1
|
Favi E, Cresseri D, Perego M, Ikehata M, Iesari S, Campise MR, Morello W, Testa S, Sioli V, Mattinzoli D, Longhi E, Del Gobbo A, Castellano G, Ferraresso M. Sequential administration of anti-complement component C5 eculizumab and type-2 anti-CD20 obinutuzumab for the treatment of early antibody-mediated rejection after kidney transplantation: A proof of concept. Clin Immunol 2024; 264:110240. [PMID: 38734036 DOI: 10.1016/j.clim.2024.110240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Kidney transplant (KT) candidates with donor-specific antibodies (DSA) exhibit exceedingly high antibody-mediated rejection (ABMR) and allograft loss rates. Currently, treatment of ABMR remains an unmet clinical need. We report the use of the anti-C5 eculizumab and the type-2 anti-CD20 obinutuzumab in two patients with early ABMR. Eculizumab (900 mg IV) led to complete inhibition of the terminal complement cascade (unremarkable AP50 and CH50 activity) and prompt stoppage of complement-dependent antibody-mediated allograft injury (clearance of intra-graft C4d and C5b-9 deposition). Despite complement inhibition, obinutuzumab (1000 mg IV) determined full and long-lasting peripheral B-cell depletion, with significant reduction in all DSA. Graft function improved, remaining stable up to three years of follow-up. No signs of active ABMR and rebound DSA were detected. Obinutuzumab B-cell depletion and inhibition of DSA production were not affected by complement blockage. Further studies are needed to confirm the potential benefit of obinutuzumab in association with complement inhibitors.
Collapse
Affiliation(s)
- Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy.
| | - Donata Cresseri
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marta Perego
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Masami Ikehata
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Samuele Iesari
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Rosaria Campise
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - William Morello
- Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sara Testa
- Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Viviana Sioli
- Laboratorio di Immunologia dei Trapianti, Trapianti Lombardia - NITp, 20122 Milan, Italy
| | - Deborah Mattinzoli
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Elena Longhi
- Laboratorio di Immunologia dei Trapianti, Trapianti Lombardia - NITp, 20122 Milan, Italy
| | - Alessandro Del Gobbo
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy; Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| |
Collapse
|
2
|
Krishnan N, Briggs D. Imlifidase: Is it the Magic Wand in Renal Transplantation? Indian J Nephrol 2024; 34:291-296. [PMID: 39156835 PMCID: PMC11326793 DOI: 10.25259/ijn_325_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/15/2023] [Indexed: 08/20/2024] Open
Abstract
Potential kidney transplant patients with HLA-specific antibodies have reduced access to transplantation. Their harmful effects are mediated by the Fc portion of IgG, including activation of the complement system and Fc receptor-initiated cytotoxic processes by circulating leucocytes. Avoiding antibody incompatibility is the conventional approach, but for some patients this can mean extended waiting times, or even no chance of a transplant if there are no alternative, compatible donors. For these cases, pretransplant antibody removal may provide access to transplantation. Plasmapheresis is currently used to achieve this, with acceptable outcome results, but the process can take days to reduce the antibody levels to a safe level, so has limited use for deceased donors. There is now an alternative, in the form of an IgG-digesting enzyme, Imlifidase, which can be administered for in vivo IgG inactivation. Imlifidase cleaves human IgG, separating the antigen-binding part, F(ab')2 from Fc. Typically, within six hours of dosing, most, if not all, of the circulating IgG has been inactivated, allowing safe transplantation from a previously incompatible donor. For deceased donor transplantation, where minimizing cold ischaemia is critical, this six-hour delay before implantation should be manageable, with the compatibility testing processes adjusted to accommodate the treatment. This agent has been used successfully in phase 2 clinical trials, with good short to medium term outcomes. While a donation rate that matches demand may be one essential answer to providing universal access to kidney transplantation, this is currently unrealistic. IgG inactivation, using Imlifidase, is, however, a realistic and proven alternative.
Collapse
Affiliation(s)
- Nithya Krishnan
- Department of Renal and Transplant Medicine, Institute of Cardiometabolic Medicine, University of Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Institute of Community and Health Care, Coventry University, Coventry, United Kingdom
| | - David Briggs
- Histocompatibility and Immunogenetics Lab, NHS Blood and Transplant, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Coventry, United Kingdom
| |
Collapse
|
3
|
Maenosono R, Unagami K, Oki R, Fujiwara Y, Banno T, Okada D, Yagisawa T, Kanzawa T, Hirai T, Omoto K, Hanafusa N, Azuma H, Takagi T, Ishida H. The medical cost and outcome of desensitization protocol in kidney transplantation recipients with high immunological risks. Int J Urol 2024; 31:422-429. [PMID: 38193573 DOI: 10.1111/iju.15383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 12/17/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Kidney transplantation is a well-established alternative in renal replacement therapy. Compared with hemodialysis, low-immunological-risk kidney transplantation can reduce the medical treatment costs associated with end-stage renal disease. However, there are few reports on whether high-immunological-risk kidney transplantation reduces the financial burden on governments. We investigated the medical costs of high-immunological-risk kidney transplantation in comparison with the cost of hemodialysis in Japan. METHODS We compared the medical costs of high-immunological-risk kidney transplantation with those of hemodialysis. 15 patients who underwent crossmatch-positive and/or donor-specific antibody-positive kidney transplantations between 2020 and 2021 were enrolled in this study. The patients received intravenous immunoglobulin, plasmapheresis, and rituximab as desensitizing therapy. RESULTS Acute antibody-mediated rejection was detected in nine (60%) recipients, while there were no indications of graft function deterioration during the follow-up. For each patient, the transplant hospitalization cost was 38 428 ± 8789 USD. However, the cumulative costs were 59 758 ± 10 006 USD and 79 781 ± 16 366 USD, at 12 and 24 months, respectively. Compared with hemodialysis (34 286 USD per year), high-immunological-risk kidney transplantation tends to be expensive in the first year, but the cost is likely to be lower than that of hemodialysis after 3 years. CONCLUSIONS Although kidney transplantation is initially expensive compared with hemodialysis, the medical cost becomes advantageous after 3 years even in kidney transplant recipients with high immunological risk.
Collapse
Affiliation(s)
- Ryoichi Maenosono
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Urology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kohei Unagami
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Rikako Oki
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuya Fujiwara
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Urology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Taro Banno
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daigo Okada
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takafumi Yagisawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
4
|
Kang ZY, Liu C, Liu W, Li D. Association between blood transfusion after kidney transplantation and risk for the development of de novo HLA donor-specific antibodies and poor clinical outcomes: A single-center retrospective study. Transpl Immunol 2023; 81:101930. [PMID: 37730183 DOI: 10.1016/j.trim.2023.101930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Blood transfusion after kidney transplantation may increase the risk of sensitization and development of de novo human leukocyte antigen (HLA) donor-specific antibodies (DSAs). This study aimed to evaluate whether blood transfusion during the first year after kidney transplantation influences the development of de novo DSAs and clinical outcomes of kidney transplantation recipients. METHODS This retrospective cohort study included nonsensitized first-time kidney transplantation recipients at Tianjin First Central Hospital from 2010 to 2022. The incidence of de novo DSA development and clinical outcomes between the groups were compared. Luminex single antigen beads were used to monitor DSAs. RESULTS Of the 538 non-HLA-sensitized kidney transplantation recipients included in the study, 164 patients who received at least one unit of leukoreduced red blood cell transfusion within the first year (the transfused group), whereas the remaining 374 patients received no blood transfusion (the non-transfused group). Our analysis showed that there was a significant difference in the development of de novo DSAs and de novo anti-class I HLA-Ab between the two groups. Indeed, the transfused recipients had a higher serum creatinine and lower estimated glomerular filtration rate (eGFR) at 1-, 6-, and 12-month (all p > 0.05) after transplantation. Futhermore, a higher incidence of CMV infection, antibody-mediated rejection (AMR), hyper acute rejection (HAR), and delayed graft function (DGF) was identified in the transfused group (all p < 0.05). The graft survival was lower in the transfused group compared with patients in the non-transfused group (P = 0.002). Blood transfusion post-transplantation was a risk factor for de novo DSAs development but not an independent predictive factor for AMR and graft loss (odds ratio = 2.064 [1.243-3.429], p = 0.005). CONCLUSIONS Our study showed that blood transfusion after transplantation is associated with the occurrence of de novo DSAs increasing an immunological risk for poor clinical outcomes for kidney transplantation recipients.
Collapse
Affiliation(s)
- Zhong-Yu Kang
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Chun Liu
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Wei Liu
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China
| | - Daihong Li
- Department of Blood Transfusion, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, Nankai, China.
| |
Collapse
|
5
|
van den Broek DAJ, Meziyerh S, Budde K, Lefaucheur C, Cozzi E, Bertrand D, López del Moral C, Dorling A, Emonds MP, Naesens M, de Vries APJ. The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice. Transpl Int 2023; 36:11321. [PMID: 37560072 PMCID: PMC10408721 DOI: 10.3389/ti.2023.11321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/22/2023] [Indexed: 08/11/2023]
Abstract
Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.
