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Furian L, Bestard O, Budde K, Cozzi E, Diekmann F, Mamode N, Naesens M, Pengel LHM, Schwartz Sorensen S, Vistoli F, Thaunat O. European Consensus on the Management of Sensitized Kidney Transplant Recipients: A Delphi Study. Transpl Int 2024; 37:12475. [PMID: 38665475 PMCID: PMC11043529 DOI: 10.3389/ti.2024.12475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
An increasing number of sensitized patients awaiting transplantation face limited options, leading to fatalities during dialysis and higher costs. The absence of established evidence highlights the need for collaborative consensus. Donor-specific antibodies (DSA)-triggered antibody-mediated rejection (AMR) significantly contributes to kidney graft failure, especially in sensitized patients. The European Society for Organ Transplantation (ESOT) launched the ENGAGE initiative, categorizing sensitized candidates by AMR risk to improve patient care. A systematic review assessed induction and maintenance regimens as well as antibody removal strategies, with statements subjected to the Delphi methodology. A Likert-scale survey was distributed to 53 European experts (Nephrologists, Transplant surgeons and Immunologists) with experience in kidney transplant recipient care. A rate ≥75% with the same answer was considered consensus. Consensus was achieved in 95.3% of statements. While most recommendations aligned, two statements related to complement inhibitors for AMR prophylaxis lacked consensus. The ENGAGE consensus presents contemporary recommendations for desensitization and immunomodulation strategies, grounded in predefined risk categories. The adoption of tailored, patient-specific measures is anticipated to streamline the care of sensitized recipients undergoing renal allografts. While this approach holds the promise of enhancing transplant accessibility and fostering long-term success in transplantation outcomes, its efficacy will need to be assessed through dedicated studies.
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Affiliation(s)
- Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Oriol Bestard
- Kidney Transplant Unit, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Emanuele Cozzi
- Transplant Immunology Unit, Department of Cardiac, Thoracic and Vascular Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Fritz Diekmann
- Experimental Nephrology and Transplant Laboratory, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Liset H. M. Pengel
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Soren Schwartz Sorensen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Fabio Vistoli
- University of Pisa, Pisa, Italy
- Department of Biothecnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Olivier Thaunat
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hospices Civils de Lyon, Lyon, France
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2
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Heeger PS, Haro MC, Jordan S. Translating B cell immunology to the treatment of antibody-mediated allograft rejection. Nat Rev Nephrol 2024; 20:218-232. [PMID: 38168662 DOI: 10.1038/s41581-023-00791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 01/05/2024]
Abstract
Antibody-mediated rejection (AMR), including chronic AMR (cAMR), causes ~50% of kidney allograft losses each year. Despite attempts to develop well-tolerated and effective therapeutics for the management of AMR, to date, none has obtained FDA approval, thereby highlighting an urgent unmet medical need. Discoveries over the past decade from basic, translational and clinical studies of transplant recipients have provided a foundation for developing novel therapeutic approaches to preventing and treating AMR and cAMR. These interventions are aimed at reducing donor-specific antibody levels, decreasing graft injury and fibrosis, and preserving kidney function. Innovative approaches emerging from basic science findings include targeting interactions between alloreactive T cells and B cells, and depleting alloreactive memory B cells, as well as donor-specific antibody-producing plasmablasts and plasma cells. Therapies aimed at reducing the cytotoxic antibody effector functions mediated by natural killer cells and the complement system, and their associated pro-inflammatory cytokines, are also undergoing evaluation. The complexity of the pathogenesis of AMR and cAMR suggest that multiple approaches will probably be required to treat these disease processes effectively. Definitive answers await results from large, double-blind, multicentre, randomized controlled clinical trials.
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Affiliation(s)
- Peter S Heeger
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA
| | - Maria Carrera Haro
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA.
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3
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Bureau C, Rafat C, Taupin JL, Malard S, Mesnard L, François H, Petit-Hoang C, Ouali N, Hertig A, Jamme M, Buob D, Rondeau E, Galichon P, Luque Y. Immunoadsorption-Based HLA Desensitization in Patients Awaiting Deceased Donor Kidney Transplantation: An Interventional, Non-Randomised, Single Cohort Study. Transpl Int 2023; 36:11212. [PMID: 37680645 PMCID: PMC10481532 DOI: 10.3389/ti.2023.11212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
Abstract
Whether immunoadsorption (IADS) as part of desensitization protocols could facilitate deceased donor kidney transplantation (KT) in highly sensitized (HS) patients remains to be proven. We retrospectively analyzed our IADS based desensitization protocol for deceased donor KTs between 2013 and 2018. Fifteen HS patients (age 52 years [40-56]) were included. Waiting time before IADS was 6 years [5-10] and the interval between IADS initiation and KT was 5 months [1-12] for the 14 transplanted patients. Nine patients had prior KT. Calculated panel reactive antibody decreased significantly during the protocol (99.3% [92.5-99.9] vs. 79.4% [56.7-81.9]; p = 0.004). Death-censored graft survival was 85.7% at 1 and 2 years post-transplantation. One-year median plasma creatinine level was 135 µmol/L [111-202]. Six developed active antibody mediated rejection (ABMR) at 1 year, with a median delay of 13 days [11-26]. Eight patients developed severe infections, including two fatal outcomes. Finally, compared to 93% of patients who received desensitization receiving a KT, only 43% of a control with similar characteristics underwent transplantation. However, no difference was found in overall probability of being alive with a functioning graft at the end of follow-up. The results indicate that our IADS-based desensitization strategy was not effective due to a high rate of ABMR and severe infectious complications which pose a challenge to its universalization.
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Affiliation(s)
- Côme Bureau
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Cédric Rafat
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Jean Luc Taupin
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d’Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Stéphanie Malard
- Assistance Publique-Hôpitaux de Paris, Laboratoire Régional d’Histocompatibilité, Hôpital Saint Louis, Paris, France
| | - Laurent Mesnard
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Hélène François
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Camille Petit-Hoang
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Nacera Ouali
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - Alexandre Hertig
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Matthieu Jamme
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
| | - David Buob
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service d’Anatomie et Cytologie Pathologiques, Hôpital Tenon, Paris, France
| | - Eric Rondeau
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Pierre Galichon
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
| | - Yosu Luque
- Assistance Publique – Hôpitaux de Paris, Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Paris, France
- Sorbonne Université, CoRaKid Inserm UMR_S1155, Paris, France
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Couzi L, Malvezzi P, Amrouche L, Anglicheau D, Blancho G, Caillard S, Freist M, Guidicelli GL, Kamar N, Lefaucheur C, Mariat C, Koenig A, Noble J, Thaunat O, Thierry A, Taupin JL, Bertrand D. Imlifidase for Kidney Transplantation of Highly Sensitized Patients With a Positive Crossmatch: The French Consensus Guidelines. Transpl Int 2023; 36:11244. [PMID: 37448448 PMCID: PMC10336835 DOI: 10.3389/ti.2023.11244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023]
Abstract
Imlifidase recently received early access authorization for highly sensitized adult kidney transplant candidates with a positive crossmatch against an ABO-compatible deceased donor. These French consensus guidelines have been generated by an expert working group, in order to homogenize patient selection, associated treatments and follow-up. This initiative is part of an international effort to analyze properly the benefits and tolerance of this new costly treatment in real-life. Eligible patients must meet the following screening criteria: cPRA ≥ 98%, ≤ 65-year of age, ≥ 3 years on the waiting list, and a low risk of biopsy-related complications. The final decision to use Imlifidase will be based on the two following criteria. First, the results of a virtual crossmatch on recent serum, which shall show a MFI for the immunodominant donor-specific antibodies (DSA) > 6,000 but the value of which does not exceed 5,000 after 1:10 dilution. Second, the post-Imlifidase complement-dependent cytotoxicity crossmatch must be negative. Patients treated with Imlifidase will receive an immunosuppressive regimen based on steroids, rATG, high dose IVIg, rituximab, tacrolimus and mycophenolic acid. Frequent post-transplant testing for DSA and systematic surveillance kidney biopsies are highly recommended to monitor post-transplant DSA rebound and subclinical rejection.
