1
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Manook M, Olaso D, Anwar I, DeLaura I, Yoon J, Bae Y, Barbas A, Shaw B, Moris D, Song M, Farris AB, Stiede K, Youd M, Knechtle S, Kwun J. Prolonged xenokidney graft survival in sensitized NHP recipients by expression of multiple human transgenes in a triple knockout pig. Sci Transl Med 2024; 16:eadk6152. [PMID: 38865482 DOI: 10.1126/scitranslmed.adk6152] [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] [Received: 09/01/2023] [Accepted: 05/07/2024] [Indexed: 06/14/2024]
Abstract
Genetic modification of porcine donors, combined with optimized immunosuppression, has been shown to improve outcomes of experimental xenotransplant. However, little is known about outcomes in sensitized recipients, a population that could potentially benefit the most from the clinical implementation of xenotransplantation. Here, five highly allosensitized rhesus macaques received a porcine kidney from GGTA1 (α1,3-galactosyltransferase) knockout pigs expressing the human CD55 transgene (1KO.1TG) and were maintained on an anti-CD154 monoclonal antibody (mAb)-based immunosuppressive regimen. These recipients developed de novo xenoreactive antibodies and experienced xenograft rejection with evidence of thrombotic microangiopathy and antibody-mediated rejection (AMR). In comparison, three highly allosensitized rhesus macaques receiving a kidney from GGTA1, CMAH (cytidine monophospho-N-acetylneuraminic acid hydroxylase), and b4GNT2/b4GALNT2 (β-1,4-N-acetyl-galactosaminyltransferase 2) knockout pigs expressing seven human transgenes including human CD46, CD55, CD47, THBD (thrombomodulin), PROCR (protein C receptor), TNFAIP3 (tumor necrosis factor-α-induced protein 3), and HMOX1 (heme oxygenase 1) (3KO.7TG) experienced significantly prolonged graft survival and reduced AMR, associated with dampened post-transplant humoral responses, early monocyte and neutrophil activation, and T cell repopulation. After withdrawal of all immunosuppression, recipients who received kidneys from 3KO.7TG pigs rejected the xenografts via AMR. These data suggest that allosensitized recipients may be suitable candidates for xenografts from genetically modified porcine donors and could benefit from an optimized immunosuppression regimen designed to target the post-transplant humoral response, thereby avoiding AMR.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Imran Anwar
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Isabel DeLaura
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Andrew Barbas
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Alton B Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | | - Stuart Knechtle
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Duke University School of Medicine, Durham, NC 27710, USA
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2
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Kanbay M, Copur S, Yilmaz ZY, Baydar DE, Bilge I, Susal C, Kocak B, Ortiz A. The role of anticomplement therapy in the management of the kidney allograft. Clin Transplant 2024; 38:e15277. [PMID: 38485664 DOI: 10.1111/ctr.15277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
As the number of patients living with kidney failure grows, the need also grows for kidney transplantation, the gold standard kidney replacement therapy that provides a survival advantage. This may result in an increased rate of transplantation from HLA-mismatched donors that increases the rate of antibody-mediated rejection (AMR), which already is the leading cause of allograft failure. Plasmapheresis, intravenous immunoglobulin therapy, anti-CD20 therapies (i.e., rituximab), bortezomib and splenectomy have been used over the years to treat AMR as well as to prevent AMR in high-risk sensitized kidney transplant recipients. Eculizumab and ravulizumab are monoclonal antibodies targeting the C5 protein of the complement pathway and part of the expanding field of anticomplement therapies, which is not limited to kidney transplant recipients, and also includes complement-mediated microangiopathic hemolytic anemia, paroxysmal nocturnal hemoglobinuria, and ANCA-vasculitis. In this narrative review, we summarize the current knowledge concerning the pathophysiological background and use of anti-C5 strategies (eculizumab and ravulizumab) and C1-esterase inhibitor in AMR, either to prevent AMR in high-risk desensitized patients or to treat AMR as first-line or rescue therapy and also to treat de novo thrombotic microangiopathy in kidney transplant recipients.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dilek Ertoy Baydar
- Department of Pathology, Koc University School of Medicine, Istanbul, Turkey
| | - Ilmay Bilge
- Department of Pediatrics, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Susal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz, Madrid, Spain
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3
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Long JJ, Motter JD, Jackson KR, Chen J, Orandi BJ, Montgomery RA, Stegall MD, Jordan SC, Benedetti E, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Verbesey JE, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Wellen JR, Bozorgzadeh A, Gaber AO, Heher EC, Weng FL, Djamali A, Helderman JH, Concepcion BP, Brayman KL, Oberholzer J, Kozlowski T, Covarrubias K, Massie AB, McAdams-DeMarco MA, Segev DL, Garonzik-Wang JM. Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients. Am J Transplant 2023; 23:1980-1989. [PMID: 37748554 PMCID: PMC10767749 DOI: 10.1016/j.ajt.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/26/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
Older compatible living donor kidney transplant (CLDKT) recipients have higher mortality and death-censored graft failure (DCGF) compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant (ILDKT) recipients who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997, and December 15, 2016, we compared mortality, DCGF, delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age ≥60 years) and 1172 younger (age 18-59 years) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17 542 CLDKT recipients, we used an interaction term to determine whether the relationship between posttransplant outcomes and transplant type (ILDKT vs CLDKT) was modified by age. Overall, older recipients had higher mortality (hazard ratio: 1.632.072.65, P < .001), lower DCGF (hazard ratio: 0.360.530.77, P = .001), and AR (odds ratio: 0.390.540.74, P < .001), and similar DGF (odds ratio: 0.461.032.33, P = .9) and LOS (incidence rate ratio: 0.880.981.10, P = 0.8) compared to younger recipients. The impact of age on mortality (interaction P = .052), DCGF (interaction P = .7), AR interaction P = .2), DGF (interaction P = .9), and LOS (interaction P = .5) were similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.
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Affiliation(s)
- Jane J Long
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer D Motter
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Kyle R Jackson
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Jennifer Chen
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Babak J Orandi
- Department of Surgery, University of Alabama, Birmingham, Alabama, USA
| | - Robert A Montgomery
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mark D Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stanley C Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Ty B Dunn
- Department of Surgery, University of Pennsylvania, Philadelphia, Philadelphia, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Sandip Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, New York, USA
| | - Ronald P Pelletier
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - John P Roberts
- Department of Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Pooja Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Philadelphia, USA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Marc P Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jose M El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, Oklahoma, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA
| | - Jennifer E Verbesey
- Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA
| | - George S Lipkowitz
- Department of Surgery, Baystate Medical Center Springfield, Massachusetts, Massachusetts, USA
| | - Michael A Rees
- Department of Urology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Christopher L Marsh
- Department of Surgery, Scripps Clinic and Green Hospital, La Jolla, California, USA
| | | | - David A Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jason R Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Adel Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Eliot C Heher
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francis L Weng
- Renal and Pancreas Transplant Division, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - J Harold Helderman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kenneth L Brayman
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jose Oberholzer
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Tomasz Kozlowski
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Karina Covarrubias
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Allan B Massie
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
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4
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de Klerk M, Kal-van Gestel JA, Roelen D, Betjes MGH, de Weerd AE, Reinders MEJ, van de Wetering J, Kho MML, Glorie K, Roodnat JI. Increasing Kidney-Exchange Options Within the Existing Living Donor Pool With CIAT: A Pilot Implementation Study. Transpl Int 2023; 36:11112. [PMID: 37342179 PMCID: PMC10278123 DOI: 10.3389/ti.2023.11112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/16/2023] [Indexed: 06/22/2023]
Abstract
Computerized integration of alternative transplantation programs (CIAT) is a kidney-exchange program that allows AB0- and/or HLA-incompatible allocation to difficult-to-match patients, thereby increasing their chances. Altruistic donors make this available for waiting list patients as well. Strict criteria were defined for selected highly-immunized (sHI) and long waiting (LW) candidates. For LW patients AB0i allocation was allowed. sHI patients were given priority and AB0i and/or CDC cross-match negative HLAi allocations were allowed. A local pilot was established between 2017 and 2022. CIAT results were assessed against all other transplant programs available. In the period studied there were 131 incompatible couples; CIAT transplanted the highest number of couples (35%), compared to the other programs. There were 55 sHI patients; CIAT transplanted as many sHI patients as the Acceptable Mismatch program (18%); Other programs contributed less. There were 69 LW patients; 53% received deceased donor transplantations, 20% were transplanted via CIAT. In total, 72 CIAT transplants were performed: 66 compatible, 5 AB0i and 1 both AB0i and HLAi. CIAT increased opportunities for difficult-to-match patients, not by increasing pool size, but through prioritization and allowing AB0i and "low risk" HLAi allocation. CIAT is a powerful addition to the limited number of programs available for difficult-to-match patients.
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Affiliation(s)
- Marry de Klerk
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Judith A. Kal-van Gestel
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Dave Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Michiel G. H. Betjes
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Annelies E. de Weerd
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Marlies E. J. Reinders
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Marcia M. L. Kho
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Joke I. Roodnat
- Erasmus Medical Center, Department of Internal Medicine, Transplantation Institute, Rotterdam, Netherlands
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5
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Manook M, Olaso D, Anwar IJ, Yoon J, Delaura I, Bae Y, Moris D, Shaw B, Song M, Farris AB, Jackson A, Kwun J, Knechtle S. Desensitization and belatacept-based maintenance therapy in pregnancy-sensitized monkeys receiving a kidney transplant. SCIENCE ADVANCES 2023; 9:eadg1448. [PMID: 37205758 PMCID: PMC10198638 DOI: 10.1126/sciadv.adg1448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
Among sensitized patients awaiting a transplant, females are disproportionately represented, partly because of pregnancy-induced sensitization. Using female NHPs sensitized by pregnancy alone, we examined the efficacy of costimulation blockade and proteasome inhibition for desensitization. Three animals received no desensitization (control), and seven animals received weekly carfilzomib (27 mg/m2) and belatacept (20 mg/kg) before kidney transplantation. All animals received renal allografts from crossmatch-positive/maximally MHC-mismatched donors. Controls and three desensitized animals received tacrolimus-based immunosuppression. Four desensitized animals received additional belatacept with tacrolimus-based immunosuppression. Multiparous females had less circulating donor-specific antibody when compared to skin-sensitized males before transplantation. While females receiving desensitization showed only a marginal survival benefit over control females (MST = 11 days versus 63 days), additional belatacept to posttransplant maintenance significantly prolonged graft survival (MST > 164 days) and suppressed posttransplant DSA and circulating follicular helper T-like cells. This combination of therapies demonstrates great potential to reduce antibody-mediated rejection in sensitized recipients.