Collapse
Affiliation(s)
- Dennis A. J. van den Broek
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Soufian Meziyerh
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, Kidney Transplant Department, Saint Louis Hospital, Université de Paris Cité, Paris, France
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Dominique Bertrand
- Department of Nephrology, Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Covadonga López del Moral
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Valdecilla Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Anthony Dorling
- Department of Inflammation Biology, Centre for Nephrology, Urology and Transplantation, School of Immunology & Microbial Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory (HILA), Belgian Red Cross-Flanders, Mechelen, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Aiko P. J. de Vries
- Division of Nephrology, Department of Medicine, Leiden Transplant Center, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | | |
Collapse
|
6
|
Couzi L, Malvezzi P, Amrouche L, Anglicheau D, Blancho G, Caillard S, Freist M, Guidicelli GL, Kamar N, Lefaucheur C, Mariat C, Koenig A, Noble J, Thaunat O, Thierry A, Taupin JL, Bertrand D. Imlifidase for Kidney Transplantation of Highly Sensitized Patients With a Positive Crossmatch: The French Consensus Guidelines. Transpl Int 2023; 36:11244. [PMID: 37448448 PMCID: PMC10336835 DOI: 10.3389/ti.2023.11244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023]
Abstract
Imlifidase recently received early access authorization for highly sensitized adult kidney transplant candidates with a positive crossmatch against an ABO-compatible deceased donor. These French consensus guidelines have been generated by an expert working group, in order to homogenize patient selection, associated treatments and follow-up. This initiative is part of an international effort to analyze properly the benefits and tolerance of this new costly treatment in real-life. Eligible patients must meet the following screening criteria: cPRA ≥ 98%, ≤ 65-year of age, ≥ 3 years on the waiting list, and a low risk of biopsy-related complications. The final decision to use Imlifidase will be based on the two following criteria. First, the results of a virtual crossmatch on recent serum, which shall show a MFI for the immunodominant donor-specific antibodies (DSA) > 6,000 but the value of which does not exceed 5,000 after 1:10 dilution. Second, the post-Imlifidase complement-dependent cytotoxicity crossmatch must be negative. Patients treated with Imlifidase will receive an immunosuppressive regimen based on steroids, rATG, high dose IVIg, rituximab, tacrolimus and mycophenolic acid. Frequent post-transplant testing for DSA and systematic surveillance kidney biopsies are highly recommended to monitor post-transplant DSA rebound and subclinical rejection.
Collapse
Affiliation(s)
- Lionel Couzi
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- CNRS-UMR 5164 Immuno ConcEpT, Université de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | | | - Gilles Blancho
- Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | | | - Marine Freist
- Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | | | - Nassim Kamar
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Christophe Mariat
- Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Saint-Etienne, France
| | | | - Johan Noble
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | - Antoine Thierry
- Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | | | | |
Collapse
|
7
|
Alvares M, Anwar S, Hashmi SK, Zaman MB, Al Mahri A, Alvares C, Al Katheeri L, Purushothaman A, Ralonya ME, Sangalang MG, Jannang R, Abdulle A, Al Qubaisi A, Al Ahmed M, Khamis AH, Al Seiari M, Al Obaidli A, Al Yafei Z, ElGhazali G. Development of a calculated panel reactive antibody calculator for the United Arab Emirates: a proof of concept study. Sci Rep 2023; 13:8468. [PMID: 37231090 DOI: 10.1038/s41598-023-34860-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
Calculated panel reactive antibody (CPRA) is used to help increase sensitized patient's access to transplantation. United Arab Emirates (UAE) has a diverse resident population hence we developed a UAE-CPRA calculator based on HLA antigen frequencies of the different ethnic groups that represent the UAE population. HLA antigen frequencies at serological split antigen level for HLA-A, -B, -C, -DRB1 and -DQB1 of 1002 healthy unrelated donors were performed. We subsequently compared the performance of the UAE CPRA calculator with the Organ Procurement and Transplantation Network (OPTN) and the Canadian CPRA calculators in 110 Kidney Transplant waitlist patients from January 2016 to December 2018. Lin's concordance correlation coefficient showed a moderate agreement between the UAE and OPTN calculator (Rc = 0.949, 95% CI 0.929-0.963) and the UAE and Canadian calculators (Rc = 0.952, 95% CI 0.932-0.965). While there continued to be a moderate agreement (Rc = 0.937, UAE versus OPTN calculator) in the lower sensitized group, a poor agreement (Rc = 0.555, UAE versus OPTN calculator) was observed in the higher sensitized group. In this study, we provide a template for countries to develop their own population-specific CPRA calculator. Implementation of the CPRA algorithm based on HLA frequencies of the multi-ethnic UAE population will be more fitting to increase access to transplantation and improve transplant outcomes. Our study demonstrates that the CPRA calculators developed using the data from the western population had poor correlation in our higher sensitized patients disadvantaging them in potential organ allocations systems. We plan to further refine this calculator by using high resolution HLA typing to address the problem of a genetically diverse population.
Collapse
Affiliation(s)
- Marion Alvares
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Siddiq Anwar
- Department of Medicine, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Shahrukh K Hashmi
- Department of Medicine, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Clinical Affairs, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Muhammad Badar Zaman
- Renal Transplant Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ayeda Al Mahri
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | - Layla Al Katheeri
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | - Mesele Emily Ralonya
- Renal Transplant Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Marie Glo Sangalang
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Raysha Jannang
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Abdulkadir Abdulle
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Alyazia Al Qubaisi
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Maitha Al Ahmed
- Renal Transplant Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Amar Hassan Khamis
- Mohamed Bin Rashed University of Medicine and Medical Sciences, Dubai, United Arab Emirates
| | - Mohamed Al Seiari
- Renal Transplant Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | | | - Zain Al Yafei
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Gehad ElGhazali
- Transplant Immunology section, Sheikh Khalifa Medical City, Union71 - Purehealth, Abu Dhabi and College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
| |
Collapse
|
8
|
Hug MN, Keller S, Marty T, Gygax D, Meinel D, Spies P, Handschin J, Kleiser M, Vazquez N, Linnik J, Buchli R, Claas F, Heidt S, Kramer CSM, Bezstarosti S, Lee JH, Schaub S, Hönger G. HLA antibody affinity determination: From HLA-specific monoclonal antibodies to donor HLA specific antibodies (DSA) in patient serum. HLA 2023. [PMID: 37191252 DOI: 10.1111/tan.15047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/08/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023]
Abstract
Organs transplanted across donor-specific HLA antibodies (DSA) are associated with a variety of clinical outcomes, including a high risk of acute kidney graft rejection. Unfortunately, the currently available assays to determine DSA characteristics are insufficient to clearly discriminate between potentially harmless and harmful DSA. To further explore the hazard potential of DSA, their concentration and binding strength to their natural target, using soluble HLA, may be informative. There are currently a number of biophysical technologies available that allow the assessment of antibody binding strength. However, these methods require prior knowledge of antibody concentrations. Our objective within this study was to develop a novel approach that combines the determination of DSA-affinity as well as DSA-concentration for patient sample evaluation within one assay. We initially tested the reproducibility of previously reported affinities of human HLA-specific monoclonal antibodies and assessed the technology-specific precision of the obtained results on multiple platforms, including surface plasmon resonance (SPR), bio-layer interferometry (BLI), Luminex (single antigen beads; SAB), and flow-induced dispersion analysis (FIDA). While the first three (solid-phase) technologies revealed comparable high binding-strengths, suggesting measurement of avidity, the latter (in-solution) approach revealed slightly lower binding-strengths, presumably indicating measurement of affinity. We believe that our newly developed in-solution FIDA-assay is particularly suitable to provide useful clinical information by not just measuring DSA-affinities in patient serum samples but simultaneously delivering a particular DSA-concentration. Here, we investigated DSA from 20 pre-transplant patients, all of whom showed negative CDC-crossmatch results with donor cells and SAB signals ranging between 571 and 14899 mean fluorescence intensity (MFI). DSA-concentrations were found in the range between 11.2 and 1223 nM (median 81.1 nM), and their measured affinities fall between 0.055 and 24.7 nM (median 5.34 nM; 449-fold difference). In 13 of 20 sera (65%), DSA accounted for more than 0.1% of total serum antibodies, and 4/20 sera (20%) revealed a proportion of DSA even higher than 1%. To conclude, this study strengthens the presumption that pre-transplant patient DSA consists of various concentrations and different net affinities. Validation of these results in a larger patient cohort with clinical outcomes will be essential in a further step to assess the clinical relevance of DSA-concentration and DSA-affinity.
Collapse
Affiliation(s)
- Melanie N Hug
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Sabrina Keller
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Talea Marty
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Daniel Gygax
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Dominik Meinel
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Peter Spies
- University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences Muttenz, Muttenz, Switzerland
| | - Joëlle Handschin
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Marc Kleiser
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Noemi Vazquez
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Janina Linnik
- Department of Biomedicine, University of Basel, Basel, Switzerland
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
- Swiss Institute for Bioinformatics, Basel, Switzerland
| | - Rico Buchli
- Department of Research and Development, PureProtein LLC, Oklahoma City, Oklahoma, USA
| | - Frans Claas
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cynthia S M Kramer
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Bezstarosti
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jar-How Lee
- Research Department, Terasaki Innovation Center (TIC), Glendale, California, USA
| | - Stefan Schaub
- Department of Biomedicine, University of Basel, Basel, Switzerland
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Gideon Hönger
- Department of Biomedicine, University of Basel, Basel, Switzerland
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
9
|
Daga S, Briggs D. Defining the lower and upper limits of immunological risk of HLA antibody incompatible kidney transplantation: Current state of the art and limitations. Transpl Immunol 2023; 76:101775. [PMID: 36528247 DOI: 10.1016/j.trim.2022.101775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Sunil Daga
- Renal Department, St James's University Hospital, Leeds, United Kingdom; NIHR Leeds In-Vitro Diagnostics Co-operative, Leeds, United Kingdom.
| | - David Briggs
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| |
Collapse
|
10
|
Karpman D, Bekassy Z, Grunenwald A, Roumenina LT. A role for complement blockade in kidney transplantation. Cell Mol Immunol 2022; 19:755-757. [PMID: 35332298 PMCID: PMC9243002 DOI: 10.1038/s41423-022-00854-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 11/09/2022] Open
|
11
|
Alloreactive memory B cell detection by flow cytometric cross match using polyclonally activated memory B cell culture supernatants. Transpl Immunol 2022; 73:101642. [PMID: 35667546 DOI: 10.1016/j.trim.2022.101642] [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: 02/10/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/23/2022]
Abstract
In addition to alloantibodies, alloreactive memory B cell (mBC) evaluation has a potential for immunological risk assessment during transplantation processes. For the alloreactive mBCs evaluation currently, direct Flow Cytometric (FC) analysis using the HLA tetramer staining is an option. Evaluation of alloantibodies produced by the polyclonally stimulated alloreactive mBCs in in vitro culture system seems to be another useful approach, but this needs further downstream applications. In this study, we investigated the usefulness of the Flow Cytometric Cross Match (FCXM-supernatant) in which in vitro polyclonally activated mBCs culture supernatants and potential donor's lymphocytes being used for the mBC detection. FCXM-supernatant assays were performed between culture supernatants of polyclonally activated mBCs obtained from 4 allosensitized multiparous women and 14 renal transplant patients, and their non-alloimmunized spouses' or donors' lymphocytes, and vice versa. HLA typing was performed by SSP method. Anti-HLA antibodies produced by in vitro activated alloreactive mBCs were also evaluated by the Luminex assays. The success of in vitro polyclonal activation of mBCs was evaluated by a total IgG ELISA test and antibody secreting cell analyses by FC. Donor specific alloreactive mBCs were detected by FCXM-supernatant in 45% of the 18 allosensitized cases. Detection rate was 85% (6 out of 7) in the strongly allosensitized cases. No alloreactive mBCs was detected in control cases without allosensitization. FCXM-supernatant negative results of the allosensitized cases were related to low level of allosensitization and insufficient polyclonal stimulation evaluated by total IgG antibody tests of the supernatants. We herein report a practical methodology for alloreactive mBC detection as a donor specific manner using the FCXM-supernatant assay so that this would easily be transformed into a routine test performed in tissue typing laboratories.
