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Kizilbash S, Claes D, Ashoor I, Chen A, Jandeska S, Matar RB, Misurac J, Sherbotie J, Twombley K, Verghese P. Bortezomib in the treatment of antibody-mediated rejection in pediatric kidney transplant recipients: A multicenter Midwest Pediatric Nephrology Consortium study. Pediatr Transplant 2017; 21. [PMID: 28092129 DOI: 10.1111/petr.12873] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/18/2023]
Abstract
Antibody-mediated rejection leads to allograft loss after kidney transplantation. Bortezomib has been used in adults for the reversal of antibody-mediated rejection; however, pediatric data are limited. This retrospective study was conducted in collaboration with the Midwest Pediatric Nephrology Consortium. Pediatric kidney transplant recipients who received bortezomib for biopsy-proven antibody-mediated rejection between 2008 and 2015 were included. The objective was to characterize the use of bortezomib in pediatric kidney transplant recipients. Thirty-three patients received bortezomib for antibody-mediated rejection at nine pediatric kidney transplant centers. Ninety percent of patients received intravenous immunoglobulin, 78% received plasmapheresis, and 78% received rituximab. After a median follow-up of 15 months, 65% of patients had a functioning graft. The estimated glomerular filtration rate improved or stabilized in 61% and 36% of patients at 3 and 12 months post-bortezomib, respectively. The estimated glomerular filtration rate at diagnosis significantly predicted estimated glomerular filtration rate at 12 months after adjusting for chronic histologic changes (P .001). Fifty-six percent of patients showed an at least 25% reduction in the mean fluorescence intensity of the immune-dominant donor-specific antibody, 1-3 months after the first dose of bortezomib. Non-life-threatening side effects were documented in 21 of 33 patients. Pediatric kidney transplant recipients tolerated bortezomib without life-threatening side effects. Bortezomib may stabilize estimated glomerular filtration rate for 3-6 months in pediatric kidney transplant recipients with antibody-mediated rejection.
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Affiliation(s)
| | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Isa Ashoor
- Children's Hospital New Orleans, New Orleans, LA, USA
| | - Ashton Chen
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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Management of sensitized pediatric patients prior to renal transplantation. Pediatr Nephrol 2016; 31:1691-8. [PMID: 26801944 DOI: 10.1007/s00467-015-3295-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 12/01/2015] [Accepted: 12/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Data on renal allograft outcome in sensitized children are scarce. We report the clinical courses of four children who received desensitization therapy prior to renal transplantation in our institution. METHODS Between 2009 and 2011, four pediatric patients with stage 5 chronic kidney disease received desensitization therapy due to: (1) positive donor-specific antibodies (DSA) and/or crossmatches with potential living donors, (2) more than three positive crossmatches with deceased donors or (3) high calculated panel-reactive antibody of >80 %. Desensitization with rituximab, intravenous immunoglobulin and bortezomib was performed in all patients. Induction therapy included combinations of plasmapheresis and/or alemtuzumab or anti-thymocyte globulin. Standard post-transplant medications included tacrolimus, mycophenolate mofetil and prednisolone. RESULTS Post-transplant screening revealed DSA in three patients. Biopsy showed no evidence of rejection at 1 month in two patients, one of whom developed chronic active antibody-mediated rejection 4.5 years later. One patient developed borderline acute cellular rejection at 1 month, but the serum creatinine level was stable and DSA disappeared without treatment 1 month later, with stable long-term allograft function at 3 years. Estimated or measured glomerular filtration rate of the patients ranged between 30 and 75 ml/min/1.73 m(2) after 1 to 4.5 years. CONCLUSIONS The four sensitized patients reported here who received desensitization therapy had successful renal transplants with a low risk of immediate post-transplant rejection. Overall, long-term allograft functions and complications from immunosuppression were encouraging.
