1
|
Cassidy MF, Doudican NA, Frazzette N, Rabbani PS, Carucci JA, Gelb BE, Rodriguez ED, Lu CP, Ceradini DJ. Molecular Signature Associated With Acute Rejection in Vascularized Composite Allotransplantation. Transplant Direct 2024; 10:e1714. [PMID: 39310283 PMCID: PMC11415116 DOI: 10.1097/txd.0000000000001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/25/2024] Open
Abstract
Background A deeper understanding of acute rejection in vascularized composite allotransplantation is paramount for expanding its utility and longevity. There remains a need to develop more precise and accurate tools for diagnosis and prognosis of these allografts, as well as alternatives to traditional immunosuppressive regimens. Methods Twenty-seven skin biopsies collected from 3 vascularized composite allotransplantation recipients, consisting of face and hand transplants, were evaluated by histology, immunohistochemistry staining, and gene expression profiling. Results Biopsies with clinical signs and symptoms of rejection, irrespective of histopathological grading, were significantly enriched for genes contributing to the adaptive immune response, innate immune response, and lymphocyte activation. Inflammation episodes exhibited significant fold change correlations between the face and hands, as well as across patients. Immune checkpoint genes were upregulated during periods of inflammation that necessitated treatment. A gene signature consisting of CCL5, CD8A, KLRK1, and IFNγ significantly predicted inflammation specific to vascularized composite allografts that required therapeutic intervention. Conclusions The mechanism of vascularized composite allograft-specific inflammation and rejection appears to be conserved across different patients and skin on different anatomical sites. A concise gene signature can be utilized to ascertain graft status along with a continuous scale, providing valuable diagnostic and prognostic information to supplement current gold standards of graft evaluation.
Collapse
Affiliation(s)
- Michael F. Cassidy
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Nicole A. Doudican
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, NY
| | - Nicholas Frazzette
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, NY
| | - Piul S. Rabbani
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - John A. Carucci
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, NY
| | - Bruce E. Gelb
- Transplant Institute, NYU Langone Health, New York, NY
| | | | - Catherine P. Lu
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Daniel J. Ceradini
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
2
|
Ryan RJ, Bentall AJ, Issa N, Dean PG, Smith BH, Stegall MD, Riad SM. Outcomes of Older Primary Kidney Transplant Recipients by Induction Agent and High-risk Viral Discordance Status in the United States. Transplant Direct 2024; 10:e1698. [PMID: 39328252 PMCID: PMC11427033 DOI: 10.1097/txd.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 09/28/2024] Open
Abstract
Background The impact of induction type or high-risk viral discordance on older kidney transplant recipients is unclear. Herein, we analyzed the association between induction type, viral discordance, and outcomes for older recipients. Methods We analyzed the Scientific Registry of Transplant Recipients standard analysis file for all primary kidney transplant recipients older than 55 y who were transplanted between 2005 and 2022. All transplants were crossmatch negative and ABO-compatible. Recipients were discharged on tacrolimus and mycophenolate ± steroids. Recipients were categorized into 3 groups by induction received: rabbit antithymocyte globulin (r-ATG; N = 51 079), interleukin-2 receptor antagonist (IL-2RA; N = 22 752), and alemtuzumab (N = 13 465). Kaplan-Meier curves were generated for recipient and graft survival, and follow-up was censored at 10 y. Mixed-effect Cox proportional hazard models examined the association between induction type, high-risk viral discordance, and outcomes of interest. Models were adjusted for pertinent recipient and donor characteristics. Results Induction type did not predict recipient survival in the multivariable model, whereas Epstein-Barr virus high-risk discordance predicted 14% higher mortality (1.14 [1.07-1.21], P < 0.01). In the multivariable model for death-censored graft survival, alemtuzumab, but not IL-2RA, was associated with an increased risk of graft loss (1.18 [1.06-1.29], P < 0.01) compared with r-ATG. High-risk cytomegalovirus discordance predicted 10% lower death-censored graft survival (1.10 [1.01-1.19], P < 0.02). Live donor and preemptive transplantation were favorable predictors of survival. Conclusions In this large cohort of older transplant recipients, alemtuzumab, but not IL-2RA, induction was associated with an increased risk of graft loss compared with r-ATG. Cytomegalovirus and Epstein-Barr virus high-risk viral discordance portended poor graft and recipient survival, respectively.
Collapse
Affiliation(s)
- Randi J Ryan
- Division of Transplant Surgery, Intermountain Health, Murray, UT
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Andrew J Bentall
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Naim Issa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Patrick G Dean
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Byron H Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Mark D Stegall
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Samy M Riad
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
3
|
Benazzo A, Bozzini S, Auner S, Berezhinskiy HO, Watzenboeck ML, Schwarz S, Schweiger T, Klepetko W, Wekerle T, Hoetzenecker K, Meloni F, Jaksch P. Differential expression of circulating miRNAs after alemtuzumab induction therapy in lung transplantation. Sci Rep 2022; 12:7072. [PMID: 35490174 PMCID: PMC9056512 DOI: 10.1038/s41598-022-10866-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody targeting CD52, used as induction therapy after lung transplantation (LTx). Its engagement produces a long-lasting immunodepletion; however, the mechanisms driving cell reconstitution are poorly defined. We hypothesized that miRNAs are involved in this process. The expression of a set of miRNAs, cytokines and co-signaling molecules was measured with RT-qPCR and flow cytometry in prospectively collected serum samples of LTx recipients, after alemtuzumab or no induction therapy. Twenty-six LTx recipients who received alemtuzumab and twenty-seven matched LTx recipients without induction therapy were included in the analysis. One year after transplantation four miRNAs were differentially regulated: miR-23b (p = 0.05) miR-146 (p = 0.04), miR-155 (p < 0.001) and miR-486 (p < 0.001). Expression of 3 miRNAs changed within the alemtuzumab group: miR-146 (p < 0.001), miR-155 (p < 0.001) and miR-31 (p < 0.001). Levels of IL-13, IL-4, IFN-γ, BAFF, IL-5, IL-9, IL-17F, IL-17A and IL-22 were different one year after transplantation compared to baseline. In no-induction group, concentration of sCD27, sB7.2 and sPD-L1 increased overtime. Expression of miR-23b, miR-146, miR-486, miR-155 and miR-31 was different in LTx recipients who received alemtuzumab compared to recipients without induction therapy. The observed cytokine pattern suggested proliferation of specific B cell subsets in alemtuzumab group and co-stimulation of T-cells in no-induction group.
Collapse
Affiliation(s)
- A Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria.
- Division of Thoracic Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090, Vienna, Austria.
| | - S Bozzini
- Department of Internal Medicine, Unit of Respiratory Diseases, Laboratory of Cell Biology and Immunology, University of Pavia and IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - S Auner
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria
| | - H Oya Berezhinskiy
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria
| | - M L Watzenboeck
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - S Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - T Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - W Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - T Wekerle
- Section of Transplantation Immunology, Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - K Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - F Meloni
- Department of Internal Medicine, Unit of Respiratory Diseases, Laboratory of Cell Biology and Immunology, University of Pavia and IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - P Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Rossi AP, Alloway RR, Hildeman D, Woodle ES. Plasma cell biology: Foundations for targeted therapeutic development in transplantation. Immunol Rev 2021; 303:168-186. [PMID: 34254320 DOI: 10.1111/imr.13011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients with end-stage organ disease. Over the past 70 years, tremendous progress has been made in solid organ transplantation, particularly in T-cell-targeted immunosuppression and organ allocation systems. However, humoral alloimmune responses remain a major challenge to progress. Patients with preexisting antibodies to human leukocyte antigen (HLA) are at significant disadvantages in regard to receiving a well-matched organ, moreover, those who develop anti-HLA antibodies after transplantation face a significant foreshortening of renal allograft survival. Historical therapies to desensitize patients prior to transplantation or to treat posttransplant AMR have had limited effectiveness, likely because they do not significantly reduce antibody levels, as plasma cells, the source of antibody production, remain largely unaffected. Herein, we will discuss the significance of plasma cells in transplantation, aspects of their biology as potential therapeutic targets, clinical challenges in developing strategies to target plasma cells in transplantation, and lastly, novel approaches that have potential to advance the field.
Collapse
Affiliation(s)
- Amy P Rossi
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - David Hildeman
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Immunology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
5
|
Differential Effects of MS Therapeutics on B Cells-Implications for Their Use and Failure in AQP4-Positive NMOSD Patients. Int J Mol Sci 2020; 21:ijms21145021. [PMID: 32708663 PMCID: PMC7404039 DOI: 10.3390/ijms21145021] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/25/2022] Open
Abstract
B cells are considered major contributors to multiple sclerosis (MS) pathophysiology. While lately approved disease-modifying drugs like ocrelizumab deplete B cells directly, most MS medications were not primarily designed to target B cells. Here, we review the current understanding how approved MS medications affect peripheral B lymphocytes in humans. These highly contrasting effects are of substantial importance when considering these drugs as therapy for neuromyelitis optica spectrum disorders (NMOSD), a frequent differential diagnosis to MS, which is considered being a primarily B cell- and antibody-driven diseases. Data indicates that MS medications, which deplete B cells or induce an anti-inflammatory phenotype of the remaining ones, were effective and safe in aquaporin-4 antibody positive NMOSD. In contrast, drugs such as natalizumab and interferon-β, which lead to activation and accumulation of B cells in the peripheral blood, lack efficacy or even induce catastrophic disease activity in NMOSD. Hence, we conclude that the differential effect of MS drugs on B cells is one potential parameter determining the therapeutic efficacy or failure in antibody-dependent diseases like seropositive NMOSD.
Collapse
|
6
|
Kwun J, Knechtle S. Experimental modeling of desensitization: What have we learned about preventing AMR? Am J Transplant 2020; 20 Suppl 4:2-11. [PMID: 32538533 PMCID: PMC7522789 DOI: 10.1111/ajt.15873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 01/25/2023]
Abstract
During the past 5 decades, short-term outcomes in kidney transplant have significantly improved, in large part due to reduced rates and severity of acute rejection. Development of better immunosuppressive maintenance agents, as well as new induction therapies, helped make these advances. Nonhuman primate models provided a rigorous testing platform to evaluate candidate biologics during this process. However, antibody-mediated rejection remains a major cause of late failure of kidney allografts despite advances made in pharmacologic immunosuppression and strategies developed to facilitate improved donor-recipient matching. Our laboratory has been actively working to develop strategies to prevent and treat antibody-mediated rejection and immunologic sensitization in organ transplant, relying largely on a nonhuman primate model of kidney transplant. In this review, we will cover outcomes achieved by managing antibody-mediated rejection or sensitization in nonhuman primate models and discuss promises, limitations, and future directions for this model.