Collapse
|
12
|
Phillpott M, Daga S, Higgins R, Lowe D, Krishnan N, Zehnder D, Briggs D, Khovanova N. Dynamic Behaviour of Donor Specific Antibodies in the Early Period Following HLA Incompatible Kidney Transplantation. Transpl Int 2022; 35:10128. [PMID: 35516975 PMCID: PMC9062976 DOI: 10.3389/ti.2022.10128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/03/2022] [Indexed: 11/24/2022]
Abstract
In HLA-incompatible kidney transplantation, monitoring donor-specific antibodies (DSA) plays a crucial role in providing appropriate treatment and increases kidney survival times. This work aimed to determine if early post-transplant DSA dynamics inform graft outcome over and above other predictive factors. Eighty-eight cases were classified by unsupervised machine learning into five distinct DSA response groups: no response, fast modulation, slow modulation, rise to sustained and sustained. Fast modulation dynamics gave an 80% rate for early acute rejection, whereas the sustained group was associated with the lowest rejection rates (19%). In complete contrast, the five-year graft failure was lowest in the modulation groups (4–7%) and highest in the sustained groups (25–31%). Multivariable analysis showed that a higher pre-treatment DSA level, male gender and absence of early acute rejection were strongly associated with a sustained DSA response. The modulation group had excellent five-year outcomes despite higher rates of early rejection episodes. This work further develops an understanding of post-transplant DSA dynamics and their influence on graft survival following HLA-incompatible kidney transplantation.
Collapse
Affiliation(s)
- Mason Phillpott
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Sunil Daga
- St James's University Hospital, LTHT NHS Trust, Leeds, United Kingdom.,Warwick Medical School, University of Warwick, Coventry, United Kingdom.,NIHR Leeds In-Vitro Diagnostics Co-operative, Leeds, United Kingdom
| | - Rob Higgins
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - David Lowe
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, United Kingdom
| | - Nithya Krishnan
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Daniel Zehnder
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,North Cumbria Integrated Care NHS Trust, Carlisle, Cumbria, United Kingdom
| | - David Briggs
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, United Kingdom.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Natalia Khovanova
- School of Engineering, University of Warwick, Coventry, United Kingdom
| |
Collapse
|
13
|
Cornell LD. Histopathologic Features of Antibody Mediated Rejection: The Banff Classification and Beyond. Front Immunol 2021; 12:718122. [PMID: 34646262 PMCID: PMC8503253 DOI: 10.3389/fimmu.2021.718122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/07/2021] [Indexed: 01/27/2023] Open
Abstract
Antibody mediated rejection (ABMR) in the kidney can show a wide range of clinical presentations and histopathologic patterns. The Banff 2019 classification currently recognizes four diagnostic categories: 1. Active ABMR, 2. Chronic active ABMR, 3. Chronic (inactive) ABMR, and 4. C4d staining without evidence of rejection. This categorization is limited in that it does not adequately represent the spectrum of antibody associated injury in allograft, it is based on biopsy findings without incorporating clinical features (e.g., time post-transplant, de novo versus preformed DSA, protocol versus indication biopsy, complement inhibitor drugs), the scoring is not adequately reproducible, and the terminology is confusing. These limitations are particularly relevant in patients undergoing desensitization or positive crossmatch kidney transplantation. In this article, I discuss Banff criteria for these ABMR categories, with a focus on patients with pre-transplant DSA, and offer a framework for considering the continuum of allograft injury associated with donor specific antibody in these patients.
Collapse
Affiliation(s)
- Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
14
|
C3 complement inhibition prevents antibody-mediated rejection and prolongs renal allograft survival in sensitized non-human primates. Nat Commun 2021; 12:5456. [PMID: 34526511 PMCID: PMC8443599 DOI: 10.1038/s41467-021-25745-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 08/24/2021] [Indexed: 12/20/2022] Open
Abstract
Sensitized kidney transplant recipients experience high rates of antibody-mediated rejection due to the presence of donor-specific antibodies and immunologic memory. Here we show that transient peri-transplant treatment with the central complement component C3 inhibitor Cp40 significantly prolongs median allograft survival in a sensitized nonhuman primate model. Despite donor-specific antibody levels remaining high, fifty percent of Cp40-treated primates maintain normal kidney function beyond the last day of treatment. Interestingly, presence of antibodies of the IgM class associates with reduced median graft survival (8 vs. 40 days; p = 0.02). Cp40 does not alter lymphocyte depletion by rhesus-specific anti-thymocyte globulin, but inhibits lymphocyte activation and proliferation, resulting in reduced antibody-mediated injury and complement deposition. In summary, Cp40 prevents acute antibody-mediated rejection and prolongs graft survival in primates, and inhibits T and B cell activation and proliferation, suggesting an immunomodulatory effect beyond its direct impact on antibody-mediated injury. Donor-specific antibodies in sensitized recipients may cause kidney transplant rejection. Here the authors show that complement component C3 inhibition prolongs graft survival by inhibiting T and B cell proliferation/activation and hence tissue injury, despite antibody levels remaining unaffected.
Collapse
|
15
|
Schinstock C, Tambur A, Stegall M. Current Approaches to Desensitization in Solid Organ Transplantation. Front Immunol 2021; 12:686271. [PMID: 34046044 PMCID: PMC8144637 DOI: 10.3389/fimmu.2021.686271] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Major advancements in the development of HLA antibody detection techniques and our understanding of the outcomes of solid organ transplant in the context of HLA antibody have occurred since the relevance of sensitization was first recognized nearly 50 years ago. Additionally, kidney paired donation programs (KPD) have become widespread, deceased donor allocation policies have changed, and several new therapeutic options have become available with promise to reduce HLA antibody. In this overview we aim to provide thoughtful guidance about when desensitization in kidney transplantation should be considered taking into account the outcomes of HLA incompatible transplantation. Novel therapeutics, desensitization endpoints, and strategies for future study will also be discussed. While most of our understanding about desensitization comes from studying kidney transplant candidates and recipients, many of the concepts discussed can be easily applied to desensitization in all of solid organ transplantation.
Collapse
Affiliation(s)
- Carrie Schinstock
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Anat Tambur
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Mark Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
16
|
Franz BJ, Petraroia R, Faust CD, Crawford T, Smalls S, Vongsavanh C, Gibson K, Schmitz JL. Abrogating biologics interference in flow cytometric crossmatching. Hum Immunol 2021; 82:574-580. [PMID: 33934934 DOI: 10.1016/j.humimm.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
The flow cytometric crossmatch is currently the gold standard for evaluating donor and recipient histocompatibility. The assay however does have limitations and is sensitive to false positive reactions resulting from the presence of non-HLA antibodies or therapy related immune biologics. Such false positive reactions can lead to the inappropriate decline of an acceptable donor organ or unnecessary therapeutic intervention. Here we describe the successful validation of anti-idiotype blocking antibodies in prevention of false positive flow crossmatch results caused by biologic therapy. Blocking antibodies specific for the Fab portion of Rituximab and/or Alemtuzumab were incubated with biologic containing patient serum prior to use in flow cytometric crossmatching. Biologic blocking successfully negated false positive crossmatch results with Rituximab (B cell ave. % change = -97%) or Alemtuzumab (T cell ave. % change = -99%, B cell ave. % change = -95%) infused sera respectively. Simultaneous blocking of these biologics was also successful. A complex case is presented to demonstrate the application of this procedure.
Collapse
Affiliation(s)
- Brian J Franz
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Rosanne Petraroia
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Cynthia D Faust
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Tricia Crawford
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Shari Smalls
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Candy Vongsavanh
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA
| | - Keisha Gibson
- Division Pediatric Nephrology, Department of Pediatrics, UNC School of Medicine, Chapel Hill, NC, USA
| | - John L Schmitz
- Histocompatibility Laboratory, McLendon Clinical Laboratories, UNC Hospitals, Chapel Hill, NC, USA; Department of Pathology & Laboratory Medicine, UNC School of Medicine, Chapel Hill, NC, USA.
| |
Collapse
|
17
|
Bestard O, Couzi L, Crespo M, Kessaris N, Thaunat O. Stratifying the humoral risk of candidates to a solid organ transplantation: a proposal of the ENGAGE working group. Transpl Int 2021; 34:1005-1018. [PMID: 33786891 DOI: 10.1111/tri.13874] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022]
Abstract
Detection of circulating antibodies directed against human leukocyte antigen (HLA) molecules, which corresponds to the current definition of 'sensitized patient', has been shown to have a severe impact on both access to transplantation and, if the anti-HLA antibodies are specific to the selected donor, survival of the graft. However, not all donor-specific antibodies (DSA) are equally harmful to the graft and progress in the understanding of humoral memory has led to the conclusion that absence of DSA at transplantation does not rule out the possibility that the patient has a preformed cellular humoral memory against the graft (thereby defining a category of DSA-negative sensitized recipients). Technological progress has led to the generation of new assays that offer unprecedented precision in exploring the different layers (serological and cellular) of alloimmune humoral memory. Based on this recent knowledge, the EuropeaN Guidelines for the mAnagement of Graft rEcipients (ENGAGE) working group to propose an updated definition of sensitization in candidates for solid organ transplantation - one that moves away from the current binary division towards a definition based on homogenous strata with similar humoral risk.