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Affiliation(s)
- Lionel Couzi
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- CNRS-UMR 5164 Immuno ConcEpT, Université de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | | | - Gilles Blancho
- Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | | | - Marine Freist
- Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | | | - Nassim Kamar
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Christophe Mariat
- Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Saint-Etienne, France
| | | | - Johan Noble
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | - Antoine Thierry
- Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
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5
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Chen X, Wang Y, Dong P, Wang J, Yu X, Yu B. Efficacy of Combined Desensitization Therapy Based on Protein A Immunoadsorption on Anti-human Leukocyte Antigen Antibodies in Sensitized Kidney Transplant Recipients: A Retrospective Study. Cureus 2022; 14:e28661. [PMID: 36196288 PMCID: PMC9525051 DOI: 10.7759/cureus.28661] [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] [Accepted: 08/31/2022] [Indexed: 11/07/2022] Open
Abstract
Background and objectives Protein A immunoadsorption (PA-IA) therapy is an immunoglobulin selective apheresis for pre-transplantation desensitization therapy and treatment of post-transplantation antibody-mediated rejection. There is no unified protocol for the timing of PA-IA therapy or its combination with other drug therapy. This study aimed to investigate and analyze the clearance effects of desensitization therapy on human leukocyte antigen (HLA) antibodies to provide a reference for the formulation of clinical desensitization therapy regimens. Materials and methods Overall, 27 kidney transplant recipients who received preoperative/postoperative desensitization therapy based on PA-IA therapy in combination with drug therapy were enrolled. The pre-treatment mean fluorescence intensity (MFI) of 1324 human leukocyte antigen (HLA) antibody specificities (MFI >2000) and the post-treatment MFI of the corresponding antibody specificities (after one, four, seven, and 10 sessions) were recorded to analyze the changes in antibody level reduction for the different antibody classes and MFI ranges. Results After 10 sessions of PA-IA therapy, the MFI of class I antibodies decreased from 8298.56 to 3196.15 (reduction of 66.80%), while the MFI of class II antibodies decreased from 13,521.09 to 2773.29 (reduction of 71.14%). The pre-treatment level of class II antibodies was significantly higher than that of class I antibodies (p<0.001), whereas the post-treatment levels of class I and II antibodies were comparable (p>0.05). The clearance effects of PA-IA therapy were greater for strongly positive (MFI>10,000) class II antibodies than for strongly positive class I antibodies, showing a reduction of 62.59% (25.17% to 91.04%) and 45.13% (32.70% to 73.94%), respectively (p=0.015). Conclusions We confirmed the removal efficacy of PA-IA for HLA antibodies. The removal efficacy of class II antibodies on PA-IA is not inferior to that of class I. Under an adequate number of treatment sessions, the clearance effect of PA-IA therapy for strongly positive class II antibodies may be greater than that for strongly positive class I antibodies.
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6
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Kälble F, Süsal C, Pego da Silva L, Speer C, Benning L, Nusshag C, Pham L, Tran H, Schaier M, Sommerer C, Beimler J, Mehrabi A, Zeier M, Morath C. Living Donor Kidney Transplantation in Patients With Donor-Specific HLA Antibodies After Desensitization With Immunoadsorption. Front Med (Lausanne) 2022; 8:781491. [PMID: 34977083 PMCID: PMC8719417 DOI: 10.3389/fmed.2021.781491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Due to the current organ shortage, living donor kidney transplantation is increasingly performed across HLA (human leukocyte antigen) or ABO antibody barriers. There is still uncertainty about the risk of antibody-mediated rejection (AMR) episodes, which may limit long-term graft survival. From March 2007 to December 2016, 58 sensitized living donor kidney transplant candidates were identified and 38 patients eventually included in the study: 36 patients (95%) had pre-transplant and pre-desensitization Luminex-detected donor-specific HLA antibodies (DSA), and 17/36 patients (47%) in addition had a positive crossmatch result. Two patients had no detectable DSA but a positive CDC B-cell crossmatch result. Patients were treated with pre- and post-transplant apheresis and powerful immunosuppression including the anti-CD20 antibody rituximab (N = 36) in combination with thymoglobulin (N = 20) or anti-IL2 receptor antibody (N = 18). The results of the 38 successfully desensitized and transplanted patients were retrospectively compared to the results of 76 matched standard-risk recipients. Desensitized patients showed patient and graft survival rates similar to that of standard-risk recipients (P = 0.55 and P = 0.16, respectively). There was a trend toward reduced death-censored graft survival in desensitized patients (P = 0.053) which, however, disappeared when the 34 patients who were transplanted after introduction of sensitive Luminex testing were analyzed (P = 0.43). The incidence of rejection episodes without borderline changes were in desensitized patients with 21% similar to the 18% in standard-risk patients (P = 0.74). Thirty-six patients had pre-transplant HLA class I and/or II DSA that were reduced by 85 and 81%, respectively, during pre-transplant desensitization (P < 0.001 for both). On day 360 after transplantation, 20 of 36 (56%) patients had lost their DSA. The overall AMR rate was 6% in these patients, but as high as 60% in 5 (14%) patients with persistent and de novo DSA during year 1; 2 (40%) of whom lost their graft due to AMR. Eleven (31%) patients with persistent DSA but without de novo DSA had an AMR rate of 18% without graft loss while one patient lost her graft without signs of AMR. Our desensitization protocol for pre-sensitized living donor kidney transplant recipients with DSA resulted in good graft outcomes with side effects and rejection rates similar to that of standard-risk recipients. Adequate patient selection prior to transplantation and frequent immunological monitoring thereafter is critical to minimize rejection episodes and subsequent graft loss.
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Affiliation(s)
- Florian Kälble
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Caner Süsal
- Transplant Immunology Research Center of Excellence, Koç University Hospital, Istanbul, Turkey.,Transplantation-Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Luiza Pego da Silva
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Louise Benning
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Lien Pham
- Transplantation-Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hien Tran
- Transplantation-Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Schaier
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Claudia Sommerer
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jörg Beimler
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
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Olaso D, Manook M, Moris D, Knechtle S, Kwun J. Optimal Immunosuppression Strategy in the Sensitized Kidney Transplant Recipient. J Clin Med 2021; 10:3656. [PMID: 34441950 PMCID: PMC8396983 DOI: 10.3390/jcm10163656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with previous sensitization events against anti-human leukocyte antigens (HLA) often have circulating anti-HLA antibodies. Following organ transplantation, sensitized patients have higher rates of antibody-mediated rejection (AMR) compared to those who are non-sensitized. More stringent donor matching is required for these patients, which results in a reduced donor pool and increased time on the waitlist. Current approaches for sensitized patients focus on reducing preformed antibodies that preclude transplantation; however, this type of desensitization does not modulate the primed immune response in sensitized patients. Thus, an optimized maintenance immunosuppressive regimen is necessary for highly sensitized patients, which may be distinct from non-sensitized patients. In this review, we will discuss the currently available therapeutic options for induction, maintenance, and adjuvant immunosuppression for sensitized patients.
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Affiliation(s)
| | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (D.O.); (M.M.); (D.M.)
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (D.O.); (M.M.); (D.M.)
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8
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Choi AY, Manook M, Olaso D, Ezekian B, Park J, Freischlag K, Jackson A, Knechtle S, Kwun J. Emerging New Approaches in Desensitization: Targeted Therapies for HLA Sensitization. Front Immunol 2021; 12:694763. [PMID: 34177960 PMCID: PMC8226120 DOI: 10.3389/fimmu.2021.694763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023] Open
Abstract
There is an urgent need for therapeutic interventions for desensitization and antibody-mediated rejection (AMR) in sensitized patients with preformed or de novo donor-specific HLA antibodies (DSA). The risk of AMR and allograft loss in sensitized patients is increased due to preformed DSA detected at time of transplant or the reactivation of HLA memory after transplantation, causing acute and chronic AMR. Alternatively, de novo DSA that develops post-transplant due to inadequate immunosuppression and again may lead to acute and chronic AMR or even allograft loss. Circulating antibody, the final product of the humoral immune response, has been the primary target of desensitization and AMR treatment. However, in many cases these protocols fail to achieve efficient removal of all DSA and long-term outcomes of patients with persistent DSA are far worse when compared to non-sensitized patients. We believe that targeting multiple components of humoral immunity will lead to improved outcomes for such patients. In this review, we will briefly discuss conventional desensitization methods targeting antibody or B cell removal and then present a mechanistically designed desensitization regimen targeting plasma cells and the humoral response.