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Affiliation(s)
- Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Danae Olaso
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Isabel Delaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Yeeun Bae
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dimitrios Moris
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Brian Shaw
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Annette Jackson
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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6
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Santarsiero D, Aiello S. The Complement System in Kidney Transplantation. Cells 2023; 12:cells12050791. [PMID: 36899927 PMCID: PMC10001167 DOI: 10.3390/cells12050791] [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: 01/02/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Kidney transplantation is the therapy of choice for patients who suffer from end-stage renal diseases. Despite improvements in surgical techniques and immunosuppressive treatments, long-term graft survival remains a challenge. A large body of evidence documented that the complement cascade, a part of the innate immune system, plays a crucial role in the deleterious inflammatory reactions that occur during the transplantation process, such as brain or cardiac death of the donor and ischaemia/reperfusion injury. In addition, the complement system also modulates the responses of T cells and B cells to alloantigens, thus playing a crucial role in cellular as well as humoral responses to the allograft, which lead to damage to the transplanted kidney. Since several drugs that are capable of inhibiting complement activation at various stages of the complement cascade are emerging and being developed, we will discuss how these novel therapies could have potential applications in ameliorating outcomes in kidney transplantations by preventing the deleterious effects of ischaemia/reperfusion injury, modulating the adaptive immune response, and treating antibody-mediated rejection.
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7
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Daga S, Briggs D. Defining the lower and upper limits of immunological risk of HLA antibody incompatible kidney transplantation: Current state of the art and limitations. Transpl Immunol 2023; 76:101775. [PMID: 36528247 DOI: 10.1016/j.trim.2022.101775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Sunil Daga
- Renal Department, St James's University Hospital, Leeds, United Kingdom; NIHR Leeds In-Vitro Diagnostics Co-operative, Leeds, United Kingdom.
| | - David Briggs
- Histocompatibility and Immunogenetics, NHS Blood and Transplant, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
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8
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Nishikawa K, Masui S, Ishida H. Virtual crossmatching and epitope analysis in kidney transplantation: What the physician involved in kidney transplantation should know? Int J Urol 2023; 30:7-19. [PMID: 36194790 DOI: 10.1111/iju.15059] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/04/2022] [Indexed: 01/31/2023]
Abstract
Solid-phase single antigen bead (SAB) assay for detection of anti-human leukocyte antigen (HLA) antibodies and high-resolution HLA typing have enabled tremendous progress in virtual crossmatch (VXM) technology in recent years. However, misinterpretation of the SAB assay may result in detrimental consequences after kidney transplantation. Meanwhile, epitope analysis could be an effective method to estimate immunizing eplets, which may provide ancillary information for better understanding of the SAB assay. To perform epitope analysis appropriately, it is necessary to understand the basic principles related to histocompatibility testing and the characteristics of the SAB assay. Therefore, knowledge of the properties and limitations of the SAB assay is critical. In this review, we aim to describe the fundamental concepts regarding immunobiological assessment, including HLA, anti-HLA antibodies, and SAB assay, and explain epitope analysis using examples.
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Affiliation(s)
- Kouhei Nishikawa
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Satoru Masui
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University Hospital, Tokyo, Japan
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9
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Schmitz R, Fitch ZW, Manook M, Schroder PM, Choi AY, Olaso D, Yoon J, Bae Y, Shaw BI, Song M, Kuchibhatla M, Farris AB, Kirk A, Kwun J, Knechtle SJ. Belatacept-Based Maintenance Immunosuppression Controls the Post-Transplant Humoral Immune Response in Highly Sensitized Nonhuman Primates. KIDNEY360 2022; 3:2116-2130. [PMID: 36591367 PMCID: PMC9802566 DOI: 10.34067/kid.0001732022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
Preexisting donor-specific antibodies (DSA) to MHC antigens increase the risk of antibody-mediated rejection (AMR) in sensitized transplant recipients and reduces graft survival. Pretransplant desensitization with costimulation blockade and proteasome inhibition has facilitated transplantation in our preclinical nonhuman primate (NHP) model. However, long-term graft survival is limited by rebound of DSA after transplantation. In this study, we performed kidney transplants between highly sensitized, maximally MHC-mismatched NHPs (n=14). At kidney transplantation, primates received T cell depletion with rhesus-specific anti-thymocyte globulin (rhATG; n=10) or monoclonal anti-CD4 and anti-CD8 antibodies (n=4). Maintenance immunosuppression consisted of belatacept and tacrolimus (n=5) or belatacept and rapamycin (n=9) with steroids. Rebound of DSA post-kidney transplantation was significantly reduced compared with maintenance immunosuppression with tacrolimus, mycophenolate, and steroids. Protocol lymph node biopsy specimens showed a decrease in germinal center activity, with low frequencies of T follicular helper cells and class-switched B cells after kidney transplantation. Combined belatacept and rapamycin was superior in controlling viral reactivation, enabling weaning of ganciclovir prophylaxis. Tacrolimus was associated with increased morbidity that included cytomegalovirus and parvovirus viremia and post-transplant lymphoproliferative disorder. All primates in the tacrolimus/belatacept group failed discontinuation of antiviral therapy. Overall, belatacept-based immunosuppression increased AMR-free graft survival by controlling post-transplant humoral responses in highly sensitized NHP recipients and should be further investigated in a human clinical trial.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Zachary W. Fitch
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Miriam Manook
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Paul M. Schroder
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Ashley Y. Choi
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Danae Olaso
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Janghoon Yoon
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Yeeun Bae
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Brian I. Shaw
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Mingqing Song
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Kirk
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Stuart J. Knechtle
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
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10
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Kervella D, Le Bas-Bernardet S, Bruneau S, Blancho G. Protection of transplants against antibody-mediated injuries: from xenotransplantation to allogeneic transplantation, mechanisms and therapeutic insights. Front Immunol 2022; 13:932242. [PMID: 35990687 PMCID: PMC9389360 DOI: 10.3389/fimmu.2022.932242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term allograft survival in allotransplantation, especially in kidney and heart transplantation, is mainly limited by the occurrence of antibody-mediated rejection due to anti-Human Leukocyte Antigen antibodies. These types of rejection are difficult to handle and chronic endothelial damages are often irreversible. In the settings of ABO-incompatible transplantation and xenotransplantation, the presence of antibodies targeting graft antigens is not always associated with rejection. This resistance to antibodies toxicity seems to associate changes in endothelial cells phenotype and modification of the immune response. We describe here these mechanisms with a special focus on endothelial cells resistance to antibodies. Endothelial protection against anti-HLA antibodies has been described in vitro and in animal models, but do not seem to be a common feature in immunized allograft recipients. Complement regulation and anti-apoptotic molecules expression appear to be common features in all these settings. Lastly, pharmacological interventions that may promote endothelial cell protection against donor specific antibodies will be described.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Sarah Bruneau
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Néphrologie et Immunologie Clinique, Institut Transplantation Urologie Néphrologie (ITUN), Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, France
- *Correspondence: Gilles Blancho,
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11
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Chandra Shrestha P, Bhandari TR, Adhikari R, Baral H, Verma RK, Shrestha KK. Living donor kidney paired exchange: An observational study. Ann Med Surg (Lond) 2022; 78:103761. [PMID: 35734678 PMCID: PMC9206995 DOI: 10.1016/j.amsu.2022.103761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/02/2022] [Accepted: 05/08/2022] [Indexed: 11/28/2022] Open
Abstract
Background Kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESKD). Kidney paired donation (KPD) provides the chance to match an incompatible donor/recipient pair with another donor and recipient in a similar condition. We aimed to compare the outcomes of pair exchange kidney transplantation with traditional live donor kidney transplantation in our context. Method A review of medical records of 62 patients (31 pairs) who underwent two-way conventional living kidney pair exchange from July 2016 to June 2021 was done. The control group was considered those 62 patients who had undergone classic live donor kidney transplantation (LDKT) during the study period. The patient's demographics, intraoperative and postoperative variables including delayed graft function, length of hospital stay, graft survival, patient survival, and rejections rates were compared between the groups (KPD and LDKT). Results The majority of recipients were male (77.4 and 80.6%) while donors were female (77.4 and 69.4%) in KPD and the LDKT groups. Mean ages were 37 years (range: 19–59) and 37 years (range: 17–65) for the recipient's in KPD and the LDKT. KPD transplantation was performed in 62 recipients to avoid blood group incompatibility. There were no significant differences in outcomes comprising delayed graft function (1.6 and 3.2%), graft survival (100% in both groups), patient survival (95.2 and 96.8%), and rejections rates (1.6 and 1.6%) between KPD and LDKT group (P > 0.005). The length of stay was similar (5.9 and 5.7 days) in KPD and LDKT groups (P > 0.005). Conclusions The outcomes of KPD were comparable with classic LDKT in terms of delayed graft function, length of hospital stay, graft survival, patient survival, and rejections rates in our study. Therefore, the kidney paired donation program should be encouraged and promoted in centers where the ABO-incompatible transplant is expensive with added risk and the rate of deceased donor transplantation is very low. Kidney paired donation (KPD) provides the chance to match for an incompatible donor/recipient pair with another donor and recipient in a similar condition. The outcomes of KPD were comparable with classic live donor kidney transplantation (LDKT) in this study. KPD program should be promoted in centers where the ABO incompatible transplant is expensive with added risk and the rate of deceased donor transplantation is very low.
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Affiliation(s)
- Pukar Chandra Shrestha
- Department of Transplant Surgery, Shahid Dharmabhakta National Transplant Centre, Bhaktapur, Nepal
| | - Tika Ram Bhandari
- Department of Transplant Surgery, Shahid Dharmabhakta National Transplant Centre, Bhaktapur, Nepal
- Corresponding author. Department of Transplant Surgery, Shahid Dharmabhakta National Transplant Centre (SDNTC), Bhaktapur, Nepal.
| | - Rojan Adhikari
- Department of Urology, Shahid Dharmabhakta National Transplant Centre, Bhaktapur, Nepal
| | - Hari Baral
- Department of Urology, Shahid Dharmabhakta National Transplant Centre, Bhaktapur, Nepal
| | - Rakesh Kumar Verma
- Department of Urology, Shahid Dharmabhakta National Transplant Centre, Bhaktapur, Nepal
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12
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Bansal SB, Gade A, Sinha S, Mahapatra A, Jha P, Sethi SK. HLA Desensitization Based on Results of the Luminex Technique in Kidney Transplant - A Single-center Experience. Indian J Nephrol 2021; 31:454-459. [PMID: 34880555 PMCID: PMC8597796 DOI: 10.4103/ijn.ijn_237_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/19/2020] [Accepted: 09/01/2020] [Indexed: 12/02/2022] Open
Abstract
Background: There is little experience of human leucocyte antigen (HLA) desensitization in India based on the Luminex single-antigen bead (SAB) testing. We retrospectively analyzed our patients, who underwent HLA desensitization based on Luminex SAB results. Method: Between 2014 and 2018, patients with complement-dependent cytotoxicity cross-match (CDC-XM) negativity but flow cytometry crossmatch (FC-XM) positivity were further analyzed with Luminex SAB for donor-specific antibodies (DSAs). A total of 12 patients who had DSA mean fluorescent intensity (MFI) of >1000 and <10,000 were included in the study. Our protocol for desensitization consisted of plasmapheresis (PP) followed by low dose intravenous immunoglobulin (IV IG) 100 mg/kg and induction with antithymocyte globulin (ATG). Patients were taken for transplant when either MFI was <1000 and/or FC-XM was negative. Results: All 12 patients were first transplant and 10 had a history of some sensitizing event; pregnancy in 4, blood transfusions in 4, and both in 2 patients. FC-XM was positive for T-cell in 4, B-cell in 6, and both in 2 patients. On evaluation by Luminex SAB, 6 patients had MFI from 1000 to 2000, and 6 had MFI of >2000. All underwent desensitization successfully. Two patients had an increase in posttransplant DSA titers requiring posttransplant PP. The mean follow-up was 26.6 ± 13.9 months. On follow-up, only one patient developed acute T cell-mediated rejection 1 year after transplant, which responded to pulse steroids. There was no graft or patient loss until the last follow-up. Conclusion: This study shows that HLA desensitization is feasible and successful in the Indian setting if patients are properly selected.