Collapse
Affiliation(s)
- Oriol Bestard
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain.,Bellvitge Research Institute (IDIBELL), Barcelona, Spain
| | - Lionel Couzi
- Nephrology-Transplantation-Dialysis, CHU Bordeaux, Bordeaux, France.,CNRS-UMR 5164 Immuno ConcEpT, Bordeaux University, Bordeaux, France
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Nephropathies Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK.,King's College London, London, UK
| | - Olivier Thaunat
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hôpital Edouard Herriot, Lyon, France.,Université Claude-Bernard Lyon I, Lyon, France.,Institut National de la Santé et de la Recherche Médicale U1111, Lyon, France
| |
Collapse
|
18
|
Tan X, Feng H, Guo Z, Wang L, Fu C, Sun L, Li Y, Xia Q, Hou L, Liu C, Zhu L, Chen G. Rabbit antithymocyte globulin induces human lymphocyte activation, proliferation, and apoptosis in the absence of complement: an experimental study. Transpl Int 2021; 34:930-941. [PMID: 33725365 DOI: 10.1111/tri.13864] [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: 12/09/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Abstract
Rabbit antithymocyte globulin (rATG) has become the first choice for induction therapy in HLA-presensitized patients undergoing organ transplantation. Meanwhile, complement inhibitors have been approved for preventing or treating antibody-mediated rejection in these patients. The biological effects of rATG on lymphocytes in cases of complement deficiency or significant inhibition are not yet clear. We measured lymphocyte activation, proliferation, and apoptosis in response to rATG treatment in the absence of complement. T-cell subsets were analyzed transcriptomically features to rATG stimulation. Activation-related phenotypes on T cells were determined in patients after rATG administration. We found that rATG treatment led to lymphocyte activation and proliferation in vitro without the addition of complement. A dose-dependent apoptosis in rATG-treated lymphocytes was detected, which was partially caspase-3-dependent but Fas/FasL-independent. T cells were more sensitive to rATG stimulation than were non-T cells. Both CD4+ T cells and CD8+ T cells upregulated a series of genes related to cell activation, cytokine production and apoptosis to rATG stimulation. CD69 and CD25 levels in surviving T cells were increased in patients after rATG administration. These findings indicate that rATG can stimulate lymphocyte activation, proliferation, and apoptosis in the absence of complement. Biologic effects of rATG other than complement-dependent cytotoxicity need to be concerned.
Collapse
Affiliation(s)
- Xiaosheng Tan
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Hao Feng
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiliang Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Cheng Fu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingjuan Sun
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yakun Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiangbing Xia
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Hou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| |
Collapse
|
19
|
Aziz F, Tiwari A, Patel H, Chauhan R. Pretransplant histocompatibility testing algorithm: Laboratory and clinical approach in the Indian context. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_82_20] [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
|
20
|
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]
|
21
|
Schwotzer N, Paganetti G, Barchi M, Perrottet N, Aubert V, Sadallah S, Rotman S, Venetz JP, Matter M, Golshayan D, Pascual M. Upfront use of eculizumab to treat early acute antibody-mediated rejection after kidney allotransplantation and relevance for xenotransplantation. Xenotransplantation 2020; 27:e12630. [PMID: 32698246 DOI: 10.1111/xen.12630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 01/08/2023]
Abstract
Acute antibody-mediated rejection (AMR) early after transplant remains a challenge, both in allotransplantation and in xenotransplantation. We report the case of an early and severe acute AMR episode in a kidney transplant recipient that was successfully treated with upfront eculizumab. A 58-year-old woman had been on dialysis since 2014. She underwent a first kidney transplant in 2018 with primary non-function and received several blood transfusions. Postoperatively, she developed anti-HLA antibodies. One year later, she received a second allograft from a deceased donor. At day 0, there was only one preformed low-level donor-specific antibody (DSA) anti-DQ7. After initial excellent allograft function, serum creatinine increased on days 7-9, and this was associated with oligo-anuria. On day 7, there was an increase in her DSA anti-DQ7 and 4 de novo DSA had developed at high MFI values. Allograft biopsy showed severe active AMR with diffuse C4d deposits in peritubular capillaries. The early acute AMR episode was treated with upfront eculizumab administration (2 doses) with efficient CH50 blockade (< 10% CH50). Rituximab was also administered on day 12, and intravenous immunoglobulin (IVIG) was given over the following days. There was an excellent clinical response to eculizumab administration. Eculizumab administration rapidly reversed the acute AMR episode without the need for plasmapheresis. Rituximab and IVIG were also used as B-cell immunomodulators to decrease DSA. Blocking efficiently the terminal complement pathway may become a useful strategy to treat acute AMR in sensitized recipients of allografts, and possibly in recipients of discordant xenografts.
Collapse
Affiliation(s)
- Nora Schwotzer
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Giulia Paganetti
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Matteo Barchi
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Nancy Perrottet
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Salima Sadallah
- Service of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Samuel Rotman
- Service of clinical Pathology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Jean-Pierre Venetz
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Maurice Matter
- Visceral Surgery Department, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Dela Golshayan
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
22
|
Association of Antibody-Secreting Cells With Allograft Rejection After Renal Transplantation. Transplant Proc 2020; 52:1729-1733. [DOI: 10.1016/j.transproceed.2019.12.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/06/2019] [Indexed: 12/20/2022]
|
23
|
Wehmeier C, Karahan GE, Heidt S. HLA-specific memory B-cell detection in kidney transplantation: Insights and future challenges. Int J Immunogenet 2020; 47:227-234. [PMID: 32390325 PMCID: PMC7317812 DOI: 10.1111/iji.12493] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/27/2020] [Accepted: 04/14/2020] [Indexed: 12/12/2022]
Abstract
Humoral alloimmunity mediated by anti‐human leucocyte antigen (HLA) antibodies is a major challenge in kidney transplantation and impairs the longevity of the transplanted organ. The immunological risk of an individual patient is currently mainly assessed by detection of HLA antibodies in the serum, which are produced by long‐lived bone marrow‐residing plasma cells. However, humoral alloimmunity is complex, and alloreactive memory B cells constitute an additional factor in the interplay of immune cells. These recirculating “silent” cells are responsible for the immunological recall response by differentiating into antibody‐producing cells upon antigen re‐encounter. Historically, due to the lack of appropriate and routinely applicable assays to determine the presence and HLA specificity of alloreactive memory B cells, their contribution to the humoral alloimmune response has clinically often been suspected but could not be determined. In this review, we give an overview of recent advances in techniques to detect alloreactive memory B cells and discuss their strengths and limitations. Furthermore, we summarize experiences with these techniques in alloimmunized individuals and transplant recipients, thereby emphasizing unmet needs to be addressed in future studies.
Collapse
Affiliation(s)
- Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Gonca E Karahan
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
24
|
Donor-specific B Cell Memory in Alloimmunized Kidney Transplant Recipients: First Clinical Application of a Novel Method. Transplantation 2020; 104:1026-1032. [DOI: 10.1097/tp.0000000000002909] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
25
|
Pandey P, Setya D, Sinha V, Bhatt A, Devra A, Pande A, Kumar P, Ranjan S. Renal transplantation in HLA sensitized patients: Traversing the immunological barrier. Ther Apher Dial 2019; 24:578-590. [PMID: 31863544 DOI: 10.1111/1744-9987.13467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/23/2019] [Accepted: 12/19/2019] [Indexed: 11/27/2022]
Abstract
Successful renal transplantation across HLA barrier in sensitized individuals has been on the rise during the past decade, primarily due to improved desensitization regimes. The aim of this study was to share outcome of desensitization in renal transplant recipients with donor-specific anti-HLA antibodies (DSA). This was a retrospective analysis of all HLA immunized individuals who were prospective renal transplant recipients. All such patients underwent preconditioning as per the institutional desensitization protocol. Complement-dependent cytoxicity-based crossmatch (CDC-XM), luminex-based crossmatch (LM-XM) and flowcytometry-based crossmatch (FC-XM) were done in all cases. If any of these tests turned out positive, single antigen bead assay (SAB) was performed. Desensitization for DSA was performed in 55 patients and all patients were followed-up for 1 year to assess graft function and patient outcome. CDC-XM being a less sensitive assay, could not detect incompatibility in 29 (52.73%) cases. After desensitization, even though SAB and LM-XM results revealed an MFI within acceptable range, FC-XM being an extremely sensitive assay, continued to give a positive result in eight (14.55%) cases. The mean ± SD number of pretransplant TPE were 3.44 ± 0.98 (2-11). Out of 55, there were 10 patients who were lost to follow up. Patient and graft survival of 45 patients at 1 year was found to be 100%. Preconditioning for renal transplants in the form of immunosuppression with TPE is an extremely useful auxiliary for transplantation in HLA sensitized renal transplant recipients.
Collapse
Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| |
Collapse
|
26
|
Tan EK, Bentall AJ, Dean PG, Shaheen MF, Stegall MD, Schinstock CA. Use of Eculizumab for Active Antibody-mediated Rejection That Occurs Early Post-kidney Transplantation: A Consecutive Series of 15 Cases. Transplantation 2019; 103:2397-2404. [PMID: 30801549 PMCID: PMC6699919 DOI: 10.1097/tp.0000000000002639] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Active antibody-mediated rejection (AMR) that occurs during the amnestic response within the first month posttransplant is a rare but devastating cause of early allograft loss after kidney transplant. Prior reports of eculizumab treatment for AMR have been in heterogeneous patient groups needing salvage therapy or presenting at varied time points. We investigated the role of eculizumab as primary therapy for active AMR early posttransplant. METHODS We performed a retrospective observational study of a consecutive cohort of solitary kidney transplant recipients who were transplanted between January 1, 2014, and January 31, 2018, and had AMR within the first 30 days posttransplant and treated with eculizumab ± plasmapheresis. RESULTS Fifteen patients had early active AMR at a median (interquartile range [IQR]) of 10 (7-11) days posttransplant and were treated with eculizumab ± plasmapheresis. Thirteen cases were biopsy proven, and 2 cases were presumed on the basis of donor-specific antibody trends and allograft function. Within 1 week of treatment, the median estimated glomerular filtration rate increased from 21 to 34 mL/min (P = 0.001); and persistent active AMR was only found in 16.7% (2/12) of biopsied patients within 4-6 months. No graft losses occurred, and at last follow-up (median [IQR] of 13 [12-19] mo), the median IQR estimated glomerular filtration rate increased to 52 (46-60) mL/min. CONCLUSIONS Prompt eculizumab treatment as primary therapy is safe and effective for early active AMR after kidney transplant or abrupt increases in donor-specific antibodies when biopsy cannot be performed for diagnosis confirmation.