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Affiliation(s)
| | | | | | | | | | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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9
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Jambon F, Merville P, Guidicelli G, Taton B, De Précigout V, Couzi L, Moreau K, Visentin J. Efficacy of plasmapheresis and semi-selective immunoadsorption for removal of anti-HLA antibodies. J Clin Apher 2020; 36:291-298. [PMID: 33253430 DOI: 10.1002/jca.21858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/10/2020] [Accepted: 11/12/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND In organ transplantation, apheresis is frequently used for removal of anti-HLA antibodies. However, it is unclear whether plasmapheresis (PP) or semi-selective immunoadsorption (IA) should be employed, and the optimal number of apheresis sessions required to reach post-treatment objectives is also unknown. METHODS We enrolled 43 patients from Bordeaux University Hospital who were treated with PP (n = 29) or IA (n = 14) for antibody-mediated rejection or pre-transplant desensitization. Using Luminex single-antigen flow beads, we assessed the initial mean fluorescence intensity (MFI) of 1416 positive beads with MFIs obtained after 7 to 8 apheresis sessions (extended protocol) and, if a serum was available, after the first four sessions (short protocol). RESULTS MFI reduction after extended apheresis protocol was stronger with IA [87% (61%-100%)] than with PP [73% (22%-100%)] (P < .001). Indeed, 59% of the beads had a final MFI < 2000 with IA, whereas only 38% with PP (P < .001). The efficacy of removal depended on initial MFI but not on HLA specificity. A short protocol of apheresis showed excellent results without superiority of IA over PP for antibodies with an initial MFI < 3000. For antibodies showing MFI ≥2000 after four sessions, the residual MFI predicted the effectiveness of four additional sessions. CONCLUSION Monitoring the MFI of anti-HLA antibodies before and during apheresis protocol can guide physicians in the selection of apheresis technique and the number of sessions to be performed.
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Affiliation(s)
- Frédéric Jambon
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Pierre Merville
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Gwendaline Guidicelli
- CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France
| | - Benjamin Taton
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Valérie De Précigout
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Lionel Couzi
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Karine Moreau
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Jonathan Visentin
- CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France.,CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France
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10
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Doberer K, Schiemann M, Strassl R, Haupenthal F, Dermuth F, Görzer I, Eskandary F, Reindl‐Schwaighofer R, Kikić Ž, Puchhammer‐Stöckl E, Böhmig GA, Bond G. Torque teno virus for risk stratification of graft rejection and infection in kidney transplant recipients-A prospective observational trial. Am J Transplant 2020; 20:2081-2090. [PMID: 32034850 PMCID: PMC7496119 DOI: 10.1111/ajt.15810] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 01/25/2023]
Abstract
The nonpathogenic and ubiquitous torque teno virus (TTV) is associated with immunosuppression in solid organ transplant recipients. Studies in kidney transplant patients proposed TTV quantification for risk stratification of graft rejection and infection. In this prospective trial (DRKS00012335) 386 consecutive kidney transplant recipients were subjected to longitudinal per-protocol monitoring of plasma TTV load by polymerase chain reaction for 12 months posttransplant. TTV load peaked at the end of month 3 posttransplant and reached steady state thereafter. TTV load after the end of month 3 was analyzed in the context of subsequent rejection diagnosed by indication biopsy and infection within the first year posttransplant, respectively. Each log increase in TTV load decreased the odds for rejection by 22% (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.62-0.97; P = .027) and increased the odds for infection by 11% (OR 1.11, 95% CI 1.06-1.15; P < .001). TTV was quantified at a median of 14 days before rejection was diagnosed and 27 days before onset of infection, respectively. We defined a TTV load between 1 × 106 and 1 × 108 copies/mL as optimal range to minimize the risk for rejection and infection. These data support the initiation of an interventional trial assessing the efficacy of TTV-guided immunosuppression to reduce infection and graft rejection in kidney transplant recipients.
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Affiliation(s)
- Konstantin Doberer
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | - Martin Schiemann
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | - Robert Strassl
- Division of VirologyDepartment of Laboratory MedicineMedical University ViennaViennaAustria
| | - Frederik Haupenthal
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | - Florentina Dermuth
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | - Irene Görzer
- Center for VirologyMedical University ViennaViennaAustria
| | - Farsad Eskandary
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | | | - Željko Kikić
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | | | - Georg A. Böhmig
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
| | - Gregor Bond
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University ViennaViennaAustria
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11
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Montagud-Marrahi E, Revuelta I, Cucchiari D, Piñeiro GJ, Ventura-Aguiar P, Lozano M, Cid J, Martorell J, Solé M, Quintana LF, Oppenheimer F, Diekmann F, Poch E, Campistol JM, Blasco M. Successful use of nonantigen-specific immunoadsorption with antihuman Ig-columns in kidney graft antibody-mediated rejection. J Clin Apher 2020; 35:188-199. [PMID: 32219886 DOI: 10.1002/jca.21779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Nonantigen-specific immunoadsorption (IA) has proven to be effective in acute antibody-mediated rejection (aAMR). However, there is a lack of solid studies evaluating the safety and efficacy of IA with antihuman Ig-columns in aAMR. For chronic-active AMR (cAMR), no studies have evaluated the efficacy of nonantingen-specific IA with antihuman Ig-columns. The purpose of this study was to evaluate the role of nonantigen-specific IA with antihuman Ig-columns in the treatment of both aAMR and cAMR in kidney transplantation. MATERIAL AND METHODS In retrospective and observational study, kidney graft and recipient survival rates were assessed after treatment of aAMR and cAMR with nonantigen-specific IA with Ig-Flex columns (Therasorb) between January 2012 and May 2018. Protocols included nonantigen-specific IA, rituximab, intravenous immunoglobulin, and rescue plasma exchange, if necessary. RESULTS The study included 14 patients with AMR (acute in 9, chronic active in 5). For aAMR, mean follow-up was 13 ± 6 months, and patient and graft survival were, respectively, of 100% and 83%, with a mean increase in estimated glomerular filtration rate (eGFR) of 7.98 ± 12.96, 10.18 ± 16.71, and 11.43 ± 13.85 mL/min/1.72 m2 (P > .05) at 3, 12 months after treatment, and at the end of follow-up, respectively. For cAMR, mean follow-up was 14 ± 8 months, and patient and graft survival were, respectively, of 100% and 60%, with an average increase in eGFR of 4.30 ± 7.86, 5.64 ± 10.47, and 14.5 ± 7.86 mL/min/m2 (P > .05) at 3, 12 months after IA treatment, and at the end of the follow-up, respectively, although 40% did not respond and required chronic hemodialysis. CONCLUSION Nonantigen-specific IA with Ig-Flex columns was safe and effective for aAMR treatment in kidney transplantation. In cAMR, IA with Ig-Flex columns was associated with a satisfactory kidney graft survival, suggesting that IA could potentially offer some benefits supporting its indication in cAMR.