Collapse
Affiliation(s)
- Jean Kwun
- Address all correspondence and requests for reprints to: Jean Kwun, PhD, 207 Research Drive, Jones 362, DUMC Box 2645, Durham, NC 27710, USA Phone: 919-668-6792; Fax: 919-684-8716;
| | | |
Collapse
|
7
|
Association of More Intensive Induction With Less Acute Rejection Following Intestinal Transplantation: Results of 445 Consecutive Cases From a Single Center. Transplantation 2020; 104:2166-2178. [PMID: 31929425 DOI: 10.1097/tp.0000000000003074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In intestinal transplantation, acute cellular rejection (ACR) remains a significant challenge to achieving long-term graft survival. It is still not clear which are the most important prognostic factors. METHODS We performed a Cox multivariable analysis of the hazard rates of developing any ACR, severe ACR, and cause-specific graft loss during the first 60 months posttransplant among 445 consecutive intestinal transplant recipients at our institution since 1994. Of particular interest was to determine the prognostic influence of induction type: rabbit antithymocyte globulin (rATG; 2 mg/kg × 5)/rituximab (150 mg/m × 1; begun in 2013), alemtuzumab (2001-2011), and less intensive forms. RESULTS First ACR and severe ACR occurred in 61.3% (273/445) and 22.2% (99/445) of cases. The following 3 multivariable predictors were associated with significantly lower hazard rates of developing ACR and severe ACR: transplant type modified multivisceral or full multivisceral (P = 0.0009 and P < 0.000001), rATG/rituximab induction (P < 0.000001 and P < 0.01), and alemtuzumab induction (P = 0.004 and P = 0.07). For both ACR and severe ACR, the protective effects of rATG/rituximab and alemtuzumab were highly significant (P ≤ 0.000005 for ACR; P ≤ 0.01 for severe ACR) but only during the first 24 days posttransplant (when the ACR hazard rate was at its peak). The prognostic effects of rATG/rituximab and alemtuzumab on ACR/severe ACR disappeared beyond 24 days posttransplant (ie, nonproportional hazards). While significant protective effects of both rATG/rituximab and alemtuzumab existed during the first 6 months posttransplant for the hazard rate of graft loss-due-to-rejection (P = 0.01 and P = 0.003), rATG/rituximab was additionally associated with a consistently lower hazard rate of graft loss-due-to-infection (P = 0.003). All significant effects remained after controlling for the propensity-to-be-transplanted since 2013. CONCLUSIONS More intensive induction was associated with a significant lowering of ACR risk, particularly during the early posttransplant period.
Collapse
|
8
|
Zhang H, Wang S, Su X, Fu Q, Li J, Wang J, Deng R, Wu C, Huang Q, Liu L, Wang C. The role of soluble B cell-activating factor in further stratifying the risk of antibody-mediated rejection post-renal transplant: A meta-analysis. Int Immunopharmacol 2019; 79:106059. [PMID: 31865240 DOI: 10.1016/j.intimp.2019.106059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND We conducted a meta-analysis to evaluate the predictive value of serum soluble B cell-activating factor (sBAFF) for antibody-mediated rejection (ABMR), which remains controversial. METHODS Systematic literature search was performed in PubMed, EMBASE, Scopus, Cochrane Library, Web of Science and three Chinese databases. Studies of any relevant design were included. Random and fixed-effects meta-analytical models were used. Study quality, publication bias, and heterogeneity were assessed. This study was registered with PROSPERO (CRD42019109198). RESULTS Nine observational studies were included in the meta-analysis, including 1302 cases (median NOS quality score = 8, range 6-8). The incidence of ABMR was significantly higher in the high sBAFF group than in the low sBAFF level group (Risk ratio [RR] 2.04 [95% CI 1.52-2.74], I2 = 26%, P < 0.01, N = 1014). The subgroup analysis showed that regardless of pre-transplant donor-specific antibody (DSA) status, the high sBAFF level group still had a significantly higher incidence of ABMR. sBAFF was not associated with the risk of TCMR. The sBAFF level was significantly higher in the anti-HLA-antibody (+) group than in anti-HLA-antibody (-) patients before or after kidney transplantation (Standardized mean difference [SMD] 0.43 [0.29-0.56], P < 0.01, I2 = 34%, N = 1001). CONCLUSION sBAFF is a promising biomarker to further stratify the risk of ABMR post-renal transplant.
Collapse
Affiliation(s)
- Huanxi Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shuyi Wang
- Department of Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Su
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiali Wang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ronghai Deng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chenglin Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingshan Huang
- Medical Information Institute, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.
| |
Collapse
|
9
|
Abstract
The BAFF receptor BR3 plays key roles in B-cell activation, maturation, and survival whereas the function of BR3 on T lymphocytes is less well characterized. Previous reports have demonstrated that BR3 costimulates human T-cell activation in vitro in the presence of high nonphysiological levels of plate-bound BAFF. Here, relying on the soluble and membrane-bound BAFF expressed by T cells themselves, we investigated the function of BR3 on activated primary CD4 and CD8 T lymphocytes using a BR3-specific neutralization antibody and shRNA gene down-modulation. Interestingly, the anti-BR3 blocking antibody resulted in significant augmentation of CD25 and IFN-γ expression by both subsets, as did shRNA-mediated down-modulation of BR3. In addition, granzyme B expression was substantially elevated in anti-BR3-treated and BR3-silenced T cells. Anti-BR3 blockade increased the expression of CD25 on cytolytic CRTAM T cells. Importantly, anti-BR3 significantly enhanced redirected killing of P-815 cells by both CD4 and CD8 cytotoxic T cells [cytotoxic T lymphocytes (CTLs)]. Furthermore, anti-BR3-augmented CD4 T-cell-mediated killing of class II melanoma cell line A375 and cervical cancer cell line HeLa in vitro, increasing the level of granzyme B activity as measured by PARP-1 cleavage and active caspase 3. Together, our data indicate that BR3 neutralization increases the activation and cytolytic function of CD4 and CD8 cytotoxic T lymphocytes. Our findings provide a novel strategy for ex vivo T-cell activation applicable to T-cell immunotherapy platforms such as TIL or CAR-T cell therapeutics.
Collapse
|
10
|
Knechtle SJ, Shaw JM, Hering BJ, Kraemer K, Madsen JC. Translational impact of NIH-funded nonhuman primate research in transplantation. Sci Transl Med 2019; 11:eaau0143. [PMID: 31292263 PMCID: PMC7197021 DOI: 10.1126/scitranslmed.aau0143] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 12/13/2018] [Indexed: 12/23/2022]
Abstract
The National Institutes of Health (NIH) has long supported using nonhuman primate (NHP) models for research on kidney, pancreatic islet, heart, and lung transplantation. The primary purpose of this research has been to develop new treatments for down-modulating or preventing deleterious immune responses after transplantation in human patients. Here, we discuss NIH-funded NHP studies of immune cell depletion, costimulation blockade, regulatory cell therapy, desensitization, and mixed hematopoietic chimerism that either preceded clinical trials or prevented the human application of therapies that were toxic or ineffective.
Collapse
Affiliation(s)
- Stuart J Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Julia M Shaw
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20852, USA
| | - Bernhard J Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kristy Kraemer
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20852, USA
| | - Joren C Madsen
- Center for Transplantation Sciences and Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| |
Collapse
|
11
|
Fitch Z, Schmitz R, Kwun J, Hering B, Madsen J, Knechtle SJ. Transplant research in nonhuman primates to evaluate clinically relevant immune strategies in organ transplantation. Transplant Rev (Orlando) 2019; 33:115-129. [PMID: 31027947 PMCID: PMC6599548 DOI: 10.1016/j.trre.2019.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/08/2019] [Accepted: 03/26/2019] [Indexed: 12/27/2022]
Abstract
Research in transplant immunology using non-human primate (NHP) species to evaluate immunologic strategies to prevent rejection and prolong allograft survival has yielded results that have translated successfully into human organ transplant patient management. Other therapies have not proceeded to human translation due to failure in NHP testing, arguably sparing humans the futility and risk of such testing. The NHP transplant models are ethically necessary for drug development in this field and provide the closest analogue to human transplant patients available. The refinement of this resource with respect to colony MHC typing, reagent and assay development, and availability to the research community has greatly enhanced knowledge about transplant immunology and drug development.
Collapse
Affiliation(s)
- Zachary Fitch
- Department of Surgery, Duke Transplant Center, Durham, NC 27710, USA; Center for Transplantation Sciences, Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, White 510c, 55 Fruit Street, Boston, MA, USA
| | - Robin Schmitz
- Department of Surgery, Duke Transplant Center, Durham, NC 27710, USA
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Durham, NC 27710, USA
| | - Bernhard Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Joren Madsen
- Department of Surgery, Duke Transplant Center, Durham, NC 27710, USA
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Durham, NC 27710, USA.
| |
Collapse
|
12
|
Wang XZ, Wan Z, Xue WJ, Zheng J, Li Y, Ding CG. B-Cell Activating Factor Predicts Acute Rejection Risk in Kidney Transplant Recipients: A 6-Month Follow-Up Study. Front Immunol 2019; 10:1046. [PMID: 31156628 PMCID: PMC6529956 DOI: 10.3389/fimmu.2019.01046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/24/2019] [Indexed: 01/03/2023] Open
Abstract
B cell activating factor (BAFF) belonging to TNF family is a cytokine that enhances B-cell proliferation and differentiation. Recently, It has been suggested that BAFF might be a potential therapeutic target for treating autoimmune disease. However, the relationship between BAFF and allograft rejection is controversial, and the clinical significance of BAFF in predicting allograft rejection need to be further explored. We conducted 6-month follow-up study to confirm the hypothesis that BAFF might be a risk factor for predicting acute rejection in kidney transplant recipients. At the end of the study, a total of 155 kidney transplant recipients were recruited from October 2015 to October 2017, and classified into acute rejection group (n = 34) and stable renal function group (n = 121) according to their clinical course. We demonstrate that the serum BAFF levels when acute rejection occurred was significantly higher than that in the stable renal function group (2426.19 ± 892.19 vs. 988.17 ± 485.63 pg/mL, P < 0.05). BAFF expression was significantly enhanced in the membrane and cytoplasm of renal tubule epithelial cells in the transplant kidney tissue with acute rejection, and a positive correlation between BAFF and C4d expression was also observed (r = 0.880, P = 0.001). ROC analyses highlight the superiority of serum BAFF level before transplant over those on other post-transplant days in prediction of acute rejection episodes. The sensitivity, specificity and AUC (area under curve) were 83.3, 89.5, and 0.886%, respectively. Kaplan-Meier survival analysis showed that recipients with higher pretransplant BAFF levels had higher acute rejection incidence (P = 0.003). In conclusion, we have identified that BAFF levels are associated with the acute rejection and could be a promising biomarker to predict kidney transplant rejection risks.