Collapse
Affiliation(s)
- Ek Khoon Tan
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew J. Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Patrick G. Dean
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | | | - Mark D. Stegall
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
27
|
Senev A, Lerut E, Van Sandt V, Coemans M, Callemeyn J, Sprangers B, Kuypers D, Emonds MP, Naesens M. Specificity, strength, and evolution of pretransplant donor-specific HLA antibodies determine outcome after kidney transplantation. Am J Transplant 2019; 19:3100-3113. [PMID: 31062492 DOI: 10.1111/ajt.15414] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/26/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023]
Abstract
In this cohort study (N = 924), we investigated the evolution and clinical significance of pretransplant donor-specific HLA antibodies (preDSA), detected in the single-antigen beads assay but complement-dependent cytotoxicity crossmatch-negative. Donor specificity of the preDSA (N = 107) was determined by high-resolution genotyping of donor-recipient pairs. We found that in 52% of the patients with preDSA, preDSA spontaneously resolved within the first 3 months posttransplant. PreDSA that persisted posttransplant had higher pretransplant median fluorescence intensity values and more specificity against DQ. Patients with both resolved and persistent DSA had a high incidence of histological picture of antibody-mediated rejection (ABMRh ; 54% and 59% respectively). Patients with preDSA that persisted posttransplant had worse 10-year graft survival compared to resolved DSA and preDSA-negative patients. Compared to cases without preDSA, Cox modeling revealed an increased risk of graft failure only in the patients with persistent DSA, in the presence (hazard ratio [HR] = 8.3) but also in the absence (HR = 4.3) of ABMRh . In contrast, no increased risk of graft failure was seen in patients with resolved DSA. We conclude that persistence of preDSA posttransplant has a negative impact on graft survival, beyond ABMRh . Even in the absence of antibody-targeting therapy, low median fluorescence intensity DSA and non-DQ preDSA often disappear early posttransplantation and are not deleterious for graft outcome.
Collapse
Affiliation(s)
- Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Evelyne Lerut
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Vicky Van Sandt
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
28
|
Tatapudi VS, Montgomery RA. Therapeutic Modulation of the Complement System in Kidney Transplantation: Clinical Indications and Emerging Drug Leads. Front Immunol 2019; 10:2306. [PMID: 31632397 PMCID: PMC6779821 DOI: 10.3389/fimmu.2019.02306] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/12/2019] [Indexed: 12/20/2022] Open
Abstract
The complement system is integral to innate immunity, and it is an essential deterrent against infections. The complement apparatus comprises of >30 fluid-phase and surface-bound elements that also engage with the adaptive immune system, clear harmful immune complexes, and orchestrates several salutary physiological processes. An imbalance in the complement system's tightly regulated machinery and the consequent unrestrained complement activation underpins the pathogenesis of a wide array of inflammatory, autoimmune, neoplastic and degenerative disorders. Antibody-mediated rejection is a leading cause of graft failure in kidney transplantation. Complement-induced inflammation and endothelial injury have emerged as the primary mechanisms in the pathogenesis of this form of rejection. Researchers in the field of transplantation are now trying to define the role and efficacy of complement targeting agents in the prevention and treatment of rejection and other complement related conditions that lead to graft injury. Here, we detail the current clinical indications for complement therapeutics and the scope of existing and emerging therapies that target the complement system, focusing on kidney transplantation.
Collapse
|
29
|
Marks WH, Mamode N, Montgomery RA, Stegall MD, Ratner LE, Cornell LD, Rowshani AT, Colvin RB, Dain B, Boice JA, Glotz D. Safety and efficacy of eculizumab in the prevention of antibody-mediated rejection in living-donor kidney transplant recipients requiring desensitization therapy: A randomized trial. Am J Transplant 2019; 19:2876-2888. [PMID: 30887675 PMCID: PMC6790671 DOI: 10.1111/ajt.15364] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 01/25/2023]
Abstract
We report results of a phase 2, randomized, multicenter, open-label, two-arm study evaluating the safety and efficacy of eculizumab in preventing acute antibody-mediated rejection (AMR) in sensitized recipients of living-donor kidney transplants requiring pretransplant desensitization (NCT01399593). In total, 102 patients underwent desensitization. Posttransplant, 51 patients received standard of care (SOC) and 51 received eculizumab. The primary end point was week 9 posttransplant treatment failure rate, a composite of: biopsy-proven acute AMR (Banff 2007 grade II or III; assessed by blinded central pathology); graft loss; death; or loss to follow-up. Eculizumab was well tolerated with no new safety concerns. No significant difference in treatment failure rate was observed between eculizumab (9.8%) and SOC (13.7%; P = .760). To determine whether data assessment assumptions affected study outcome, biopsies were reanalyzed by central pathologists using clinical information. The resulting treatment failure rates were 11.8% and 21.6% for the eculizumab and SOC groups, respectively (nominal P = .288). When reassessment included grade I AMR, the treatment failure rates were 11.8% (eculizumab) and 29.4% (SOC; nominal P = .048). This finding suggests a potential benefit for eculizumab compared with SOC in preventing acute AMR in recipients sensitized to their living-donor kidney transplants (EudraCT 2010-019630-28).
Collapse
Affiliation(s)
- William H. Marks
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent ConsultantBellevueWashington
| | - Nizam Mamode
- Department of Transplant SurgeryGuy's and St Thomas’Evelina London Children's and Great Ormond Street Hospitals NHS TrustLondonUK
| | - Robert A. Montgomery
- NYU Langone Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Mark D. Stegall
- The William J. von Liebig Center for Transplantation and Clinical Regeneration and Division of Transplantation SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesota
| | | | - Lynn D. Cornell
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesota
| | - Ajda T. Rowshani
- Department of Internal MedicineSection of Nephrology and TransplantationErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Robert B. Colvin
- Department of PathologyHarvard Medical SchoolMassachusetts General HospitalBostonMassachusetts
| | - Bradley Dain
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent statistics consultantGuilfordConnecticut
| | | | - Denis Glotz
- Paris Translational Research Center for Organ TransplantationInstitut National de la Santé et de la Recherche MédicaleUnité Mixte de Recherche‐S970ParisFrance,Department of Nephrology and Organ TransplantationSaint‐Louis HospitalAssistance Publique‐Hôpitaux de ParisInstitut National de la Santé et de la Recherche MédicaleUnité U1160ParisFrance
| | | |
Collapse
|
30
|
Glotz D, Russ G, Rostaing L, Legendre C, Tufveson G, Chadban S, Grinyó J, Mamode N, Rigotti P, Couzi L, Büchler M, Sandrini S, Dain B, Garfield M, Ogawa M, Richard T, Marks WH. Safety and efficacy of eculizumab for the prevention of antibody-mediated rejection after deceased-donor kidney transplantation in patients with preformed donor-specific antibodies. Am J Transplant 2019; 19:2865-2875. [PMID: 31012541 PMCID: PMC9328661 DOI: 10.1111/ajt.15397] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/17/2019] [Accepted: 04/04/2019] [Indexed: 01/25/2023]
Abstract
The presence of preformed donor-specific antibodies in transplant recipients increases the risk of acute antibody-mediated rejection (AMR). Results of an open-label single-arm trial to evaluate the safety and efficacy of eculizumab in preventing acute AMR in recipients of deceased-donor kidney transplants with preformed donor-specific antibodies are reported. Participants received eculizumab as follows: 1200 mg immediately before reperfusion; 900 mg on posttransplant days 1, 7, 14, 21, and 28; and 1200 mg at weeks 5, 7, and 9. All patients received thymoglobulin induction therapy and standard maintenance immunosuppression including steroids. The primary end point was treatment failure rate, a composite of biopsy-proved grade II/III AMR (Banff 2007 criteria), graft loss, death, or loss to follow-up, within 9 weeks posttransplant. Eighty patients received transplants (48 women); the median age was 52 years (range 24-70 years). Observed treatment failure rate (8.8%) was significantly lower than expected for standard care (40%; P < .001). By 9 weeks, 3 of 80 patients had experienced AMR, and 4 of 80 had experienced graft loss. At 36 months, graft and patient survival rates were 83.4% and 91.5%, respectively. Eculizumab was well tolerated and no new safety concerns were identified. Eculizumab has the potential to provide prophylaxis against injury caused by acute AMR in such patients (EudraCT 2010-019631-35).
