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MacMillan S, Hosgood SA, Walker-Panse L, Rahfeld P, Macdonald SS, Kizhakkedathu JN, Withers SG, Nicholson ML. Enzymatic conversion of human blood group A kidneys to universal blood group O. Nat Commun 2024; 15:2795. [PMID: 38555382 PMCID: PMC10981661 DOI: 10.1038/s41467-024-47131-9] [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: 01/04/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024] Open
Abstract
ABO blood group compatibility restrictions present the first barrier to donor-recipient matching in kidney transplantation. Here, we present the use of two enzymes, FpGalNAc deacetylase and FpGalactosaminidase, from the bacterium Flavonifractor plautii to enzymatically convert blood group A antigens from the renal vasculature of human kidneys to 'universal' O-type. Using normothermic machine perfusion (NMP) and hypothermic machine perfusion (HMP) strategies, we demonstrate blood group A antigen loss of approximately 80% in as little as 2 h NMP and HMP. Furthermore, we show that treated kidneys do not bind circulating anti-A antibodies in an ex vivo model of ABO-incompatible transplantation and do not activate the classical complement pathway. This strategy presents a solution to the donor organ shortage crisis with the potential for direct clinical translation to reduce waiting times for patients with end stage renal disease.
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Affiliation(s)
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Peter Rahfeld
- Avivo Biomedical Inc., Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Spence S Macdonald
- Avivo Biomedical Inc., Vancouver, BC, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Stephen G Withers
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
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Couzi L, Malvezzi P, Amrouche L, Anglicheau D, Blancho G, Caillard S, Freist M, Guidicelli GL, Kamar N, Lefaucheur C, Mariat C, Koenig A, Noble J, Thaunat O, Thierry A, Taupin JL, Bertrand D. Imlifidase for Kidney Transplantation of Highly Sensitized Patients With a Positive Crossmatch: The French Consensus Guidelines. Transpl Int 2023; 36:11244. [PMID: 37448448 PMCID: PMC10336835 DOI: 10.3389/ti.2023.11244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023]
Abstract
Imlifidase recently received early access authorization for highly sensitized adult kidney transplant candidates with a positive crossmatch against an ABO-compatible deceased donor. These French consensus guidelines have been generated by an expert working group, in order to homogenize patient selection, associated treatments and follow-up. This initiative is part of an international effort to analyze properly the benefits and tolerance of this new costly treatment in real-life. Eligible patients must meet the following screening criteria: cPRA ≥ 98%, ≤ 65-year of age, ≥ 3 years on the waiting list, and a low risk of biopsy-related complications. The final decision to use Imlifidase will be based on the two following criteria. First, the results of a virtual crossmatch on recent serum, which shall show a MFI for the immunodominant donor-specific antibodies (DSA) > 6,000 but the value of which does not exceed 5,000 after 1:10 dilution. Second, the post-Imlifidase complement-dependent cytotoxicity crossmatch must be negative. Patients treated with Imlifidase will receive an immunosuppressive regimen based on steroids, rATG, high dose IVIg, rituximab, tacrolimus and mycophenolic acid. Frequent post-transplant testing for DSA and systematic surveillance kidney biopsies are highly recommended to monitor post-transplant DSA rebound and subclinical rejection.
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Affiliation(s)
- Lionel Couzi
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- CNRS-UMR 5164 Immuno ConcEpT, Université de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | | | - Gilles Blancho
- Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | | | - Marine Freist
- Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | | | - Nassim Kamar
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Christophe Mariat
- Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Saint-Etienne, France
| | | | - Johan Noble
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
| | | | - Antoine Thierry
- Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
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3
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Dudreuilh C, Jarvis P, Beadle N, Pilecka I, Shaw O, Gardner L, Scottà C, Mamode N, Game DS, Sanchez-Fueyo A, Lombardi G, Learoyd A, Douiri A, Dorling A. Can regulatory T cells improve outcomes of sensitised patients after HLA-Ab incompatible renal transplantation: study protocol for the Phase IIa GAMECHANgER-1 trial. BMC Nephrol 2023; 24:117. [PMID: 37118685 PMCID: PMC10140710 DOI: 10.1186/s12882-023-03157-7] [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: 11/08/2022] [Accepted: 04/06/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Kidney transplantation is the gold-standard treatment for patients with kidney failure. However, one-third of patients awaiting a kidney transplant are highly sensitized to human leukocyte antigens (HLA), resulting in an increased waiting time for a suitable kidney, more acute and chronic rejection, and a shorter graft survival compared to non-highly sensitised patients. Current standard immunosuppression protocols do not adequately suppress memory responses, and so alternative strategies are needed. Autologous polyclonally expanded regulatory T cells (Tregs) have been demonstrated to be safe in transplant settings and could be a potential alternative to modulate memory immune alloresponses. METHODS The aim of this trial is to determine whether adoptive transfer of autologous Tregs into HLA sensitised patients can suppress memory T and B cell responses against specific HLA antigens. This is a two-part, multi-centre, prospective clinical trial, comprising an observational phase (Part 1) aiming to identify patients with unregulated cellular memory responses to HLA (Pure HLA Proteins) followed by an interventional phase (Part 2). The first 9 patients identified as being eligible in Part 1 will undergo baseline immune monitoring for 2 months to inform statistical analysis of the primary endpoint. Part 2 is an adaptive, open labelled trial based on Simon's two-stage design, with 21 patients receiving Good Manufacturing Practice (GMP)-grade polyclonally expanded Tregs to a dose of 5-10 × 106 cells/kg body weight. The primary EP is suppression of in vitro memory responses for 2 months post-infusion. 12 patients will receive treatment in stage 1 of Part 2, and 9 patients will receive treatment in stage 2 of Part 2 if ≥ 50% patients pass the primary EP in stage 1. DISCUSSION This is a prospective study aiming to identify patients with unregulated cellular memory responses to Pure HLA Proteins and determine baseline variation in these patterns of response. Part 2 will be an adaptive phase IIa clinical trial with 21 patients receiving a single infusion of GMP-grade polyclonally expanded Tregs in two stages. It remains to be demonstrated that modulating memory alloresponses clinically using Treg therapy is achievable. TRIAL REGISTRATION EudraCT Number: 2021-001,664-23. REC Number: 21/SC/0253. Trial registration number ISRCTN14582152.
