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Fulchiero R, Galea L, Hewlett J, Savant JD, Lopez S, Amaral S, Viteri B. Bortezomib for antibody-mediated rejection of kidney transplant in youth: Associations with donor-specific antibody. Pediatr Transplant 2024; 28:e14774. [PMID: 38808699 PMCID: PMC11189613 DOI: 10.1111/petr.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Antibody-mediated rejection is one of the most significant risk factors for allograft dysfunction and failure in children and adolescents with kidney transplants, yet optimal treatment remains unidentified. To date, there are mixed findings regarding the use of Bortezomib, a plasma cell apoptosis inducer, as an adjunct therapy in the treatment of antibody-mediated rejection. METHODS In a retrospective single center study, we reviewed the efficacy and tolerability of bortezomib as adjunct therapy for treatment-refractory antibody-mediated rejection. RESULTS Six patients with a median age of 14.6 years (range 6.9-20.1 years) received bortezomib at a mean of 71 months (range 15-83 months) post-kidney transplant. Four patients experienced decline in estimated glomerular filtration rate (eGFR) from 4% to 42%. One patient started bortezomib while on hemodialysis and did not recover graft function, and another patient progressed to hemodialysis 6 months after receiving bortezomib. Although DSA did not completely resolve, there was a statistically significant decline in DSA MFI pre and 12-months post-BZ (p = .012, paired t-test) for the subjects who were not on dialysis at the time of bortezomib. Chronic Allograft Damage Index (CADI) score of ≥3 was seen in all six subjects at their biopsy prior to therapy. No adverse effects were reported. CONCLUSIONS Bortezomib was well tolerated and resulted in improvements in MFI of DSA among four pediatric subjects without allograft failure, although no effects were observed on eGFR trajectory. Further studies are needed to clarify whether earlier intervention with bortezomib could prevent renal failure progression.
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Affiliation(s)
- Rosanna Fulchiero
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Nephrology Division, Inova Children's Hospital, Falls Church, Virginia, USA
| | - Lauren Galea
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Hewlett
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan D Savant
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sonya Lopez
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sandra Amaral
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernarda Viteri
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Ashoor IF, Engen RM, Puliyanda D, Hayde N, Peterson CG, Zahr RS, Solomon S, Kallash M, Garro R, Jain A, Harshman LA, McEwen ST, Mansuri A, Gregoski MJ, Twombley KE. Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant 2024; 28:e14734. [PMID: 38602171 PMCID: PMC11013566 DOI: 10.1111/petr.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes. METHODS Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined. RESULTS We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome. CONCLUSIONS In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.
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Affiliation(s)
- Isa F Ashoor
- Department of Pediatrics, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Dechu Puliyanda
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicole Hayde
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Caitlin G Peterson
- Division of Pediatric Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Rima S Zahr
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Sonia Solomon
- Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Boston Children's Health Physicians, Valhalla, New York, USA
| | - Mahmoud Kallash
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Amrish Jain
- Department of Pediatrics, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Scott T McEwen
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Asifhusen Mansuri
- Department of Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine E Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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3
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Laroche C, Marks SD. Carfilzomib: Looking for 'The Holy Grail' to treat antibody-mediated rejection. Pediatr Transplant 2023; 27:e14533. [PMID: 37132152 DOI: 10.1111/petr.14533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Affiliation(s)
- Camille Laroche
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
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4
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Chung EYM, Wang YM, Keung K, Hu M, McCarthy H, Wong G, Kairaitis L, Bose B, Harris DCH, Alexander SI. Membranous nephropathy: Clearer pathology and mechanisms identify potential strategies for treatment. Front Immunol 2022; 13:1036249. [PMID: 36405681 PMCID: PMC9667740 DOI: 10.3389/fimmu.2022.1036249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
Primary membranous nephropathy (PMN) is one of the common causes of adult-onset nephrotic syndrome and is characterized by autoantibodies against podocyte antigens causing in situ immune complex deposition. Much of our understanding of the disease mechanisms underpinning this kidney-limited autoimmune disease originally came from studies of Heymann nephritis, a rat model of PMN, where autoantibodies against megalin produced a similar disease phenotype though megalin is not implicated in human disease. In PMN, the major target antigen was identified to be M-type phospholipase A2 receptor 1 (PLA2R) in 2009. Further utilization of mass spectrometry on immunoprecipitated glomerular extracts and laser micro dissected glomeruli has allowed the rapid discovery of other antigens (thrombospondin type-1 domain-containing protein 7A, neural epidermal growth factor-like 1 protein, semaphorin 3B, protocadherin 7, high temperature requirement A serine peptidase 1, netrin G1) targeted by autoantibodies in PMN. Despite these major advances in our understanding of the pathophysiology of PMN, treatments remain non-specific, often ineffective, or toxic. In this review, we summarize our current understanding of the immune mechanisms driving PMN from animal models and clinical studies, and the implications on the development of future targeted therapeutic strategies.