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Lee CY, Lin WC, Wu MS, Yang CY, Yeh CC, Tsai MK. Repeated cycles of high-dose intravenous immunoglobulin and plasmapheresis for treatment of late antibody-mediated rejection of renal transplants. J Formos Med Assoc 2016; 115:845-852. [PMID: 27542515 DOI: 10.1016/j.jfma.2016.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/PURPOSE Intravenous immunoglobulin (IVIG) plays a central role in the treatment of antibody-mediated rejection (AMR) of renal allografts, but the treatment outcomes for late AMR (>6 months after transplantation) are poor. METHODS We performed a retrospective study to assess the response patterns of IVIG-based (2 g/kg) desensitization for late AMR. Patients who received desensitization after the pathological diagnosis of late AMR positive for complement component C4d were grouped as the Desensitized Group and compared to a historical Control Group with complement component C4d positivity in retrospective stainings. RESULTS The 10-year graft survival of the Desensitized Group (73.9%, n = 35) was significantly better than that of the historical Control Group (35.0%, n = 40) without desensitization. In the Desensitized Group, a subgroup of patients (D2 Subgroup, n = 11), who responded to desensitization initially but deteriorated later, was identified to benefit from repeated cycles of desensitization at 31.1 ± 20.9 months. Patients receiving only one cycle of desensitization were further grouped into D1-good (n = 10) and D1-poor (n = 14) based on their long-term renal function. The D2 Subgroup patients did not exhibit significant improvements in renal function compared to the D1-poor patients, until 30 months after IVIG-based desensitization, suggesting desensitization therapy has a working window of approximately 24 months. CONCLUSION Repeated cycles of IVIG-based desensitization help stabilize long-term renal function in patients with persistent AMR.
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Affiliation(s)
- Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Ming-Shiou Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Chi-Chuan Yeh
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Meng-Kun Tsai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan.
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Pearl MH, Nayak AB, Ettenger RB, Puliyanda D, Palma Diaz MF, Zhang Q, Reed EF, Tsai EW. Bortezomib may stabilize pediatric renal transplant recipients with antibody-mediated rejection. Pediatr Nephrol 2016; 31:1341-8. [PMID: 27048228 PMCID: PMC5590841 DOI: 10.1007/s00467-016-3319-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Current therapeutic strategies to effectively treat antibody-mediated rejection (AMR) are insufficient. Thus, we aimed to determine the benefit of a therapeutic protocol using bortezomib for refractory C4d + AMR in pediatric kidney transplant patients. METHODS We examined seven patients with treatment-refractory C4d + AMR. Immunosuppression included antithymocyte globulin or anti-CD25 monoclonal antibody for induction therapy with maintenance corticosteroids, calcineurin inhibitor, and anti-metabolite. Estimated glomerular filtration rate (eGFR) calculated by the Schwartz equation, biopsy findings assessed by 2013 Banff criteria, and human leukocyte antigen (HLA) donor-specific antibodies (DSA) performed using the Luminex single antigen bead assay were monitored pre- and post- bortezomib therapy. RESULTS Seven patients (86 % male, 86 % with ≥6/8 HLA mismatch, and 14 % with pre-formed DSA) age 5 to 19 (median 15) years developed refractory C4d + AMR between 1 and 145 (median 65) months post-transplantation. All patients tolerated bortezomib. One patient had allograft loss. Of the six patients with surviving grafts (86 %), mean pre-bortezomib eGFR was 42 ml/min/1.73 m(2) and the mean 1 year post-bortezomib eGFR was 53 ml/min/1.73 m(2). Five of seven (71 %) had improvement of histological findings of AMR, C4d staining, and/or acute cellular rejection. Reduction in HLA DSAs was more effective for class I than class II. CONCLUSIONS Bortezomib appears safe and may correlate with stabilization of eGFR in pediatric kidney transplant patients with refractory C4d + AMR.