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Affiliation(s)
- Enrique Montagud-Marrahi
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - David Cucchiari
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Gaston J Piñeiro
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Pedro Ventura-Aguiar
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Jaume Martorell
- Immunology Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Manel Solé
- Pathology Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Federico Oppenheimer
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
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12
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Salvadori M, Tsalouchos A. Therapeutic apheresis in kidney transplantation: An updated review. World J Transplant 2019; 9:103-122. [PMID: 31750088 PMCID: PMC6851502 DOI: 10.5500/wjt.v9.i6.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
Therapeutic apheresis is a cornerstone of therapy for several conditions in transplantation medicine and is available in different technical variants. In the setting of kidney transplantation, immunological barriers such as ABO blood group incompatibility and preformed donor-specific antibodies can complicate the outcome of deceased- or living- donor transplantation. Postoperatively, additional problems such as antibody-mediated rejection and a recurrence of primary focal segmental glomerulosclerosis can limit therapeutic success and decrease graft survival. Therapeutic apheresis techniques find application in these issues by separating and selectively removing exchanging or modifying pathogenic material from the patient by an extracorporeal aphaeresis system. The purpose of this review is to describe the available techniques of therapeutic aphaeresis with their specific advantages and disadvantages and examine the evidence supporting the application of therapeutic aphaeresis as an adjunctive therapeutic option to immunosuppressive agents in protocols before and after kidney transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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13
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Strassl R, Schiemann M, Doberer K, Görzer I, Puchhammer-Stöckl E, Eskandary F, Kikic Ž, Gualdoni GA, Vossen MG, Rasoul-Rockenschaub S, Herkner H, Böhmig GA, Bond G. Quantification of Torque Teno Virus Viremia as a Prospective Biomarker for Infectious Disease in Kidney Allograft Recipients. J Infect Dis 2019; 218:1191-1199. [PMID: 30007341 PMCID: PMC6490304 DOI: 10.1093/infdis/jiy306] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/17/2018] [Indexed: 12/14/2022] Open
Abstract
Background Drug-induced immunosuppression following kidney transplantation is crucial to prevent allograft rejection, but increases risk for infectious disease. Tailoring of drug dosing to prevent both rejection and infection is greatly desirable. The apathogenic and ubiquitous torque teno virus (TTV) reflects immunocompetence of the host and might be a potential candidate for immunologic monitoring. Methods To assess TTV as an infection biomarker, virus load was prospectively quantified in peripheral blood of 169 consecutive renal allograft recipients at the Medical University Vienna. Results Patients with infection showed higher TTV levels compared to patients without infection (4.2 × 108 copies/mL [interquartile range, IQR, 2.7 × 107–1.9 × 109] vs 2.9 × 107 [IQR 1.0 × 106–7.2 × 108]; P = .006). Differences in TTV load became evident almost 3 months before infection (median 77 days, IQR 19–98). Each log level of TTV copies/mL increased the odds ratio for infection by 23% (95% confidence interval 1.04–1.45; P = .014). TTV >3.1 × 109 copies/mL corresponded to 90% sensitivity to predict infections. Logistic regression demonstrated independent association between TTV levels and infection. Conclusions TTV quantification predicts infection after kidney transplantation and might be a potential tool to tailor immunosuppressive drug therapy.
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Affiliation(s)
- Robert Strassl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Martin Schiemann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Irene Görzer
- Department of Virology, Medical University of Vienna, Austria
| | | | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Željko Kikic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Guido A Gualdoni
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Mathias G Vossen
- Division of Infectious Diseases, Department of Medicine I, Medical University of Vienna, Austria
| | | | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Austria
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14
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Burghuber CK, Manook M, Ezekian B, Gibby AC, Leopardi FV, Song M, Jenks J, Saccoccio F, Permar S, Farris AB, Iwakoshi NN, Kwun J, Knechtle SJ. Dual targeting: Combining costimulation blockade and bortezomib to permit kidney transplantation in sensitized recipients. Am J Transplant 2019; 19:724-736. [PMID: 30102844 PMCID: PMC7185755 DOI: 10.1111/ajt.15067] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 01/25/2023]
Abstract
Previous evidence suggests that a homeostatic germinal center (GC) response may limit bortezomib desensitization therapy. We evaluated the combination of costimulation blockade with bortezomib in a sensitized non-human primate kidney transplant model. Sensitized animals were treated with bortezomib, belatacept, and anti-CD40 mAb twice weekly for a month (n = 6) and compared to control animals (n = 7). Desensitization therapy-mediated DSA reductions approached statistical significance (P = .07) and significantly diminished bone marrow PCs, lymph node follicular helper T cells, and memory B cell proliferation. Graft survival was prolonged in the desensitization group (P = .073). All control animals (n = 6) experienced graft loss due to antibody-mediated rejection (AMR) after kidney transplantation, compared to one desensitized animal (1/5). Overall, histological AMR scores were significantly lower in the treatment group (n = 5) compared to control (P = .020). However, CMV disease was common in the desensitized group (3/5). Desensitized animals were sacrificed after long-term follow-up with functioning grafts. Dual targeting of both plasma cells and upstream GC responses successfully prolongs graft survival in a sensitized NHP model despite significant infectious complications and drug toxicity. Further work is planned to dissect underlying mechanisms, and explore safety concerns.
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Affiliation(s)
- Christopher K. Burghuber
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Division of Vascular Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Brian Ezekian
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Adriana C. Gibby
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | - Frank V. Leopardi
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Minqing Song
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Jennifer Jenks
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Frances Saccoccio
- Pediatric Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
- Pediatric Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Alton B. Farris
- Department of Pathology, Emory School of Medicine, Atlanta, GA, USA
| | - Neal N. Iwakoshi
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | - Jean Kwun
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
| | - Stuart J. Knechtle
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
- Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, USA
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15
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Kang ES, Choi SI, Park YH, Park GB, Jang HR. Results of Questionnaire Survey of Current Immune Monitoring Practice of Transplant Clinicians and Clinical Pathologists in Korea: Basis for Establishment of Harmonized Immune Monitoring Guidelines. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo In Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youn Hee Park
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geum Borae Park
- Department of Laboratory Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hye Ryon Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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16
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Kobashigawa J, Colvin M, Potena L, Dragun D, Crespo-Leiro MG, Delgado JF, Olymbios M, Parameshwar J, Patel J, Reed E, Reinsmoen N, Rodriguez ER, Ross H, Starling RC, Tyan D, Urschel S, Zuckermann A. The management of antibodies in heart transplantation: An ISHLT consensus document. J Heart Lung Transplant 2018; 37:537-547. [PMID: 29452978 DOI: 10.1016/j.healun.2018.01.1291] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/18/2018] [Indexed: 12/19/2022] Open
Abstract
Despite the successes from refined peri-operative management techniques and immunosuppressive therapies, antibodies remain a serious cause of morbidity and mortality for patients both before and after heart transplantation. Patients awaiting transplant who possess antibodies against human leukocyte antigen are disadvantaged by having to wait longer to receive an organ from a suitably matched donor. The number of pre-sensitized patients has been increasing, a trend that is likely due to the increased use of mechanical circulatory support devices. Even patients who are not pre-sensitized can go on to produce donor-specific antibodies after transplant, which are associated with worse outcomes. The difficulty in managing antibodies is uncertainty over which antibodies are of clinical relevance, which patients to treat, and which treatments are most effective and safe. There is a distinct lack of data from prospective trials. An international consensus conference was organized and attended by 103 participants from 75 centers to debate contentious issues, determine the best practices, and formulate ideas for future research on antibodies. Prominent experts presented state-of-the-art talks on antibodies, which were followed by group discussions, and then, finally, a reconvened session to establish consensus where possible. Herein we address the discussion, consensus points, and research ideas.
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Affiliation(s)
- Jon Kobashigawa
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA.
| | - Monica Colvin
- Cardiovascular Division, University of Michigan, Ann Arbor, Michigan, USA
| | - Luciano Potena
- Department of Specialist, Diagnostic, and Experimental Medicine, Bologna University Hospital, Bologna, Italy
| | - Duska Dragun
- Center for Cardiovascular Research, Charité Universtätsmedizin, Berlin, Germany
| | - Maria G Crespo-Leiro
- Heart Failure and Heart Transplant Program, Hospital Universitario A Coruña, Coruña, Spain
| | - Juan F Delgado
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Michael Olymbios
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | | | - Jignesh Patel
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Elaine Reed
- UCLA Immunogenetics Center, Los Angeles, California, USA
| | - Nancy Reinsmoen
- Department of Immunology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - E Rene Rodriguez
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Heather Ross
- Ted Rogers Centre of Excellence in Heart Function, University of Toronto, Toronto, Ontario, Canada
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dolly Tyan
- Department of Clinical Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Simon Urschel
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Andreas Zuckermann
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
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17
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Morath C, Zeier M, Süsal C. Increased risk of infection-associated death with incompatible kidney transplantations. Transpl Int 2017; 30:1209-1211. [DOI: 10.1111/tri.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Christian Morath
- Division of Nephrology; University of Heidelberg; Heidelberg Germany
| | - Martin Zeier
- Division of Nephrology; University of Heidelberg; Heidelberg Germany
| | - Caner Süsal
- Department of Transplantation Immunology; Institute of Immunology; University of Heidelberg; Heidelberg Germany
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18
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Torque Teno Virus Load-Inverse Association With Antibody-Mediated Rejection After Kidney Transplantation. Transplantation 2017; 101:360-367. [PMID: 27525643 DOI: 10.1097/tp.0000000000001455] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) represents one of the cardinal causes of late allograft loss after kidney transplantation, and there is great need for noninvasive tools improving early diagnosis of this rejection type. One promising strategy might be the quantification of peripheral blood DNA levels of the highly prevalent and apathogenic Torque Teno virus (TTV), which might mirror the overall level of immunosuppression and thus help determine the risk of alloimmune response. METHODS To assess the association between TTV load in the peripheral blood and AMR, 715 kidney transplant recipients (median, 6.3 years posttransplantation) were subjected to a systematical cross-sectional AMR screening and, in parallel, TTV quantification. RESULTS Eighty-six of these recipients had donor-specific antibodies and underwent protocol biopsy, AMR-positive patients (n = 46) showed only 25% of the TTV levels measured in patients without AMR (P = 0.003). In a generalized linear model, higher TTV levels were associated with a decreased risk for AMR after adjustment for potential confounders (risk ratio 0.94 per TTV log level; 95% confidence interval 0.90-0.99; P = 0.02). CONCLUSIONS Future studies will have to clarify whether longitudinal assessment of TTV load might predict AMR risk and help guide the type and intensity of immunosuppression to prevent antibody-mediated graft injury.