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Affiliation(s)
- Edmund Y. M. Chung
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Yuan M. Wang
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Karen Keung
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Min Hu
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - Hugh McCarthy
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Lukas Kairaitis
- Department of Nephrology, Blacktown Hospital, Blacktown, NSW, Australia
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Kingswood, NSW, Australia
| | - David C. H. Harris
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen I. Alexander
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
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5
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Charnaya O, Levy Erez D, Amaral S, Monos DS. Pediatric Kidney Transplantation-Can We Do Better? The Promise and Limitations of Epitope/Eplet Matching. Front Pediatr 2022; 10:893002. [PMID: 35722502 PMCID: PMC9204054 DOI: 10.3389/fped.2022.893002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Kidney transplant is the optimal treatment for end-stage kidney disease as it offers significant survival and quality of life advantages over dialysis. While recent advances have significantly improved early graft outcomes, long-term overall graft survival has remained largely unchanged for the last 20 years. Due to the young age at which children receive their first transplant, most children will require multiple transplants during their lifetime. Each subsequent transplant becomes more difficult because of the development of de novo donor specific HLA antibodies (dnDSA), thereby limiting the donor pool and increasing mortality and morbidity due to longer time on dialysis awaiting re-transplantation. Secondary prevention of dnDSA through increased post-transplant immunosuppression in children is constrained by a significant risk for viral and oncologic complications. There are currently no FDA-approved therapies that can meaningfully reduce dnDSA burden or improve long-term allograft outcomes. Therefore, primary prevention strategies aimed at reducing the risk of dnDSA formation would allow for the best possible long-term allograft outcomes without the adverse complications associated with over-immunosuppression. Epitope matching, which provides a more nuanced assessment of immunological compatibility between donor and recipient, offers the potential for improved donor selection. Although epitope matching is promising, it has not yet been readily applied in the clinical setting. Our review will describe current strengths and limitations of epitope matching software, the evidence for and against improved outcomes with epitope matching, discussion of eplet load vs. variable immunogenicity, and conclude with a discussion of the delicate balance of improving matching without disadvantaging certain populations.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniella Levy Erez
- Schneider Children's Medical Center, Institute of Pediatric Nephrology, Petah Tikvah, Israel
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sandra Amaral
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Dimitrios S. Monos
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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6
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Pearl M, Weng PL, Chen L, Dokras A, Pizzo H, Garrison J, Butler C, Zhang J, Reed EF, Kim IK, Choi J, Haas M, Zhang X, Vo A, Chambers ET, Ettenger R, Jordan S, Puliyanda D. Long term tolerability and clinical outcomes associated with tocilizumab in the treatment of refractory antibody mediated rejection (AMR) in pediatric renal transplant recipients. Clin Transplant 2022; 36:e14734. [PMID: 35657013 PMCID: PMC9378624 DOI: 10.1111/ctr.14734] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment options for antibody-mediated rejection (AMR) are limited. Recent studies have shown that