Collapse
Affiliation(s)
- Xu-Zhen Wang
- Critical Care Medicine, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhen Wan
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wu-Jun Xue
- Department of Kidney Transplantation, Hospital of Nephropathy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jin Zheng
- Department of Kidney Transplantation, Hospital of Nephropathy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang Li
- Department of Kidney Transplantation, Hospital of Nephropathy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Chen Guang Ding
- Department of Kidney Transplantation, Hospital of Nephropathy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|
13
|
|
14
|
Li J, Luo Y, Wang X, Feng G. Regulatory B cells and advances in transplantation. J Leukoc Biol 2018; 105:657-668. [PMID: 30548970 DOI: 10.1002/jlb.5ru0518-199r] [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: 05/19/2018] [Revised: 10/03/2018] [Accepted: 11/14/2018] [Indexed: 12/12/2022] Open
Abstract
The effects of B cell subsets with regulatory activity on the immune response to an allograft have evoked increasing interest. Here, we summarize the function and signaling of regulatory B cells (Bregs) and their potential effects on transplantation. These cells are able to suppress the immune system directly via ligand-receptor interactions and indirectly by secretion of immunosuppressive cytokines, particularly IL-10. In experimental animal models, the extensively studied IL-10-producing B cells have shown unique therapeutic advantages in the transplant field. In addition, adoptive transfer of B cell subsets with regulatory activity may reveal a new approach to prolonging allograft survival. Recent clinical observations on currently available therapies targeting B cells have revealed that Bregs play an important role in immune tolerance and that these cells are expected to become a new target of immunotherapy for transplant-related diseases.
Collapse
Affiliation(s)
- Jinfeng Li
- Kidney Transplantation Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongsheng Luo
- Kidney Transplantation Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xu Wang
- Institute of Medical Microbiology and Hospital Hygiene, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Guiwen Feng
- Kidney Transplantation Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
15
|
Kwun J, Park J, Yi JS, Farris AB, Kirk AD, Knechtle SJ. IL-21 Biased Alemtuzumab Induced Chronic Antibody-Mediated Rejection Is Reversed by LFA-1 Costimulation Blockade. Front Immunol 2018; 9:2323. [PMID: 30374350 PMCID: PMC6196291 DOI: 10.3389/fimmu.2018.02323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/18/2018] [Indexed: 11/25/2022] Open
Abstract
Despite its excellent efficacy in controlling T cell mediated acute rejection, lymphocyte depletion may promote a humoral response. While T cell repopulation after depletion has been evaluated in many aspects, the B cell response has not been fully elucidated. We tested the hypothesis that the mechanisms also involve skewed T helper phenotype after lymphocytic depletion. Post-transplant immune response was measured from alemtuzumab treated hCD52Tg cardiac allograft recipients with or without anti-LFA-1 mAb. Alemtuzumab induction promoted serum DSA, allo-B cells, and CAV in humanized CD52 transgenic (hCD52Tg) mice after heterotopic heart transplantation. Additional anti-LFA-1 mAb treatment resulted in reduced DSA (Fold increase 4.75 ± 6.9 vs. 0.7 ± 0.5; p < 0.01), allo-specific B cells (0.07 ± 0.06 vs. 0.006 ± 0.002 %; p < 0.01), neo-intimal hyperplasia (56 ± 14% vs. 23 ± 13%; p < 0.05), arterial disease (77.8 ± 14.2 vs. 25.8 ± 20.1%; p < 0.05), and fibrosis (15 ± 23.3 vs. 4.3 ± 1.65%; p < 0.05) in this alemtuzumab-induced chronic antibody-mediated rejection (CAMR) model. Surprisingly, elevated serum IL-21 levels in alemtuzumab-treated mice was reduced with LFA-1 blockade. In accordance with the increased serum IL-21 level, alemtuzumab treated mice showed hyperplastic germinal center (GC) development, while the supplemental anti-LFA-1 mAb significantly reduced the GC frequency and size. We report that the incomplete T cell depletion inside of the GC leads to a systemic IL-21 dominant milieu with hyperplastic GC formation and CAMR. Conventional immunosuppression, such as tacrolimus and rapamycin, failed to reverse AMR, while co-stimulation blockade with LFA-1 corrected the GC hyperplastic response. The identification of IL-21 driven chronic AMR elucidates a novel mechanism that suggests a therapeutic approach with cytolytic induction.
Collapse
Affiliation(s)
- Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Jaeberm Park
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, United States
| | - Allan D Kirk
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, United States
| |
Collapse
|
16
|
Chen M, Lin X, Olsen N, He X, Zheng SG. Advances in T follicular helper and T follicular regulatory cells in transplantation immunity. Transplant Rev (Orlando) 2018; 32:187-193. [PMID: 30139705 DOI: 10.1016/j.trre.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/08/2018] [Accepted: 07/20/2018] [Indexed: 12/14/2022]
Abstract
B cells play a crucial role in alloreactivity of organ transplant rejection and graft versus host diseases (GVHD). Over the past decade, it has been well recognized that B-cell infiltration in allografts and de novo donor-specific antibodies (DSA) were strongly associated with severe graft rejection and loss, as well as glucocorticoid resistance. Emerging evidence has demonstrated that Follicular T helper (Tfh) cells are key effectors to promote the proliferation and differentiation of B cells into antibody-producing plasmablasts and memory B cells. T-follicular regulatory (Tfr) cells are a recently recognized cell population that has a negative regulatory role on Tfh cells in the follicle, preventing incessant antibody production. It is still less clear how those humoral immunoreactive cells affect transplant rejection and allograft loss. This review focuses on the production and function of Tfr/Tfh cells in the transplant environment. Better understanding of the functions and mechanisms of Tfr/Tfh cells will help to design new strategies to prevent allograft rejection and prolong graft survival.
Collapse
Affiliation(s)
- Maogen Chen
- Organ transplant center, First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, PR China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, PR China
| | - Xiaohong Lin
- Division of general surgery, The Eastern Hospital of the First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China
| | - Nancy Olsen
- Division of Rheumatology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Xiaoshun He
- Organ transplant center, First affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, PR China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, PR China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, PR China
| | - Song Guo Zheng
- Division of Rheumatology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
| |
Collapse
|
17
|
Mannon RB, Askar M, Jackson AM, Newell K, Mengel M. Meeting report of the STAR-Sensitization in Transplantation Assessment of Risk: Naïve Abdominal Transplant Organ subgroup focus on kidney transplantation. Am J Transplant 2018; 18:2120-2134. [PMID: 29943908 DOI: 10.1111/ajt.14977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/30/2018] [Accepted: 05/31/2018] [Indexed: 01/25/2023]
Abstract
The development of de novo donor-specific HLA antibody (dnDSA) is a critical feature contributing to late allograft failure. The complexity of the issue is further complicated by organ-specific differences, detection techniques, reliance of tissue histopathology and changing diagnostic criteria, ineffective therapies, and lack of consensus. To tackle these issues, the Sensitization in Transplantation Assessment of Risk (STAR) 2017 was initiated as a collaboration of the American Society of Transplantation and American Society of Histocompatibility and Immunogenetics consisting of 8 working groups with the goal to provide guidelines on how to assess risk and risk stratify patients based on their potential alloimmune and DSA status. Herein is a summary of discussions by the Naïve Abdominal Working Group, highlighting currently available data and identifying gaps in our knowledge on the development and impact of dnDSA following kidney transplantation.
Collapse
Affiliation(s)
- Roslyn B Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Medhat Askar
- Transplant Immunology, Baylor University Medical Center, Dallas, TX, USA
| | - Annette M Jackson
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
18
|
Pongpirul W, Chancharoenthana W, Pongpirul K, Leelahavanichkul A, Kittikowit W, Jutivorakool K, Nonthasoot B, Avihingsanon Y, Eiam-Ong S, Praditpornsilpa K, Townamchai N. B-cell activating factor, a predictor of antibody mediated rejection in kidney transplantation recipients. Nephrology (Carlton) 2018; 23:169-174. [PMID: 27888573 DOI: 10.1111/nep.12972] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 10/17/2016] [Accepted: 11/23/2016] [Indexed: 01/30/2023]
Abstract
AIM Donor-specific antibody (DSA) is a widely-used biomarker for antibody-mediated rejection (ABMR) but correctly indicates only 30-40% of patients with ABMR. Additional biomarkers of ABMR in kidney transplant recipients are needed. METHODS All 68 kidney transplanted-recipients enrolled in this study were negative for graft rejection as determined by surveillance-biopsy ELISA at day 7 post-transplantation. Allograft biopsy was then performed at 6 months post-transplantation for subclinical-ABMR detection. Recipients were stratified by pre-transplant DSA and BAFF at day 7 into four groups. RESULTS During the study period, 13.2% of the recipients demonstrated subclinical-ABMR at 6 months, without patient with clinical ABMR presentations. Overall mean BAFF at day 7 was 393 pg/mL (95% CI = 316-471 pg/mL). The optimal cut-off value for low vs. high BAFF level was 573 pg/mL, with sensitivity and specificity at 77.8% and 88.1%, respectively. Fifty percent of recipients with high BAFF at day 7 (14 patients) and only 3.7% of patients with low BAFF demonstrated ABMR (P < 0.05). Indeed, ABMR was more common in patients high BAFF level (hazard ratio = 7.30; 95% CI = 3.77-14.15). The prevalence of ABMR among negative pre-transplant DSA/low BAFF, positive DSA/low BAFF, negative DSA/high BAFF, and positive DSA/ high BAFF recipients were 4.4, 0, 37.5 and 66.7%, respectively (P < 0.05). CONCLUSIONS Post-transplant ABMR can be predicted by perioperative serum BAFF level. Together with DSA testing, BAFF provides additional predictive value for ABMR.