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Affiliation(s)
- S B Bansal
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta-Medicity, Gurugram, Haryana, India
| | - A Gade
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta-Medicity, Gurugram, Haryana, India
| | - S Sinha
- Department of Nephrology, BYL Nair Hospital, Mumbai, Maharashtra, India
| | - A Mahapatra
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta-Medicity, Gurugram, Haryana, India
| | - P Jha
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta-Medicity, Gurugram, Haryana, India
| | - S K Sethi
- Department of Nephrology, Medanta Kidney and Urology Institute, Medanta-Medicity, Gurugram, Haryana, India
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13
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Cornell LD. Histopathologic Features of Antibody Mediated Rejection: The Banff Classification and Beyond. Front Immunol 2021; 12:718122. [PMID: 34646262 PMCID: PMC8503253 DOI: 10.3389/fimmu.2021.718122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/07/2021] [Indexed: 01/27/2023] Open
Abstract
Antibody mediated rejection (ABMR) in the kidney can show a wide range of clinical presentations and histopathologic patterns. The Banff 2019 classification currently recognizes four diagnostic categories: 1. Active ABMR, 2. Chronic active ABMR, 3. Chronic (inactive) ABMR, and 4. C4d staining without evidence of rejection. This categorization is limited in that it does not adequately represent the spectrum of antibody associated injury in allograft, it is based on biopsy findings without incorporating clinical features (e.g., time post-transplant, de novo versus preformed DSA, protocol versus indication biopsy, complement inhibitor drugs), the scoring is not adequately reproducible, and the terminology is confusing. These limitations are particularly relevant in patients undergoing desensitization or positive crossmatch kidney transplantation. In this article, I discuss Banff criteria for these ABMR categories, with a focus on patients with pre-transplant DSA, and offer a framework for considering the continuum of allograft injury associated with donor specific antibody in these patients.
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Affiliation(s)
- Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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14
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C3 complement inhibition prevents antibody-mediated rejection and prolongs renal allograft survival in sensitized non-human primates. Nat Commun 2021; 12:5456. [PMID: 34526511 PMCID: PMC8443599 DOI: 10.1038/s41467-021-25745-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 08/24/2021] [Indexed: 12/20/2022] Open
Abstract
Sensitized kidney transplant recipients experience high rates of antibody-mediated rejection due to the presence of donor-specific antibodies and immunologic memory. Here we show that transient peri-transplant treatment with the central complement component C3 inhibitor Cp40 significantly prolongs median allograft survival in a sensitized nonhuman primate model. Despite donor-specific antibody levels remaining high, fifty percent of Cp40-treated primates maintain normal kidney function beyond the last day of treatment. Interestingly, presence of antibodies of the IgM class associates with reduced median graft survival (8 vs. 40 days; p = 0.02). Cp40 does not alter lymphocyte depletion by rhesus-specific anti-thymocyte globulin, but inhibits lymphocyte activation and proliferation, resulting in reduced antibody-mediated injury and complement deposition. In summary, Cp40 prevents acute antibody-mediated rejection and prolongs graft survival in primates, and inhibits T and B cell activation and proliferation, suggesting an immunomodulatory effect beyond its direct impact on antibody-mediated injury. Donor-specific antibodies in sensitized recipients may cause kidney transplant rejection. Here the authors show that complement component C3 inhibition prolongs graft survival by inhibiting T and B cell proliferation/activation and hence tissue injury, despite antibody levels remaining unaffected.
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15
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Kumar V, Locke JE. New Perspectives on Desensitization in the Current Era - An Overview. Front Immunol 2021; 12:696467. [PMID: 34394089 PMCID: PMC8363260 DOI: 10.3389/fimmu.2021.696467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022] Open
Abstract
Blood group and tissue incompatibilities remain significant barriers to achieving transplantation. Although no patient should be labeled “un-transplantable” due to blood group or tissue incompatibility, all candidates should be provided with individualized and realistic counseling regarding their anticipated wait times for deceased donor or kidney paired donation matching, with early referral to expert centers for desensitization when needed. Vital is the careful selection of patients whose health status is such that desensitizing treatment is less likely to cause serious harm and whose anti-HLA antibody status is such that treatment is likely to accomplish the goal of increasing organ offers with an acceptable final crossmatch. Exciting new developments have re-energized the interest and scope of desensitization in the times ahead.
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Affiliation(s)
- Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States
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16
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Miyairi S, Ueda D, Yagisawa T, Okada D, Keslar KS, Tanabe K, Dvorina N, Valujskikh A, Baldwin WM, Hazen SL, Fairchild RL. Recipient myeloperoxidase-producing cells regulate antibody-mediated acute versus chronic kidney allograft rejection. JCI Insight 2021; 6:148747. [PMID: 34081629 PMCID: PMC8410093 DOI: 10.1172/jci.insight.148747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
Antibody-mediated rejection (ABMR) continues to be a major problem undermining the success of kidney transplantation. Acute ABMR of kidney grafts is characterized by neutrophil and monocyte margination in the tubular capillaries and by graft transcripts indicating NK cell activation, but the myeloid cell mechanisms required for acute ABMR have remained unclear. Dysregulated donor-specific antibody (DSA) responses with high antibody titers are induced in B6.CCR5-/- mice transplanted with complete MHC-mismatched A/J kidneys and are required for rejection of the grafts. This study tested the role of recipient myeloid cell production of myeloperoxidase (MPO) in the cellular and molecular components of acute ABMR. Despite induction of equivalent DSA titers, B6.CCR5-/- recipients rejected A/J kidneys between days 18 and 25, with acute ABMR, whereas B6.CCR5-/-MPO-/- recipients rejected the grafts between days 46 and 54, with histopathological features of chronic graft injury. On day 15, myeloid cells infiltrating grafts from B6.CCR5-/- and B6.CCR5-/-MPO-/- recipients expressed marked phenotypic and functional transcript differences that correlated with the development of acute versus chronic allograft injury, respectively. Near the time of peak DSA titers, activation of NK cells to proliferate and express CD107a was decreased within allografts in B6.CCR5-/-MPO-/- recipients. Despite high titers of DSA, depletion of neutrophils reproduced the inhibition of NK cell activation and decreased macrophage infiltration but increased monocytes producing MPO. Overall, recipient myeloid cells producing MPO regulate graft-infiltrating monocyte/macrophage function and NK cell activation that are required for DSA-mediated acute kidney allograft injury, and their absence switches DSA-mediated acute pathology and graft outcomes to chronic ABMR.
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Affiliation(s)
- Satoshi Miyairi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Daisuke Ueda
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Takafumi Yagisawa
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Daigo Okada
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Karen S. Keslar
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Nina Dvorina
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William M. Baldwin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stanley L. Hazen
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert L. Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Reese SR, Wilson NA, Huang Y, Ptak L, Degner KR, Xiang D, Redfield RR, Zhong W, Panzer SE. B-cell Deficiency Attenuates Transplant Glomerulopathy in a Rat Model of Chronic Active Antibody-mediated Rejection. Transplantation 2021; 105:1516-1529. [PMID: 33273321 PMCID: PMC8106694 DOI: 10.1097/tp.0000000000003530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transplant glomerulopathy (TG) is a pathological feature of chronic active antibody-mediated rejection (cAMR) and is associated with renal allograft failure. The specific role of B cells in the pathogenesis of TG is unclear. METHODS We used a minor mismatched rat kidney transplant model with B cell-deficient recipients, generated by clustered regularly interspaced short palindromic repeats/Cas9 technology, to investigate the impact of B-cell depletion on the pathogenesis of TG. We hypothesized that B-cell deficiency would prevent TG in the rat kidney transplant model of cAMR. Treatment groups included syngeneic, allogeneic, sensitized allogeneic, and B cell-deficient allogeneic transplant recipients. RESULTS B cell-deficient recipients demonstrated reduced TG lesions, decreased microvascular inflammation, reduced allograft infiltrating macrophages, and reduced interferon gamma transcripts within the allograft. Allograft transcript levels of interferon gamma, monocyte chemoattractant protein-1, and interleukin-1β correlated with numbers of intragraft macrophages. B cell-deficient recipients lacked circulating donor-specific antibodies and had an increased splenic regulatory T-cell population. CONCLUSIONS In this model of cAMR, B-cell depletion attenuated the development of TG with effects on T cell and innate immunity.
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Affiliation(s)
- Shannon R. Reese
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Nancy A. Wilson
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Yabing Huang
- Department of Pathology, Renmin Hospital of Wuhan University, China
| | - Lucille Ptak
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenna R. Degner
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Ding Xiang
- Department of Organ Transplantation, Xiangya Hospital, Central South University, China
| | - Robert R. Redfield
- Department of Surgery, Division of Transplant Surgery, University of Wisconsin, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI, United States
| | - Sarah E. Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
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18
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Kwofie L, Anderson R, Steel H, Meyer WA P. Evaluation of three different laboratory methods to detect preformed human leukocyte antigen antibodies in a South African kidney transplant population. Afr Health Sci 2021; 21:735-742. [PMID: 34795730 PMCID: PMC8568216 DOI: 10.4314/ahs.v21i2.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Anti-human leukocyte antigen antibodies (anti-HLA) play a crucial role in graft. Detection of anti-HLA, both pre- and post-transplant is a crucial investigation in clinical organ transplantation. Objectives Three methodologies for the detection of lymphocytotoxic antibodies were compared to establish which of these is best suited to optimise pre-transplant donor-recipient matching. Methods Serum samples from 15 renal transplant patients were tested for the presence of anti-HLA by i) cytotoxic-dependent cross-match (CDCXM), ii) flow cytometric cross-match (FCXM) and iii) Luminex-based donor specific antibody cross-match (DSAXM) method, Confirmatory tests for the presence of preformed HLA antibodies were tested using Luminex methodology. Results Two (13%) of the 15 patients had positive HLA Class I antibodies (Ab) using all 3 methods. An additional 2 HLA Class I Ab were identified with FCXM/CDCXM. DSAXM identified 1 HLA Class I positive, not indicated by CDCXM/FCXM. High HLA Class II positivity (40%), identified by CDCXM, while DSAXM and FCXM identified two and one patients, respectively. CDCXM produced 4 false-positive results confirmed by lymphocyte single antigen (LSA) assay. Conclusions The DSAXM method appears to add value in pre-transplantation screening to identify pre-sensitised patients that may not reject the donor graft due to the absence of donor-specific antibodies.