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Affiliation(s)
- C Dudreuilh
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK.
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK.
| | - P Jarvis
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - N Beadle
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - I Pilecka
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Clinical Trials Unit, King's College London, London, UK
| | - O Shaw
- Guy's and St Thomas's Hospital Trust, London, UK
| | - L Gardner
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - C Scottà
- Peter Gorer Department of Immunobiology, King's College London, London, UK
| | - N Mamode
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - D S Game
- Department of Transplantation, Guys and St, Thomas's Hospital NHS Trust, London, UK
| | - A Sanchez-Fueyo
- Institute of Liver Studies, King's College London University and King's College Hospital, London, UK
| | - G Lombardi
- Peter Gorer Department of Immunobiology, King's College London, London, UK
| | - A Learoyd
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - A Douiri
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - A Dorling
- Centre for Nephrology, Urology and Transplantation, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London & NIHR Biomedical Research Centre-Transplant Theme, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
- Centre for Nephrology, Urology and Transplantation, School of Immunology and Microbial Sciences, King's College London, London, UK
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4
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Hew EY, Kessaris N, Stojanovic J, Jones H, Christian M, Edwards A, Milford DV, Ognjanovic M, Shenoy M, Baker RJ, Marks SD. Successful ABO and HLA incompatible kidney transplantation in children in the UK. Pediatr Nephrol 2023; 38:529-535. [PMID: 35695967 PMCID: PMC9763153 DOI: 10.1007/s00467-022-05583-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is increasing evidence of good short-term and medium-term outcomes of ABO incompatible (ABOi) and HLA incompatible (HLAi) kidney transplantation with pre-transplant positive crossmatches in paediatric practice. However, there remain concerns regarding the higher risks of infective complications and antibody-mediated rejections. The aim of our study is to show longer-term follow-up on all ABOi and HLAi paediatric kidney transplant recipients (pKTR) in the UK. METHODS Questionnaires specifying kidney transplant type, desensitisation requirement and kidney allograft function were sent to 13 paediatric nephrology centres that performed kidney transplantation in children and young people under 18 years of age who received an ABOi and/or HLAi transplant between 1 January 2006 and 31 December 2016. Patient and kidney allograft survival were compared between ABOi, HLAi and ABO/HLA compatible (ABOc/HLAc) groups. RESULTS Among 711 living donor kidney transplants performed in the UK, 23 were ABOi and 6 were HLAi. Patient survival was 87%, 100% and 96% in ABOi, HLAi and ABOc/HLAc groups, respectively, at median follow-up of 6.8 (3.6-14.0) years post-transplant. Death-censored kidney allograft survival was 100% in all 3 groups at last follow-up. There were no cases of primary non-function in ABOi or HLAi groups, but 2% in the ABOc/HLAc group. There was one reported case of Epstein-Barr viral-induced post-transplant lymphoproliferative disorder. CONCLUSION Longer term follow-up has shown that ABOi and HLAi kidney transplantation are feasible for pKTR where no compatible donors are available, and that minimising desensitisation should be achieved where possible. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Eun Yee Hew
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Nicos Kessaris
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
- Department of Nephrology and Transplantation, NHS Foundation Trust, Guy's and St Thomas, London, SE1 9RT, UK
- Department of Paediatric Nephro-Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jelena Stojanovic
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Helen Jones
- Department of Paediatric Nephro-Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Martin Christian
- Department of Pediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
| | - Anusha Edwards
- Renal Transplantation Unit, Southmead Hospital, Southmead Road, Bristol, BS110 5NB, UK
| | - David V Milford
- Department of Paediatric Nephrology, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Milos Ognjanovic
- Department of Paediatric Nephrology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Richard J Baker
- Renal Unit, Lincoln Wing, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK.