Collapse
Affiliation(s)
- Denis Glotz
- Paris Translational Research Center for Organ TransplantationInstitut National de la Santé et de la Recherche MédicaleUnité Mixte de Recherche‐S970ParisFrance,Department of Nephrology and Organ TransplantationSaint‐Louis HospitalAssistance Publique‐Hôpitaux de ParisInstitut National de la Santé et de la Recherche MédicaleUnité U1160ParisFrance
| | - Graeme Russ
- Central and Northern Adelaide Renal and Transplantation ServicesRoyal Adelaide Hospital and University of AdelaideAdelaideSouth AustraliaAustralia
| | - Lionel Rostaing
- Formerly Department of Nephrology and Organ TransplantationRangueil University Hospital CenterToulouseFrance,Department of NephrologyHemodialysis, Apheresis and TransplantationGrenoble‐Alpes University Hospital CenterAvenue du Maquis du GrésivaudanLa TroncheFrance
| | - Christophe Legendre
- Adult Nephrology Transplantation ServiceHôpital Necker‐Enfants MaladesUniversité Paris DescartesSorbonne Paris CitéParisFrance,Institut National de la Santé et de la Recherche Médicale U1151Institut Necker‐Enfants MaladesHôpital Necker‐Enfants MaladesParisFrance
| | - Gunnar Tufveson
- Section of Transplantation SurgeryDepartment of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Steve Chadban
- Department of Renal MedicineRoyal Prince Alfred HospitalUniversity of SydneySydneyNew South WalesAustralia
| | - Josep Grinyó
- Department of NephrologyHospital Universitari de BellvitgeUniversity of BarcelonaBarcelonaSpain
| | - Nizam Mamode
- Department of Transplant SurgeryGuy's and St Thomas’, Evelina London Children's and Great Ormond Street Hospitals NHS TrustLondonUK
| | - Paolo Rigotti
- Kidney and Pancreas Transplant UnitUniversity Hospital of PaduaPaduaItaly
| | - Lionel Couzi
- UMR CNRS 5164ImmunoConcEpTBordeaux UniversityBordeauxFrance,Department of Nephrology–Transplantation–Dialysis–ApheresisCHUBordeauxFrance
| | | | - Silvio Sandrini
- Division of NephrologyUniversity of Brescia and Spedali Civili General HospitalBresciaItaly
| | - Bradley Dain
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent Statistics ConsultantGuilfordConnecticut
| | - Mary Garfield
- Formerly Alexion PharmaceuticalsBostonMassachusetts,ArvinasNew HavenConnecticut
| | | | | | - William H. Marks
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent ConsultantBellevueWashington
| | | |
Collapse
|
31
|
Abstract
The human major histocompatibility complex is a family of genes that encodes HLAs, which have a crucial role in defence against foreign pathogens and immune surveillance of tumours. In the context of transplantation, HLA molecules are polymorphic antigens that comprise an immunodominant alloreactive trigger for the immune response, resulting in rejection. Remarkable advances in knowledge and technology in the field of immunogenetics have considerably enhanced the safety of transplantation. However, access to transplantation among individuals who have become sensitized as a result of previous exposure to alloantigens is reduced proportional to the breadth of their sensitization. New approaches for crossing the HLA barrier in transplantation using plasmapheresis, intravenous immunoglobulin and kidney paired donation have been made possible by the relative ease with which even low levels of anti-HLA antibodies can now be detected and tracked. The development of novel protocols for the induction of tolerance and new approaches to immunomodulation was also facilitated by advances in HLA technology. Here, we review the progress made in understanding HLAs that has enabled organ transplantation to become a life-saving endeavour that is accessible even for sensitized patients. We also discuss novel approaches to desensitization, immunomodulation and tolerance induction that have the potential to further improve transplantation access and outcomes.
Collapse
|
32
|
Wehmeier C, Hönger G, Schaub S. Caveats of HLA antibody detection by solid‐phase assays. Transpl Int 2019; 33:18-29. [DOI: 10.1111/tri.13484] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/26/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology University Hospital Basel Basel Switzerland
| | - Gideon Hönger
- Clinic for Transplantation Immunology and Nephrology University Hospital Basel Basel Switzerland
- Transplantation Immunology Department of Biomedicine University of Basel Basel Switzerland
- HLA‐Diagnostic and Immunogenetics Department of Laboratory Medicine University Hospital Basel Basel Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology University Hospital Basel Basel Switzerland
- Transplantation Immunology Department of Biomedicine University of Basel Basel Switzerland
- HLA‐Diagnostic and Immunogenetics Department of Laboratory Medicine University Hospital Basel Basel Switzerland
| |
Collapse
|
33
|
Schinstock CA, Bentall AJ, Smith BH, Cornell LD, Everly M, Gandhi MJ, Stegall MD. Long-term outcomes of eculizumab-treated positive crossmatch recipients: Allograft survival, histologic findings, and natural history of the donor-specific antibodies. Am J Transplant 2019; 19:1671-1683. [PMID: 30412654 PMCID: PMC6509017 DOI: 10.1111/ajt.15175] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/25/2023]
Abstract
We aimed to determine the long-term outcomes of eculizumab-treated, positive crossmatch (+XM) kidney transplant recipients compared with +XM and age-matched negative crossmatch (-XM) controls. We performed an observational retrospective study and examined allograft survival, histologic findings, long-term B-cell flow cytometric XM (BFXM), and allograft-loss-associated factors. The mean (SD) posttransplant follow-up was 6.3 (2.5) years in the eculizumab group; 7.6 (3.5), +XM control group; 7.9 (2.5), -XM control group. The overall and death-censored allograft survival rates were similar in +XM groups (P = .73, P = .48) but reduced compared with -XM control patients (P < .001, P < .001). In the eculizumab-treated group, 57.9% (11/19) of the allografts had chronic antibody-mediated rejection, but death-censored allograft survival was 76.6%, 5 years; 75.4%, 7 years. Baseline IgG3 positivity and BFXM ≥300 were associated with allograft loss. C1q positivity was also associated with allograft loss but did not reach statistical significance. Donor-specific antibodies appeared to decrease in eculizumab-treated patients. After excluding patients with posttransplant plasmapheresis, 42.3% (9/21) had negative BFXMs; 31.8% (7/22), completely negative single-antigen beads 1 year posttransplant. Eculizumab-treated +XM patients had reduced allograft survival compared with -XM controls but similar survival to +XM controls. BFXM and complement-activating donor-specific antibodies (by IgG3 and C1q testing) may be used for risk stratification in +XM transplantation.
Collapse
Affiliation(s)
- Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Andrew J. Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Byron H. Smith
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Lynn D. Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Manish J. Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mark D. Stegall
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA,Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
34
|
Kwon H, Kim YH, Kim JY, Choi JY, Shin S, Jung JH, Park SK, Han DJ. The results of HLA-incompatible kidney transplantation according to pre-transplant crossmatch tests: Donor-specific antibody as a prominent predictor of acute rejection. Clin Transplant 2019; 33:e13533. [PMID: 30864255 DOI: 10.1111/ctr.13533] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Crossmatching (XM) between organ donors and recipients is correlated with clinical outcomes. This study evaluates the results of HLA-incompatible kidney transplant (HLA-i KT) according to pre-transplant XM modalities. METHODS This study included 731 consecutive patients. HLA-i KT was defined as a transplant under conditions of complement-dependent cytotoxicity (CDC) XM positivity, flow-cytometric XM (FCXM) positivity, and/or maximal donor-specific antibody (DSA) mean fluorescence intensity (MFI) ≥5000. RESULTS The incidence of antibody-mediated rejection (AMR) within 1 year after transplant was significantly higher in the HLA-i group than in the HLA compatible (HLA-c) group (15 vs 9 patients, 14.2% vs 1.4%; P < 0.01). Multivariate analysis indicated that a DSA MFI ≥5000 (odds ratio [OR] = 2.63; 95% confidence interval [CI], 1.00-6.98; P = 0.05) was significantly associated with acute rejection (AR), whereas CDC (OR = 2.09; 95% CI, 0.55-7.99; P = 0.28) and FCXM positivity (OR = 2.07; 95% CI, 0.73-5.87; P = 0.17) were not. Similarly, DSA MFI ≥ 5000 (OR = 4.14; P = 0.02) was the only significant factor affecting the risk of AMR. CONCLUSIONS Of the various XM tests, DSA MFI ≥5000 was the most prominent predictor of AR in patients undergoing HLA-i KT.
Collapse
Affiliation(s)
- Hyunwook Kwon
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jee Yeon Kim
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yoon Choi
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
35
|
Preformed C1q-binding Donor-specific Anti-HLA Antibodies and Graft Function After Kidney Transplantation. Transplant Proc 2018; 50:3460-3466. [DOI: 10.1016/j.transproceed.2018.07.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/08/2018] [Accepted: 07/18/2018] [Indexed: 01/06/2023]
|
36
|
Haas M. The relationship between pathologic lesions of active and chronic antibody-mediated rejection in renal allografts. Am J Transplant 2018; 18:2849-2856. [PMID: 30133953 DOI: 10.1111/ajt.15088] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 01/25/2023]
Abstract
The Banff classification of renal allograft pathology defines specific morphologic lesions that are used in the diagnosis of active (glomerulitis, peritubular capillaritis, endarteritis) and chronic (transplant glomerulopathy, peritubular capillary basement membrane multilayering, transplant arteriopathy) antibody-mediated rejection (ABMR). However, none of these individual lesions are specific for ABMR, and for this reason Banff requires 1 or more additional findings, including C4d deposition in peritubular capillaries, presence of circulating donor-specific antibodies (DSAs), and/or expression in the tissue of transcripts strongly associated with ABMR, for a definitive diagnosis of ABMR to be made. In addition, while animal studies examining serial biopsies have established the progression of morphologic lesions of active to chronic ABMR as well as intermediate forms (chronic active ABMR) exhibiting features of both, clear documentation that lesions of chronic ABMR require the earlier presence of corresponding active and intermediate lesions is less well established in human renal allografts. This review examines temporal relationships between key morphologic lesions of active and chronic ABMR in biopsies of human grafts, likely intermediate forms, and findings for and possibly against direct and potentially interruptible progression from active to chronic lesions.
Collapse
Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
37
|
The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitization and Calculated Chance of Future Transplant. Transplant Direct 2018; 4:e409. [PMID: 30584590 PMCID: PMC6283087 DOI: 10.1097/txd.0000000000000848] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/22/2018] [Indexed: 01/09/2023] Open
Abstract
Background The development of HLA antibodies towards a failing renal allograft is a barrier to retransplantation. This study aimed to compare the formation of HLA donor-specific antibodies (DSA) in patients undergoing graft nephrectomy and in those with a failed graft left in situ who had maintenance immunosuppression (IS) stopped, and assess the relative impact of IS cessation and graft nephrectomy on future relative chance of transplant (R-CoT). Methods A single-center retrospective study of patients with failed grafts between 2005 and 2015 was performed. Samples were tested for DSA pre-IS wean, post-IS wean, and post-IS cessation. Nephrectomy patients additionally had samples tested for DSA before and after nephrectomy. Calculated reaction frequency (cRF) was determined at each timepoint and entered into the UK Organ Donation and Transplant R-CoT calculator. Results Forty-one patients were included in the study: 24 with nephrectomy and 17 with a failed graft in situ. Patient demographics and duration of IS wean were similar between groups. There was a higher rate of blood transfusion (54% vs 24%) in nephrectomy patients. In patients whose graft remained in situ, cRF rose from 13% pre-IS wean to 40% post-IS wean and 62% after IS cessation. This equated to a reduction in mean R-CoT from 54% to 46% at 5 years. In patients undergoing nephrectomy mean cRF rose from 31% pre-IS wean to 69% post-IS wean and 89% post-IS cessation. Mean R-CoT fell from 54% to 42% at 5 years. Conclusions A stepwise increase in cRF with reduced chance of transplant was observed in both groups as IS was withdrawn, with a similar pattern irrespective of graft nephrectomy. Calculated reaction frequency was higher in the nephrectomy group. The risks and benefits of stopping IS need to be carefully considered on an individual basis to maximize chance of future transplant.