inhibition of interleukin-6 (IL-6)/interleukin-6 receptor (IL-6R) signaling can reduce inflammation and slow AMR progression. METHODS We report our experience using monthly tocilizumab (anti-IL6R) in 25 pediatric renal transplant recipients with AMR, refractory to IVIg/Rituximab. From January 2013 to June 2019, a median (IQR) of 12 (6.019.0) doses of tocilizumab were given per patient. Serial assessments of renal function, biopsy findings, and HLA DSA (by immunodominant HLA DSA [iDSA] and relative intensity score [RIS]) were performed. RESULTS Median (IQR) time from transplant to AMR was 41.4 (24.367.7) months, and time from AMR to first tocilizumab was 10.6 (8.317.6) months. At median (IQR) follow up of 15.8 (8.435.7) months post-tocilizumab initiation, renal function was stable except for 1 allograft loss. There was no significant decrease in iDSA or RIS. Follow up biopsies showed reduction in peritubular capillaritis (p = .015) and C4d scoring (p = .009). The most frequent adverse events were cytopenias. CONCLUSIONS Tocilizumab in pediatric patients with refractory AMR was well tolerated and appeared to stabilize renal function. The utility of tocilizumab in the treatment of AMR in this population should be further explored.
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Affiliation(s)
- Meghan Pearl
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Patricia L Weng
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Lucia Chen
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Aditi Dokras
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Helen Pizzo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jonathan Garrison
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carrie Butler
- Department of Pathology, University of California Los Angeles, Los Angeles, California, USA
| | - Jennifer Zhang
- Department of Pathology, University of California Los Angeles, Los Angeles, California, USA
| | - Elaine F Reed
- Department of Pathology, University of California Los Angeles, Los Angeles, California, USA
| | - Irene K Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mark Haas
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaohai Zhang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eileen Tsai Chambers
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert Ettenger
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dechu Puliyanda
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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7
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Bertacchi M, Parvex P, Villard J. Antibody-mediated rejection after kidney transplantation in children; therapy challenges and future potential treatments. Clin Transplant 2022; 36:e14608. [PMID: 35137982 PMCID: PMC9286805 DOI: 10.1111/ctr.14608] [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: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
Antibody‐mediated rejection (AMR) remains one of the most critical problems in renal transplantation, with a significant impact on patient and graft survival. In the United States, no treatment has received FDA approval jet. Studies about treatments of AMR remain controversial, limited by the absence of a gold standard and the difficulty in creating large, multi‐center studies. These limitations emerge even more in pediatric transplantation because of the limited number of pediatric studies and the occasional use of some therapies with unknown and poorly documented side effects. The lack of recommendations and the unsharp definition of different forms of AMR contribute to the challenging management of the therapy by pediatric nephrologists. In an attempt to help clinicians involved in the care of renal transplanted children affected by an AMR, we rely on the latest recommendations of the Transplantation Society (TTS) for the classification and treatment of AMR to describe treatments available today and potential new treatments with a particular focus on the pediatric population.