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
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5
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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Mamode N, Bestard O, Claas F, Furian L, Griffin S, Legendre C, Pengel L, Naesens M. European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group. Transpl Int 2022; 35:10511. [PMID: 36033645 PMCID: PMC9399356 DOI: 10.3389/ti.2022.10511] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
This guideline, from a European Society of Organ Transplantation (ESOT) working group, concerns the management of kidney transplant patients with HLA antibodies. Sensitization should be defined using a virtual parameter such as calculated Reaction Frequency (cRF), which assesses HLA antibodies derived from the actual organ donor population. Highly sensitized patients should be prioritized in kidney allocation schemes and linking allocation schemes may increase opportunities. The use of the ENGAGE 5 ((Bestard et al., Transpl Int, 2021, 34: 1005–1018) system and online calculators for assessing risk is recommended. The Eurotransplant Acceptable Mismatch program should be extended. If strategies for finding a compatible kidney are very unlikely to yield a transplant, desensitization may be considered and should be performed with plasma exchange or immunoadsorption, supplemented with IViG and/or anti-CD20 antibody. Newer therapies, such as imlifidase, may offer alternatives. Few studies compare HLA incompatible transplantation with remaining on the waiting list, and comparisons of morbidity or quality of life do not exist. Kidney paired exchange programs (KEP) should be more widely used and should include unspecified and deceased donors, as well as compatible living donor pairs. The use of a KEP is preferred to desensitization, but highly sensitized patients should not be left on a KEP list indefinitely if the option of a direct incompatible transplant exists.
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Affiliation(s)
- Nizam Mamode
- Department of Transplantation, Guys Hospital, London, United Kingdom
- *Correspondence: Nizam Mamode,
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Frans Claas
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunology, University of Antwerp, Antwerp, Belgium
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical Gastroenterological and Oncological Sciences, University Hospital of Padua, Padua, Italy
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, United Kingdom
| | - Christophe Legendre
- Department of Nephrology and Adult Kidney Transplantation, Hôpital Necker and Université de Paris, Paris, France
| | - Liset Pengel
- Centre for Evidence in Transplantation, University of Oxford, Oxford, United Kingdom
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Pan JS, Chen YD, Ding HD, Lan TC, Zhang F, Zhong JB, Liao GY. A Statistical Prediction Model for Survival After Kidney Transplantation from Deceased Donors. MEDICAL SCIENCE MONITOR : INTERNATIONAL MEDICAL JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022; 28:e933559. [PMID: 34972813 PMCID: PMC8729034 DOI: 10.12659/msm.933559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background In an environment of limited kidney donation resources, patient recovery and survival after kidney transplantation (KT) are highly important. We used pre-operative data of kidney recipients to build a statistical model for predicting survivability after kidney transplantation. Material/Methods A dataset was constructed from a pool of patients who received a first KT in our hospital. For allogeneic transplantation, all donated kidneys were collected from deceased donors. Logistic regression analysis was used to change continuous variables into dichotomous ones through the creation of appropriate cut-off values. A regression model based on the least absolute shrinkage and selection operator (LASSO) algorithm was used for dimensionality reduction, feature selection, and survivability prediction. We used receiver operating characteristic (ROC) analysis, calibration, and decision curve analysis (DCA) to evaluate the performance and clinical impact of the proposed model. Finally, a 10-fold cross-validation scheme was implemented to verify the model robustness. Results We identified 22 potential variables from which 30 features were selected as survivability predictors. The model established based on the LASSO regression algorithm had shown discrimination with an area under curve (AUC) value of 0.690 (95% confidence interval: 0.557–0.823) and good calibration result. DCA demonstrated clinical applicability of the prognostic model when the intervention progressed to the possibility threshold of 2%. An average AUC value of 0.691 was obtained on the validation data. Conclusions Our results suggest that the proposed model can predict the mortality risk for patients after kidney transplants and could help kidney specialists choose kidney recipients with better prognosis.
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Affiliation(s)
- Jia-Shan Pan
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Yi-Ding Chen
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Han-Dong Ding
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Tian-Chi Lan
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Fei Zhang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Jin-Biao Zhong
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Gui-Yi Liao
- Department of Urology, The First Affiliated Hospital of Anhui Medical University and Institute of Urology and Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, Anhui, China (mainland)
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Sethi S, Ammerman N, Vo A, Jordan SC. Approach to Highly Sensitized Kidney Transplant Candidates and a Positive Crossmatch. Adv Chronic Kidney Dis 2021; 28:587-595. [PMID: 35367027 DOI: 10.1053/j.ackd.2021.09.004] [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: 05/29/2021] [Accepted: 09/08/2021] [Indexed: 11/11/2022]
Abstract
Human leukocyte antigen (HLA)-incompatible kidney transplantation offers survival benefit compared with ongoing dialysis. There have been considerable advances in the last decade to allow for increased access to transplant for the HLA-sensitized kidney transplant candidates. These include increased priority in the kidney allocation system, kidney paired donation, and novel desensitization strategies. A better understanding of the role of B cells, plasma cells, and complement and inflammatory cytokines in the pathophysiology of HLA antibody-mediated allograft injury has led to the use of novel therapeutics for desensitization and treatment of antibody-mediated rejection. Here we discuss current approaches to kidney transplantation in HLA-sensitized kidney transplant candidates.