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Affiliation(s)
- Luyanda Kwofie
- National Health Laboratory Service, Immunology Department, Pretoria, South Africa
- University of Pretoria, Faculty of Health Sciences, Department of Immunology, Pretoria, South Africa
| | - Ronald Anderson
- University of Pretoria, Faculty of Health Sciences, Department of Immunology, Pretoria, South Africa
| | - Helen Steel
- University of Pretoria, Faculty of Health Sciences, Department of Immunology, Pretoria, South Africa
| | - Pieter Meyer WA
- National Health Laboratory Service, Immunology Department, Pretoria, South Africa
- University of Pretoria, Faculty of Health Sciences, Department of Immunology, Pretoria, South Africa
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19
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Schinstock C, Tambur A, Stegall M. Current Approaches to Desensitization in Solid Organ Transplantation. Front Immunol 2021; 12:686271. [PMID: 34046044 PMCID: PMC8144637 DOI: 10.3389/fimmu.2021.686271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Major advancements in the development of HLA antibody detection techniques and our understanding of the outcomes of solid organ transplant in the context of HLA antibody have occurred since the relevance of sensitization was first recognized nearly 50 years ago. Additionally, kidney paired donation programs (KPD) have become widespread, deceased donor allocation policies have changed, and several new therapeutic options have become available with promise to reduce HLA antibody. In this overview we aim to provide thoughtful guidance about when desensitization in kidney transplantation should be considered taking into account the outcomes of HLA incompatible transplantation. Novel therapeutics, desensitization endpoints, and strategies for future study will also be discussed. While most of our understanding about desensitization comes from studying kidney transplant candidates and recipients, many of the concepts discussed can be easily applied to desensitization in all of solid organ transplantation.
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Affiliation(s)
- Carrie Schinstock
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Anat Tambur
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Mark Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
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20
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Eleftheriadis T, Pissas G, Crespo M, Filippidis G, Antoniadis N, Liakopoulos V, Stefanidis I. The effect of anti‑HLA class I antibodies on the immunological properties of human glomerular endothelial cells and their modification by mTOR inhibition or GCN2 kinase activation. Mol Med Rep 2021; 23:355. [PMID: 33760196 PMCID: PMC7974416 DOI: 10.3892/mmr.2021.11994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/26/2021] [Indexed: 11/06/2022] Open
Abstract
In antibody‑mediated rejection (ABMR), the graft endothelium is at the forefront of the kidney transplant against the assault from the recipient's humoral immune system, and is a target of the latter. The present study investigated the effect of antibodies against human leukocyte antigen (HLA) class I (anti‑HLAI) on the immunological properties of human glomerular endothelial cells. Additionally, the effect of the mammalian target of rapamycin (mTOR) complex 1 (mTORC1) inhibitor (everolimus), or the general control nonderepressible 2 kinase (GCN2K) activator (halofuginone) on anti‑HLAI antibody‑mediated alterations was assessed. Cell integrity was examined, an lactate dehydrogenase (LDH) release assay was performed and cleaved caspase‑3 levels were determined. Furthermore, cell proliferation was analyzed by performing a bromodeoxyuridine assay and the cellular proteins involved in signal transduction or immune effector mechanisms were assessed via western blotting. IL‑8, monocyte chemoattractive protein‑1 (MCP‑1), von Willebrand factor (vWF) and transforming growth factor‑beta 1 (TGF‑β1) were assayed via ELISA. The results revealed that anti‑HLAI triggered integrin signaling, activated mTOR and GCN2K, preserved cell integrity and promoted cell proliferation. Additionally, by increasing intercellular adhesion molecule 1 (ICAM‑1), HLA‑DR, IL‑8 and MCP‑1 levels, anti‑HLAI enhanced the ability of immune cells to interact with endothelial cells thus facilitating graft rejection. Contrarily, by upregulating CD46 and CD59, anti‑HLAI rendered the endothelium less vulnerable to complement‑mediated injury. Finally, by enhancing vWF and TGF‑β1, anti‑HLAI may render the endothelium prothrombotic and facilitate fibrosis and graft failure, respectively. According to our results, mTORC1 inhibition and GCN2K activation may prove useful pharmaceutical targets, as they prevent cell proliferation and downregulate ICAM‑1, IL‑8, MCP‑1 and TGF‑β1. mTORC1 inhibition also decreases vWF.
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Affiliation(s)
- Theodoros Eleftheriadis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Georgios Pissas
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Mar Health Park, Hospital del Mar Medical Research Institute, Barcelona 08003, Spain
| | - Georgios Filippidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Nikolaos Antoniadis
- Organ Transplant Unit, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Vassilios Liakopoulos
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, Larissa 41110, Greece
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21
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de Klerk M, Kal-van Gestel JA, van de Wetering J, Kho ML, Middel-de Sterke S, Betjes MGH, Zuidema WC, Roelen D, Glorie K, Roodnat JI. Creating Options for Difficult-to-match Kidney Transplant Candidates. Transplantation 2021; 105:240-248. [PMID: 32101984 DOI: 10.1097/tp.0000000000003203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Most transplantation centers recognize a small patient population that unsuccessfully participates in all available, both living and deceased donor, transplantation programs for many years: the difficult-to-match patients. This population consists of highly immunized and/or ABO blood group O or B patients. METHODS To improve their chances, Computerized Integration of Alternative Transplantation programs (CIAT) were developed to integrate kidney paired donation, altruistic/unspecified donation, and ABO and HLA desensitization. To compare CIAT with reality, a simulation was performed, including all patients, donors, and pairs who participated in our programs in 2015-2016. Criteria for inclusion as difficult-to-match, selected-highly immunized (sHI) patient were as follows: virtual panel reactive antibody >85% and participating for 2 years in Eurotransplant Acceptable Mismatch program. sHI patients were given priority, and ABO blood group incompatible (ABOi) and/or HLA incompatible (HLAi) matching with donor-specific antigen-mean fluorescence intensity (MFI) <8000 were allowed. For long-waiting blood group O or B patients, ABOi matches were allowed. RESULTS In reality, 90 alternative program transplantations were carried out: 73 compatible, 16 ABOi, and 1 both ABOi and HLAi combination. Simulation with CIAT resulted in 95 hypothetical transplantations: 83 compatible (including 1 sHI) and 5 ABOi combinations. Eight sHI patients were matched: 1 compatible, 6 HLAi with donor-specific antigen-MFI <8000 (1 also ABOi), and 1 ABOi match. Six/eight combinations for sHI patients were complement-dependent cytotoxicity cross-match negative. CONCLUSIONS CIAT led to 8 times more matches for difficult-to-match sHI patients. This offers them better chances because of a more favorable MFI profile against the new donor. Besides, more ABO compatible matches were found for ABOi couples, while total number of transplantations was not hampered. Prioritizing difficult-to-match patients improves their chances without affecting the chances of regular patients.
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Affiliation(s)
- Marry de Klerk
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marcia L Kho
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Willij C Zuidema
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Dave Roelen
- Department of Immunohaematology and Blood Transfusion LUMC, Leiden, The Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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22
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Recommended Treatment for Antibody-mediated Rejection After Kidney Transplantation: The 2019 Expert Consensus From the Transplantion Society Working Group. Transplantation 2020; 104:911-922. [PMID: 31895348 PMCID: PMC7176344 DOI: 10.1097/tp.0000000000003095] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the development of modern solid-phase assays to detect anti-HLA antibodies and a more precise histological classification, the diagnosis of antibody-mediated rejection (AMR) has become more common and is a major cause of kidney graft loss. Currently, there are no approved therapies and treatment guidelines are based on low-level evidence. The number of prospective randomized trials for the treatment of AMR is small, and the lack of an accepted common standard for care has been an impediment to the development of new therapies. To help alleviate this, The Transplantation Society convened a meeting of international experts to develop a consensus as to what is appropriate treatment for active and chronic active AMR. The aim was to reach a consensus for standard of care treatment against which new therapies could be evaluated. At the meeting, the underlying biology of AMR, the criteria for diagnosis, the clinical phenotypes, and outcomes were discussed. The evidence for different treatments was reviewed, and a consensus for what is acceptable standard of care for the treatment of active and chronic active AMR was presented. While it was agreed that the aims of treatment are to preserve renal function, reduce histological injury, and reduce the titer of donor-specific antibody, there was no conclusive evidence to support any specific therapy. As a result, the treatment recommendations are largely based on expert opinion. It is acknowledged that properly conducted and powered clinical trials of biologically plausible agents are urgently needed to improve patient outcomes.
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23
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Ko Y, Kim JY, Kim SH, Kim DH, Lim SJ, Shin S, Kim YH, Jung JH, Park SK, Kwon H, Han DJ. Acute Rejection and Infectious Complications in ABO- and HLA-Incompatible Kidney Transplantations. Ann Transplant 2020; 25:e927420. [PMID: 33020465 PMCID: PMC7547531 DOI: 10.12659/aot.927420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients receiving ABO-incompatible (ABOi) or human leukocyte antigen (HLA)-incompatible (HLAi) kidney transplantation (KT) require potent immunosuppression and are thus at a higher risk of infectious complications. We evaluated the clinical outcomes of KT stratified by ABO and HLA incompatibilities and identified the factors associated with the clinical outcomes. Material/Methods Recipients who underwent living-related KT between 2012 and 2017 were included and classified into 4 groups: ABO-compatible and HLA-compatible (ABOc/HLAc), HLA-incompatible (ABOc/HLAi), ABO-incompatible (ABOi/HLAc), and ABO-incompatible and HLA-incompatible (ABOi/HLAi). Cox proportional hazards regression analyses were carried out to evaluate the risk factors of acute rejection. Out of the 1732 patients who underwent KT, 1190, 131, 358, and 53 were in the ABOc/HLAc, ABOi/HLAc, ABOc/HLAi, and ABOi/HLAi groups, respectively. Results The ABO/HLAi group showed the lowest 5-year graft survival rate (91.7%). Death-censored graft survival was not significantly different among the groups. The mortality rate from infections was significantly higher in the ABOi/HLAi group (7.5%) than the other groups. Antibody-mediated rejection-free graft survival was the lowest in the ABOi/HLAi group, with significant differences compared with the ABOi/HLAc group (P=0.02) and the ABOc/HLAi group (P=0.03). ABOi/HLAi (hazard ratio [HR], 2.63; 95% confidence interval [CI], 1.04–6.65; P<0.01) and combined infection (HR, 1.91; 95% CI, 1.45–2.51; P<0.01) were significant risk factors for acute rejection. Conclusions Patients with both ABO and HLA incompatibilities showed inferior rates of overall patient and graft survival due to infectious complications. Infection was a prominent risk factor of acute rejection following KT after adjusting for possible confounders including ABO and HLA incompatibility.