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Affiliation(s)
| | - Paloma Parvex
- Division of Pediatric Nephrology, University Children Hospital of Geneva, Geneva, Switzerland
| | - Jean Villard
- Division of Nephrology, University Hospital of Geneva, Geneva, Switzerland.,Division of Transplantation Immunology, University Hospital of Geneva, Geneva, Switzerland
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8
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Bhadauria D, Kumar S, Yachha M, Kaul A, Patel M, Kushwaha R, Behera M, Prasad N. Efficacy and safety of bortezomib in the treatment of active antibody-mediated rejection in adult kidney-transplant recipients: A single-center retrospective study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_155_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Cheng H, Xu B, Zhang L, Wang Y, Chen M, Chen S. Bortezomib alleviates antibody-mediated rejection in kidney transplantation by facilitating Atg5 expression. J Cell Mol Med 2021; 25:10939-10949. [PMID: 34734681 PMCID: PMC8642675 DOI: 10.1111/jcmm.16998] [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: 05/23/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022] Open
Abstract
Antibody‐mediated rejection (AMR) is one of the most dominant mechanisms responsible for the loss of kidney grafts. Previous researches have shown that donor‐specific antibodies (DSAs) are the major mediators of AMR. In order to prolong the survival time of grafts, it is vital to reduce the incidence of AMR and inhibit the generation of DSAs. We established an animal model of AMR by performing kidney transplantation in pre‐sensitized rats. Then, we investigated the effect of bortezomib (BTZ) on AMR. We found that BTZ could reduce the serum level of DSAs and alleviate post‐transplantation inflammation in peritubular capillaries (PTCs) and glomeruli, which was demonstrated by the reduction of C4d and IgG deposition in PTCs, and the reduced number of B cell and plasma cell in peripheral blood and the transplanted kidney (p < 0.05). Our results also suggested that BTZ increased the number of regulatory T cell (Treg) and significantly reduced the proportion of T helper (Th17) cell (p < 0.05). Besides, BTZ induced the significant upregulation of anti‐inflammatory cytokines but downregulated pro‐inflammatory cytokines (p < 0.05). After dealing with Atg5 siRNA‐lentivirus, the effect of BTZ alleviating AMR was reversed and Th17/Treg proportions were also significantly modulated. Collectively, these findings show that BTZ slows down the process of AMR and Atg5 may be the key mechanism. Furthermore, Atg5 silencing results may be demonstrated that Atg5 alleviated AMR by modulating the ratio of Th17/Treg.
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Affiliation(s)
- Hong Cheng
- Department of Urology, Zhongda Hospital Affiliated to Southeastern China University, Nanjing, China
| | - Bin Xu
- Department of Urology, Zhongda Hospital Affiliated to Southeastern China University, Nanjing, China
| | - Lijie Zhang
- Department of Urology, Zhongda Hospital Affiliated to Southeastern China University, Nanjing, China
| | - Yi Wang
- Department of Urology, Affiliated Hospital of Nantong University, Nantong, China
| | - Ming Chen
- Department of Urology, Zhongda Hospital Affiliated to Southeastern China University, Nanjing, China
| | - Shuqiu Chen
- Department of Urology, Zhongda Hospital Affiliated to Southeastern China University, Nanjing, China
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10
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Liverman R, Chandran MM, Crowther B. Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient. Pharmacotherapy 2021; 41:77-102. [PMID: 33151553 DOI: 10.1002/phar.2483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 12/23/2022]
Abstract
Pediatric kidney transplantation has experienced considerable growth and improvement in patient and allograft outcomes over the past 20 years, in part due to advancements in immunosuppressive regimens and management. Despite this progress, care for this unique population can be challenging due to limited pediatric transplant data and trials, intricacies related to differences in children and adolescents compared with their adult counterparts, and limitations to long-term survival facing all solid organ transplant populations. Immunosuppression and infection prevention practices vary from one pediatric transplant center to another and clinical controversies exist surrounding treatment and dosing. This review aims to summarize key aspects of pharmacologic management in this population and present pertinent data that describe the influence of practice to serve as a resource for practitioners caring for this unique specialty patient population. Additionally, this review highlights select controversies that exist within pediatric kidney transplantation.