Collapse
Affiliation(s)
- Wannarat Pongpirul
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wiwat Chancharoenthana
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Asada Leelahavanichkul
- Division of Immunology, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
| | - Wipawee Kittikowit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kamonwan Jutivorakool
- Division of Infectious Disease, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Bunthoon Nonthasoot
- Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
19
|
Banham GD, Flint SM, Torpey N, Lyons PA, Shanahan DN, Gibson A, Watson CJE, O'Sullivan AM, Chadwick JA, Foster KE, Jones RB, Devey LR, Richards A, Erwig LP, Savage CO, Smith KGC, Henderson RB, Clatworthy MR. Belimumab in kidney transplantation: an experimental medicine, randomised, placebo-controlled phase 2 trial. Lancet 2018; 391:2619-2630. [PMID: 29910042 DOI: 10.1016/s0140-6736(18)30984-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND B cells produce alloantibodies and activate alloreactive T cells, negatively affecting kidney transplant survival. By contrast, regulatory B cells are associated with transplant tolerance. Immunotherapies are needed that inhibit B-cell effector function, including antibody secretion, while sparing regulators and minimising infection risk. B lymphocyte stimulator (BLyS) is a cytokine that promotes B-cell activation and has not previously been targeted in kidney transplant recipients. We aimed to determine the safety and activity of an anti-BLyS antibody, belimumab, in addition to standard-of-care immunosuppression in adult kidney transplant recipients. We used an experimental medicine study design with multiple secondary and exploratory endpoints to gain further insight into the effect of belimumab on the generation of de-novo IgG and on the regulatory B-cell compartment. METHODS We undertook a double-blind, randomised, placebo-controlled phase 2 trial of belimumab, in addition to standard-of-care immunosuppression (basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone) at two centres, Addenbrooke's Hospital, Cambridge, UK, and Guy's and St Thomas' Hospital, London, UK. Participants were eligible if they were aged 18-75 years and receiving a kidney transplant and were planned to receive standard-of-care immunosuppression. Participants were randomly assigned (1:1) to receive either intravenous belimumab 10 mg per kg bodyweight or placebo, given at day 0, 14, and 28, and then every 4 weeks for a total of seven infusions. The co-primary endpoints were safety and change in the concentration of naive B cells from baseline to week 24, both of which were analysed in all patients who received a transplant and at least one dose of drug or placebo (the modified intention-to-treat [mITT] population). This trial has been completed and is registered with ClinicalTrials.gov, NCT01536379, and EudraCT, 2011-006215-56. FINDINGS Between Sept 13, 2013, and Feb 8, 2015, of 303 patients assessed for eligibility, 28 kidney transplant recipients were randomly assigned to receive belimumab (n=14) or placebo (n=14). 25 patients (12 [86%] patients assigned to the belimumab group and 13 [93%] patients assigned to the placebo group) received a transplant and were included in the mITT population. We observed similar proportions of adverse events in the belimumab and placebo groups, including serious infections (one [8%] of 12 in the belimumab group and five [38%] of 13 in the placebo group during the 6-month on-treatment phase; and none in the belimumab group and two [15%] in the placebo group during the 6-month follow-up). In the on-treatment phase, one patient in the placebo group died because of fatal myocardial infarction and acute cardiac failure. The co-primary endpoint of a reduction in naive B cells from baseline to week 24 was not met. Treatment with belimumab did not significantly reduce the number of naive B cells from baseline to week 24 (adjusted mean difference between the belimumab and placebo treatment groups -34·4 cells per μL, 95% CI -109·5 to 40·7). INTERPRETATION Belimumab might be a useful adjunct to standard-of-care immunosuppression in renal transplantation, with no major increased risk of infection and potential beneficial effects on humoral alloimmunity. FUNDING GlaxoSmithKline.
Collapse
Affiliation(s)
- Gemma D Banham
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Shaun M Flint
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Nicholas Torpey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Don N Shanahan
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Adele Gibson
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ann-Marie O'Sullivan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Joseph A Chadwick
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Katie E Foster
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Luke R Devey
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Anna Richards
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Lars-Peter Erwig
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Caroline O Savage
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Menna R Clatworthy
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.
| |
Collapse
|
20
|
Schinstock C, Cosio F, Cheungpasitporn W, Dadhania D, Everly M, Samaniego-Picota M, Cornell L, Stegall M. The Value of Protocol Biopsies to Identify Patients With De Novo Donor-Specific Antibody at High Risk for Allograft Loss. Am J Transplant 2017; 17:1574-1584. [PMID: 27977905 PMCID: PMC5445019 DOI: 10.1111/ajt.14161] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/11/2016] [Accepted: 11/28/2016] [Indexed: 01/25/2023]
Abstract
De novo donor-specific antibody (dnDSA) is associated with antibody-mediated rejection (AMR) and allograft loss, yet the allograft histology associated with dnDSA remains unclear. The aim of this study was to examine the allograft histology associated with dnDSA in patients with serial surveillance biopsies. We retrospectively studied adult conventional solitary kidney transplant recipients from October 2007 to May 2014. The definition of dnDSA was new donor-specific antibody (DSA) with mean fluorescence intensity (MFI) >1000. The incidence of dnDSA was 7.0% (54 of 771) over mean follow-up of 4.2 ± 1.9 years. Patients with dnDSA had reduced death-censored allograft survival (87.0% vs. 97.0% no dnDSA, p < 0.01). Moreover, 94% of patients received a biopsy after dnDSA (mean of three biopsies per patient). AMR was present in 25.0% and 52.9% of patients at dnDSA detection and at 1 year, respectively. Patients with both class I and II dnDSA had the highest rate of allograft loss. The higher the sum MFI at dnDSA detection, the higher the incidence of AMR. In conclusion, patients with dnDSA without AMR at time of detection may benefit from a follow-up biopsy within 1 year because AMR can be missed initially. In addition, the dnDSA class and sum MFI at baseline appear to be prognostic. The higher the sum MFI of dnDSA at baseline, the higher the incidence of AMR.
Collapse
Affiliation(s)
- C.A. Schinstock
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - F. Cosio
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | | | - D.M. Dadhania
- Joan and Sanford I. Weill Department of Medicine, Cornell Medical College, New York, NY
| | - M.J. Everly
- Paul I. Terasaki Foundation, Los Angeles, CA
| | - M.D. Samaniego-Picota
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - L. Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - M.D. Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| |
Collapse
|
21
|
Ensor CR, Yousem SA, Marrari M, Morrell MR, Mangiola M, Pilewski JM, D'Cunha J, Wisniewski SR, Venkataramanan R, Zeevi A, McDyer JF. Proteasome Inhibitor Carfilzomib-Based Therapy for Antibody-Mediated Rejection of the Pulmonary Allograft: Use and Short-Term Findings. Am J Transplant 2017; 17:1380-1388. [PMID: 28173620 DOI: 10.1111/ajt.14222] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/08/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
We present this observational study of lung transplant recipients (LTR) treated with carfilzomib (CFZ)-based therapy for antibody-mediated rejection (AMR) of the lung. Patients were considered responders to CFZ if complement-1q (C1q)-fixing ability of their immunodominant (ID) donor-specific anti-human leukocyte antibody (DSA) was suppressed after treatment. Treatment consisted of CFZ plus plasma exchange and immunoglobulins. Fourteen LTRs underwent CFZ for 20 ID DSA AMR. Ten (71.4%) of LTRs responded to CFZ. DSA IgG mean fluorescence intensity (MFI) fell from 7664 (IQR 3230-11 874) to 1878 (653-7791) after therapy (p = 0.001) and to 1400 (850-8287) 2 weeks later (p = 0.001). DSA C1q MFI fell from 3596 (IQR 714-14 405) to <30 after therapy (p = 0.01) and <30 2 weeks later (p = 0.02). Forced expiratory volume in 1s ( FEV1 ) fell from mean 2.11 L pre-AMR to 1.92 L at AMR (p = 0.04). FEV1 was unchanged after CFZ (1.91 L) and subsequently rose to a maximum of 2.13 L (p = 0.01). Mean forced expiratory flow during mid forced vital capacity (25-75) (FEF25-75 ) fell from mean 2.5 L pre-AMR to 1.95 L at AMR (p = 0.01). FEF25-75 rose after CFZ to 2.54 L and reached a maximum of 2.91 L (p = 0.01). Responders had less chronic lung allograft dysfunction or progression versus nonresponders (25% vs. 83%, p = 0.04). No deaths occurred within 120 days and 7 patients died post CFZ therapy of allograft failure. Larger prospective interventional studies are needed to further describe the benefit of CFZ-based therapy for pulmonary AMR.
Collapse
Affiliation(s)
- C R Ensor
- School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S A Yousem
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M Marrari
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M R Morrell
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - M Mangiola
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J M Pilewski
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J D'Cunha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S R Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R Venkataramanan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J F McDyer
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
22
|
van den Bosch TPP, Kannegieter NM, Hesselink DA, Baan CC, Rowshani AT. Targeting the Monocyte-Macrophage Lineage in Solid Organ Transplantation. Front Immunol 2017; 8:153. [PMID: 28261211 PMCID: PMC5312419 DOI: 10.3389/fimmu.2017.00153] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/30/2017] [Indexed: 01/04/2023] Open
Abstract
There is an unmet clinical need for immunotherapeutic strategies that specifically target the active immune cells participating in the process of rejection after solid organ transplantation. The monocyte–macrophage cell lineage is increasingly recognized as a major player in acute and chronic allograft immunopathology. The dominant presence of cells of this lineage in rejecting allograft tissue is associated with worse graft function and survival. Monocytes and macrophages contribute to alloimmunity via diverse pathways: antigen processing and presentation, costimulation, pro-inflammatory cytokine production, and tissue repair. Cross talk with other recipient immune competent cells and donor endothelial cells leads to amplification of inflammation and a cytolytic response in the graft. Surprisingly, little is known about therapeutic manipulation of the function of cells of the monocyte–macrophage lineage in transplantation by immunosuppressive agents. Although not primarily designed to target monocyte–macrophage lineage cells, multiple categories of currently prescribed immunosuppressive drugs, such as mycophenolate mofetil, mammalian target of rapamycin inhibitors, and calcineurin inhibitors, do have limited inhibitory effects. These effects include diminishing the degree of cytokine production, thereby blocking costimulation and inhibiting the migration of monocytes to the site of rejection. Outside the field of transplantation, some clinical studies have shown that the monoclonal antibodies canakinumab, tocilizumab, and infliximab are effective in inhibiting monocyte functions. Indirect effects have also been shown for simvastatin, a lipid lowering drug, and bromodomain and extra-terminal motif inhibitors that reduce the cytokine production by monocytes–macrophages in patients with diabetes mellitus and rheumatoid arthritis. To date, detailed knowledge concerning the origin, the developmental requirements, and functions of diverse specialized monocyte–macrophage subsets justifies research for therapeutic manipulation. Here, we will discuss the effects of currently prescribed immunosuppressive drugs on monocyte/macrophage features and the future challenges.