Collapse
|
38
|
Cioni M, Nocera A, Tagliamacco A, Basso S, Innocente A, Fontana I, Magnasco A, Trivelli A, Klersy C, Gurrado A, Ramondetta M, Boghen S, Catenacci L, Verrina E, Garibotto G, Ghiggeri GM, Cardillo M, Ginevri F, Comoli P. Failure to remove de novo donor-specific HLA antibodies is influenced by antibody properties and identifies kidney recipients with late antibody-mediated rejection destined to graft loss - a retrospective study. Transpl Int 2018; 32:38-48. [PMID: 30076765 DOI: 10.1111/tri.13325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 12/15/2022]
Abstract
Current research is focusing on identifying bioclinical parameters for risk stratification of renal allograft loss, largely due to antibody-mediated rejection (AMR). We retrospectively investigated graft outcome predictors in 24 unsensitized pediatric kidney recipients developing HLA de novo donor-specific antibodies (dnDSAs), and treated for late AMR with plasmapheresis + low-dose IVIG + Rituximab or high-dose IVIG + Rituximab. Renal function and DSA properties were assessed before and longitudinally post treatment. The estimated GFR (eGFR) decline after treatment was dependent on a negative % eGFR variation in the year preceding treatment (P = 0.021) but not on eGFR at treatment (P = 0.74). At a median follow-up of 36 months from AMR diagnosis, 10 patients lost their graft. Altered eGFR (P < 0.001) and presence of C3d-binding DSAs (P = 0.005) at treatment, and failure to remove DSAs (P = 0.01) were negatively associated with graft survival in the univariable analysis. Given the relevance of DSA removal for therapeutic success, we analyzed antibody properties dictating resistance to anti-humoral treatment. In the multivariable analysis, C3d-binding ability (P < 0.05), but not C1q-binding, and high mean fluorescence intensity (P < 0.05) were independent factors characterizing DSAs scarcely susceptible to removal. The poor prognosis of late AMR is related to deterioration of graft function prior to treatment and failure to remove C3d binding and/or high-MFI DSAs.
Collapse
Affiliation(s)
- Michela Cioni
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Arcangelo Nocera
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Augusto Tagliamacco
- Clinical Nephrology Unit and Transplant Coordination Unit, Policlinico San Martino, Genova, Italy
| | - Sabrina Basso
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Annalisa Innocente
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Iris Fontana
- Vascular and Endovascular Unit and Kidney Transplant Surgery Unit, Policlinico San Martino, Genova, Italy
| | - Alberto Magnasco
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Antonella Trivelli
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Catherine Klersy
- Biometry and Statistics Service, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Antonella Gurrado
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Miriam Ramondetta
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Stella Boghen
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Laura Catenacci
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Enrico Verrina
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giacomo Garibotto
- Clinical Nephrology Unit, University of Genova and Policlinico San Martino, Genova, Italy
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Massimo Cardillo
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Fabrizio Ginevri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| |
Collapse
|
39
|
Kang ES, Choi SI, Park YH, Park GB, Jang HR. Results of Questionnaire Survey of Current Immune Monitoring Practice of Transplant Clinicians and Clinical Pathologists in Korea: Basis for Establishment of Harmonized Immune Monitoring Guidelines. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo In Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youn Hee Park
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geum Borae Park
- Department of Laboratory Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hye Ryon Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
40
|
Analysis of Luminex-based Algorithms to Define Unacceptable HLA Antibodies in CDC-crossmatch Negative Kidney Transplant Recipients. Transplantation 2018; 102:969-977. [DOI: 10.1097/tp.0000000000002129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
41
|
The Kinetics of Anti-HLA Antibodies in the First Year after Kidney Transplantation: In Whom and When Should They Be Monitored? J Transplant 2018; 2018:8316860. [PMID: 29850195 PMCID: PMC5937436 DOI: 10.1155/2018/8316860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/25/2018] [Accepted: 03/18/2018] [Indexed: 11/21/2022] Open
Abstract
The impact of the kinetics of the anti-HLA antibodies after KTx on the occurrence of acute rejection as well as the better time-point to monitor anti-HLA Abs after transplantation is not completely defined. This prospective study followed 150 patients over 12 months after transplantation. Serum IgG anti-HLA Abs were detected by single antigen beads after typing donors and recipients for loci A, B, C, DR, and DQ. Before KTx, 89 patients did not present anti-HLA Abs and 2% developed “de novo” Abs during the 1st year, 39 patients were sensitized without DSAs, and 13% developed DSA after surgery; all of them presented ABMR. Sensitized patients presented higher acute rejection rates (36.4% versus 13.5%, p < 0.001), although 60% of the patients did not present ABMR. Patients, in whom DSA-MFI decreased during the first two weeks after surgery, did not develop ABMR. Those who sustained their levels presented a rate of 22% of ABMR. 85% of patients developed ABMR when MFIs increased early after transplantation (which occurred in 30% of the DSA positive patients). In the ABMR group, we observed an iDSA-MFI sharp drop on the fourth day and then an increase between the 7th and 14th POD, which suggests DSA should be monitored at this moment in sensitized patients for better ABMR prediction.
Collapse
|
42
|
Ali HA, Pavlisko EN, Snyder LD, Frank M, Palmer SM. Complement system in lung transplantation. Clin Transplant 2018; 32:e13208. [DOI: 10.1111/ctr.13208] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Hakim Azfar Ali
- Division of Pulmonary, Allergy and Critical Care; Department of Medicine; Duke University Hospital; Durham NC USA
| | | | - Laurie D. Snyder
- Division of Pulmonary, Allergy and Critical Care; Department of Medicine; Duke University Hospital; Durham NC USA
| | - Michael Frank
- Department of Pediatrics; Duke University Hospital; Durham NC USA
| | - Scott M. Palmer
- Division of Pulmonary, Allergy and Critical Care; Department of Medicine; Duke University Hospital; Durham NC USA
| |
Collapse
|
43
|
Cheungpasitporn W, Kremers WK, Lorenz E, Amer H, Cosio FG, Stegall MD, Gandhi MJ, Schinstock CA. De novo donor-specific antibody following BK nephropathy: The incidence and association with antibody-mediated rejection. Clin Transplant 2018; 32:e13194. [PMID: 29315820 DOI: 10.1111/ctr.13194] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The risk of de novo donor-specific antibody (dnDSA) development following BK viremia (BKV) or nephropathy (BKN) after kidney transplant remains unclear. We aimed to evaluate the relationships among dnDSA, BKV (BK blood PCR > 15 000 copies), BKN, antibody-mediated rejection (AMR), and allograft loss. PATIENTS AND METHODS We performed a retrospective cohort study of 904 solitary kidney transplant recipients transplanted between 10/2007 and 5/2014. Cox proportional hazards regression with time-dependent covariates were used to assess the relationships among BKN, isolated BKV, dnDSA, and the subsequent risk of AMR and allograft loss. RESULTS In multivariate analysis, we observed that BKN, but not BKV was a risk factor for dnDSA (HR, 3.18, P = .008). Of the patients with BK nephropathy, 14.0% (6/43) developed dnDSA, which occurred within 14 months of BK diagnosis. DnDSA in this setting remains a risk factor for subsequent AMR (HR 4.75, P = .0001) and allograft loss (HR 2.63, P = .018). CONCLUSIONS BKN is an independent risk factor for development of dnDSA. Improved understanding of the characteristics of patients with BKN who are at highest risk for development of dnDSA would be valuable to customize immunosuppression reduction in this population.
Collapse
Affiliation(s)
- Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Walter K Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Lorenz
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Fernando G Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Mark D Stegall
- The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.,Division of Transplantation Surgery, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Manish J Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Carrie A Schinstock
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
44
|
Tatapudi VS, Lonze BE, Wu M, Montgomery RA. Early Conversion from Tacrolimus to Belatacept in a Highly Sensitized Renal Allograft Recipient with Calcineurin Inhibitor-Induced de novo Post-Transplant Hemolytic Uremic Syndrome. Case Rep Nephrol Dial 2018; 8:10-19. [PMID: 29594146 PMCID: PMC5836164 DOI: 10.1159/000486158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/06/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Kidney transplantation is the first-line therapy for patients with end-stage renal disease since it offers greater long-term survival and improved quality of life when compared to dialysis. The advent of calcineurin inhibitor (CNI)-based maintenance immunosuppression has led to a clinically significant decline in the rate of acute rejection and better short-term graft survival rates. However, these gains have not translated into improvement in long-term graft survival. CNI-related nephrotoxicity and metabolic side effects are thought to be partly responsible for this. CASE PRESENTATION Here, we report the conversion of a highly sensitized renal transplant recipient with pretransplant donor-specific antibodies from tacrolimus to belatacept within 1 week of transplantation. This substitution was necessitated by the diagnosis of CNI-induced de novo post-transplant hemolytic uremic syndrome. CONCLUSION Belatacept is a novel costimulation blocker that is devoid of the nephrotoxic properties of CNIs and has been shown to positively impact long-term graft survival and preserve renal allograft function in low-immunologic-risk kidney transplant recipients. Data regarding its use in patients who are broadly sensitized to human leukocyte antigens are scarce, and the increased risk of rejection associated with belatacept has been a deterrent to more widespread use of this immunosuppressive agent. This case serves as an example of a highly sensitized patient that has been successfully converted to a belatacept-based CNI-free regimen.