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Affiliation(s)
- Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mary Moss Chandran
- Department of Pharmacy, Childeren's Hospital Colorado, Aurora, Colorado, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Hospital, Aurora, Colorado, USA
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11
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Jain D, Rajab A, Young JS, Yin D, Nadasdy T, Chong AS, Pelletier RP. Reversing donor-specific antibody responses and antibody-mediated rejection with bortezomib and belatacept in mice and kidney transplant recipients. Am J Transplant 2020; 20:2675-2685. [PMID: 32243663 PMCID: PMC8232017 DOI: 10.1111/ajt.15881] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 01/25/2023]
Abstract
Active antibody-mediated rejection (AMR) is a potentially devastating complication and consistently effective treatment remains elusive. We hypothesized that the reversal of acute AMR requires rapid elimination of antibody-secreting plasma cells (PC) with a proteasome inhibitor, bortezomib, followed by the sustained inhibition of PC generation with CTLA4-Ig or belatacept (B/B). We show in mice that B/B therapy selectively depleted mature PC producing donor-specific antibodies (DSA) and reduced DSA, when administered after primary and secondary DSA responses had been established. A pilot investigation was initiated to treat six consecutive patients with active AMR with B/B. Compassionate use of this regimen was initiated for the first patient who developed early, severe acute AMR that did not respond to steroids, plasmapheresis, and intravenous immunoglobulin after his third kidney transplant. B/B treatment resulted in a rapid reversal of AMR, leading us to treat five additional patients who also resolved their acute AMR episode and had sustained disappearance of circulating DSA for ≤30 months. This study provides a proof-of-principle demonstration that mouse models can identify mechanistically rational therapies for the clinic. Follow-up investigations with a more stringent clinical design are warranted to test whether B/B improves on the standard of care for the treatment of acute AMR.
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Affiliation(s)
- Dharmendra Jain
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Amer Rajab
- Department of Surgery, The Ohio State University, Columbus, OH
| | - James S Young
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Dengping Yin
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
| | - Tibor Nadasdy
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Anita S Chong
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL
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12
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Bortezomib ameliorates acute allograft rejection after renal transplant by inhibiting Tfh cell proliferation and differentiation via miR-15b/IRF4 axis. Int Immunopharmacol 2019; 75:105758. [PMID: 31377589 DOI: 10.1016/j.intimp.2019.105758] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/10/2019] [Accepted: 07/10/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The present study aimed to investigate the functional role of bortezomib in the development of acute allograft rejection (AR) after renal transplant. METHODS The mouse model of AR was established by allograft kidney transplant followed by the treatment of bortezomib. The serum cytokines, renal function, and the percentage of T follicular helper (Tfh) cells in CD4+ T cells were measured. The effect of miR-15b and interferon-regulatory factor 4 (IRF4) on Tfh cell proliferation and differentiation was assessed by cell transfection technology and CCK-8 assay. The interaction between miR-15b and IRF4 was assessed by luciferase reporter assay. RESULTS Bortezomib relieved acute AR after renal transplant by suppressing Tfh cell proliferation and differentiation. Meanwhile, bortezomib treatment markedly increased miR-15b expression in AR renal tissues. The upregulation of miR-15b inhibited Tfh cell proliferation and differentiation by reducing IRF4. In addition, bortezomib ameliorated AR by suppressing Tfh cell proliferation and differentiation through miR-15b/IRF4 axis in vitro and in vivo. CONCLUSION Our findings indicated the mechanism underlying the bortezomib in treating acute AR after renal transplant, and suggested the critical role of miR-15b in Tfh cell proliferation and differentiation, which provided a therapeutic target in attenuating acute AR.
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Cioni M, Nocera A, Tagliamacco A, Basso S, Innocente A, Fontana I, Magnasco A, Trivelli A, Klersy C, Gurrado A, Ramondetta M, Boghen S, Catenacci L, Verrina E, Garibotto G, Ghiggeri GM, Cardillo M, Ginevri F, Comoli P. Failure to remove de novo donor-specific HLA antibodies is influenced by antibody properties and identifies kidney recipients with late antibody-mediated rejection destined to graft loss - a retrospective study. Transpl Int 2018; 32:38-48. [PMID: 30076765 DOI: 10.1111/tri.13325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 12/15/2022]
Abstract
Current research is focusing on identifying bioclinical parameters for risk stratification of renal allograft loss, largely due to antibody-mediated rejection (AMR). We retrospectively investigated graft outcome predictors in 24 unsensitized pediatric kidney recipients developing HLA de novo donor-specific antibodies (dnDSAs), and treated for late AMR with plasmapheresis + low-dose IVIG + Rituximab or high-dose IVIG + Rituximab. Renal function and DSA properties were assessed before and longitudinally post treatment. The estimated GFR (eGFR) decline after treatment was dependent on a negative % eGFR variation in the year preceding treatment (P = 0.021) but not on eGFR at treatment (P = 0.74). At a median follow-up of 36 months from AMR diagnosis, 10 patients lost their graft. Altered eGFR (P < 0.001) and presence of C3d-binding DSAs (P = 0.005) at treatment, and failure to remove DSAs (P = 0.01) were negatively associated with graft survival in the univariable analysis. Given the relevance of DSA removal for therapeutic success, we analyzed antibody properties dictating resistance to anti-humoral treatment. In the multivariable analysis, C3d-binding ability (P < 0.05), but not C1q-binding, and high mean fluorescence intensity (P < 0.05) were independent factors characterizing DSAs scarcely susceptible to removal. The poor prognosis of late AMR is related to deterioration of graft function prior to treatment and failure to remove C3d binding and/or high-MFI DSAs.