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Affiliation(s)
- Youngmin Ko
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jee Yeon Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong Hyun Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Jun Lim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Shin
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Hoon Kim
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joo Hee Jung
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyunwook Kwon
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duck Jong Han
- Division of Kidney and Pancreas Transplant Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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24
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Babu A, Khovanova N, Shaw O, Griffin S, Briggs D, Krishnan NS, Fletcher S, Imray C, Seitz A, Baker R, Wellberry-Smith M, Clarke B, Cullen K, Rees T, Edwards F, Burrows E, Howe L, Martin C, Dorling A, Zehnder D, Higgins RM, Mitchell DA, Daga S. C3d-positive donor-specific antibodies have a role in pretransplant risk stratification of cross-match-positive HLA-incompatible renal transplantation: United Kingdom multicentre study. Transpl Int 2020; 33:1128-1139. [PMID: 32479670 DOI: 10.1111/tri.13663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/09/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
Anti-HLA-antibody characteristics aid to risk-stratify patients and improve long-term renal graft outcomes. Complement activation by donor-specific antibody (DSA) is an important characteristic that may determine renal allograft outcome. There is heterogeneity in graft outcomes within the moderate to high immunological risk cases (cross-match-positive). We explored the role of C3d-positive DSAs in sub-stratification of cross-match-positive cases and relate to the graft outcomes. We investigated 139 cross-match-positive living-donor renal transplant recipients from four transplant centres in the United Kingdom. C3d assay was performed on serum samples obtained at pretreatment (predesensitization) and Day 14 post-transplant. C3d-positive DSAs were found in 52 (37%) patients at pretreatment and in 37 (27%) patients at Day 14 post-transplant. Median follow-up of patients was 48 months (IQR 20.47-77.57). In the multivariable analysis, pretreatment C3d-positive DSA was independently associated with reduced overall graft survival, the hazard ratio of 3.29 (95% CI 1.37-7.86). The relative risk of death-censored five-year graft failure was 2.83 (95% CI 1.56-5.13). Patients with both pretreatment and Day 14 C3d-positive DSAs had the worst five-year graft survival at 45.5% compared with 87.2% in both pretreatment and Day 14 C3d-negative DSA patients with the relative risk of death-censored five-year graft failure was 4.26 (95% CI 1.79, 10.09). In this multicentre study, we have demonstrated for the first time the utility of C3d analysis as a distinctive biomarker to sub-stratify the risk of poor graft outcome in cross-match-positive living-donor renal transplantation.
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Affiliation(s)
- Adarsh Babu
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Olivia Shaw
- Department of Histocompatibility and Immunogenetics, Viapath, London, UK
| | - Sian Griffin
- Department of Renal Medicine and Transplantation, University of Wales Hospital, Cardiff, UK
| | | | - Nithya S Krishnan
- Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Simon Fletcher
- Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Christopher Imray
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Adrienne Seitz
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK.,Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Richard Baker
- Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Matthew Wellberry-Smith
- Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Brendan Clarke
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Katherine Cullen
- Department of Histocompatibility and Immunogenetics, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Tracey Rees
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Frankie Edwards
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Emma Burrows
- Welsh Transplantation and Immunogenetics Laboratory, Cardiff, UK
| | - Louise Howe
- School of Engineering, University of Warwick, Coventry, UK
| | - Chloe Martin
- School of Engineering, University of Warwick, Coventry, UK
| | - Anthony Dorling
- Department of Renal Medicine and Transplantation, Guys and St Thomas NHS Foundation Trust, London, UK
| | - Daniel Zehnder
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Nephrology/Acute Medicine, North Cumbria University Hospital NHS Trust, Carlisle, UK
| | - Robert M Higgins
- Warwick Medical School, University of Warwick, Coventry, UK.,Renal Medicine and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Sunil Daga
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Nephrology and Transplantation, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
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25
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Desensitization in Kidney Transplant: A Risky (but Necessary?) Endeavor for Those With Limited Options. Transplantation 2020; 103:2460-2461. [PMID: 31343578 DOI: 10.1097/tp.0000000000002692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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26
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Kuppachi S, Axelrod DA. Desensitization strategies: is it worth it? Transpl Int 2020; 33:251-259. [PMID: 31553805 DOI: 10.1111/tri.13532] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/04/2019] [Accepted: 09/19/2019] [Indexed: 01/10/2023]
Abstract
Preformed donor-specific antibodies (DSAs) limit access to transplantation for thousands of renal transplant patients. While kidney paired donation offers the best strategy for patients with a living donor, for very highly sensitized patients and those without living donors, a strategy of desensitization offers the best hope of transplantation. Removal of DSAs with plasmapheresis, intravenous immunoglobulin and anti-CD20 antibodies can permit successful transplantation. While the clinical outcomes remain inferior to compatible transplant and the costs are significantly greater, when compared with long-term dialysis treatment, these strategies are offer improved survival and are cost-effective given nationally accepted benchmarks.
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Affiliation(s)
- Sarat Kuppachi
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, IA, USA
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27
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Kim DG, Lee J, Park Y, Kim MS, Jeong HJ, Kim SI, Kim YS, Kim BS, Huh KH. Transplant outcomes in positive complement-dependent cytotoxicity- versus flow cytometry-crossmatch kidney transplant recipients after successful desensitization: a retrospective study. BMC Nephrol 2019; 20:456. [PMID: 31818254 PMCID: PMC6902609 DOI: 10.1186/s12882-019-1625-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the obvious survival benefit compared to that among waitlist patients, outcomes of positive crossmatch kidney transplantation (KT) are generally inferior to those of human leukocyte antigen (HLA)-compatible KT. This study aimed to compare the outcomes of positive complement-dependent cytotoxicity (CDC) crossmatch (CDC + FC+) and positive flow cytometric crossmatch (CDC-FC+) with those of HLA-compatible KT (CDC-FC-) after successful desensitization. METHODS We retrospectively analyzed 330 eligible patients who underwent KTs between June 2011 and August 2017: CDC-FC- (n = 274), CDC-FC+ (n = 39), and CDC + FC+ (n = 17). Desensitization protocol targeting donor-specific antibody (DSA) involved plasmapheresis, intravenous immunoglobulin (IVIG), and rituximab with/without bortezomib for positive-crossmatch KT. RESULTS Death-censored graft survival and patient survival were not different among the three groups. The median estimated glomerular filtration rate was significantly lower in the CDC + FC+ group than in the compatible group at 6 months (P < 0.001) and 2 years (P = 0.020). Biopsy-proven rejection within 1 year of CDC-FC-, CDC-FC+, and CDC + FC+ were 15.3, 28.2, and 47.0%, respectively. Urinary tract infections (P < 0.001), Pneumocystis jirovecii pneumonia (P < 0.001), and cytomegalovirus viremia (P < 0.001) were more frequent in CDC-FC+ and CDC + FC+ than in CDC-FC-. CONCLUSIONS This study showed that similar graft and patient survival was achieved in CDC-FC+ and CDC + FC+ KT compared with CDC-FC- through DSA-targeted desensitization despite the higher incidence of rejection and infection than that in compatible KT.
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Affiliation(s)
- Deok Gie Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Younhee Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Joo Jeong
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea. .,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.
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28
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Schinstock CA, Smith BH, Montgomery RA, Jordan SC, Bentall AJ, Mai M, Khamash HA, Stegall MD. Managing highly sensitized renal transplant candidates in the era of kidney paired donation and the new kidney allocation system: Is there still a role for desensitization? Clin Transplant 2019; 33:e13751. [DOI: 10.1111/ctr.13751] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Carrie A. Schinstock
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Rochester MN USA
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
| | - Byron H. Smith
- Department of Health Sciences Research Mayo Clinic Rochester MN USA
| | | | | | - Andrew J. Bentall
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Rochester MN USA
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
| | - Martin Mai
- Transplant Center Mayo Clinic Jacksonville FL USA
| | - Hasan A. Khamash
- Division of Nephrology and Hypertension Department of Internal Medicine Mayo Clinic Phoenix AZ USA
| | - Mark D. Stegall
- The William J von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic Rochester MN USA
- Division of Transplantation Surgery Department of Medicine Mayo Clinic Rochester MN USA
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29
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Parajuli S, Aziz F, Garg N, Panzer SE, Joachim E, Muth B, Mohamed M, Blazel J, Zhong W, Astor BC, Mandelbrot DA, Djamali A. Histopathological characteristics and causes of kidney graft failure in the current era of immunosuppression. World J Transplant 2019; 9:123-133. [PMID: 31750089 PMCID: PMC6851501 DOI: 10.5500/wjt.v9.i6.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The histopathological findings on the failing kidney allograft in the modern era is not well studied. In this study, we present our experience working with kidney transplant recipients with graft failure within one year of the biopsy. AIM To report the histopathological characteristics of failed kidney allografts in the current era of immunosuppression based on the time after transplant, cause of the end-stage renal disease and induction immunosuppressive medications. METHODS In a single-center observational study, we characterized the histopathological findings of allograft biopsies in kidney transplant recipients with graft failure within one year after the biopsy. RESULTS We identified 329 patients with graft failure that met the selection criteria between January 1, 2006 and December 31, 2016. The three most common biopsy findings were interstitial fibrosis and tubular atrophy (IFTA, 53%), acute rejection (AR, 43%) and transplant glomerulopathy (TG, 33%). Similarly, the three most common causes of graft failure based on the primary diagnosis were AR (40%), TG (17%), and IFTA (13%). Most grafts failed within two years of post-transplant (36%). Subsequently, approximately 10%-15% of grafts failed every two years: > 2-4 years (16%), > 4-6 years (13%), > 6-8 years (11%), > 8-10 years (9%) and > 10 years (16%). AR was the most common cause of graft failure in the first six years (48%), whereas TG was the most prevalent cause of graft failure after 6 years (32%) of transplant. CONCLUSION In the current era of immunosuppression, AR is still the most common cause of early graft failure, while TG is the most prevalent cause of late graft failure.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Sarah E Panzer
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Emily Joachim
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Brenda Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Justin Blazel
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI 53705, United States
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Department of Population Health Sciences, University of Wisconsin, Madison, WI 53705, United States
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI 53705, United States
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI 53705, United States
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30
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Ezekian B, Schroder PM, Mulvihill MS, Barbas A, Collins B, Freischlag K, Yoon J, Yi JS, Smith F, Olaso D, Saccoccio FM, Permar S, Farris AB, Kwun J, Knechtle SJ. Pretransplant Desensitization with Costimulation Blockade and Proteasome Inhibitor Reduces DSA and Delays Antibody-Mediated Rejection in Highly Sensitized Nonhuman Primate Kidney Transplant Recipients. J Am Soc Nephrol 2019; 30:2399-2411. [PMID: 31658991 DOI: 10.1681/asn.2019030304] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/17/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with broad HLA sensitization have poor access to donor organs, high mortality while waiting for kidney transplant, and inferior graft survival. Although desensitization strategies permit transplantation via lowering of donor-specific antibodies, the B cell-response axis from germinal center activation to plasma cell differentiation remains intact. METHODS To investigate targeting the germinal center response and plasma cells as a desensitization strategy, we sensitized maximally MHC-mismatched rhesus pairs with two sequential skin transplants. We administered a proteasome inhibitor (carfilzomib) and costimulation blockade agent (belatacept) to six animals weekly for 1 month; four controls received no treatment. We analyzed blood, lymph node, bone marrow cells, and serum before desensitization, after desensitization, and after kidney transplantation. RESULTS The group receiving carfilzomib and belatacept exhibited significantly reduced levels of donor-specific antibodies (P=0.05) and bone marrow plasma cells (P=0.02) compared with controls, with a trend toward reduced lymph node T follicular helper cells (P=0.06). Compared with controls, carfilzomib- and belatacept-treated animals had significantly prolonged graft survival (P=0.02), and renal biopsy at 1 month showed significantly reduced antibody-mediated rejection scores (P=0.02). However, four of five animals with long-term graft survival showed gradual rebound of donor-specific antibodies and antibody-mediated rejection. CONCLUSIONS Desensitization using proteasome inhibition and costimulation blockade reduces bone marrow plasma cells, disorganizes germinal center responses, reduces donor-specific antibody levels, and prolongs allograft survival in highly sensitized nonhuman primates. Most animals experienced antibody-mediated rejection with humoral-response rebound, suggesting desensitization must be maintained after transplantation using ongoing suppression of the B cell response.