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9
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Noble J, Metzger A, Daligault M, Chevallier E, Bugnazet M, Bardy B, Naciri Bennani H, Terrier N, Fiard G, Franquet Q, Janbon B, Masson D, Giovannini D, Malvezzi P, Jouve T, Rostaing L. Immortal Time-Bias-Corrected Survival of Highly Sensitized Patients and HLA-desensitized Kidney Transplant Recipients. Kidney Int Rep 2021; 6:2629-2638. [PMID: 34622102 PMCID: PMC8484495 DOI: 10.1016/j.ekir.2021.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/04/2021] [Accepted: 07/26/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction In the setting of kidney transplantation (KT), we assessed the efficacy of desensitization and compared the survival of desensitized patients (HLA-incompatible KT) with similarly sensitized patients receiving HLA-compatible KT or sensitized patients still on a waiting list after adjusting for the usually unaccounted immortal time bias. Methods All patients in a French KT center on the waiting list between August 1994 and December 2019 with a high level of sensitization (panel-reactive antibodies [PRAs] ≥80%) were included. The primary outcome was all-cause mortality. A time-varying covariate Cox survival model was used to account for the immortal time bias. A landmark analysis was used as a sensitivity analysis. Results During the study period, 326 patients with high PRAs were followed, among which 147 (45%) remained on the waiting list at the time of last follow-up and 179 benefited from a KT. Thirty-six patients were desensitized, of which 30 received a kidney transplant, including eight deceased kidney donors. There were no differences in mortality rates between desensitized KT patients, nondesensitized KT patients, and waitlisted patients after adjusting for immortal time bias (hazard ratio [HR] = 0.48, P = 0.22). Death-censored graft survival was similar between desensitized and nondesensitized KT patients (HR = 0.92, P = 0.88 adjusting for donor age >65 years, donor status, and time on the waiting list). Mean estimated glomerular filtration rate at 1 year post-KT was similar for desensitized KT patients (53.3 ± 21 vs. 53.6 ± 21 ml/min per 1.73 m2 for nondesensitized patients; P = 0.95). Conclusions HLA-desensitization was effective for highly sensitized patients and gave access to KT without detrimental effects on patient or graft survival rates.
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Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Antoine Metzger
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Melanie Daligault
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Eloi Chevallier
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Mathilde Bugnazet
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Beatrice Bardy
- HLA Laboratory - Établissement Français du Sang (EFS), Grenoble, France
| | - Hamza Naciri Bennani
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Nicolas Terrier
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Gaelle Fiard
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Quentin Franquet
- Urology Department, University Hospital Grenoble, Grenoble, France
| | - Benedicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Dominique Masson
- HLA Laboratory - Établissement Français du Sang (EFS), Grenoble, France
| | - Diane Giovannini
- Pathology Department, University Hospital Grenoble, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- University Grenoble Alpes, Grenoble, France
- Correspondence: Lionel Rostaing, MD, PhD, Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Avenue Maquis du Grésivaudan, 38700 La Tronche, France.
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10
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Avery RK, Motter JD, Jackson KR, Montgomery RA, Massie AB, Kraus ES, Marr KA, Lonze BE, Alachkar N, Holechek MJ, Ostrander D, Desai N, Waldram MM, Shoham S, Steinke SM, Subramanian A, Hiller JM, Langlee J, Young S, Segev DL, Garonzik Wang JM. Quantifying infection risks in incompatible living donor kidney transplant recipients. Am J Transplant 2021; 21:1564-1575. [PMID: 32949093 PMCID: PMC7972996 DOI: 10.1111/ajt.16316] [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: 05/01/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
Desensitization has enabled incompatible living donor kidney transplantation (ILDKT) across HLA/ABO barriers, but added immunomodulation might put patients at increased risk of infections. We studied 475 recipients from our center from 2010 to 2015, categorized by desensitization intensity: none/compatible (n = 260), low (0-4 plasmaphereses, n = 47), moderate (5-9, n = 74), and high (≥10, n = 94). The 1-year cumulative incidence of infection was 50.1%, 49.8%, 66.0%, and 73.5% for recipients who received none, low, moderate, and high-intensity desensitization (P < .001). The most common infections were UTI (33.5% of ILDKT vs. 21.5% compatible), opportunistic (21.9% vs. 10.8%), and bloodstream (19.1% vs. 5.4%) (P < .001). In weighted models, a trend toward increased risk was seen in low (wIRR = 0.77 1.402.56 ,P = .3) and moderately (wIRR = 0.88 1.352.06 ,P = .2) desensitized recipients, with a statistically significant 2.22-fold (wIRR = 1.33 2.223.72 ,P = .002) increased risk in highly desensitized recipients. Recipients with ≥4 infections were at higher risk of prolonged hospitalization (wIRR = 2.62 3.574.88 , P < .001) and death-censored graft loss (wHR = 1.15 4.0113.95 ,P = .03). Post-KT infections are more common in desensitized ILDKT recipients. A subset of highly desensitized patients is at ultra-high risk for infections. Strategies should be designed to protect patients from the morbidity of recurrent infections, and to extend the survival benefit of ILDKT across the spectrum of recipients.