Collapse
Affiliation(s)
- Thierry P P van den Bosch
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam , Rotterdam , Netherlands
| | - Nynke M Kannegieter
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam , Rotterdam , Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam , Rotterdam , Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam , Rotterdam , Netherlands
| | - Ajda T Rowshani
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam , Rotterdam , Netherlands
| |
Collapse
|
23
|
Soluble BAFF Cytokine Levels and Antibody-Mediated Rejection of the Kidney Allograft. Arch Immunol Ther Exp (Warsz) 2017; 64:47-53. [PMID: 28083608 DOI: 10.1007/s00005-016-0428-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 11/02/2016] [Indexed: 01/07/2023]
Abstract
The B-cell activating factor (BAFF) cytokine has important functions for the survival and maturation of B lymphocytes, which implies that this cytokine might play a role in the development of antibody-mediated rejection (AMR) after kidney transplantation. In our study, we compared the concentrations of the soluble BAFF cytokine in kidney graft recipients with AMR and patients without rejection with the goal of testing the hypothesis whether BAFF level measurement might be useful as a diagnostic marker of AMR. The study included a cohort of 19 high-risk patients with diagnosed AMR and 17 control patients free of rejection. BAFF was measured in all patients before transplantation, during the rejection episodes, and three months after transplantation in patients free of rejection using the Luminex technique. Before transplantation, the serum concentrations of BAFF in patients with AMR and kidney recipients without rejection did not significantly differ. After transplantation, however, BAFF levels were significantly lower in patients with AMR and also in patients with concurrent humoral and cellular rejection compared with patients without rejection (p < 0.05 and p < 0.01, respectively). No correlation was found between BAFF and the production of donor-specific antibodies (DSA) before and after transplantation. Patients experiencing AMR and simultaneous cellular and AMR had significantly lower concentrations of BAFF in comparison with patients free of rejection.
Collapse
|
24
|
Karahan GE, Claas FHJ, Heidt S. B Cell Immunity in Solid Organ Transplantation. Front Immunol 2017; 7:686. [PMID: 28119695 PMCID: PMC5222792 DOI: 10.3389/fimmu.2016.00686] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/22/2016] [Indexed: 01/03/2023] Open
Abstract
The contribution of B cells to alloimmune responses is gradually being understood in more detail. We now know that B cells can perpetuate alloimmune responses in multiple ways: (i) differentiation into antibody-producing plasma cells; (ii) sustaining long-term humoral immune memory; (iii) serving as antigen-presenting cells; (iv) organizing the formation of tertiary lymphoid organs; and (v) secreting pro- as well as anti-inflammatory cytokines. The cross-talk between B cells and T cells in the course of immune responses forms the basis of these diverse functions. In the setting of organ transplantation, focus has gradually shifted from T cells to B cells, with an increased notion that B cells are more than mere precursors of antibody-producing plasma cells. In this review, we discuss the various roles of B cells in the generation of alloimmune responses beyond antibody production, as well as possibilities to specifically interfere with B cell activation.
Collapse
Affiliation(s)
- Gonca E Karahan
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
| | - Frans H J Claas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
| | - Sebastiaan Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
| |
Collapse
|
25
|
Min JW, Kim KW, Kim BM, Doh KC, Choi MS, Choi BS, Park CW, Yang CW, Kim YS, Oh EJ, Chung BH. Clinical Significance of Pre- and Post-Transplant BAFF Levels in Kidney Transplant Recipients. PLoS One 2016; 11:e0162964. [PMID: 27631619 PMCID: PMC5025051 DOI: 10.1371/journal.pone.0162964] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/31/2016] [Indexed: 11/18/2022] Open
Abstract
It is well known that pre-transplant B cell activating factor (BAFF) levels are associated with the development of de novo anti-HLA antibodies and antibody mediated rejection post-transplant. However, the clinical significance of BAFF values at allograft rejection has not been determined. In this study, we investigated the clinical significance of pre-transplant BAFF level as well as post-transplant BAFF levels measured when indication biopsy was done. We checked for anti-HLA antibodies in 115 kidney transplant recipients who required allograft biopsy due to an increase in serum creatinine. With the same serum specimen, we measured BAFF levels, and in 78 of these patients, pre-transplant BAFF and anti-HLA antibody levels were detected as well. Patients in each group were divided into tertiles according to BAFF levels. We investigated the relationship between BAFF levels and the occurrence of anti-HLA antibodies. Pre-transplant BAFF levels showed significant association with pre-transplant sensitization, and also with early rejection (Tertile 3, 26.9% vs. Tertile 1, 11.5%; P<0.05). Post-transplant BAFF levels showed significant association with pre-transplant sensitization, but did not show association with anti-HLA antibodies and positive donor-specific antibodies at the time of biopsy. We did not find any association between post-transplant BAFF levels and allograft biopsy results, Banff scores and microvascular inflammation scores. In conclusion, pre-transplant BAFF levels are associated with pre-transplant sensitization and are useful in predicting allograft rejection. But post-transplant BAFF levels measured at the time of indication biopsy are not associated with the appearance of de novo HLA-DSA, allograft rejection, biopsy findings and other allograft outcomes.
Collapse
Affiliation(s)
- Ji Won Min
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyoung Woon Kim
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-Mi Kim
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyoung Chan Doh
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Seok Choi
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bum Soon Choi
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Cheol Whee Park
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong-Soo Kim
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- * E-mail: (BHC); (EJO)
| | - Byung Ha Chung
- Transplant research center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- * E-mail: (BHC); (EJO)
| |
Collapse
|
26
|
Preemptive CD20+ B cell Depletion Attenuates Cardiac Allograft Vasculopathy in CD154-Treated Monkeys. Transplantation 2016; 101:63-73. [PMID: 27362307 DOI: 10.1097/tp.0000000000001258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Anti-CD154 monotherapy is associated with antidonor allo-antibody (Ab) elaboration, cardiac allograft vasculopathy (CAV), and allograft failure in preclinical primate cell and organ transplant models. In the context of calcineurin inhibitors (CNI), these pathogenic phenomena are delayed by preemptive "induction" B cell depletion. METHODS αCD154 (IDEC-131)-treated cynomolgus monkey heart allograft recipients were given peritransplant rituximab (αCD20) alone or with rabbit antihuman thymocyte globulin. RESULTS Relative to previously reported reference groups, αCD20 significantly prolonged survival, delayed Ab detection, and attenuated CAV within 3 months in αCD154-treated recipients (αCD154 + αCD20 graft median survival time > 90 days, n = 7, vs 28 days for αCD154 alone (IDEC-131), n = 21; P = 0.05). Addition of rabbit antihuman thymocyte globulin to αCD154 (n = 6) or αCD154 + αCD20 (n = 10) improved graft protection from graft rejection and failure during treatment but was associated with significant morbidity in 8 of 16 recipients (6 infections, 2 drug-related complications). In αCD20-treated animals, detection of antidonor Ab and relatively severe CAV were anticipated by appearance of CD20 cells (>1% of lymphocytes) in peripheral blood and were associated with low αCD154 trough levels (below 100 μg/mL). CONCLUSIONS These observations support the hypothesis that efficient preemptive "induction" CD20 B cell depletion consistently modulates pathogenic alloimmunity and attenuates CAV in this translational model, extending our prior findings with calcineurin inhibitors to the context of CD154 blockade.
Collapse
|
27
|
Ezzelarab MB, Zhang H, Guo H, Lu L, Zahorchak AF, Wiseman RW, Nalesnik MA, Bhama JK, Cooper DKC, Thomson AW. Regulatory T Cell Infusion Can Enhance Memory T Cell and Alloantibody Responses in Lymphodepleted Nonhuman Primate Heart Allograft Recipients. Am J Transplant 2016; 16:1999-2015. [PMID: 26700196 PMCID: PMC4919255 DOI: 10.1111/ajt.13685] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/25/2015] [Accepted: 12/13/2015] [Indexed: 01/25/2023]
Abstract
The ability of regulatory T cells (Treg) to prolong allograft survival and promote transplant tolerance in lymphodepleted rodents is well established. Few studies, however, have addressed the therapeutic potential of adoptively transferred, CD4(+) CD25(+) CD127(-) Foxp3(+) (Treg) in clinically relevant large animal models. We infused ex vivo-expanded, functionally stable, nonselected Treg (up to a maximum cumulative dose of 1.87 billion cells) into antithymocyte globulin-lymphodepleted, MHC-mismatched cynomolgus monkey heart graft recipients before homeostatic recovery of effector T cells. The monkeys also received tacrolimus, anti-interleukin-6 receptor monoclonal antibodies and tapered rapamycin maintenance therapy. Treg administration in single or multiple doses during the early postsurgical period (up to 1 month posttransplantation), when host T cells were profoundly depleted, resulted in inferior graft function compared with controls. This was accompanied by increased incidences of effector memory T cells, enhanced interferon-γ production by host CD8(+) T cells, elevated levels of proinflammatory cytokines, and antidonor alloantibodies. The findings caution against infusion of Treg during the early posttransplantation period after lymphodepletion. Despite marked but transient increases in Treg relative to endogenous effector T cells and use of reputed "Treg-friendly" agents, the host environment/immune effector mechanisms instigated under these conditions can perturb rather than favor the potential therapeutic efficacy of adoptively transferred Treg.