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Affiliation(s)
| | | | | | | | | | | | | | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina; and
| | | | - Danae Olaso
- Department of Surgery, Duke Transplant Center
| | - Frances M Saccoccio
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center,
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31
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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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32
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Gorbacheva V, Fan R, Beavers A, Fairchild RL, Baldwin WM, Valujskikh A. Anti-donor MHC Class II Alloantibody Induces Glomerular Injury in Mouse Renal Allografts Subjected to Prolonged Cold Ischemia. J Am Soc Nephrol 2019; 30:2413-2425. [PMID: 31597715 DOI: 10.1681/asn.2018111169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 09/07/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The mechanisms underlying the effects of prolonged cold-ischemia storage on kidney allografts are poorly understood. METHODS To investigate effects of cold ischemia on donor-reactive immune responses and graft pathology, we used a mouse kidney transplantation model that subjected MHC-mismatched BALB/c kidney allografts to cold-ischemia storage for 0.5 or 6 hours before transplant into C57BL/6 mice. RESULTS At day 14 post-transplant, recipients of allografts subjected to 6 versus 0.5 hours of cold-ischemia storage had increased levels of anti-MHC class II (but not class I) donor-specific antibodies, increased donor-reactive T cells, and a significantly higher proportion of transplant glomeruli infiltrated with macrophages. By day 60 post-transplant, allografts with a 6 hour cold-ischemia time developed extensive glomerular injury compared with moderate pathology in allografts with 0.5 hour of cold-ischemia time. Pathology was associated with increased serum levels of anti-class 2 but not anti-class 1 donor-specific antibodies. Recipient B cell depletion abrogated early macrophage recruitment, suggesting augmented donor-specific antibodies, rather than T cells, increase glomerular pathology after prolonged cold ischemia. Lymphocyte sequestration with sphingosine-1-phosphate receptor 1 antagonist FTY720 specifically inhibited anti-MHC class II antibody production and abrogated macrophage infiltration into glomeruli. Adoptive transfer of sera containing anti-donor MHC class II antibodies or mAbs against donor MHC class II restored early glomerular macrophage infiltration in FTY720-treated recipients. CONCLUSIONS Post-transplant inflammation augments generation of donor-specific antibodies against MHC class II antigens. Resulting MHC class II-reactive donor-specific antibodies are essential mediators of kidney allograft glomerular injury caused by prolonged cold ischemia.
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Affiliation(s)
- Victoria Gorbacheva
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ran Fan
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley Beavers
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - William M Baldwin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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33
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Miyake K, Okumi M, Kakuta Y, Unagami K, Furusawa M, Ishida H, Tanabe K. Prognostic value of C3d-fixing, preformed donor-specific antibodies in crossmatch-positive living kidney transplantation. Transpl Immunol 2019; 57:101230. [PMID: 31398461 DOI: 10.1016/j.trim.2019.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/26/2019] [Accepted: 08/04/2019] [Indexed: 11/28/2022]
Abstract
The occurrence of acute antibody-mediated rejection (ABMR) is higher in flow cytometric crossmatch (FCXM)-positive patients despite desensitization. Accumulating evidence suggests a correlation between the complement-binding ability of donor-specific antibodies (DSAs) and the risk of ABMR. Here, we investigated the correlation between complement C3d-fixing ability of preformed DSA and ABMR risk, the efficacy of a desensitization protocol for patients with C3d-fixing DSA, and the risk of ABMR in 21 DSA- and FCXM-positive patients. We retrospectively analyzed the C3d-fixing ability and mean fluorescence intensity (MFI) of preformed DSA before and after desensitization. Six patients had non-C3d-fixing DSA and 15 had C3d-fixing DSA. The presence of C3d-fixing DSA before desensitization was correlated with the incidence of acute ABMR within 1 year after transplantation (p = .04) and chronic ABMR (p = .03). Moreover, the MFI of preformed DSA differed between responder and non-responder C3d-fixing DSA after desensitization (p < .0001). The C3d-fixing ability of preformed DSA with low MFI disappeared after desensitization. These results indicate that measuring DSA C3d-fixing ability may identify patients with a high risk of ABMR, especially before desensitization. CLINICAL TRIAL NOTATION: UMIN Clinical Trials Registry (UMIN-CTR) number: UMIN000033449.
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Affiliation(s)
- Katsunori Miyake
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan; Department of Transplant Surgery, Shonan Kamakaura General Hospital, Kanagawa, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Miyuki Furusawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Bentall A, Smith BH, Gonzales MM, Bonner K, Park WD, Cornell LD, Dean PG, Schinstock CA, Borrows R, Lefaucheur C, Loupy A, Stegall MD. Modeling graft loss in patients with donor-specific antibody at baseline using the Birmingham-Mayo (BirMay) predictor: Implications for clinical trials. Am J Transplant 2019; 19:2274-2283. [PMID: 30768833 DOI: 10.1111/ajt.15312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/31/2018] [Accepted: 02/06/2019] [Indexed: 01/25/2023]
Abstract
Predicting which renal allografts will fail and the likely cause of failure is important in clinical trial design to either enrich patient populations to be or as surrogate efficacy endpoints for trials aimed at improving long-term graft survival. This study tests our previous Birmingham-Mayo model (termed the BirMay Predictor) developed in a low-risk kidney transplant population in order to predict the outcome of patients with donor specific alloantibody (DSA) at the time of transplantation and identify new factors to improve graft loss prediction in DSA+ patients. We wanted define ways to enrich the population for future therapeutic intervention trials. The discovery set included 147 patients from Mayo Cohort and the validation set included 111 patients from the Paris Cohort-all of whom had DSA at the time of transplantation. The BirMay predictor performed well predicting 5-year outcome well in DSA+ patients (Mayo C statistic = 0.784 and Paris C statistic = 0.860). Developing a new model did not improve on this performance. A high negative predictive value of greater than 90% in both cohorts excluded allografts not destined to fail within 5 years. We conclude that graft-survival models including histology predict graft loss well, both in DSA+ cohorts as well as DSA- patients.
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Affiliation(s)
- Andrew Bentall
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Byron H Smith
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Manuel Moreno Gonzales
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota.,Servicio de Cirugía General, Americana, Lima, Perú
| | - Keisha Bonner
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Walter D Park
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Patrick G Dean
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | | | - Richard Borrows
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Carmen Lefaucheur
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Department of Nephrology-Transplantation Necker Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France.,Paris Cardiovascular Research Centre - Biostatistics Unit University Paris Descartes, UMR-S970, Paris, France
| | - Mark D Stegall
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
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Kwun J, Matignon M, Manook M, Guendouz S, Audard V, Kheav D, Poullot E, Gautreau C, Ezekian B, Bodez D, Damy T, Faivre L, Menouch D, Yoon J, Park J, Belhadj K, Chen D, Bilewski AM, Yi JS, Collins B, Stegall M, Farris AB, Knechtle S, Grimbert P. Daratumumab in Sensitized Kidney Transplantation: Potentials and Limitations of Experimental and Clinical Use. J Am Soc Nephrol 2019; 30:1206-1219. [PMID: 31227636 DOI: 10.1681/asn.2018121254] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Donor-specific antibodies are associated with increased risk of antibody-mediated rejection and decreased allograft survival. Therefore, reducing the risk of these antibodies remains a clinical need in transplantation. Plasma cells are a logical target of therapy given their critical role in antibody production. METHODS To target plasma cells, we treated sensitized rhesus macaques with daratumumab (anti-CD38 mAb). Before transplant, we sensitized eight macaques with two sequential skin grafts from MHC-mismatched donors; four of them were also desensitized with daratumumab and plerixafor (anti-CXCR4). We also treated two patients with daratumumab in the context of transplant. RESULTS The animals treated with daratumumab had significantly reduced donor-specific antibody levels compared with untreated controls (57.9% versus 13% reduction; P<0.05) and prolonged renal graft survival (28.0 days versus 5.2 days; P<0.01). However, the reduction in donor-specific antibodies was not maintained because all recipients demonstrated rapid rebound of antibodies, with profound T cell-mediated rejection. In the two clinical patients, a combined heart and kidney transplant recipient with refractory antibody-mediated rejection and a highly sensitized heart transplant candidate, we also observed a significant decrease in class 1 and 2 donor-specific antibodies that led to clinical improvement of antibody-mediated rejection and to heart graft access. CONCLUSIONS Targeting CD38 with daratumumab significantly reduced anti-HLA antibodies and anti-HLA donor-specific antibodies in a nonhuman primate model and in two transplant clinical cases before and after transplant. This supports investigation of daratumumab as a potential therapeutic strategy; however, further research is needed regarding its use for both antibody-mediated rejection and desensitization.
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Affiliation(s)
| | - Marie Matignon
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | | | - Soulef Guendouz
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | - Vincent Audard
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - David Kheav
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Chantal Gautreau
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Diane Bodez
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | - Thibault Damy
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | | | - Dehbia Menouch
- Department of Apheresis, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France; and
| | | | | | - Karim Belhadj
- Haematology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Dongfeng Chen
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Alyssa M Bilewski
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | | | - Mark Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | | | - Philippe Grimbert
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France;
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36
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Schinstock CA, Bentall AJ, Smith BH, Cornell LD, Everly M, Gandhi MJ, Stegall MD. Long-term outcomes of eculizumab-treated positive crossmatch recipients: Allograft survival, histologic findings, and natural history of the donor-specific antibodies. Am J Transplant 2019; 19:1671-1683. [PMID: 30412654 PMCID: PMC6509017 DOI: 10.1111/ajt.15175] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/25/2023]
Abstract
We aimed to determine the long-term outcomes of eculizumab-treated, positive crossmatch (+XM) kidney transplant recipients compared with +XM and age-matched negative crossmatch (-XM) controls. We performed an observational retrospective study and examined allograft survival, histologic findings, long-term B-cell flow cytometric XM (BFXM), and allograft-loss-associated factors. The mean (SD) posttransplant follow-up was 6.3 (2.5) years in the eculizumab group; 7.6 (3.5), +XM control group; 7.9 (2.5), -XM control group. The overall and death-censored allograft survival rates were similar in +XM groups (P = .73, P = .48) but reduced compared with -XM control patients (P < .001, P < .001). In the eculizumab-treated group, 57.9% (11/19) of the allografts had chronic antibody-mediated rejection, but death-censored allograft survival was 76.6%, 5 years; 75.4%, 7 years. Baseline IgG3 positivity and BFXM ≥300 were associated with allograft loss. C1q positivity was also associated with allograft loss but did not reach statistical significance. Donor-specific antibodies appeared to decrease in eculizumab-treated patients. After excluding patients with posttransplant plasmapheresis, 42.3% (9/21) had negative BFXMs; 31.8% (7/22), completely negative single-antigen beads 1 year posttransplant. Eculizumab-treated +XM patients had reduced allograft survival compared with -XM controls but similar survival to +XM controls. BFXM and complement-activating donor-specific antibodies (by IgG3 and C1q testing) may be used for risk stratification in +XM transplantation.