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Affiliation(s)
- Michela Cioni
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Arcangelo Nocera
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Augusto Tagliamacco
- Clinical Nephrology Unit and Transplant Coordination Unit, Policlinico San Martino, Genova, Italy
| | - Sabrina Basso
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Annalisa Innocente
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Iris Fontana
- Vascular and Endovascular Unit and Kidney Transplant Surgery Unit, Policlinico San Martino, Genova, Italy
| | - Alberto Magnasco
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Antonella Trivelli
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Catherine Klersy
- Biometry and Statistics Service, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Antonella Gurrado
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Miriam Ramondetta
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Stella Boghen
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Laura Catenacci
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Enrico Verrina
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giacomo Garibotto
- Clinical Nephrology Unit, University of Genova and Policlinico San Martino, Genova, Italy
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Massimo Cardillo
- Transplantation Immunology, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Fabrizio Ginevri
- Nephrology, Dialysis, Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology & Cell Factory, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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14
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Roders N, Herr F, Ambroise G, Thaunat O, Portier A, Vazquez A, Durrbach A. SYK Inhibition Induces Apoptosis in Germinal Center-Like B Cells by Modulating the Antiapoptotic Protein Myeloid Cell Leukemia-1, Affecting B-Cell Activation and Antibody Production. Front Immunol 2018; 9:787. [PMID: 29740433 PMCID: PMC5928208 DOI: 10.3389/fimmu.2018.00787] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/29/2018] [Indexed: 12/24/2022] Open
Abstract
B cells play a major role in the antibody-mediated rejection (AMR) of solid organ transplants, a major public health concern. The germinal center (GC) is involved in the generation of donor-specific antibody-producing plasma cells and memory B cells, which are often poorly controlled by current treatments. Myeloid cell leukemia-1 (Mcl-1), an antiapoptotic member of the B-cell lymphoma-2 family, is essential for maintenance of the GC reaction and B-cell differentiation. During chronic AMR (cAMR), tertiary lymphoid structures resembling GCs appear in the rejected organ, suggesting local lymphoid neogenesis. We report the infiltration of the kidneys with B cells expressing Mcl-1 in patients with cAMR. We modulated GC viability by impairing B-cell receptor signaling, by spleen tyrosine kinase (SYK) inhibition. SYK inhibition lowers viability and Mcl-1 protein levels in Burkitt's lymphoma cell lines. This downregulation of Mcl-1 is coordinated at the transcriptional level, possibly by signal transducer and activator of transcription 3 (STAT3), as shown by (1) the impaired translocation of STAT3 to the nucleus following SYK inhibition, and (2) the lower levels of Mcl-1 transcription upon STAT3 inhibition. Mcl-1 overproduction prevented cells from entering apoptosis following SYK inhibition. In vitro studies with primary tonsillar B cells confirmed that SYK inhibition impaired cell survival and decreased Mcl-1 protein levels. It also impaired B-cell activation and immunoglobulin G secretion by tonsillar B cells. These findings suggest that the SYK-Mcl-1 pathway could be targeted, to improve graft survival by manipulating the humoral immune response.
