 15.3% (4 of 26) of the IVIG group and 12.0% (3 of 25) of the non-IVIG group (p = 0.5). CONCLUSIONS The use of low-dose prophylactic IVIG after left ventricular assist device implantation affects neither the incidence nor the severity of HLA allosensitization.
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Affiliation(s)
- Stavros G Drakos
- LDS Hospital, University of Utah School of Medicine, Utah Transplantation Affiliated Hospitals Cardiac Transplant Program, Salt Lake City, Utah 84143, USA
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45
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Transplantation of the highly human leukocyte antigen–sensitized patient: long-term outcomes and future directions. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2006.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ivan E, Colovai AI. Human Fc receptors: critical targets in the treatment of autoimmune diseases and transplant rejections. Hum Immunol 2006; 67:479-91. [PMID: 16829303 DOI: 10.1016/j.humimm.2005.12.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Indexed: 01/29/2023]
Abstract
The receptors for the Fc region of immunoglobulins (FcR) are members of the immunoglobulin superfamily. They are expressed on various hematopoietic cells and constitute a link between humoral and cell-mediated immunity. The activation and downmodulation of immune responses are controlled by signals from activating and inhibitory FcR, expressed on the surface of immune cells. The signaling regions, defined as immunoreceptor-tyrosine-based activation motif and immunoreceptor-tyrosine-based inhibitory motif, are contained within the cytoplasmic domain of FcR or of the adaptor proteins associated with FcR. Activating and inhibitory FcR are usually coexpressed on the surface of the same cell and coengaged by the same ligand, functioning in concert to keep a balanced immune response. Impairment of the functional balance between activating and inhibitory FcR leads either to hyperactivity to foreign and self antigens or to unresponsiveness as seen in many autoimmune diseases and infections. Pathologic conditions in which immunoglobulin-FcR interactions play a major role, as well as the outcome of treatment with intravenous immunoglobulin and monoclonal antibodies, may be influenced by targeting FcR.
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MESH Headings
- Animals
- Antigen Presentation
- Antigen-Presenting Cells/metabolism
- Arthritis, Rheumatoid/genetics
- Arthritis, Rheumatoid/metabolism
- Arthritis, Rheumatoid/therapy
- Endothelial Cells/metabolism
- Graft Rejection/drug therapy
- Graft Rejection/metabolism
- Humans
- Immunoglobulins/metabolism
- Immunoglobulins, Intravenous/therapeutic use
- Immunologic Factors/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Lupus Erythematosus, Systemic/genetics
- Lupus Erythematosus, Systemic/metabolism
- Lupus Erythematosus, Systemic/therapy
- Lymphocytes/metabolism
- Muromonab-CD3/therapeutic use
- Neutrophils/metabolism
- Polymorphism, Single Nucleotide
- Protein Structure, Tertiary
- Purpura, Thrombocytopenic, Idiopathic/genetics
- Purpura, Thrombocytopenic, Idiopathic/metabolism
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Receptors, IgG/classification
- Receptors, IgG/genetics
- Receptors, IgG/metabolism
- Signal Transduction
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Affiliation(s)
- Elena Ivan
- Department of Pathology, Columbia University, New York, NY, USA
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47
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Abstract
Much attention has been placed recently on transplantation in highly HLA-sensitized patients. In attempts to remove these antibodies and enable successful transplantation, several novel approaches have been developed. These include intravenous Ig (IVIg), mycophenolate mofetil, sirolimus, alemtuzumab, protein A immunoabsorption, and rituximab. IVIg has emerged as a very effective agent when used alone in high dose or when used in low dose and combined with plasmapheresis. Although alemtuzumab has been used to eliminated B cells, it fails to prevent antibody-mediated rejection and therefore probably is not suitable for desensitization. Rituximab, a B cell-specific antibody, seems to be safe and to have some efficacy as a sole agent in elimination of alloantibodies but most likely will require combination therapy with IVIg or other agents. Newer agents, such as humanized anti-CD20, are being developed. Despite the great interest in the problem of allosensitization, with one notable exception, there is a major deficiency in controlled clinical trials, the conduct of which should be a focus for the near future.
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Affiliation(s)
- Stanley C Jordan
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California 90048, USA.
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Jordan SC, Vo AA, Peng A, Toyoda M, Tyan D. Intravenous gammaglobulin (IVIG): a novel approach to improve transplant rates and outcomes in highly HLA-sensitized patients. Am J Transplant 2006; 6:459-66. [PMID: 16468954 DOI: 10.1111/j.1600-6143.2005.01214.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intravenous immunoglobulin (IVIG) products are derived from pooled human plasma and have been used for the treatment of primary immunodeficiency disorders for more than 24 years. Shortly after their introduction, IVIG products were also found to be effective in the treatment of autoimmune and inflammatory disorders. Over the past 2 decades, the list of diseases where IVIG has a demonstrable beneficial effect has grown rapidly. These include Kawasaki disease, Guillain-Barre syndrome, myasthenia gravis, dermatomyositis and demyelinating polyneuropathy. Recently, we have described a beneficial effect on the reduction of anti-HLA antibodies with subsequent improvement in transplantation of highly HLA-sensitized patients as well as a potent anti-inflammatory effect that is beneficial in the treatment of antibody-mediated rejection (AMR). These advancements have enabled transplantation of patients previously considered untransplantable. These studies and relevant mechanism(s) of action will be discussed here.
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Affiliation(s)
- S C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, UCLA School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.
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Bucin D, Johansson S, Malm T, Jögi P, Johansson J, Westrin P, Lindberg LO, Olsson AK, Gelberg J, Peres V, Harling S, Bennhagen R, Kornhall B, Ekmehag B, Kurkus J, Otto G. Heart transplantation across the antibodies against HLA and ABO. Transpl Int 2006; 19:239-44. [PMID: 16441774 DOI: 10.1111/j.1432-2277.2005.00260.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We have intentionally performed heart transplantation in a 5-year-old child, despite the most unfavourable risk factors for patient survival; the presence of high level of antibodies against donor's human leucocyte antigen (HLA) class I/II and blood group antigens. Pretransplant treatment by mycophenolate mofetil, prednisolone, tacrolimus, intravenous immunoglobulin, rituximab, protein-A immunoadsorption (IA) and plasma exchange reduced antibody titres against the donor's lymphocytes from 128 to 16 and against the donor's blood group antigen from 256 to 0. The patient was urgently transplanted with a heart from an ABO incompatible donor (A(1) to O). A standard triple-drug immunosuppressive protocol was used. No hyperacute rejection was seen. Antibodies against the donor's HLA antigens remained at a low level despite three acute rejections. Rising anti-A(1) blood group antibodies preceded the second rejection and were reduced by two blood group-specific IAs and remained at a low level. The patient is doing well despite the persistence of donor-reactive antibodies.
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Affiliation(s)
- Dragan Bucin
- Transplantation Laboratory, University Hospital Blood Centre, Lund, Sweden.
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Zachary AA, Montgomery RA, Leffell MS. Desensitization protocols improving access and outcome in transplantation. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.cair.2005.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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