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Affiliation(s)
- Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Andrew J. Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Byron H. Smith
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Lynn D. Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Manish J. Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mark D. Stegall
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA,Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
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37
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Green H, Nesher E, Aizner S, Israeli M, Klein T, Zakai H, Rahamimov R, Rozen‐Zvi B, Mor E. Long‐term results of desensitization protocol with and without rituximab in sensitized kidney transplant recipients. Clin Transplant 2019; 33:e13562. [DOI: 10.1111/ctr.13562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/27/2018] [Accepted: 03/14/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Hefziba Green
- Department of Medicine B Rabin Medical Center Petah‐Tikva Israel
- Nephrology and Hypertension Rabin Medical Center Petah‐Tikva Israel
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
| | - Eviatar Nesher
- Department of Transplantation Rabin Medical Center Petah‐Tikva Israel
| | - Sigal Aizner
- Department of Transplantation Rabin Medical Center Petah‐Tikva Israel
| | - Moshe Israeli
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
- Tissue Typing Laboratory Rabin Medical Center Petah‐Tikva Israel
| | - Tirza Klein
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
- Tissue Typing Laboratory Rabin Medical Center Petah‐Tikva Israel
| | - Hana Zakai
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
- Tissue Typing Laboratory Rabin Medical Center Petah‐Tikva Israel
| | - Ruth Rahamimov
- Nephrology and Hypertension Rabin Medical Center Petah‐Tikva Israel
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
| | - Benaya Rozen‐Zvi
- Nephrology and Hypertension Rabin Medical Center Petah‐Tikva Israel
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
| | - Eytan Mor
- Sackler School of Medicine Tel‐Aviv University Tel‐aviv Israel
- Transplant Center, Department of Surgery B Sheba Medical Center Ramat‐Gan Israel
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38
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Detection of Complement-binding Donor-specific Antibodies, Not IgG-antibody Strength Nor C4d Status, at Antibody-mediated Rejection Diagnosis Is an Independent Predictor of Kidney Graft Failure. Transplantation 2019; 102:1943-1954. [PMID: 29757900 DOI: 10.1097/tp.0000000000002265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) remains associated with reduced kidney graft survival and no clear prognostic marker is available. METHODS We investigated whether donor-specific antibodies (DSA) ability to bind C1q in comparison with AMR C4d status, both indirect signs of complement activation, improve risk stratification at time of AMR. Hence, among 467 patients in whom 1 or more graft biopsies were performed between 2008 and 2015, we included 56 with AMR according to Banff '15 criteria. Using concurrent sera, we prospectively identified DSA by single-antigen beads (IgG and C1q) assays. RESULTS Antibody-mediated rejection C4d (+) (n = 28) was associated with preformed DSA (P = 0.007), whereas DSA C1q (+) (n = 25) cases had stronger IgG-DSA (P < 0.001). At AMR, graft function was similar between DSA C1q groups, but in the first year after, it improved in DSA C1q (-), whereas a steady decline was observed in DSA C1q (+) cases, remaining significantly lower from 1 year until 4 years after AMR. DSA C1q (+) was significantly associated with reduced graft survival (P = 0.021), whereas AMR C4d (+) was not (P = 0.550). Importantly, a similar negative impact of DSA C1q (+) on graft survival was observed within AMR C4d (+) (P = 0.040) and (-) (P = 0.036), cases. In multivariable analysis, DSA C1q (+) (hazard ratio, 3.939, P = 0.005) and de novo DSA (hazard ratio, 4.409, P = 0.033) were independent predictors of graft failure, but stronger IgG-DSA was not. Similar results were obtained considering C1q-DSA and IgG-DSA strength as continuous variables. CONCLUSIONS C1q-DSA assessment at AMR can be a valuable tool in detecting patients with higher risk of graft failure.
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39
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Preformed Donor-specific Antibodies Against HLA Class II and Graft Outcomes in Deceased-donor Kidney Transplantation. Transplant Direct 2019; 5:e446. [PMID: 31165081 PMCID: PMC6511444 DOI: 10.1097/txd.0000000000000893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/22/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023] Open
Abstract
Background Many kidney transplant centers in the United States report both HLA class I and II antibodies detected by sensitive solid-phase assays (SPAs) to United Network for Organ Sharing as unacceptable antigens, significantly reducing the compatible donor organ pool and prolonging waiting time for highly sensitized patients. However, the clinical relevance of all detected donor-specific antibodies (DSAs) by SPA is not unequivocal, because fluorescence intensity does not always accurately reflect antibody pathogenicity. Our center does not exclude patients from transplantation based on DSA class II. Methods We performed a retrospective analysis in 179 deceased-donor kidney transplant recipients with solely DSA class II before transplant and patients without DSA and compared graft survival, rejection, and clinical outcomes. Patient survival was also compared with matched controls on the waiting list. Results Patients transplanted with DSA class II showed a clear survival benefit compared with matched patients who remained on dialysis or were waitlisted on dialysis/transplanted at 5 years (100%, 34%, and 73%, respectively). After a mean follow-up of 5.5 years, there was no significant difference in death-censored graft survival between transplanted patients without DSA and those with preformed DSA class II (adjusted HR 1.10; 95% confidence interval, 0.41-2.97), although the incidence of rejection was higher in recipients with DSA class II (adjusted HR 5.84; 95% confidence interval, 2.58-13.23; P < 0.001). Serum creatinine levels at 1, 3, and 5 years posttransplant did not differ between groups. No predictors of rejection were found, although patients who received basiliximab induction therapy had higher incidence of rejection (100%) compared with those who received antithymocyte globulin (52%). Conclusions We conclude that for highly sensitized patients, deceased-donor kidney transplantation with DSA class II yields a survival benefit over prolonged waiting time on dialysis. Instead of listing DSA class II as unacceptable antigens, an individual approach with further immunologic risk assessment is recommended.
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40
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Kwon H, Kim YH, Kim JY, Choi JY, Shin S, Jung JH, Park SK, Han DJ. The results of HLA-incompatible kidney transplantation according to pre-transplant crossmatch tests: Donor-specific antibody as a prominent predictor of acute rejection. Clin Transplant 2019; 33:e13533. [PMID: 30864255 DOI: 10.1111/ctr.13533] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Crossmatching (XM) between organ donors and recipients is correlated with clinical outcomes. This study evaluates the results of HLA-incompatible kidney transplant (HLA-i KT) according to pre-transplant XM modalities. METHODS This study included 731 consecutive patients. HLA-i KT was defined as a transplant under conditions of complement-dependent cytotoxicity (CDC) XM positivity, flow-cytometric XM (FCXM) positivity, and/or maximal donor-specific antibody (DSA) mean fluorescence intensity (MFI) ≥5000. RESULTS The incidence of antibody-mediated rejection (AMR) within 1 year after transplant was significantly higher in the HLA-i group than in the HLA compatible (HLA-c) group (15 vs 9 patients, 14.2% vs 1.4%; P < 0.01). Multivariate analysis indicated that a DSA MFI ≥5000 (odds ratio [OR] = 2.63; 95% confidence interval [CI], 1.00-6.98; P = 0.05) was significantly associated with acute rejection (AR), whereas CDC (OR = 2.09; 95% CI, 0.55-7.99; P = 0.28) and FCXM positivity (OR = 2.07; 95% CI, 0.73-5.87; P = 0.17) were not. Similarly, DSA MFI ≥ 5000 (OR = 4.14; P = 0.02) was the only significant factor affecting the risk of AMR. CONCLUSIONS Of the various XM tests, DSA MFI ≥5000 was the most prominent predictor of AR in patients undergoing HLA-i KT.
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Affiliation(s)
- Hyunwook Kwon
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jee Yeon Kim
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yoon Choi
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Division of Kidney & Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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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: 53] [Impact Index Per Article: 10.6] [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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Panzer SE, Joachim E, Parajuli S, Zhong W, Astor BC, Djamali A. Glomerular C3 Deposition Is an Independent Risk Factor for Allograft Failure in Kidney Transplant Recipients With Transplant Glomerulopathy. Kidney Int Rep 2019; 4:582-593. [PMID: 30993233 PMCID: PMC6451156 DOI: 10.1016/j.ekir.2019.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction Transplant glomerulopathy (TG) becomes increasingly prevalent in kidney transplant recipients over time, and it is strongly associated with allograft failure. To date, our prognostic biomarkers and understanding of the processes of immunologic injury in TG are limited. Methods This is a retrospective cohort analysis of kidney transplant recipients with TG (double contours of the glomerular basement membrane as defined by the chronic glomerulopathy score). Glomerular deposition of the complement protein C3 was determined, and its association with allograft survival was analyzed by Cox regression analysis. Results Of the 111 patients with TG, 72 (65%) had allograft failure, with a median follow-up time of 3 years from biopsy diagnosis of TG. C3-positive compared to C3-negative patients did not differ with respect to cause of end-stage renal disease, induction or maintenance immunosuppression, or sensitization. A greater proportion of patients with glomerular C3 deposition developed allograft failure compared to those with no C3 deposition (78% vs. 55%, P = 0.01). C3 deposition was independently associated with allograft failure in multivariate analyses (adjusted hazard ratio [HR] = 1.38, 95% confidence interval [CI] = 1.13−1.69, P = 0.002). There was no association between C4d or C1q deposition and allograft failure. Chronicity score was also associated with allograft failure in multivariate analysis (adjusted HR 1.26, 95% CI 1.12-1.41, P = 0.0001). Conclusion In this cohort of patients with TG, glomerular C3 deposition was independently associated with a higher risk of allograft failure. These findings identify glomerular C3 as a novel prognostic indicator in patients with TG.