Collapse
Affiliation(s)
- M. B. Ezzelarab
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine
| | - H. Zhang
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine
| | - H. Guo
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine
| | - L. Lu
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine
| | - A. F. Zahorchak
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine
| | - R. W. Wiseman
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI
| | - M. A. Nalesnik
- Department of Pathology, University of Pittsburgh School of Medicine
| | - J. K. Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine
| | - D. K. C. Cooper
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine,Department of Immunology, University of Pittsburgh School of Medicine
| | - A. W. Thomson
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine,Department of Immunology, University of Pittsburgh School of Medicine,Corresponding author: Angus W. Thomson PhD DSc,
| |
Collapse
|
28
|
Xu H, Samy KP, Guasch A, Mead SI, Ghali A, Mehta A, Stempora L, Kirk AD. Postdepletion Lymphocyte Reconstitution During Belatacept and Rapamycin Treatment in Kidney Transplant Recipients. Am J Transplant 2016; 16:550-64. [PMID: 26436448 PMCID: PMC4822163 DOI: 10.1111/ajt.13469] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/09/2015] [Accepted: 07/17/2015] [Indexed: 01/25/2023]
Abstract
Belatacept is used to prevent allograft rejection but fails to do so in a sizable minority of patients due to inadequate control of costimulation-resistant T cells. In this study, we report control of costimulation-resistant rejection when belatacept was combined with perioperative alemtuzumab-mediated lymphocyte depletion and rapamycin. To assess the means by which the alemtuzumab, belatacept and rapamycin (ABR) regimen controls belatacept-resistant rejection, we studied 20 ABR-treated patients and characterized peripheral lymphocyte phenotype and functional responses to donor, third-party and viral antigens using flow cytometry, intracellular cytokine staining and carboxyfluorescein succinimidyl ester-based lymphocyte proliferation. Compared with conventional immunosuppression in 10 patients, lymphocyte depletion evoked substantial homeostatic lymphocyte activation balanced by regulatory T and B cell phenotypes. The reconstituted T cell repertoire was enriched for CD28(+) naïve cells, notably diminished in belatacept-resistant CD28(-) memory subsets and depleted of polyfunctional donor-specific T cells but able to respond to third-party and latent herpes viruses. B cell responses were similarly favorable, without alloantibody development and a reduction in memory subsets-changes not seen in conventionally treated patients. The ABR regimen uniquely altered the immune profile, producing a repertoire enriched for CD28(+) T cells, hyporesponsive to donor alloantigen and competent in its protective immune capabilities. The resulting repertoire was permissive for control of rejection with belatacept monotherapy.
Collapse
Affiliation(s)
- He Xu
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Kannan P. Samy
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | - Sue I. Mead
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Ada Ghali
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Aneesh Mehta
- Emory Transplant Center, Emory University, Atlanta, GA
| | - Linda Stempora
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Allan D. Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC,Emory Transplant Center, Emory University, Atlanta, GA
| |
Collapse
|
29
|
Vallin P, Désy O, Béland S, Wagner E, De Serres SA. Clinical relevance of circulating antibodies and B lymphocyte markers in allograft rejection. Clin Biochem 2016; 49:385-93. [PMID: 26721422 DOI: 10.1016/j.clinbiochem.2015.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/27/2015] [Accepted: 12/06/2015] [Indexed: 01/08/2023]
Abstract
The main challenge in solid organ transplantation remains to tackle antibody-mediated rejection. Our understanding of the antibody-mediated response and the capacity to detect it has improved in the last decade. However, the sensitivity and specificity of the current clinical tools to monitor B cell activation are perfectible. New strategies, including the refinement in the characterization of HLA and non-HLA antibodies, as well as a better understanding of the circulating B cell phenotype will hopefully help to non-invasively identify patients at risk or undergoing antibody-mediated allograft damage. The current review discusses the current knowledge of the B cell biomarkers in solid organ transplantation, with a focus on circulating antibodies and peripheral B cells.
Collapse
Affiliation(s)
- Patrice Vallin
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Olivier Désy
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Stéphanie Béland
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Eric Wagner
- Immunology and Histocompatibility Laboratory, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Sacha A De Serres
- Transplantation Unit, Renal Division, Department of Medicine, CHU de Québec, Faculty of Medicine, Laval University, Québec, QC, Canada.
| |
Collapse
|
30
|
Abstract
B cells play a central role in the immunopathogenesis of glomerulonephritides and transplant rejection. B cells secrete antibodies that contribute to tissue injury via multiple mechanisms. In addition, B cells contribute to disease pathogenesis in autoimmunity and alloimmunity by presenting antigens as well as providing costimulation and cytokines to T cells. B cells also play an immunomodulatory role in regulating the immune response by secreting cytokines that inhibit disease onset and/or progression. B cell-targeted approaches for treating immune diseases of the kidney and other organs have gained significant momentum. However, much remains to be understood about B-cell biology in order to determine the timing, duration, and context of optimal therapeutic response to B cell-targeted approaches. In this review, we discuss the multifaceted roles of B cells as enhancers and regulators of immunity with relevance to kidney disease and transplantation.
Collapse
Affiliation(s)
| | - Fadi G Lakkis
- Departments of Medicine (Renal-Electrolyte), Surgery, and Immunology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Geetha Chalasani
- Departments of Medicine (Renal-Electrolyte), Surgery, and Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Renal Section, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| |
Collapse
|
31
|
Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
Collapse
Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Wiebe C, Gibson IW, Blydt-Hansen TD, Pochinco D, Birk PE, Ho J, Karpinski M, Goldberg A, Storsley L, Rush DN, Nickerson PW. Rates and determinants of progression to graft failure in kidney allograft recipients with de novo donor-specific antibody. Am J Transplant 2015; 15:2921-30. [PMID: 26096305 DOI: 10.1111/ajt.13347] [Citation(s) in RCA: 264] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/13/2015] [Accepted: 04/05/2015] [Indexed: 01/25/2023]
Abstract
Understanding rates and determinants of clinical pathologic progression for recipients with de novo donor-specific antibody (dnDSA), especially subclinical dnDSA, may identify surrogate endpoints and inform clinical trial design. A consecutive cohort of 508 renal transplant recipients (n = 64 with dnDSA) was studied. Recipients (n = 388) without dnDSA or dysfunction had an eGFR decline of -0.65 mL/min/1.73 m(2) /year. In recipients with dnDSA, the rate eGFR decline was significantly increased prior to dnDSA onset (-2.89 vs. -0.65 mL/min/1.73 m(2) /year, p < 0.0001) and accelerated post-dnDSA (-3.63 vs. -2.89 mL/min/1.73 m(2) /year, p < 0.0001), suggesting that dnDSA is both a marker and contributor to ongoing alloimmunity. Time to 50% post-dnDSA graft loss was longer in recipients with subclinical versus a clinical dnDSA phenotype (8.3 vs. 3.3 years, p < 0.0001). Analysis of 1091 allograft biopsies found that dnDSA and time independently predicted chronic glomerulopathy (cg), but not interstitial fibrosis and tubular atrophy (IFTA). Early T cell-mediated rejection, nonadherence, and time were multivariate predictors of IFTA. Independent risk factors for post-dnDSA graft survival available prior to, or at the time of, dnDSA detection were delayed graft function, nonadherence, dnDSA mean fluorescence intensity sum score, tubulitis, and cg. Ultimately, dnDSA is part of a continuum of mixed alloimmune-mediated injury, which requires solutions targeting T and B cells.
Collapse
Affiliation(s)
- C Wiebe
- Department of Medicine, University of Manitoba, Diagnostic Services of Manitoba, Winnipeg, Manitoba, Canada
| | - I W Gibson
- Department of Pathology, University of Manitoba, Diagnostic Services of Manitoba, Winnipeg, Manitoba, Canada
| | - T D Blydt-Hansen
- Department of Pediatrics and Child Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - D Pochinco
- Diagnostic Services of Manitoba, Winnipeg, Manitoba, Canada
| | - P E Birk
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - J Ho
- Department of Medicine and Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - M Karpinski
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - A Goldberg
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - L Storsley
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - D N Rush
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - P W Nickerson
- Departments of Medicine and Immunology, University of Manitoba, Diagnostic Services of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
33
|
Noureldeen T, Albekioni Z, Machado L, Muddana N, Marcus RJ, Hussain SM, Sureshkumar KK. Alemtuzumab induction and antibody-mediated rejection in kidney transplantation. Transplant Proc 2015; 46:3405-7. [PMID: 25498060 DOI: 10.1016/j.transproceed.2014.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Induction therapy improves graft outcomes in kidney transplant recipients (KTRs). We aimed to compare the incidences of antibody-mediated rejection (AMR) and acute cellular rejection (ACR) as well as graft and patient outcomes in KTRs who underwent induction with alemtuzumab versus rabbit-antithymocyte globulin (r-ATG). METHODS This was a single-center retrospective study involving patients who underwent kidney transplantation between January 2009 and December 2011 after receiving induction therapy with either alemtuzumab or r-ATG. Maintenance immunosuppression included tacrolimus and mycophenolate mofetil with early steroid withdrawal. Acute rejection was diagnosed using allograft biopsy. RESULTS Among the 108 study patients, 68 received alemtuzumab and 40 got r-ATG. There was a significantly higher incidence of AMR (15% vs 2.5%; P = .008) and similar incidence of ACR (4.4% vs 10%; P = .69) for alemtuzumab versus r-ATG groups. One-year serum creatinine levels (l.68 ± 0.8 mg/dL vs 1.79 ± 1.8 mg/dL; P = .66) as well as graft (91.1 ± 3.5% vs 94.5 ± 3.8%; P = .48) and patient (93.8 ± 3.0% vs 96.4 ± 3.5%; P = .92) survivals were similar for the alemtuzumab versus the r-ATG groups. CONCLUSION Our study showed a higher incidence of AMR and similar incidence of ACR in KTRs who underwent induction with alemtuzumab compared with those who received r-ATG and were maintained on tacrolimus and MMF. This was despite a lower HLA mismatch in the alemtuzumab group. One-year graft survival, patient survival, and allograft function were similar. Inadequate B-cell suppression by alemtuzumab as well as altered phenotypic and functional properties of repopulating B cells could be contributing to heightened risk of AMR in these patients.