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Affiliation(s)
- Robin K. Avery
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Jennifer D. Motter
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Kyle R. Jackson
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Robert A. Montgomery
- The NYU Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Allan B. Massie
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland,Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMaryland
| | - Edward S. Kraus
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Kieren A. Marr
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Bonnie E. Lonze
- The NYU Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Nada Alachkar
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary J. Holechek
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Darin Ostrander
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Niraj Desai
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Madeleine M. Waldram
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Shmuel Shoham
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Seema Mehta Steinke
- Division of Infectious DiseaseDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | | | - Janet M. Hiller
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Julie Langlee
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Sheila Young
- Division of NephrologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
| | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMaryland,Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMaryland,Scientific Registry of Transplant RecipientsMinneapolisMinnesotaUSA
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11
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Acharya S. Kidney transplantation in sensitized patients: Two case reports. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_4_21] [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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12
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Pandey P, Setya D, Sinha VK, Devra AK, Bhatt AP, Pande A, Kumar P, Singh MK, Ranjan S. Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants. J Clin Apher 2020; 36:299-312. [PMID: 33316838 DOI: 10.1002/jca.21860] [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: 07/08/2020] [Revised: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone. MATERIALS AND METHODS This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included. RESULTS There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study. CONCLUSION Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Kumar Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit K Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Prasad Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
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13
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Clinical outcome of living donor kidney transplantation across simultaneous ABO and HLA incompatibility: Single center experience of first ten cases. Transfus Apher Sci 2020; 60:102954. [PMID: 33008743 DOI: 10.1016/j.transci.2020.102954] [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: 07/03/2020] [Revised: 08/08/2020] [Accepted: 09/06/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Preconditioning using different protocols has been tested to prevent antibody mediated rejection (ABMR) individually for ABO and HLA incompatibility. However, simultaneous presence of both barriers is still less explored. The aim of this study was to report outcomes of institutional desensitization protocol in renal transplant recipients with simultaneous ABO and HLA incompatibility. MATERIALS AND METHODS This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of dialysis dependent chronic kidney disease (CKD), who were prospective coexistent HLA and ABO incompatible renal transplant recipients were included in the study. Patients were followed up and graft function and patient survival was assessed at 1 y from the date of transplant. RESULTS Median and mode baseline anti-A titers were 64, while median and mode baseline anti-B titers were 256. All recipients were discharged by tenth postoperative day. None of the patients had any bleeding complications. Post transplant infection rate was found to be 20 %. A total of 54 therapeutic plasma exchange (TPE) procedures were performed before transplant and 8 were performed after transplant. Graft survival and patient survival was 100 % at 3, 6, 9, and 12 months. Range and mean follow-up period was 15-42 months and 23 months respectively. Mean glomerular filtration rate (GFR) at 1 y using the CKD-EPI equation was 85.25 ± 13.76 mL/min. Biopsy proven ABMR was observed in one case only which was managed with TPE and immunosuppression. CONCLUSION Simultaneous ABO and HLA incompatibility in renal transplant recipients can be managed successfully with adequate preconditioning and careful monitoring.
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14
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Kidney Rejection Following Simultaneous Liver-kidney Transplantation. Transplant Direct 2020; 6:e569. [PMID: 32766424 PMCID: PMC7339316 DOI: 10.1097/txd.0000000000001004] [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] [Received: 03/25/2020] [Revised: 04/11/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
Background. Donor-specific antibodies are reported to increase the risk of rejection and reduce allograft survival following simultaneous liver-kidney transplantation. Optimal immunosuppression regimens to reduce this risk and to treat rejection episodes are underinvestigated. Methods. Cohort analysis of the first 27 simultaneous liver-kidney transplant recipients, between 2014 and 2018 at our unit, is performed under a new risk stratification policy. Those with donor-specific antibodies to class II HLA with a mean fluorescence intensity >10 000 are considered high risk for antibody-mediated rejection (AMR). These patients received immunosuppression, which consisted of induction therapy, tacrolimus, mycophenolate mofetil, and prednisolone. All other patients are considered low risk and received tacrolimus and prednisolone alone. Results. Three patients were high risk for rejection, and 2 of these patients developed AMR, which was treated with plasma exchange and intravenous immunoglobulin. At 1 y, their estimated glomerular filtration rate (eGFR) were 50 and 59 mL/min. Two other patients developed AMR, which was similarly treated, and their 1-y eGFR was 31 and 50 mL/min. The overall histologically proven acute rejection rate within the first year was 33%, and median eGFR, for the 27 patients, at 1 y was 52 mL/min and at 2 y was 49 mL/min. Conclusions. This study confirms that there is a risk of AMR following simultaneous liver-kidney transplantation despite increased immunosuppression. This can be effectively treated with plasma exchange and intravenous immunoglobulin.
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15
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Kwon H, Kim JY, Kim DH, Ko Y, Choi JY, Shin S, Jung JH, Kim YH, Han DJ. Effect of simultaneous presence of anti-blood group A/B and -HLA antibodies on clinical outcomes in kidney transplantation across positive crossmatch: a nationwide cohort study. Sci Rep 2019; 9:18229. [PMID: 31796812 PMCID: PMC6890690 DOI: 10.1038/s41598-019-54397-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023] Open
Abstract
ABO-incompatible (ABOi) and positive crossmatch (XM) kidney transplantation (KT) have been considered immunologically challenging. The present study analyzed the clinical outcomes in XM positive KT based on ABO incompatibility. We used data from the Korea Organ Transplantation Registry, a nationwide database, and a single-center registry. A total of 263 patients with positive XM were divided into an ABO compatible (ABOc) & XM positive (ABOc/XM+, n = 176) group and an ABOi & XM positive (ABOi/XM+, n = 87) group. The overall rejection rate one year after KT was significantly higher in the ABOi/XM+ group than in the ABOc/XM+ group (P < 0.01). A total of four mortalities occurred, all in the ABOi/XM+ patients (P < 0.01). There were no differences in surgical complications or the occurrence of infection-related complications, including BK virus nephropathy. Multivariate analysis indicated that female vs. male (odds ratio (OR), 2.27; P = 0.03), DSA class I (MFI/1000) (OR, 1.10; P = 0.03), DSA class II (MFI/1000) (OR, 1.10; P < 0.01), and ABOi & XM+ status (OR, 2.38; P < 0.01) were significant risk factors for acute rejection during the year after transplantation. Overall graft survival was inferior in ABOi/XM+ patients than in ABOc/XM+ patients (P = 0.02). ABO incompatibility in XM-positive KT patients was found to be a significant risk factor for the development of rejection within one year after transplantation as well as for long-term graft survival. The anti-blood group A, B and anti-HLA antibodies may show synergistic activity.