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Affiliation(s)
- Meghan H Pearl
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA.
| | - Anjali B Nayak
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Robert B Ettenger
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Dechu Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Miguel Fernando Palma Diaz
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Eileen W Tsai
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
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A Phase I/II Trial of the Interleukin-6 Receptor–Specific Humanized Monoclonal (Tocilizumab) + Intravenous Immunoglobulin in Difficult to Desensitize Patients. Transplantation 2015; 99:2356-63. [DOI: 10.1097/tp.0000000000000741] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Burton SA, Amir N, Asbury A, Lange A, Hardinger KL. Treatment of antibody-mediated rejection in renal transplant patients: a clinical practice survey. Clin Transplant 2015; 29:118-23. [DOI: 10.1111/ctr.12491] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2014] [Indexed: 01/27/2023]
Affiliation(s)
- Stephanie A. Burton
- Department of Pharmacy; Saint Luke's Hospital of Kansas City; Kansas City MO USA
| | - Naaseha Amir
- Department of Pharmacy Practice and Administration; School of Pharmacy; University of Missouri-Kansas City; Kansas City MO USA
| | - Alaina Asbury
- Department of Pharmacy Practice and Administration; School of Pharmacy; University of Missouri-Kansas City; Kansas City MO USA
| | - Alex Lange
- Department of Pharmacy Practice and Administration; School of Pharmacy; University of Missouri-Kansas City; Kansas City MO USA
| | - Karen L. Hardinger
- Department of Pharmacy Practice and Administration; School of Pharmacy; University of Missouri-Kansas City; Kansas City MO USA
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Nguyen S, Gallay B, Butani L. Efficacy of bortezomib for reducing donor-specific antibodies in children and adolescents on a steroid minimization regimen. Pediatr Transplant 2014; 18:463-8. [PMID: 24814755 DOI: 10.1111/petr.12274] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2014] [Indexed: 01/22/2023]
Abstract
AMR is increasingly being recognized as an important cause of renal allograft injury, contributing to significant morbidity and graft loss. There are few controlled trials and no well-established treatment guidelines for AMR in renal transplant recipients. We retrospectively reviewed the outcome of four pediatric renal transplant recipients on a steroid minimization immunosuppression protocol treated with bortezomib for elevated DSA and acute AMR from 2012 to 2013. All patients received four doses of bortezomib 1.3 mg/m2 given on days one, four, eight, and 11. All patients also received other treatments prior to bortezomib, which may have included rituximab, methylprednisolone, plasmapheresis, and/or IVIg. While bortezomib in addition to other therapies significantly decreased DSA titers, DSA remained very elevated months after treatment. All four patients had immediate improvement or stabilization of renal function but one eventually lost her graft. There were no adverse events related to bortezomib six months after treatment.
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Affiliation(s)
- Stephanie Nguyen
- Department of Pediatrics, Section of Nephrology, University of California, Davis, Sacramento, CA, USA
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Claes DJ, Yin H, Goebel J. Protective immunity and use of bortezomib for antibody-mediated rejection in a pediatric kidney transplant recipient. Pediatr Transplant 2014; 18:E100-5. [PMID: 24725066 DOI: 10.1111/petr.12256] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 12/27/2022]
Abstract
Standard treatments for AMR-rituximab, intravenous immunoglobulin, and/or plasmapheresis-aim to suppress the production and modulate the effect of donor-specific antibodies and remove them, respectively. Proteasome inhibitors such as bortezomib are potent therapeutic agents that target plasma cells more effectively than rituximab to reduce measurable donor-specific antibody production. Little is known in adults, and no data exist in children about effects of proteasome inhibition to treat AMR on protective antibody titers. We present a pediatric renal transplant recipient who received bortezomib for relatively early AMR and whose antibody titers to measles and tetanus were tracked. The AMR was treated successfully, and we noted no clinical decrease in the overall level of protective immunity from pretransplant baseline levels at almost one yr after AMR treatment cessation. Larger studies will elucidate more clearly how proteasome inhibition to treat AMR affects protective immunity in pediatric transplant recipients.
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Affiliation(s)
- Donna J Claes
- Department of Pediatric Nephrology & Hypertension, Cincinnati Children's Hospital & Medical Center, Cincinnati, OH, USA
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