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19
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Garces JC, Giusti S, Staffeld-Coit C, Bohorquez H, Cohen AJ, Loss GE. Antibody-Mediated Rejection: A Review. Ochsner J 2017; 17:46-55. [PMID: 28331448 PMCID: PMC5349636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection. METHODS We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies. RESULTS Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody). CONCLUSION AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.
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Affiliation(s)
- Jorge Carlos Garces
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Sixto Giusti
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Catherine Staffeld-Coit
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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20
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Koefoed-Nielsen P, Bistrup C, Christiansen M. Protein a Immunoadsorption May Hamper the Decision to Transplant Due to Interference With CDC Crossmatch Results. J Clin Apher 2016; 32:163-169. [PMID: 27258774 DOI: 10.1002/jca.21476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/16/2016] [Indexed: 11/10/2022]
Abstract
Transplanting immunized patients requires immunological monitoring in the pretransplant phase to follow reduction of donor specific HLA antibodies (DSA) after Staphylococcus aureus protein A (SPA) immunoadsorption (IA) or therapeutic plasma exchange followed by IVIG and Rituximab administration. Pretreatment aims to significantly reduce DSA strength. The Tissue Typing Lab at Aarhus University Hospital performs immunological monitoring of approximately 150 kidney transplantation patients per year from two transplant centers. From 2012 to 2013, we experienced seven patients desensitized using SPA IA, initially presenting negative cytotoxic complement dependent (CDC) T-cell crossmatches but positive B and T cell flowcytometric crossmatch, who despite significant DSA reduction developed weakly positive CDC T-cell crossmatch shortly prior to transplantation. We hypothesised that leached SPA during IA could be the cause, as the complication was not observed in patients who received plasma exchanges. We found that the positive CDC was not donor specific and SPA column material incubated with control serum reproduced a positive CDC T-cell crossmatch. Finally, we detected leached SPA in one of the patient samples using a highly sensitive time-resolved fluorescent assay. In conclusion, the results emphasize the importance of carefully considering CDC crossmatch results subsequent to IA, before a planned transplantation is either postponed or cancelled. J. Clin. Apheresis 32:163-169, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Mette Christiansen
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus N, Denmark
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21
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Sharma A, King A, Kumar D, Behnke M, McDougan F, Kimball PM. Perioperative Desensitization Improves Outcomes Among Crossmatch Positive Recipients of Deceased Donor Renal Transplants. Prog Transplant 2016; 26:157-61. [DOI: 10.1177/1526924816640678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context: Graft failure due to chronic rejection is greater among renal transplant patients with donor-specific antibody (DSA) than among DSA-free patients. For patients dependent on deceased donor transplantation, preoperative desensitization to eliminate DSAs may be impractical. We speculated that perioperative desensitization might eliminate preexisting DSAs and prevent de novo DSAs and improve graft outcomes. We report that brief perioperative desensitization using either intravenous immunoglobulin (IVIG) or plasmapheresis/IVIG (PP/IVIG) treatment improves clinical outcomes among patients with positive crossmatches. Design: Immediately following deceased donor transplantation, 235 renal recipients were assigned points for PRA and flow crossmatches (FCXM): delayed graft function (DGF) ≤ 1 point received standard therapy; 2 points received high-dose IVIG; and ≥3 points received PP/IVIG. The DSAs were serially monitored by single antigen bead luminex for 1 year. Five-year clinical outcomes were determined from the chart review. Results: All desensitized patients had preoperatively positive FCXM with DSA. Rejection was more common ( P < .05) among desensitized than nonsensitized groups. However, overall graft survivals were similar between the groups ( P = not significant) and superior to historic untreated patients ( P < .05). Treatment with PP/IVIG more effectively eliminated preexisting DSAs (67% vs 33%, P < 0.05) than IVIG, but neither regimen prevented de novo formation of DSA (20%, P = not significant). Graft survival was >90% in all desensitizated patients with DSA elimination as well as PP/IVIG patients with residual DSA. In contrast, IVIG patients with persistent DSA had poorer graft survival (45%, P < .05). Conclusion: Preemptive perioperative desensitization improved overall graft survival of sensitized patients compared to historic untreated patients. Plasmapheresis/IVIG had greater impact on DSA eradication and graft survival than IVIG alone.
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Affiliation(s)
- Amit Sharma
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
| | - Anne King
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
- Department of Internal Medicine, Virginia Commonwealth University Hospitals, Richmond, VA, USA
| | - Dhiren Kumar
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
- Department of Internal Medicine, Virginia Commonwealth University Hospitals, Richmond, VA, USA
| | - Martha Behnke
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
| | - Felecia McDougan
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
| | - Pamela M. Kimball
- Department of Transplant Surgery, Virginia Commonwealth University Hospitals, Richmond, VA, USA
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Schwaiger E, Eskandary F, Kozakowski N, Bond G, Kikić Ž, Yoo D, Rasoul-Rockenschaub S, Oberbauer R, Böhmig GA. Deceased donor kidney transplantation across donor-specific antibody barriers: predictors of antibody-mediated rejection. Nephrol Dial Transplant 2016; 31:1342-51. [PMID: 27190362 DOI: 10.1093/ndt/gfw027] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/28/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Apheresis-based desensitization allows for successful transplantation across major immunological barriers. For donor-specific antibody (DSA)- and/or crossmatch-positive transplantation, however, it has been shown that even intense immunomodulation may not completely prevent antibody-mediated rejection (ABMR). METHODS In this study, we evaluated transplant outcomes in 101 DSA+ deceased donor kidney transplant recipients (transplantation between 2009 and 2013; median follow-up: 24 months) who were subjected to immunoadsorption (IA)-based desensitization. Treatment included a single pre-transplant IA session, followed by anti-lymphocyte antibody and serial post-transplant IA. In 27 cases, a positive complement-dependent cytotoxicity crossmatch (CDCXM) was rendered negative immediately before transplantation. Seventy-four of the DSA+ recipients had a negative CDCXM already before IA. RESULTS Three-year death-censored graft survival in DSA+ patients was significantly worse than in 513 DSA- recipients transplanted during the same period (79 versus 88%, P = 0.008). Thirty-three DSA+ recipients (33%) had ABMR. While a positive baseline CDCXM showed only a trend towards higher ABMR rates (41 versus 30% in CDCXM- recipients, P = 0.2), DSA mean fluorescence intensity (MFI) in single bead assays significantly associated with rejection, showing 20 versus 71% ABMR rates at <5000 versus >15 000 peak DSA MFI. The predictive value of MFI was moderate, with the highest accuracy at a median of 13 300 MFI (after cross-validation: 0.72). Other baseline variables, including CDC assay results, human leukocyte antigen mismatch, prior transplantation or type of induction treatment, did not add independent predictive information. CONCLUSIONS IA-based desensitization failed to prevent ABMR in a considerable number of DSA+ recipients. Assessing DSA MFI may help stratify risk of rejection, supporting its use as a guide to organ allocation and individualized treatment.