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Affiliation(s)
- Nathalie Roders
- Institut Francilien de Recherche en Nephrologie et Transplantation (IFRNT), Service de Néphrologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France.,INSERM UMRS-MD 1197, Villejuif, France.,Université Paris Sud, Orsay, France
| | - Florence Herr
- Institut Francilien de Recherche en Nephrologie et Transplantation (IFRNT), Service de Néphrologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France.,INSERM UMRS-MD 1197, Villejuif, France.,Université Paris Sud, Orsay, France
| | | | - Olivier Thaunat
- French National Institute of Health and Medical Research (INSERM) Unit 1111, Lyon, France.,Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot University Hospital, Lyon, France.,Claude Bernard University Lyon 1, Lyon, France
| | - Alain Portier
- INSERM UMRS-MD 1197, Villejuif, France.,Université Paris Sud, Orsay, France
| | - Aimé Vazquez
- INSERM UMRS-MD 1197, Villejuif, France.,Université Paris Sud, Orsay, France
| | - Antoine Durrbach
- Institut Francilien de Recherche en Nephrologie et Transplantation (IFRNT), Service de Néphrologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France.,INSERM UMRS-MD 1197, Villejuif, France.,Université Paris Sud, Orsay, France
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15
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Bujnowska A, Michon M, Konopelski P, Hryniewiecka E, Jalbrzykowska A, Perkowska-Ptasinska A, Cieciura T, Zagozdzon R, Paczek L, Ciszek M. Outcomes of Prolonged Treatment With Intravenous Immunoglobulin Infusions for Acute Antibody-mediated Rejection in Kidney Transplant Recipients. Transplant Proc 2018; 50:1720-1725. [PMID: 29961551 DOI: 10.1016/j.transproceed.2018.02.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/06/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Treatment of antibody-mediated rejection (AMR) is one of the main problems after kidney transplantation (KTx). The results of intensive AMR treatment with plasmapheresis (PF) and repeated infusions of intravenous immunoglobulin (IVIg) are presented. METHODS Diagnosis of AMR was based on graft biopsy and the presence of donor-specific antibodies (DSAs). AMR therapy consisted of 5 PF and IVIg infusions given after the last PF. Subsequent IVIg doses were given every 4 weeks for 6 months. Graft biopsy and DSA assessment were repeated at the end of the treatment (ET). RESULTS Four women and 10 men were included in our study; mean time from KTx to AMR was 79 (range, 3-193) months. During the treatment, 4 patients had graft failure. Graft function at baseline was significantly worse (P = .02) in this group compared with patients who completed the therapy. At baseline, mean flourescence intensity (MFI) was 6574 (range, 852-15,917) in the whole group, 7088 (range, 1054-15,917) in patients who completed treatment, and 4828 (range, 852-11,797) in patients who restarted hemodialysis. At ET, DSA MFI decreased in 8 of 10 patients (80%) who completed the therapy. The MFI decrease was 3946 (range, 959-11,203). Control graft biopsies revealed decreased intensity of C4d deposits in peritubular capillaries in 7 patients (78%) and decreased peritubular capillaritis in 2 patients (22%). CONCLUSION Intensive, prolonged AMR therapy with PF and IVIg resulted in a decrease in DSA titer and intensity of C4d deposits, but was not associated with reduction of microcirculation inflammation. Treatment was ineffective in patients with baseline advanced graft insufficiency.