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Affiliation(s)
- Sarah E Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Emily Joachim
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, Wisconsin, USA
| | - Brad C Astor
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, USA
| | - Arjang Djamali
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, Wisconsin, USA.,Department of Surgery, Division of Transplant Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Hanaoka K, Maeda M, Tsujimoto S, Oshima S, Fukahori H, Nakamura K, Noto T, Higashi Y, Hirose J, Takakura S, Morokata T. Benefits of a loading dose of tacrolimus on graft survival of kidney transplants in nonhuman primates. Transpl Immunol 2019. [DOI: 10.1016/j.trim.2018.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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44
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Iwami D, Miura M, Chiba Y, Ota M, Matsumoto T, Hotta K, Sasaki H, Hirose T, Harada H, Shinohara N. Optimal Settings for Double Filtration Plasmapheresis With Targeted Removal Rate of Preexisting Antibody in Antibody-Incompatible Kidney Transplant. Transplant Proc 2018; 50:3478-3482. [DOI: 10.1016/j.transproceed.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/23/2018] [Indexed: 11/24/2022]
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45
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Buttigieg J, Ali H, Sharma A, Halawa A. Positive Luminex and negative flow cytometry in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2018; 34:1950-1960. [DOI: 10.1093/ndt/gfy349] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/10/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
The presence of pre-formed donor-specific antibodies (DSAs) in kidney transplantation is associated with worse overall outcomes compared with DSA-negative transplantation. A positive complement-dependant cytotoxic crossmatch presents a high immunological risk, while a negative flow cytometry crossmatch is at the lower end of the risk spectrum. Yet, the presence of low-level DSA detected by Luminex alone, that is, positive Luminex and negative flow (PLNF) cytometry crossmatch lacks robust scientific exploration. In this systematic review and pooled analysis, we investigate the glomerular filtration rate, acute rejection (AR), graft survival and patient survival of PLNF transplants compared with DSA-negative transplants. Our analysis identified seven retrospective studies consisting of 429 PLNF transplants and 10 677 DSA-negative transplants. Pooled analysis identified no significant difference in the incidence of AR at 1 year [relative risk (RR) = 1.35, 95% confidence interval (CI) 0.90–2.02, Z = 1.46, P = 0.14, I2 = 0%], graft failure at 1 year (RR = 1.66, 95% CI 0.94–2.94, Z = 1.75, P = 0.08, I2 = 23%), graft failure at 5 years (RR = 1.29, 95% CI 0.90–1.87, Z = 1.38, P = 0.17, I2 = 0%), patient mortality at 1 year (RR = 0.89, 95% CI 0.31–2.56, Z = 0.22, P = 0.82, I2 = 0%) and patient mortality at 5 years (RR = 1.76, 95% CI 0.48–6.48, Z = 0.85, P = 0.39, I2 = 61%). Pooled analysis of graft function was not possible due to insufficient data. Current evidence suggests that low-level DSA detected by Luminex alone does not pose significant risk at least in the short–medium term. Considering the shortage of kidney transplants and the ever-increasing waiting time, the avoidance of PLNF transplants may be unwarranted especially in patients who have been enlisted for a long time.
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Affiliation(s)
- Jesmar Buttigieg
- Renal Division, Department of Medicine, Mater Dei Hospital, Malta
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
| | - Hatem Ali
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Department of Renal Medicine, Royal Wolverhampton Hospitals NHS Foundation Trust, Wolverhampton, UK
| | - Ajay Sharma
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Renal Transplant Unit, Royal Liverpool University Hospital, NHS Trust, Liverpool, UK
| | - Ahmed Halawa
- Faculty of Health and Life Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
- Renal Transplant Unit, Sheffield Teaching Hospitals, NHS Trust, Sheffield, UK
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46
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Everly MJ, Roberts M, Townsend R, Bray RA, Gebel HM. Comparison of de novo IgM and IgG anti-HLA DSAs between belatacept- and calcineurin-treated patients: An analysis of the BENEFIT and BENEFIT-EXT trial cohorts. Am J Transplant 2018; 18:2305-2313. [PMID: 29767445 DOI: 10.1111/ajt.14939] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 02/06/2023]
Abstract
Preventing conversion of donor-specific anti-HLA antibodies (DSAs) from an IgM-to-IgG could a way to prevent chronic rejection. We evaluated whether belatacept-treated patients (belatacept less-intensive [LI] or more-intensive [MI] regimens) have a lower rate of conversion than do cyclosporine A (CsA)-treated patients. We included 330 HLA-mismatched patients from 2 phase 3 trials with either (a) complete donor/recipient HLA-A, -B, -DR, and -DQ loci typing or (b) incomplete HLA typing with IgG DSAs detected pretransplant or posttransplant. IgM and IgG DSAs were tested with single antigen beads at 0, 6, 12, 24, and 36 months posttransplant. The overall (preexisting or de novo) rates of IgM- and IgG-positive DSAs were 29% and 34%, respectively. The pretransplant IgM and IgG DSA-positive frequencies were similar between treatment groups. The IgG-positive dnDSA rate was significantly higher in the CsA-treated group (34%) compared with the belatacept-LI (8%) and belatacept-MI (11%) (P < .001) groups. In IgM-positive dnDSA patients, the IgG-positive dnDSA rate of conversion was 2.8 times higher in the CsA group than in the combined belatacept groups (P = .006). However, the observed association between belatacept treatment and more limited conversion of IgM-to-IgG dnDSAs was based on a limited number of patients and requires further validation.
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Affiliation(s)
| | - Mustimbo Roberts
- Immunology Biomarker Group, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Robert Townsend
- Immunology Biomarker Group, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Robert A Bray
- Emory University School of Medicine, Pathology& Laboratory Medicine, Atlanta, GA, USA
| | - Howard M Gebel
- Emory University School of Medicine, Pathology& Laboratory Medicine, Atlanta, GA, USA
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47
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Anti-HLA Donor-Specific IgG Subclasses and C1q-binding Evolution in Posttransplant Monitoring. Transplant Direct 2018; 4:e385. [PMID: 30234154 PMCID: PMC6133409 DOI: 10.1097/txd.0000000000000823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/13/2018] [Indexed: 01/17/2023] Open
Abstract
Background The identification of low-level antibodies by single-antigen bead methodology has brought advancements to risk evaluation of kidney transplant recipients. However, the use of mean fluorescence intensity (MFI) to quantify antibodies and to guide therapy is not enough. Notably, immunoglobulin G (IgG) subclass switching is hypothesized to follow a programmed sequence after an emergency signal from the germinal center. In transplantation this process is not clear yet. In the present study, we sequentially evaluate anti-HLA donor specific antibody (DSA) subclasses, their profile changes, and C1q-binding ability and the influence of those characteristics on antibody mediated rejection (AMR) occurrence and allograft function. Methods A total of 30 DSA-positive patients were tested for IgG subclass content and C1q-binding in sequential serum samples. Results Twenty-one patients were DSA-positive before transplant; patients sensitized only by transfusion or pregnancies had IgG1 and/or IgG3, and patients sensitized by both transfusion and pregnancies or previous transplant showed a broader range of IgG subclasses. C1q binding was detected in high MFI made up of IgG1 or multiple IgG subclasses. Only 4 patients were positive for C1q posttransplantation and 3 of these showed an increase in MFI, changes in subclasses patterns, AMR, and allograft dysfunction. Conclusions Posttransplant evaluation of DSA subclasses and the ability to bind C1q may be informative for both AMR occurrence and allograft dysfunction. Monitoring these events may help to better define risk and interventional time points.
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McDonald M, Veale J. The Onus for Altruism in Kidney Transplantation. Eur Urol Focus 2018; 4:206-207. [PMID: 30057344 DOI: 10.1016/j.euf.2018.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022]
Abstract
Ideally, all programs performing living donor kidney transplantation should educate patients on all contemporary exchange options. They should be strongly encouraged to participate in multicenter exchange, or at least refer those with a willing yet incompatible donor to a center that does, and to preferentially allocate altruistic donor kidneys towards chain initiation.
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Affiliation(s)
- Michelle McDonald
- Division of Renal Transplantation, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jefferey Veale
- Division of Renal Transplantation, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Banham GD, Flint SM, Torpey N, Lyons PA, Shanahan DN, Gibson A, Watson CJE, O'Sullivan AM, Chadwick JA, Foster KE, Jones RB, Devey LR, Richards A, Erwig LP, Savage CO, Smith KGC, Henderson RB, Clatworthy MR. Belimumab in kidney transplantation: an experimental medicine, randomised, placebo-controlled phase 2 trial. Lancet 2018; 391:2619-2630. [PMID: 29910042 DOI: 10.1016/s0140-6736(18)30984-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND B cells produce alloantibodies and activate alloreactive T cells, negatively affecting kidney transplant survival. By contrast, regulatory B cells are associated with transplant tolerance. Immunotherapies are needed that inhibit B-cell effector function, including antibody secretion, while sparing regulators and minimising infection risk. B lymphocyte stimulator (BLyS) is a cytokine that promotes B-cell activation and has not previously been targeted in kidney transplant recipients. We aimed to determine the safety and activity of an anti-BLyS antibody, belimumab, in addition to standard-of-care immunosuppression in adult kidney transplant recipients. We used an experimental medicine study design with multiple secondary and exploratory endpoints to gain further insight into the effect of belimumab on the generation of de-novo IgG and on the regulatory B-cell compartment. METHODS We undertook a double-blind, randomised, placebo-controlled phase 2 trial of belimumab, in addition to standard-of-care immunosuppression (basiliximab, mycophenolate mofetil, tacrolimus, and prednisolone) at two centres, Addenbrooke's Hospital, Cambridge, UK, and Guy's and St Thomas' Hospital, London, UK. Participants were eligible if they were aged 18-75 years and receiving a kidney transplant and were planned to receive standard-of-care immunosuppression. Participants were randomly assigned (1:1) to receive either intravenous belimumab 10 mg per kg bodyweight or placebo, given at day 0, 14, and 28, and then every 4 weeks for a total of seven infusions. The co-primary endpoints were safety and change in the concentration of naive B cells from baseline to week 24, both of which were analysed in all patients who received a transplant and at least one dose of drug or placebo (the modified intention-to-treat [mITT] population). This trial has been completed and is registered with ClinicalTrials.gov, NCT01536379, and EudraCT, 2011-006215-56. FINDINGS Between Sept 13, 2013, and Feb 8, 2015, of 303 patients assessed for eligibility, 28 kidney transplant recipients were randomly assigned to receive belimumab (n=14) or placebo (n=14). 25 patients (12 [86%] patients assigned to the belimumab group and 13 [93%] patients assigned to the placebo group) received a transplant and were included in the mITT population. We observed similar proportions of adverse events in the belimumab and placebo groups, including serious infections (one [8%] of 12 in the belimumab group and five [38%] of 13 in the placebo group during the 6-month on-treatment phase; and none in the belimumab group and two [15%] in the placebo group during the 6-month follow-up). In the on-treatment phase, one patient in the placebo group died because of fatal myocardial infarction and acute cardiac failure. The co-primary endpoint of a reduction in naive B cells from baseline to week 24 was not met. Treatment with belimumab did not significantly reduce the number of naive B cells from baseline to week 24 (adjusted mean difference between the belimumab and placebo treatment groups -34·4 cells per μL, 95% CI -109·5 to 40·7). INTERPRETATION Belimumab might be a useful adjunct to standard-of-care immunosuppression in renal transplantation, with no major increased risk of infection and potential beneficial effects on humoral alloimmunity. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Gemma D Banham
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Shaun M Flint
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Nicholas Torpey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Don N Shanahan
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Adele Gibson
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ann-Marie O'Sullivan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Joseph A Chadwick
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Katie E Foster
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Luke R Devey
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Anna Richards
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Lars-Peter Erwig
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Caroline O Savage
- ImmunoInflammation Therapy Area Unit, GlaxoSmithKline, Stevenage, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Menna R Clatworthy
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.
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50
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Current challenges and opportunities in the management of antibody-mediated rejection in lung transplantation. Curr Opin Organ Transplant 2018; 23:308-315. [DOI: 10.1097/mot.0000000000000537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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