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Affiliation(s)
- Hyunwook Kwon
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jee Yeon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngmin Ko
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yoon Choi
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Duck Jong Han
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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van Sandwijk MS, Klooster A, ten Berge IJM, Diepstra A, Florquin S, Hoelbeek JJ, Bemelman FJ, Sanders JS. Complement activation and long-term graft function in ABO-incompatible kidney transplantation. World J Nephrol 2019; 8:95-108. [PMID: 31662955 PMCID: PMC6817790 DOI: 10.5527/wjn.v8.i6.95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/29/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND ABO-incompatible and ABO-compatible kidney transplantation are equivalent in terms of short-term graft and patient survival. This is thought to be the result of ABO-incompatible graft accommodation, which occurs when anti-blood group antibodies re-occur after transplantation but somehow do not yield their detrimental effect. The underlying mechanism is unclear, but one of the hypotheses is that this is the result of complement inhibition. Since virtually all ABO-incompatible graft biopsies are C4d positive, this complement inhibition must occur somewhere in the complement cascade after the formation of C4d has already taken place, but where exactly is unclear. It is also unclear whether complement inhibition is complete. Incomplete accommodation could explain why recent studies have shown that long-term graft function in ABO-incompatible transplantation is somewhat inferior to ABO-compatible kidney transplantation.
AIM To unravel the relationship between pre-transplant anti-ABO antibodies, complement activation, and long-term graft function.
METHODS We included all 27 ABO-incompatible transplantations that were performed between 2008 and 2013 at the Academic Medical Center Amsterdam and the University Medical Center Groningen. For each ABO-incompatible transplantation, we included four ABO-compatible controls matched by age, sex, and transplantation date.
RESULTS Graft and patient survival were not significantly different. The slope of kidney function during five-year follow-up was also not significantly different, but ABO-incompatible recipients did have a lower kidney function at three months (creatinine clearance 58 vs 69 mL/min, P = 0.02, Modification of Diet in Renal Disease 46 vs 52 mL/min/1.73 m2, P = 0.08), due to a high rate of early rejection (33% vs 15%, P = 0.03), mostly T-cell mediated. Pre-transplant anti-ABO IgG titers were positively correlated with C5b-9 staining, which itself was positively correlated with the occurrence of T-cell mediated rejection. This may be the result of concurrent C5a formation, which could function as a costimulatory signal for T-cell activation.
CONCLUSION Co-stimulation of T-cell activation by ongoing complement activation by anti-ABO antibodies may be responsible for an impaired long-term graft function in ABO-incompatible kidney transplantation.
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Affiliation(s)
- Marit S van Sandwijk
- Department of Nephrology, Amsterdam University Medical Centers, Amsterdam NL-1105 AZ, Netherlands
- Dianet Dialysis Center, Amsterdam NL-1105 AZ, Netherlands
| | - Astrid Klooster
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen NL-9700 RB, Netherlands
- Department of Pathology, Pathology Friesland, Leeuwarden NL-8917 EN, Netherlands
| | - Ineke JM ten Berge
- Department of Nephrology, Amsterdam University Medical Centers, Amsterdam NL-1105 AZ, Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen NL-9700 RB, Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam NL-1105 AZ, Netherlands
| | - Joris J Hoelbeek
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam NL-1105 AZ, Netherlands
| | - Frederike J Bemelman
- Department of Nephrology, Amsterdam University Medical Centers, Amsterdam NL-1105 AZ, Netherlands
| | - Jan-Stephan Sanders
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen NL-9700 RB, Netherlands
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17
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Marks WH, Mamode N, Montgomery RA, Stegall MD, Ratner LE, Cornell LD, Rowshani AT, Colvin RB, Dain B, Boice JA, Glotz D. Safety and efficacy of eculizumab in the prevention of antibody-mediated rejection in living-donor kidney transplant recipients requiring desensitization therapy: A randomized trial. Am J Transplant 2019; 19:2876-2888. [PMID: 30887675 PMCID: PMC6790671 DOI: 10.1111/ajt.15364] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 01/25/2023]
Abstract
We report results of a phase 2, randomized, multicenter, open-label, two-arm study evaluating the safety and efficacy of eculizumab in preventing acute antibody-mediated rejection (AMR) in sensitized recipients of living-donor kidney transplants requiring pretransplant desensitization (NCT01399593). In total, 102 patients underwent desensitization. Posttransplant, 51 patients received standard of care (SOC) and 51 received eculizumab. The primary end point was week 9 posttransplant treatment failure rate, a composite of: biopsy-proven acute AMR (Banff 2007 grade II or III; assessed by blinded central pathology); graft loss; death; or loss to follow-up. Eculizumab was well tolerated with no new safety concerns. No significant difference in treatment failure rate was observed between eculizumab (9.8%) and SOC (13.7%; P = .760). To determine whether data assessment assumptions affected study outcome, biopsies were reanalyzed by central pathologists using clinical information. The resulting treatment failure rates were 11.8% and 21.6% for the eculizumab and SOC groups, respectively (nominal P = .288). When reassessment included grade I AMR, the treatment failure rates were 11.8% (eculizumab) and 29.4% (SOC; nominal P = .048). This finding suggests a potential benefit for eculizumab compared with SOC in preventing acute AMR in recipients sensitized to their living-donor kidney transplants (EudraCT 2010-019630-28).