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Affiliation(s)
- Elisabeth Schwaiger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria Alberta Transplant Applied Genomics Centre, ATAGC, University of Alberta, Edmonton, AB, Canada
| | - Nicolas Kozakowski
- Department of Clinical Pathology, Medical University Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Željko Kikić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Yoo
- Transcriptome Sciences Inc., 250 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Susanne Rasoul-Rockenschaub
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
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Prophylactic CMV therapy does not improve three-yr patient and graft survival compared to preemptive therapy. Clin Transplant 2015; 29:1230-8. [DOI: 10.1111/ctr.12657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2015] [Indexed: 11/26/2022]
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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Eskandary F, Wahrmann M, Mühlbacher J, Böhmig GA. Complement inhibition as potential new therapy for antibody-mediated rejection. Transpl Int 2015; 29:392-402. [DOI: 10.1111/tri.12706] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/07/2015] [Accepted: 10/13/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Farsad Eskandary
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
| | - Markus Wahrmann
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
| | - Jakob Mühlbacher
- Department of Surgery; Medical University Vienna; Vienna Austria
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis; Department of Medicine III; Medical University Vienna; Vienna Austria
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26
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Kikić Ž, Kainz A, Kozakowski N, Oberbauer R, Regele H, Bond G, Böhmig GA. Capillary C4d and Kidney Allograft Outcome in Relation to Morphologic Lesions Suggestive of Antibody-Mediated Rejection. Clin J Am Soc Nephrol 2015; 10:1435-43. [PMID: 26071493 DOI: 10.2215/cjn.09901014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/16/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Recent studies highlighting a role of C4d- antibody-mediated rejection (ABMR) have debated whether C4d staining has independent value as a rejection marker. Considering the presumed role of complement as an important effector of graft injury, this study hypothesized that capillary C4d, a footprint of antibody-triggered complement activation, indicates a particularly severe manifestation of ABMR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This large retrospective clinicopathologic study sought to assess the clinical predictive value of C4d staining in relation to ABMR morphology. Overall, 885 renal allograft recipients who underwent transplantation between 1999 and 2006 (median duration of follow-up, 63.3 [interquartile range, 40.6-93.5] months; 206 graft losses) were included if they had had one or more indication biopsies. A total of 1976 biopsy specimens were reevaluated for capillary C4d staining (C4d data were available for 825 patients) and distinct morphologic lesions suggestive of ABMR, including glomerulitis, peritubular capillaritis, capillary microthrombi, transplant glomerulopathy, and severe intimal arteritis. RESULTS C4d+ patients, with or without ABMR features, had worse death-censored 8-year graft survival (53% or 67%) than C4d- patients (66% or 81%; P<0.001). In Cox regression analysis, C4d was associated with a risk of graft loss independently of baseline confounders and ABMR morphology (hazard ratio, 1.85 [95% confidence interval, 1.34 to 2.57]; P<0.001). The risk was higher than that observed for C4d- patients, a finding that reached statistical significance in patients showing fewer than two different ABMR lesions. Moreover, in a mixed model, C4d was independently associated with a steeper decline of eGFR (slope per year, -8.23±3.97 ml/min per 1.73 m(2); P<0.001). CONCLUSIONS These results suggest that detection of intragraft complement activation has strong independent value as an additional indicator of ABMR associated with adverse kidney transplant outcomes.
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Affiliation(s)
- Željko Kikić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Alexander Kainz
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria; Department of Medicine III, Hospital of Elisabethinen Linz, Linz, Austria; and
| | - Nicolas Kozakowski
- Clinical Institute of Pathology, Medical University Vienna, Vienna, Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria; Department of Medicine III, Hospital of Elisabethinen Linz, Linz, Austria; and
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria;
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Leto Barone AA, Sun Z, Montgomery RA, Lee WPA, Brandacher G. Impact of donor-specific antibodies in reconstructive transplantation. Expert Rev Clin Immunol 2014; 9:835-44. [PMID: 24070047 DOI: 10.1586/1744666x.2013.824667] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
For many devastating injuries and tissue defects where conventional reconstruction is not possible, reconstructive transplantation such as hand and face transplantation has become a viable alternative. This novel approach allows for improved restoration of appearance, anatomy and function not feasible by other available treatment options. However, clinical management of these injuries prior to transplantation frequently requires multiple blood transfusion or skin grafts resulting in the formation of alloantibodies (anti-HLA IgG Abs) and a high degree of sensitization. The role of donor-specific antibodies (DSA) and mechanisms of antibody-mediated rejection (AMR) in reconstructive transplantation are still largely unknown. Thus there is an imminent need to develop a better understanding of the mechanisms related to DSA and AMR after reconstructive transplantation. In this review, we will define the role of DSA and mechanisms of AMR in reconstructive transplantation and compare them to established measures and treatment concepts in solid organ transplantation.
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Affiliation(s)
- Angelo A Leto Barone
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Ross Research Building 749D, 720 Rutland Avenue, Baltimore, MD, 21205 USA
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Maggiore U, Oberbauer R, Pascual J, Viklicky O, Dudley C, Budde K, Sorensen SS, Hazzan M, Klinger M, Abramowicz D. Strategies to increase the donor pool and access to kidney transplantation: an international perspective. Nephrol Dial Transplant 2014; 30:217-22. [PMID: 24907023 PMCID: PMC4309190 DOI: 10.1093/ndt/gfu212] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
In this position article, DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) board members describe the current strategies aimed at expanding living and deceased donor kidney pools. The article focuses on the recent progress in desensitization and kidney paired exchange programmes and on the expanded criteria for the use of donor kidneys and organs from donors after circulatory death. It also highlights differences in policies and practices across different regions with special regard to European Union countries. Living donor kidney paired exchange, the deceased donor Acceptable Mismatch Programme and kidneys from donors after circulatory death are probably the most promising innovations for expanding kidney transplantation in Europe over the coming decade. To maximize success, an effort is needed to standardize transplant strategies, policies and legislation across European countries.
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Affiliation(s)
- Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Rainer Oberbauer
- KH Elisabethinen Linz and Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Klemens Budde
- Department of Nephrology, Charité Medical University Berlin, Berlin, Germany
| | | | - Marc Hazzan
- Service de Néphrologie, Univ Lille Nord de France, Lille, France
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
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Keith DS. Therapeutic apheresis in renal transplantation; current practices. J Clin Apher 2014; 29:206-10. [DOI: 10.1002/jca.21330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Douglas S. Keith
- Division of Nephrology; University of Virginia Medical Center; Charlottesville Virginia
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Salvadori M, Bertoni E. Impact of donor-specific antibodies on the outcomes of kidney graft: Pathophysiology, clinical, therapy. World J Transplant 2014; 4:1-17. [PMID: 24669363 PMCID: PMC3964192 DOI: 10.5500/wjt.v4.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
Allo-antibodies, particularly when donor specific, are one of the most important factors that cause both early and late graft dysfunction. The authors review the current state of the art concerning this important issue in renal transplantation. Many antibodies have been recognized as mediators of renal injury. In particular donor-specific-Human Leukocyte Antigens antibodies appear to play a major role. New techniques, such as solid phase techniques and Luminex, have revealed these antibodies from patient sera. Other new techniques have uncovered alloantibodies and signs of complement activation in renal biopsy specimens. It has been acknowledged that the old concept of chronic renal injury caused by calcineurine inhibitors toxicity should be replaced in many cases by alloantibodies acting against the graft. In addition, the number of patients on waiting lists with preformed anti-human leukocyte antigens (HLA) antibodies is increasing, primarily from patients with a history of renal transplant failure already been sensitized. We should distinguish early and late acute antibody-mediated rejection from chronic antibody-mediated rejection. The latter often manifets late during the course of the post-transplant period and may be difficult to recognize if specific techniques are not applied. Different therapeutic strategies are used to control antibody-induced damage. These strategies may be applied prior to transplantation or, in the case of acute antibody-mediated rejection, after transplantation. Many new drugs are appearing at the horizon; however, these drugs are far from the clinic because they are in phase I-II of clinical trials. Thus the pipeline for the near future appears almost empty.