Collapse
Affiliation(s)
- Vasishta S. Tatapudi
- aDepartment of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Bonnie E. Lonze
- bDepartment of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Ming Wu
- cDepartment of Pathology, New York University Langone Medical Center, New York, NY, USA
| | - Robert A. Montgomery
- bDepartment of Surgery, New York University Langone Medical Center, New York, NY, USA
| |
Collapse
|
45
|
Friebus-Kardash J, Wilde B, Keles D, Heinold A, Kribben A, Witzke O, Heinemann FM, Eisenberger U. Pretransplant serum BAFF levels are associated with pretransplant HLA immunization and renal allograft survival. Transpl Immunol 2017; 47:10-17. [PMID: 29277566 DOI: 10.1016/j.trim.2017.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The essential function of B cell-activating factor (BAFF) is regulating the survival and differentiation of B cells. The link between pretransplant BAFF levels and pretransplant alloimmunization and its value to predict subsequent acute antibody-mediated rejection (AMR) and outcome after renal transplantation is not fully understood. METHODS Objective of our retrospective single-center study was to determine, by ELISA analysis of pretransplant serum BAFF levels in 249 patients undergoing renal transplantation, association between preformed anti-human leukocyte antigen (HLA) antibodies, occurrence of acute antibody mediated rejection (AMR) and renal allograft survival. RESULTS Pretransplant serum BAFF levels were significantly higher in presensitized recipients with anti-HLA antibodies (3262±2796pg/ml) than in recipients without occurrence of anti-HLA antibodies (2252±1425pg/ml; p<0.0001). In addition, pretransplant BAFF levels correlated with cumulative MFI values of anti-HLA antibodies (r=0.2966, p=0.0025). Patients with high pretransplant BAFF levels (≥2137pg/ml) experienced significantly lower allograft survival rates compared to low pretransplant BAFF levels (80% vs. 91%; p=0.01). Coexistence of high pretransplant BAFF levels and posttransplant AMR was associated with the worst allograft survival rates (56%). Relative risk (RR) for allograft loss was associated with high serum BAFF levels (RR 2.3; p=0.02), presence of anti-HLA antibodies (RR 2.5; p=0.007) or anti-HLA -donor-specific antibodies (DSAs) (RR 2.6; p=0.003) before transplant and AMR post transplant (RR 2.5; p=0.007). AMR was the strongest independent risk factor for allograft failure (RR 2.6; p=0.03). CONCLUSION Elevated pretransplant serum BAFF levels negatively affect renal allograft survival and represent a risk factor for allosensitization and subsequent AMR.
Collapse
Affiliation(s)
- Justa Friebus-Kardash
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Deniz Keles
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Andreas Heinold
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Oliver Witzke
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany; Department of Infectious Diseases, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, University of Duisburg-Essen, University Hospital Essen, Germany
| | - Ute Eisenberger
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Germany.
| |
Collapse
|
46
|
Evidence for an important role of both complement-binding and noncomplement-binding donor-specific antibodies in renal transplantation. Curr Opin Organ Transplant 2017; 21:433-40. [PMID: 27348472 DOI: 10.1097/mot.0000000000000324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The review describes the current clinical relevance of circulating anti-human leukocyte antigen (anti-HLA) antibodies in kidney transplantation and discusses recent improvements in their characterization that provide new insights into the identification and management of important clinical outcomes. RECENT FINDINGS Recent studies addressing the relationships between donor-specific anti-HLA antibody (HLA-DSA) properties (i.e., their strength, complement-binding capacity, and IgG subclass composition) and allograft injury and survival have highlighted their relevance in the prediction of antibody-mediated injury and allograft loss. SUMMARY Antibody-mediated rejection is the leading cause of kidney allograft loss. Although considerable experimental and clinical evidence suggests a causal effect of circulating HLA-DSAs in antibody-mediated rejection and allograft failure, HLA-DSAs induce a wide spectrum of injuries to the allograft that illustrate the need to delineate the characteristics of HLA-DSAs that confer pathogenesis. Current risk stratification is based on HLA-DSA characteristics, including antibody specificity, HLA class, and strength. Recently, the complement-binding capacity of HLA-DSAs has been recognized as a clinically relevant marker for predicting pathogenicity and allograft loss. Emerging data also support a role for HLA-DSA IgG subclass composition in discriminating distinct patterns of antibody-mediated injury. This progress in our understanding of HLA-DSA pathogenicity provides new tools to stratify individual immunological risks. However, specific prospective studies addressing immunological risk stratification in large and unselected populations are required to define the clinical benefit and cost-effectiveness of such a comprehensive assessment of HLA-DSAs before implementation in current clinical practice.
Collapse
|
47
|
Successful desensitization with proteasome inhibition and costimulation blockade in sensitized nonhuman primates. Blood Adv 2017; 1:2115-2119. [PMID: 29296858 DOI: 10.1182/bloodadvances.2017010991] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/16/2017] [Indexed: 11/20/2022] Open
Abstract
The detrimental effects of donor-directed antibodies in sensitized transplant patients remain a difficult immunologic barrier to successful organ transplantation. Antibody removal is often followed by rebound. Proteasome inhibitors (PIs) deplete antibody-producing plasma cells (PCs) but have shown marginal benefit for desensitization. In an allosensitized nonhuman primate (NHP) model, we observed increased germinal center (GC) formation after PI monotherapy, suggesting a compensatory PC repopulation mediated via GC activation. Here we show that costimulation blockade (CoB) targets GC follicular helper T (Tfh) cells in allosensitized NHPs. Combined PI and CoB significantly reduces bone marrow PCs (CD19+CD20-CD38+), Tfh cells (CD4+ICOS+PD-1hi), and GC B cells (BCL-6+CD20+); controls the homeostatic GC response to PC depletion; and sustains alloantibody decline. Importantly, dual PC and CoB therapy prolongs rejection-free graft survival in major histocompatibility complex incompatible kidney transplantation without alloantibody rebound. Our study illustrates a translatable desensitization method and provides mechanistic insight into maintenance of alloantibody sensitization.
Collapse
|
48
|
Plasma C4d+ Endothelial Microvesicles Increase in Acute Antibody-Mediated Rejection. Transplantation 2017; 101:2235-2243. [PMID: 27846156 DOI: 10.1097/tp.0000000000001572] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. Currently, AMR diagnosis relies on biopsy which is an invasive procedure. A noninvasive biomarker of acute AMR could lead to early diagnosis and treatment of this condition and improve allograft outcome. Microvesicles are membrane-bound vesicles released from the cell surface after injury. We hypothesized that because AMR is associated with allograft endothelial injury and C4d deposition, plasma microvesicles positive for endothelial (CD144) marker and C4d are increased in this condition. METHODS We studied microvesicle concentration in the plasma of 95 kidney transplant patients with allograft dysfunction and compared with 23 healthy volunteers. Biopsy diagnosis and scoring was performed using Banff classification. RESULTS In the 28 subjects with AMR, the density of C4d+/CD144+ microvesicles was on average 11-fold (P = 0.002) higher than transplant recipients with no AMR and 24-fold (P = 0.008) than healthy volunteers. Densities of C4d+ and C4d+/annexin V+ (C4d+/AVB+) microvesicles were also increased in AMR patients compared with no AMR and healthy subjects. C4d+/AVB+ microvesicles correlated with AMR biopsy severity. Nine patients with acute AMR that received treatment showed a mean 72% decrease (P = 0.01) in C4d+/CD144+ microvesicle concentration compared with pretreatment values. CONCLUSIONS Quantification of plasma C4d+ microvesicles provides information about presence of AMR, its severity and response to treatment in transplant patients.
Collapse
|
49
|
Karahan GE, de Vaal YJH, Krop J, Wehmeier C, Roelen DL, Claas FHJ, Heidt S. A Memory B Cell Crossmatch Assay for Quantification of Donor-Specific Memory B Cells in the Peripheral Blood of HLA-Immunized Individuals. Am J Transplant 2017; 17:2617-2626. [PMID: 28371365 DOI: 10.1111/ajt.14293] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Humoral responses against mismatched donor HLA are routinely measured as serum HLA antibodies, which are mainly produced by bone marrow-residing plasma cells. Individuals with a history of alloimmunization but lacking serum antibodies may harbor circulating dormant memory B cells, which may rapidly become plasma cells on antigen reencounter. Currently available methods to detect HLA-specific memory B cells are scarce and insufficient in quantifying the complete donor-specific memory B cell response due to their dependence on synthetic HLA molecules. We present a highly sensitive and specific tool for quantifying donor-specific memory B cells in peripheral blood of individuals using cell lysates covering the complete HLA class I and class II repertoire of an individual. Using this enzyme-linked immunospot (ELISpot) assay, we found a median frequency of 31 HLA class I and 89 HLA class II-specific memory B cells per million IgG-producing cells directed at paternal HLA in peripheral blood samples from women (n = 22) with a history of pregnancy, using cell lysates from spouses. The donor-specific memory B cell ELISpot can be used in HLA diagnostic laboratories as a cross-match assay to quantify donor-specific memory B cells in patients with a history of sensitizing events.
Collapse
Affiliation(s)
- G E Karahan
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Y J H de Vaal
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - J Krop
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - C Wehmeier
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - D L Roelen
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - F H J Claas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - S Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
50
|
32 Doses of Bortezomib for Desensitization Is Not Well Tolerated and Is Associated With Only Modest Reductions in Anti-HLA Antibody. Transplantation 2017; 101:1222-1227. [PMID: 27379560 DOI: 10.1097/tp.0000000000001330] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously showed that bortezomib (BTZ) partially depletes plasma cells, yet has limited efficacy for desensitization in kidney transplant candidates when up to 16 doses is given. METHODS This study aimed to determine the safety and efficacy of 32 doses of BTZ (1.3 mg/m of body surface area) in 10 highly sensitized kidney transplant candidates with alloantibodies against their intended living donor. RESULTS Dose reduction was needed in 2 patients and 2 others completely discontinued therapy for adverse events. Anti-HLA antibodies mean fluorescence intensity (MFI) values were stable prior to BTZ (P = 0.96) but decreased after therapy (mean decrease of 1916 [SE, 425] MFI, P < 0.01). No patient developed a negative crossmatch against their original intended donor, and the calculated panel-reactive antibodies based on MFI of 2000, 4000, and 8000 was unchanged in all patients. CONCLUSIONS These data suggest that 32 doses of BTZ monotherapy was not well tolerated and resulted in only a modest reduction in anti-HLA antibodies.
Collapse
|