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Affiliation(s)
- William H. Marks
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent ConsultantBellevueWashington
| | - Nizam Mamode
- Department of Transplant SurgeryGuy's and St Thomas’Evelina London Children's and Great Ormond Street Hospitals NHS TrustLondonUK
| | - Robert A. Montgomery
- NYU Langone Transplant InstituteNew York University Langone Medical CenterNew YorkNew York
| | - Mark D. Stegall
- The William J. von Liebig Center for Transplantation and Clinical Regeneration and Division of Transplantation SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesota
| | | | - Lynn D. Cornell
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesota
| | - Ajda T. Rowshani
- Department of Internal MedicineSection of Nephrology and TransplantationErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Robert B. Colvin
- Department of PathologyHarvard Medical SchoolMassachusetts General HospitalBostonMassachusetts
| | - Bradley Dain
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent statistics consultantGuilfordConnecticut
| | | | - Denis Glotz
- Paris Translational Research Center for Organ TransplantationInstitut National de la Santé et de la Recherche MédicaleUnité Mixte de Recherche‐S970ParisFrance,Department of Nephrology and Organ TransplantationSaint‐Louis HospitalAssistance Publique‐Hôpitaux de ParisInstitut National de la Santé et de la Recherche MédicaleUnité U1160ParisFrance
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18
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Glotz D, Russ G, Rostaing L, Legendre C, Tufveson G, Chadban S, Grinyó J, Mamode N, Rigotti P, Couzi L, Büchler M, Sandrini S, Dain B, Garfield M, Ogawa M, Richard T, Marks WH. Safety and efficacy of eculizumab for the prevention of antibody-mediated rejection after deceased-donor kidney transplantation in patients with preformed donor-specific antibodies. Am J Transplant 2019; 19:2865-2875. [PMID: 31012541 PMCID: PMC9328661 DOI: 10.1111/ajt.15397] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/17/2019] [Accepted: 04/04/2019] [Indexed: 01/25/2023]
Abstract
The presence of preformed donor-specific antibodies in transplant recipients increases the risk of acute antibody-mediated rejection (AMR). Results of an open-label single-arm trial to evaluate the safety and efficacy of eculizumab in preventing acute AMR in recipients of deceased-donor kidney transplants with preformed donor-specific antibodies are reported. Participants received eculizumab as follows: 1200 mg immediately before reperfusion; 900 mg on posttransplant days 1, 7, 14, 21, and 28; and 1200 mg at weeks 5, 7, and 9. All patients received thymoglobulin induction therapy and standard maintenance immunosuppression including steroids. The primary end point was treatment failure rate, a composite of biopsy-proved grade II/III AMR (Banff 2007 criteria), graft loss, death, or loss to follow-up, within 9 weeks posttransplant. Eighty patients received transplants (48 women); the median age was 52 years (range 24-70 years). Observed treatment failure rate (8.8%) was significantly lower than expected for standard care (40%; P < .001). By 9 weeks, 3 of 80 patients had experienced AMR, and 4 of 80 had experienced graft loss. At 36 months, graft and patient survival rates were 83.4% and 91.5%, respectively. Eculizumab was well tolerated and no new safety concerns were identified. Eculizumab has the potential to provide prophylaxis against injury caused by acute AMR in such patients (EudraCT 2010-019631-35).