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ERBP Guideline on the Management and Evaluation of the Kidney Donor and Recipient. Nephrol Dial Transplant 2014; 28 Suppl 2:ii1-71. [PMID: 24026881 DOI: 10.1093/ndt/gft218] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abu Jawdeh BG, Cuffy MC, Alloway RR, Shields AR, Woodle ES. Desensitization in kidney transplantation: review and future perspectives. Clin Transplant 2014; 28:494-507. [DOI: 10.1111/ctr.12335] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Bassam G. Abu Jawdeh
- Division of Nephrology; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Madison C. Cuffy
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Rita R. Alloway
- Division of Nephrology; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - Adele Rike Shields
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - E. Steve Woodle
- Division of Transplantation; Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
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Abstract
The sensitization of patients to human leukocyte antigens prior to heart transplantation is increasingly being recognized as an important challenge both before and after the transplant, and the effects of sensitization on clinical outcomes are just beginning to be understood. Many patients are listed with the requirement of a negative prospective or virtual crossmatch prior to accepting a donor organ. This strategy has been associated with both longer waitlist times and higher waitlist mortality. An alternative approach is to transplant across a potentially positive crossmatch while utilizing strategies to decrease the significance of the human leukocyte antigen antibodies. This review will examine the challenges and the impact of sensitization on pediatric patients prior to and following heart transplantation.
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Affiliation(s)
- Jennifer Conway
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Anne I Dipchand
- Labatt Family Heart Center, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Eskandary F, Wahrmann M, Biesenbach P, Sandurkov C, Konig F, Schwaiger E, Perkmann T, Kunig S, Derfler K, Zlabinger GJ, Bohmig GA. ABO antibody and complement depletion by immunoadsorption combined with membrane filtration--a randomized, controlled, cross-over trial. Nephrol Dial Transplant 2013; 29:706-14. [DOI: 10.1093/ndt/gft502] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Abstract
PURPOSE OF REVIEW A significant number of kidney transplantations in industrialized countries is currently performed over human leukocyte antigen (HLA) or ABO antibody barriers after living donation to encounter the increasing shortage of organs from deceased donors. Although patients with moderate titers of anti-A/B antibodies may easily be desensitized with no negative impact on allograft survival, recipients with high titers and HLA sensitized patients demonstrate a substantial risk for antibody-mediated rejection, limiting long-term outcomes. RECENT FINDINGS The use of powerful desensitization strategies including plasmapheresis and immunoadsorption, extended therapeutic options such as the application of the recently introduced complement inhibitors, and refined antibody detection techniques may further facilitate transplantations, especially in the HLA-sensitized kidney transplant recipient. On the contrary, special strategies such as the Eurotransplant Acceptable Mismatch Program or kidney paired exchange help improving long-term outcomes in these difficult to transplant patients by circumventing the HLA (or ABO) antibody barrier. SUMMARY As compared with waiting for a compatible deceased donor organ, HLA and ABO incompatible transplantations performed in experienced centers have become a reasonable alternative for end-stage kidney disease patients with an incompatible live donor. Whenever possible, however, the transplantation should be performed between ABO compatible donor-recipient pairs in the absence of positive crossmatch results.
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Schaefer SM, Süsal C, Sommerer C, Zeier M, Morath C. Current pharmacotherapeutical options for the prevention of kidney transplant rejection. Expert Opin Pharmacother 2013; 14:1029-41. [DOI: 10.1517/14656566.2013.788151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Consensus guidelines on the testing and clinical management issues associated with HLA and non-HLA antibodies in transplantation. Transplantation 2013; 95:19-47. [PMID: 23238534 DOI: 10.1097/tp.0b013e31827a19cc] [Citation(s) in RCA: 594] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The introduction of solid-phase immunoassay (SPI) technology for the detection and characterization of human leukocyte antigen (HLA) antibodies in transplantation while providing greater sensitivity than was obtainable by complement-dependent lymphocytotoxicity (CDC) assays has resulted in a new paradigm with respect to the interpretation of donor-specific antibodies (DSA). Although the SPI assay performed on the Luminex instrument (hereafter referred to as the Luminex assay), in particular, has permitted the detection of antibodies not detectable by CDC, the clinical significance of these antibodies is incompletely understood. Nevertheless, the detection of these antibodies has led to changes in the clinical management of sensitized patients. In addition, SPI testing raises technical issues that require resolution and careful consideration when interpreting antibody results. METHODS With this background, The Transplantation Society convened a group of laboratory and clinical experts in the field of transplantation to prepare a consensus report and make recommendations on the use of this new technology based on both published evidence and expert opinion. Three working groups were formed to address (a) the technical issues with respect to the use of this technology, (b) the interpretation of pretransplantation antibody testing in the context of various clinical settings and organ transplant types (kidney, heart, lung, liver, pancreas, intestinal, and islet cells), and (c) the application of antibody testing in the posttransplantation setting. The three groups were established in November 2011 and convened for a "Consensus Conference on Antibodies in Transplantation" in Rome, Italy, in May 2012. The deliberations of the three groups meeting independently and then together are the bases for this report. RESULTS A comprehensive list of recommendations was prepared by each group. A summary of the key recommendations follows. Technical Group: (a) SPI must be used for the detection of pretransplantation HLA antibodies in solid organ transplant recipients and, in particular, the use of the single-antigen bead assay to detect antibodies to HLA loci, such as Cw, DQA, DPA, and DPB, which are not readily detected by other methods. (b) The use of SPI for antibody detection should be supplemented with cell-based assays to examine the correlations between the two types of assays and to establish the likelihood of a positive crossmatch (XM). (c) There must be an awareness of the technical factors that can influence the results and their clinical interpretation when using the Luminex bead technology, such as variation in antigen density and the presence of denatured antigen on the beads. Pretransplantation Group: (a) Risk categories should be established based on the antibody and the XM results obtained. (b) DSA detected by CDC and a positive XM should be avoided due to their strong association with antibody-mediated rejection and graft loss. (c) A renal transplantation can be performed in the absence of a prospective XM if single-antigen bead screening for antibodies to all class I and II HLA loci is negative. This decision, however, needs to be taken in agreement with local clinical programs and the relevant regulatory bodies. (d) The presence of DSA HLA antibodies should be avoided in heart and lung transplantation and considered a risk factor for liver, intestinal, and islet cell transplantation. Posttransplantation Group: (a) High-risk patients (i.e., desensitized or DSA positive/XM negative) should be monitored by measurement of DSA and protocol biopsies in the first 3 months after transplantation. (b) Intermediate-risk patients (history of DSA but currently negative) should be monitored for DSA within the first month. If DSA is present, a biopsy should be performed. (c) Low-risk patients (nonsensitized first transplantation) should be screened for DSA at least once 3 to 12 months after transplantation. If DSA is detected, a biopsy should be performed. In all three categories, the recommendations for subsequent treatment are based on the biopsy results. CONCLUSIONS A comprehensive list of recommendations is provided covering the technical and pretransplantation and posttransplantation monitoring of HLA antibodies in solid organ transplantation. The recommendations are intended to provide state-of-the-art guidance in the use and clinical application of recently developed methods for HLA antibody detection when used in conjunction with traditional methods.
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Hunt EA, Jain NG, Somers MJ. Apheresis therapy in children: An overview of key technical aspects and a review of experience in pediatric renal disease. J Clin Apher 2013; 28:36-47. [DOI: 10.1002/jca.21260] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 01/15/2013] [Indexed: 12/15/2022]
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Morath C, Opelz G, Zeier M, Süsal C. Recent developments in desensitization of crossmatch-positive kidney transplant recipients. Transplant Proc 2013; 44:1648-51. [PMID: 22841236 DOI: 10.1016/j.transproceed.2012.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Currently, there are two major options for the successful and timely transplantation of sensitized kidney transplant recipients: (1) avoidance of the sensitization barrier using special allocation programs, or (2) desensitization. In the case of broadly sensitized kidney patients, a combination of both options might be necessary. This review focuses on new advances in desensitization of crossmatch-positive kidney transplant recipients which include immunoadsorption and the administration of new substances such as the complement C5 inhibitor eculizumab. Finally, integrated algorithms that combine different measures are acknowledged.