Collapse
Affiliation(s)
- T Noureldeen
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Z Albekioni
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - L Machado
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - N Muddana
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - R J Marcus
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - S M Hussain
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - K K Sureshkumar
- Division of Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
34
|
Cohney S, Masterson R, Hogan C, Hughes P, Haeusler M. ABOi with conventional immunosuppression alone-antiblood group antibody isn't the only contributor to antibody-mediated rejection and/or thrombotic microangiopathy. Am J Transplant 2015; 15:1730-2. [PMID: 25912527 DOI: 10.1111/ajt.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- S Cohney
- Nephrology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - R Masterson
- Nephrology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - C Hogan
- Hematology Laboratory, Royal Melbourne Hospital, Melbourne, Australia
| | - P Hughes
- Nephrology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - M Haeusler
- Hematology Laboratory, Royal Melbourne Hospital, Melbourne, Australia
| |
Collapse
|
35
|
Affiliation(s)
- M R Clatworthy
- Department of Medicine, Addenbrooke's Hospital and Pembroke College, University of Cambridge, Cambridge, UK
| |
Collapse
|
36
|
Kwun J, Page E, Hong JJ, Gibby A, Yoon J, Farris AB, Villinger F, Knechtle S. Neutralizing BAFF/APRIL with atacicept prevents early DSA formation and AMR development in T cell depletion induced nonhuman primate AMR model. Am J Transplant 2015; 15:815-22. [PMID: 25675879 PMCID: PMC5504528 DOI: 10.1111/ajt.13045] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 09/24/2014] [Accepted: 09/28/2014] [Indexed: 01/25/2023]
Abstract
Depletional strategies directed toward achieving tolerance induction in organ transplantation have been associated with an increased incidence and risk of antibody-mediated rejection (AMR) and graft injury. Our clinical data suggest correlation of increased serum B cell activating factor/survival factor (BAFF) with increased risk of antibody-mediated rejection in alemtuzumab treated patients. In the present study, we tested the ability of BAFF blockade (TACI-Ig) in a nonhuman primate AMR model to prevent alloantibody production and prolong allograft survival. Three animals received the AMR inducing regimen (CD3-IT/alefacept/tacrolimus) with TACI-Ig (atacicept), compared to five control animals treated with the AMR inducing regimen only. TACI-Ig treatment lead to decreased levels of DSA in treated animals at 2 and 4 weeks posttransplantation (p < 0.05). In addition, peripheral B cell numbers were significantly lower at 6 weeks posttransplantation. However, it provided only a marginal increase in graft survival (59 ± 22 vs. 102 ± 47 days; p = 0.11). Histological analysis revealed a substantial reduction in findings typically associated with humoral rejection with atacicept treatment. More T cell rejection findings were observed with increased graft T cell infiltration in atacicept treatment, likely secondary to the graft prolongation. We show that BAFF/APRIL blockade using concomitant TACI-Ig treatment reduced the humoral portion of rejection in our depletion-induced preclinical AMR model.
Collapse
Affiliation(s)
- J. Kwun
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA
| | - E. Page
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA
| | - J. J. Hong
- Department of Pathology, Emory University School of Medicine, Atlanta, GA,Division of Pathology, Yerkes National Primate Research Center, Emory University, Atlanta, GA
| | - A. Gibby
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA
| | - J. Yoon
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA
| | - A. B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - F. Villinger
- Department of Pathology, Emory University School of Medicine, Atlanta, GA,Division of Pathology, Yerkes National Primate Research Center, Emory University, Atlanta, GA
| | - S. Knechtle
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA,Corresponding author Stuart J. Knechtle,
| |
Collapse
|
37
|
Chong AS, Alegre ML. Transplantation tolerance and its outcome during infections and inflammation. Immunol Rev 2015; 258:80-101. [PMID: 24517427 DOI: 10.1111/imr.12147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Much progress has been made toward understanding the mechanistic basis of transplantation tolerance in experimental models, which implicates clonal deletion of alloreactive T and B cells, induction of cell-intrinsic hyporesponsiveness, and dominant regulatory cells mediating infectious tolerance and linked suppression. Despite encouraging success in the laboratory, achieving tolerance in the clinic remains challenging, although the basis for these challenges is beginning to be understood. Heterologous memory alloreactive T cells generated by infections prior to transplantation have been shown to be a critical barrier to tolerance induction. Furthermore, infections at the time of transplantation and tolerance induction provide a pro-inflammatory milieu that alters the stability and function of regulatory T cells as well as the activation requirements and differentiation of effector T cells. Thus, infections can result in enhanced alloreactivity, resistance to tolerance induction, and destabilization of the established tolerance state. We speculate that these experimental findings have relevance to the clinic, where infections have been associated with allograft rejection and may be a causal event precipitating the loss of grafts after long periods of stable operational tolerance. Understanding the mechanisms by which infections prevent and destabilize tolerance can lead to therapies that promote stable life-long tolerance in transplant recipients.
Collapse
Affiliation(s)
- Anita S Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL, USA
| | | |
Collapse
|
38
|
Rosenblum JM, Kirk AD. Recollective homeostasis and the immune consequences of peritransplant depletional induction therapy. Immunol Rev 2015; 258:167-82. [PMID: 24517433 DOI: 10.1111/imr.12155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
One's cellular immune repertoire is composed of lymphocytes in multiple stages of maturation - the dynamic product of their responses to antigenic challenges and the homeostatic contractions necessary to accommodate immune expansions within physiologic norms. Given that alloreactivity is predominantly a cross-reactive phenomenon that is stochastically distributed throughout the overall T-cell repertoire, one's allospecific repertoire is similarly made up of cells in a variety of differentiation states. As such, the continuous expansion and elimination of activated memory populations, producing a 'recollective homeostasis' of sorts, has the potential over time to alter the maturation state and effector composition of both ones protective and alloreactive T-cell repertoire. Importantly, a T cell's maturation state significantly influences its response to numerous immunomodulatory therapies used in organ transplantation, including depletional antibody induction. In this review, we discuss clinically utilized depletional induction strategies, how their use alters a transplant recipient's cellular immune repertoire, and how a recipient's repertoire influences the clinical effects of induction therapy.
Collapse
|
39
|
Lehnhardt AM, Strecker M, Eiermann T, Marget M, Thaiss F, Nashan B, Koch M. High B-cell activating factor is not associated with worse 3-year graft outcome in blood group-incompatible kidney transplantation with rituximab induction. Clin Transplant 2015; 29:359-64. [PMID: 25627801 DOI: 10.1111/ctr.12523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 01/30/2023]
Abstract
B cells and their regulation by B-cell activating factor BAFF are of growing interest in kidney transplantation (KTx). There is evidence that high serum (s) BAFF leads to increased allosensitization and impaired long-term graft function. We prospectively investigated sBAFF, peripheral blood lymphocytes (PBL), and donor-specific HLA antibodies (DSA) in patients after ABOi with B-cell depleting rituximab induction treatment and compared them to a group of blood group-compatible (ABOc) living donor kidney recipients. Twelve patients after ABOi and 18 after ABOc were included. After rituximab treatment prior to ABOi, B cells remained significantly lower 1 year after KTx (1.2% (0.0-17.8) compared to ABOc of 8.6% (2.8-35.0), p = 0.0004, and also BAFF-R expression was significantly lower in ABOi (p < 0.006). sBAFF remained elevated 1 year post-Tx compared to ABOc (3615 ± 1800 vs. 1394 ± 493 pg/mL, p < 0.004). Kidney function was not significantly different between both groups after 1, 2, and 3 years. The use of rituximab in ABOi together with maintenance immunosuppression leads to significant elevation of sBAFF and lowering of B-cell numbers for more than 1 year, and this does not correlate with worse 3-year graft outcome.
Collapse
Affiliation(s)
- Anja M Lehnhardt
- Department of Hepatobiliary Surgery and Transplantation at University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Pediatric Nephrology at University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | |
Collapse
|
40
|
Donor-Specific Antibodies, C4d and Their Relationship With the Prognosis of Transplant Glomerulopathy. Transplantation 2015; 99:69-76. [DOI: 10.1097/tp.0000000000000310] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
41
|
Posttransplant Soluble B-Cell Activating Factor Kinetics in Pediatric Recipients of First Kidney Allograft. Transplantation 2015; 99:243-9. [DOI: 10.1097/tp.0000000000000276] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
42
|
Longitudinal analysis of T and B cell phenotype and function in renal transplant recipients with or without rituximab induction therapy. PLoS One 2014; 9:e112658. [PMID: 25393622 PMCID: PMC4231065 DOI: 10.1371/journal.pone.0112658] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/06/2014] [Indexed: 12/20/2022] Open
Abstract
Background Prevention of rejection after renal transplantation requires treatment with immunosuppressive drugs. Data on their in vivo effects on T- and B-cell phenotype and function are limited. Methods In a randomized double-blind placebo-controlled study to prevent renal allograft rejection, patients were treated with tacrolimus, mycophenolate mofetil (MMF), steroids, and a single dose of rituximab or placebo during transplant surgery. In a subset of patients, we analyzed the number and phenotype of peripheral T and B cells by multiparameter flow cytometry before transplantation, and at 3, 6, 12, and 24 months after transplantation. Results In patients treated with tacrolimus/MMF/steroids the proportion of central memory CD4+ and CD8+ T cells was higher at 3 months post-transplant compared to pre-transplant levels. In addition, the ratio between the percentage of central memory CD4+ and CD4+ regulatory T cells was significantly higher up to 24 months post-transplant compared to pre-transplant levels. Interestingly, treatment with tacrolimus/MMF/steroids resulted in a shift toward a more memory-like B-cell phenotype post-transplant. Addition of a single dose of rituximab resulted in a long-lasting B-cell depletion. At 12 months post-transplant, the small fraction of repopulated B cells consisted of a high percentage of transitional B cells. Rituximab treatment had no effect on the T-cell phenotype and function post-transplant. Conclusions Renal transplant recipients treated with tacrolimus/MMF/steroids show an altered memory T and B-cell compartment post-transplant. Additional B-cell depletion by rituximab leads to a relative increase of transitional and memory-like B cells, without affecting T-cell phenotype and function. Trial Registration ClinicalTrials.gov NCT00565331
Collapse
|
43
|
Peripheral B-cell phenotype and BAFF levels are associated with HLA immunization in patients awaiting kidney transplantation. Transplantation 2014; 97:917-24. [PMID: 24827764 DOI: 10.1097/01.tp.0000438211.34842.5e] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The role of B-cell subsets in human leukocyte antigen (HLA)-specific humoral responses in patients with end-stage renal disease is poorly documented. The objective of this study was to analyze the potential association between B-cell subsets distribution and anti-HLA antibodies before kidney transplantation. METHODS The authors studied by flow cytometry peripheral B-cell subsets and serum levels of BAFF, the main homeostatic cytokine for peripheral B cells, in 101 consecutive end-stage renal disease patients admitted for transplantation. RESULTS In patients with HLA antibodies detected with Luminex single antigen, the proportion of activated naive B cells (Bm2) was significantly higher (64.4 ± 15.1% vs. 52.5 ± 19.1% in HLA antibody-negative patients, P=0.0008) at the expense of memory B cells, as were BAFF serum levels (1,651 ± 1,297 vs. 1,139 ± 693 pg/mL, P<0.0001). Proportion of Bm2 and BAFF levels were positively associated with the diversity of anti-HLA antibodies. In multivariate analysis, besides HLA-immunizing events (pregnancy and previous transplantation), proportion of Bm2 cells but not of other B-cell subsets or BAFF levels was independently associated with the presence and diversity of anti-HLA antibodies. High proportion of Bm2 cells before transplantation was associated with an increased risk of developing de novo donor-specific antibodies during the first year posttransplant. The authors did not find any association between the frequency of antibody-mediated rejection and pretransplant proportion of any B-cell subset or BAFF serum levels. CONCLUSION Increased proportions of activated naive B cells are linked with pretransplant HLA immunization and the development of posttransplant donor-specific antibodies.