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Affiliation(s)
- A Bujnowska
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - M Michon
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - P Konopelski
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - E Hryniewiecka
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland; Department of Clinical Nursing, Medical University of Warsaw, Warsaw, Poland
| | - A Jalbrzykowska
- Department of Clinical Immunology, Medical University of Warsaw, Warsaw, Poland
| | - A Perkowska-Ptasinska
- Department of Transplantation Medicine and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - T Cieciura
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - R Zagozdzon
- Department of Clinical Immunology, Medical University of Warsaw, Warsaw, Poland
| | - L Paczek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland; Department of Bioinformatics, Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - M Ciszek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
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16
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Abstract
Donor-specific antibodies have become an established biomarker predicting antibody-mediated rejection. Antibody-mediated rejection is the leading cause of graft loss after kidney transplant. There are several phenotypes of antibody-mediated rejection along post-transplant course that are determined by the timing and extent of humoral response and the various characteristics of donor-specific antibodies, such as antigen classes, specificity, antibody strength, IgG subclasses, and complement binding capacity. Preformed donor-specific antibodies in sensitized patients can trigger hyperacute rejection, accelerated acute rejection, and early acute antibody-mediated rejection. De novo donor-specific antibodies are associated with late acute antibody-mediated rejection, chronic antibody-mediated rejection, and transplant glomerulopathy. The pathogeneses of antibody-mediated rejection include not only complement-dependent cytotoxicity, but also complement-independent pathways of antibody-mediated cellular cytotoxicity and direct endothelial activation and proliferation. The novel assay for complement binding capacity has improved our ability to predict antibody-mediated rejection phenotypes. C1q binding donor-specific antibodies are closely associated with acute antibody-mediated rejection, more severe graft injuries, and early graft failure, whereas C1q nonbinding donor-specific antibodies correlate with subclinical or chronic antibody-mediated rejection and late graft loss. IgG subclasses have various abilities to activate complement and recruit effector cells through the Fc receptor. Complement binding IgG3 donor-specific antibodies are frequently associated with acute antibody-mediated rejection and severe graft injury, whereas noncomplement binding IgG4 donor-specific antibodies are more correlated with subclinical or chronic antibody-mediated rejection and transplant glomerulopathy. Our in-depth knowledge of complex characteristics of donor-specific antibodies can stratify the patient's immunologic risk, can predict distinct phenotypes of antibody-mediated rejection, and hopefully, will guide our clinical practice to improve the transplant outcomes.
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Affiliation(s)
- Rubin Zhang
- Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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17
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Rabbit anti-human thymocyte immunoglobulin for the rescue treatment of chronic antibody-mediated rejection after pediatric kidney transplantation. Pediatr Nephrol 2017; 32:2133-2142. [PMID: 28717935 DOI: 10.1007/s00467-017-3725-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/29/2017] [Accepted: 06/12/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chronic antibody-mediated rejection (cAMR) is the leading cause of late kidney graft loss, but current therapies are often ineffective. Rabbit anti-human thymocyte immunoglobulin (rATG) may be helpful, but its use is virtually undocumented. METHODS Data were analyzed retrospectively from nine pediatric kidney transplant patients with cAMR were treated with rATG (1.5 mg/kg × 5 days) at our center after non-response to pulsed prednisolone, intravenous immunoglobulin, rituximab, and increased immunosuppressive intensity (including switching to belatacept in some cases), with or without bortezomib. RESULTS The median time from diagnosis to cAMR was 179 days. rATG was started 5-741 days after diagnosis. Median estimated glomerular filtration rate (eGFR) increased from 40 mL/min/1.73 m2 when rATG was started to 62 mL/min/1.73 m2 9 months later (p = 0.039). Four patients showed substantially higher eGFR after 9 months and 2 patients showed a small improvement; eGFR continued to decline in 3 patients after starting rATG. No grafts were lost during follow-up. At last follow-up, donor-specific antibodies (DSAs) were no longer detectable in 4 out of 8 patients for whom data were available, median fluorescence intensity had decreased substantially in 1 out of 8 patients; anti-HLA DQ DSAs persisted in 2 out of 8 patients. No adverse events with a suspected relation to rATG, including allergic reactions, leukocytopenia or infections, were observed in any of the patients. CONCLUSIONS In this small series of patients, rATG appears a promising treatment for unresponsive cAMR. Further evaluation, including earlier introduction of rATG, is warranted.
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