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Affiliation(s)
- C Morath
- Department of Nephrology, University of Heidelberg, Germany
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Bartel G, Wahrmann M, Schwaiger E, Kikić Ž, Winzer C, Hörl WH, Mühlbacher F, Hoke M, Zlabinger GJ, Regele H, Böhmig GA. Solid phase detection of C4d-fixing HLA antibodies to predict rejection in high immunological risk kidney transplant recipients. Transpl Int 2012; 26:121-30. [PMID: 23145861 DOI: 10.1111/tri.12000] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/21/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023]
Abstract
Protocols for recipient desensitization may allow for successful kidney transplantation across major immunological barriers. Desensitized recipients, however, still face a considerable risk of antibody-mediated rejection (AMR), which underscores the need for risk stratification tools to individually tailor treatment. Here, we investigated whether solid phase detection of complement-fixing donor-specific antibodies (DSA) has the potential to improve AMR prediction in high-risk transplants. The study included 68 sensitized recipients of deceased donor kidney allografts who underwent peritransplant immunoadsorption for alloantibody depletion (median cytotoxic panel reactivity: 73%; crossmatch conversion: n = 21). Pre and post-transplant sera were subjected to detection of DSA-triggered C4d deposition ([C4d]DSA) applying single-antigen bead (SAB) technology. While standard crossmatch and [IgG]SAB testing failed to predict outcomes in our desensitized patients, detection of preformed [C4d]DSA (n = 44) was tightly associated with C4d-positive AMR [36% vs. 8%, P = 0.01; binary logistic regression: odds ratio: 10.1 (95% confidence interval: 1.6-64.2), P = 0.01]. Moreover, long-term death-censored graft survival tended to be worse among [C4d]DSA-positive recipients (P = 0.07). There were no associations with C4d-negative AMR or cellular rejection. [C4d]DSA detected 6 months post-transplantation were not related to clinical outcomes. Our data suggest that pretransplant SAB-based detection of complement-fixing DSA may be a valuable tool for risk stratification.
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Affiliation(s)
- Gregor Bartel
- Department of Medicine III, Medical University Vienna, Vienna, Austria
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42
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Abstract
Over the past decade, several studies have suggested that the complement system has an active role in both acute and chronic allograft rejection. These studies have been facilitated by improved techniques to detect antibody-mediated organ rejection, including immunohistological staining for C4d deposition in the allograft and solid-phase assays that identify donor-specific alloantibodies (DSAs) in the serum of transplant recipients. Studies with eculizumab, a humanized monoclonal antibody directed against complement component C5, have shown that activation of the terminal complement pathway is necessary for the development of acute antibody-mediated rejection in recipients of living-donor kidney allografts who have high levels of DSAs. The extent to which complement activation drives chronic antibody-mediated injury leading to organ rejection is less clear. In chronic antibody-mediated injury, early complement activation might facilitate chemotaxis of inflammatory cells into the allograft in a process that later becomes somewhat independent of DSA levels and complement factors. In this Review, we discuss the different roles that the complement system might have in antibody-mediated allograft rejection, with specific emphasis on renal transplantation.
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Morath C, Opelz G, Zeier M, Süsal C. Prevention of antibody-mediated kidney transplant rejection. Transpl Int 2012; 25:633-45. [PMID: 22587522 DOI: 10.1111/j.1432-2277.2012.01490.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is increasing evidence that antibody-mediated rejection is the major cause of late kidney graft failure. Prevention of antibody-mediated allograft damage has therefore become an important issue in kidney transplantation. Such prevention starts already before transplantation with the avoidance of sensitizing events. When a patient is already sensitized, precise characterization of alloantibodies and exact HLA typing of the donor at the time of transplantation are mandatory. To ensure timely and successful transplantation of highly sensitized patients, desensitization, and inclusion in special programs such as the Eurotransplant Acceptable Mismatch Program should be considered. After transplantation, close monitoring of kidney function, testing for the de novo development or changing characteristics of alloantibodies, and attention to non-adherence to immunosuppression is obligatory. In the current overview, we discuss the currently available measures for the prevention of antibody-mediated kidney graft rejection.
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Affiliation(s)
- Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Abstract
Many factors limit short- and long-term survival after pediatric heart transplantation. Historically, attention had been directed toward T-cell responses and acute cellular rejection. Presence of pretransplant antibodies against HLA is associated with increased donor wait times and poor post-transplant outcomes. Therapies aimed to mitigate circulating antibodies include plasmapheresis, protein A immunoadsorption columns, intravenous immune globulin, rituximab, and bortezomib. The negative effects of B cells, HLA antibodies, and AMR and potential interventions are the focus of this review article.
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Affiliation(s)
- Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Huber L, Lachmann N, Dürr M, Matz M, Liefeldt L, Neumayer HH, Schönemann C, Budde K. Identification and Therapeutic Management of Highly Sensitized Patients Undergoing Renal Transplantation. Drugs 2012; 72:1335-54. [DOI: 10.2165/11631110-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Roelen DL, Doxiadis IIN, Claas FHJ. Detection and clinical relevance of donor specific HLA antibodies: a matter of debate. Transpl Int 2012; 25:604-10. [DOI: 10.1111/j.1432-2277.2012.01491.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hilbrands LB. Current perspectives to overcome a positive crossmatch in living donor renal transplantation. Transpl Int 2012; 25:503-5. [PMID: 22471344 DOI: 10.1111/j.1432-2277.2012.01476.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Luuk B Hilbrands
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Morath C, Beimler J, Opelz G, Scherer S, Schmidt J, Macher-Goeppinger S, Klein K, Sommerer C, Schwenger V, Zeier M, Süsal C. Living donor kidney transplantation in crossmatch-positive patients enabled by peritransplant immunoadsorption and anti-CD20 therapy. Transpl Int 2012; 25:506-17. [PMID: 22372718 DOI: 10.1111/j.1432-2277.2012.01447.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Living donor kidney transplantation in crossmatch-positive patients is a challenge that requires specific measures. Ten patients with positive crossmatch results (n = 9) or negative crossmatch results but strong donor-specific antibodies (DSA; n = 1) were desensitized using immunoadsorption (IA) and anti-CD20 antibody induction. IA was continued after transplantation and accompanied by HLA antibody monitoring and protocol biopsies. After a median of 10 IA treatments, all patients were desensitized successfully and transplanted. Median levels of mean fluorescence intensity (MFI) of Luminex-DSA before desensitization were 6203 and decreased after desensitization and immediately before transplantation to 891. Patients received a median of seven post-transplant IA treatments. At last visit, after a median follow-up of 19 months, 9 of 10 patients had a functioning allograft and a median Luminex-DSA of 149 MFI; serum creatinine was 1.6 mg/dl, and protein to creatinine ratio 0.1. Reversible acute antibody-mediated rejection was diagnosed in three patients. One allograft was lost after the second post-transplant year in a patient with catastrophic antiphospholipid syndrome. We describe a treatment algorithm for desensitization of living donor kidney transplant recipients that allows the rapid elimination of DSA with a low rate of side effects and results in good graft outcome.
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Affiliation(s)
- Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Abstract
This review summarizes the clinical evidence and practical details for the use of plasmapheresis and other apheresis modalities for each indication in nephrology. Updated information on the molecular biology and immunology of each renal disease is discussed in relation to the rationale for apheresis therapy and its place amid other available treatments. Autoantibody-mediated diseases, such as anti-GBM (anti-glomerular basement membrane) glomerulonephritis (GN), ANCA (antineutrophil cytoplasmic antibody)-related GN and the antibody-mediated type of TTP (thrombotic thrombocytopenic purpura), and alloantibody-mediated diseases such as kidney transplant sensitization and humoral rejection, can be treated by various plasmapheresis methods. These include standard plasmapheresis with a replacement volume, or plasmapheresis with online plasma purification using adsorption columns or secondary filtration. However, it should be noted that the pathogenic molecules implicated in FSGS (focal segmental glomerulosclerosis), myeloma cast nephropathy, and perhaps other diseases are too small to be removed by most online purification methods. A great majority of controlled trials and series on which evidence-based treatment recommendations are made were performed using centrifugal plasmapheresis; it is presumed that membrane-separation plasmapheresis is equally efficacious. For some rarer diseases, such as MPGN (membranoproliferative GN) type 2 with factor H abnormalities or C3Nef (C3 nephritic factor) autoantibodies, there are only a few case reports, but enough scientific understanding to warrant a trial of plasmapheresis in severe cases. Photopheresis, which is effective for cell-mediated rejection in heart and lung transplantation, has not yet found a place in the routine treatment of kidney transplant rejection.
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Affiliation(s)
- Amber P Sanchez
- Department of Medicine, Division of Nephrology, University of California, and Therapeutic Apheresis Program, UCSD Medical Center, San Diego, California 92103-8781, USA
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