Collapse
|
44
|
Djamali A, Kaufman DB, Ellis TM, Zhong W, Matas A, Samaniego M. Diagnosis and management of antibody-mediated rejection: current status and novel approaches. Am J Transplant 2014; 14:255-71. [PMID: 24401076 PMCID: PMC4285166 DOI: 10.1111/ajt.12589] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 11/12/2013] [Indexed: 01/25/2023]
Abstract
Advances in multimodal immunotherapy have significantly reduced acute rejection rates and substantially improved 1-year graft survival following renal transplantation. However, long-term (10-year) survival rates have stagnated over the past decade. Recent studies indicate that antibody-mediated rejection (ABMR) is among the most important barriers to improving long-term outcomes. Improved understanding of the roles of acute and chronic ABMR has evolved in recent years following major progress in the technical ability to detect and quantify recipient anti-HLA antibody production. Additionally, new knowledge of the immunobiology of B cells and plasma cells that pertains to allograft rejection and tolerance has emerged. Still, questions regarding the classification of ABMR, the precision of diagnostic approaches, and the efficacy of various strategies for managing affected patients abound. This review article provides an overview of current thinking and research surrounding the pathophysiology and diagnosis of ABMR, ABMR-related outcomes, ABMR prevention and treatment, as well as possible future directions in treatment.
Collapse
Affiliation(s)
- A Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - D B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - T M Ellis
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - W Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
- Pathology and Laboratory Services, William S. Middleton Memorial Veterans HospitalMadison, WI
| | - A Matas
- Division of Transplantation, Department of Surgery, University of MinnesotaMinneapolis, MN
| | - M Samaniego
- Division of Nephrology, Department of Medicine, University of MichiganAnn Arbor, MI
| |
Collapse
|
45
|
Parsons RF, Vivek K, Redfield RR, Migone TS, Cancro MP, Naji A, Noorchashm H. B-cell tolerance in transplantation: is repertoire remodeling the answer? Expert Rev Clin Immunol 2014; 5:703. [PMID: 20161663 DOI: 10.1586/eci.09.63] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
T lymphocytes are the primary targets of immunotherapy in clinical transplantation; however, B lymphocytes and their secreted alloantibodies are also highly detrimental to the allograft. Therefore, the achievement of sustained organ transplant survival will likely require the induction of B-lymphocyte tolerance. During development, acquisition of B-cell tolerance to self-antigens relies on clonal deletion in the early stages of B-cell compartment ontogeny. We contend that this mechanism should be recapitulated in the setting of alloantigens and organ transplantation to eliminate the alloreactive B-cell subset from the recipient. Clinically feasible targets of B-cell-directed immunotherapy, such as CD20 and B-lymphocyte stimulator (BLyS), should drive upcoming clinical trials aimed at remodeling the recipient B-cell repertoire.
Collapse
Affiliation(s)
- Ronald F Parsons
- 329 Stemmler Hall, 36th and Hamilton Walk, University of Pennsylvania School of Medicine, Harrison Department of Surgical Research, Philadelphia, PA 19104, USA, Tel.: +1 215 400 1806
| | | | | | | | | | | | | |
Collapse
|
46
|
Kim EJ, Kwun J, Gibby AC, Hong JJ, Farris AB, Iwakoshi NN, Villinger F, Kirk AD, Knechtle SJ. Costimulation blockade alters germinal center responses and prevents antibody-mediated rejection. Am J Transplant 2014; 14:59-69. [PMID: 24354871 PMCID: PMC3985346 DOI: 10.1111/ajt.12526] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 09/13/2013] [Accepted: 10/01/2013] [Indexed: 01/25/2023]
Abstract
De novo donor-specific antibody (DSA) after organ transplantation promotes antibody-mediated rejection (AMR) and causes late graft loss. Previously, we demonstrated that depletion using anti-CD3 immunotoxin combined with tacrolimus and alefacept (AMR regimen) reliably induced early DSA production with AMR in a nonhuman primate kidney transplant model. Five animals were assigned as positive AMR controls, four received additional belatacept and four received additional anti-CD40 mAb (2C10R4). Notably, production of early de novo DSA was completely attenuated with additional belatacept or 2C10R4 treatment. In accordance with this, while positive controls experienced a decrease in peripheral IgM(+) B cells, bela- and 2C10R4-added groups maintained a predominant population of IgM(+) B cells, potentially indicating decreased isotype switching. Central memory T cells (CD4(+) CD28(+) CD95(+)) as well as PD-1(hi) CD4(+) T cells were decreased in both bela-added and 2C10R4-added groups. In analyzing germinal center (GC) reactions in situ, lymph nodes further revealed a reduction of B cell clonal expansion, GC-follicular helper T (Tfh) cells, and IL-21 production inside GCs with additional belatacept or 2C10R4 treatment. Here we provide evidence that belatacept and 2C10R4 selectively suppresses the humoral response via regulating Tfh cells and prevents AMR in this nonhuman primate model.
Collapse
Affiliation(s)
- Eugenia J Kim
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Jean Kwun
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Adriana C Gibby
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Jung Joo Hong
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322
| | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322
| | - Neal N Iwakoshi
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Francois Villinger
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322
| | - Allan D Kirk
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| | - Stuart J Knechtle
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322
| |
Collapse
|
47
|
|
48
|
Gaber LW, Knight RJ, Patel SJ. A surgeons' guide to renal transplant immunopathology, immunology, and immunosuppression. Surg Clin North Am 2013; 93:1293-307. [PMID: 24206852 DOI: 10.1016/j.suc.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The response to allografting involves adaptive and innate immune mechanisms. In the adaptive system, activated T cells differentiate to cytotoxic effectors that attack the graft and trigger B cells to differentiation to plasma cells that produce anti-HLA antibodies. The innate immune system recognizes antigens in a non-specific manner and recruits immune cells to the graft through the productions of chemotactic factors, and activation of cytokines and the complement cascade. In the kidney the tubules and the endothelium are the targets of the rejection response. Immune suppression is effective in modulating the adaptive immune system effect on graft histology.
Collapse
Affiliation(s)
- Lillian W Gaber
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, 6565 Fannin Street, Houston, TX 77030, USA.
| | | | | |
Collapse
|
49
|
Banham G, Prezzi D, Harford S, Taylor CJ, Hamer R, Higgins R, Bradley JA, Clatworthy MR. Elevated pretransplantation soluble BAFF is associated with an increased risk of acute antibody-mediated rejection. Transplantation 2013; 96:413-20. [PMID: 23842189 PMCID: PMC4170143 DOI: 10.1097/tp.0b013e318298dd65] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND B cells play an important role in renal allograft pathology, particularly in acute and chronic antibody-mediated rejection (AMR). B-cell activating factor belonging to the tumor necrosis factor family (BAFF; also known as BLyS) is a cytokine that enhances B-cell survival and proliferation. METHODS We analyzed serum BAFF levels in 32 patients undergoing antibody-incompatible (Ai) renal transplantation and 319 antibody-compatible transplant recipients and sought to determine whether there was a correlation with acute rejection and with transplant function and survival. RESULTS We demonstrate that, in patients undergoing Ai transplantation, elevated serum BAFF levels at baseline (before both antibody removal/desensitization and transplantation) are associated with an increased risk of subsequent AMR. In antibody-compatible transplant recipients at lower risk of AMR, no statistically significant association was observed between pretransplantation serum BAFF and AMR. CONCLUSIONS These data raise the possibility that, in high immunologic risk patients undergoing Ai transplantation, the presence of elevated pretransplantation serum BAFF might identify those at increased risk of AMR. BAFF neutralization may be an interesting therapeutic strategy to explore in these patients, particularly because such agents are available and have already been used in the treatment of autoimmunity.
Collapse
Affiliation(s)
- Gemma Banham
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Davide Prezzi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Sarah Harford
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Craig J. Taylor
- Tissue Typing Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rizwan Hamer
- Transplant Unit, University Hospitals Coventry and Warwickshire, and Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Rob Higgins
- Transplant Unit, University Hospitals Coventry and Warwickshire, and Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | | | | |
Collapse
|
50
|
Heilman RL, Khamash HA, Smith ML, Chakkera HA, Moss AA, Reddy KS. Delayed allograft inflammation following alemtuzumab induction for kidney transplantation. Clin Transplant 2013; 27:772-80. [PMID: 23924146 DOI: 10.1111/ctr.12201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND In a recent clinical trial in kidney transplant recipients, induction with alemtuzumab and rabbit-antithymocyte globulin (r-ATG) was equally effective in preventing rejection during the first post-transplant year; however, this study did not include protocol biopsies. METHODS The aim of this study was to analyze the impact of alemtuzumab induction on rejection and subclinical inflammation during the first post-transplant year compared with a historic control group receiving induction with r-ATG. All patients received tacrolimus and mycophenolate mofetil (MMF). RESULTS There were 361 in the alemtuzumab group and 478 in the r-ATG groups. Rejection (excluding Banff borderline), during the first year, occurred in 14% of the alemtuzumab group and 9% of the r-ATG group (p = 0.03). Estimated glomerular filtration rate (GFR) (chronic kidney disease (CKD)-EPI formula) at one yr and graft survival at three yr were similar. On the protocol biopsies, interstitial inflammation (Banff i scores) and tubulitis (Banff t scores) were more likely in the r-ATG group at one month, but at four and 12 months, both inflammation and tubulitis were more likely in the alemtuzumab group. CONCLUSIONS We conclude that alemtuzumab induction is associated with delayed inflammation at four and 12 months, but this inflammation did not appear to negatively impact the GFR or graft survival.
Collapse
|