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Affiliation(s)
- Denis Glotz
- Paris Translational Research Center for Organ TransplantationInstitut National de la Santé et de la Recherche MédicaleUnité Mixte de Recherche‐S970ParisFrance,Department of Nephrology and Organ TransplantationSaint‐Louis HospitalAssistance Publique‐Hôpitaux de ParisInstitut National de la Santé et de la Recherche MédicaleUnité U1160ParisFrance
| | - Graeme Russ
- Central and Northern Adelaide Renal and Transplantation ServicesRoyal Adelaide Hospital and University of AdelaideAdelaideSouth AustraliaAustralia
| | - Lionel Rostaing
- Formerly Department of Nephrology and Organ TransplantationRangueil University Hospital CenterToulouseFrance,Department of NephrologyHemodialysis, Apheresis and TransplantationGrenoble‐Alpes University Hospital CenterAvenue du Maquis du GrésivaudanLa TroncheFrance
| | - Christophe Legendre
- Adult Nephrology Transplantation ServiceHôpital Necker‐Enfants MaladesUniversité Paris DescartesSorbonne Paris CitéParisFrance,Institut National de la Santé et de la Recherche Médicale U1151Institut Necker‐Enfants MaladesHôpital Necker‐Enfants MaladesParisFrance
| | - Gunnar Tufveson
- Section of Transplantation SurgeryDepartment of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Steve Chadban
- Department of Renal MedicineRoyal Prince Alfred HospitalUniversity of SydneySydneyNew South WalesAustralia
| | - Josep Grinyó
- Department of NephrologyHospital Universitari de BellvitgeUniversity of BarcelonaBarcelonaSpain
| | - Nizam Mamode
- Department of Transplant SurgeryGuy's and St Thomas’, Evelina London Children's and Great Ormond Street Hospitals NHS TrustLondonUK
| | - Paolo Rigotti
- Kidney and Pancreas Transplant UnitUniversity Hospital of PaduaPaduaItaly
| | - Lionel Couzi
- UMR CNRS 5164ImmunoConcEpTBordeaux UniversityBordeauxFrance,Department of Nephrology–Transplantation–Dialysis–ApheresisCHUBordeauxFrance
| | | | - Silvio Sandrini
- Division of NephrologyUniversity of Brescia and Spedali Civili General HospitalBresciaItaly
| | - Bradley Dain
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent Statistics ConsultantGuilfordConnecticut
| | - Mary Garfield
- Formerly Alexion PharmaceuticalsBostonMassachusetts,ArvinasNew HavenConnecticut
| | | | | | - William H. Marks
- Formerly Alexion PharmaceuticalsBostonMassachusetts,Independent ConsultantBellevueWashington
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19
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Excellent outcome after desensitization in high immunologic risk kidney transplantation. PLoS One 2019; 14:e0222537. [PMID: 31550258 PMCID: PMC6759155 DOI: 10.1371/journal.pone.0222537] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/30/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction HLA-incompatible (HLAi) and ABO-incompatible (ABOi) kidney transplantation (KT) has been on the increase over the last decade. However, there are wide variations in outcomes from these procedures. In this study we evaluated the graft and patient outcomes in incompatible KT and non-sensitized KT. Methods Patients who underwent KT between January 2012 and April 2018 were enrolled and reviewed. We divided kidney transplant recipients (KTRs) into five groups as follows: HLAi (n = 50); ABOi (n = 65); HLAi+ABOi (n = 5); control (n = 428); and living-donor control (LD control, n = 218). We compared the risk of rejection, graft function, graft survival, and patient survival between incompatible KTRs and control/LD control KTRs. Results Although the incidence of active antibody-mediated rejection in HLAi group tends to be higher than in control and LD control groups (6.0% vs. 2.8%, P = 0.20; 6.0% vs. 3.7%, P = 0.44, respectively), the rejection-free survival, graft survival, and patient survival were not significantly different from those of the control and LD control groups in all three incompatible KT groups (all P>0.05). Graft function during the study period was also not different between incompatible KTRs and control/LD control groups (both P>0.05). Using Cox regression analysis, neither HLAi nor ABOi were risk factors for graft failure. Some infectious diseases such as urinary tract infection and cytomegalovirus infection were more common in the HLAi group than in the control/LD control group (both P<0.05), but only one infection-related death occurred in HLAi KTRs. Infection risks were similar in the ABOi and HLAi+ABOi groups compared to controls. Conclusion Our results showed favorable outcomes for incompatible KT after desensitization. Although desensitization therapy for incompatible KT has improved access to transplantation for KT candidates with high immunological risk, more clinical data are clearly needed.
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Okada M, Watarai Y, Iwasaki K, Futamura K, Yamamoto T, Hiramitsu T, Tsujita M, Goto N, Narumi S, Takeda A, Kobayashi T. Lower incidence of de novo donor-specific antibodies against HLA-DR in ABO-incompatible renal transplantation. Hum Immunol 2018; 80:169-175. [PMID: 30552908 DOI: 10.1016/j.humimm.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/25/2018] [Accepted: 12/09/2018] [Indexed: 12/12/2022]
Abstract
Recently, in vitro experiments have demonstrated that anti-blood group A/B antibody binding to endothelial cells induce a protective effect against antibody-mediated injury. This study aimed to clarify the potential clinical benefit of ABO incompatibility in donor-specific HLA antibody (DSA)-induced chronic antibody-mediated rejection (ABMR). We enrolled 215 ABO-incompatible renal transplant (ABO-I) and 467 ABO-identical/compatible renal transplant recipients (ABO-Id/C). The prevalence of de novo DSA production and incidence of biopsy-proven chronic ABMR were compared between the two groups. The incidence of DR-associated de novo DSA was significantly lower in ABO-I than in ABO-Id/C (P = 0.028). Diagnostic biopsy for ABMR was conducted in 54 patients (11 ABO-I and 43 ABO-Id/C). Biopsy-proven chronic ABMR was lower in ABO-I than in ABO-Id/C (27.3% [3/11] vs. 44.2% [19/43]) patients. Our findings suggest that ABO incompatibility may cause low production of DR-associated de novo DSA, possibly resulting in a reduced incidence of chronic ABMR.
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Affiliation(s)
- Manabu Okada
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan; Department of Renal Transplant Surgery, Aichi Medical University, School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
| | - Kenta Iwasaki
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University, School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Kenta Futamura
- Department of Transplant Internal Medicine, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Takayuki Yamamoto
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
| | - Makoto Tsujita
- Department of Transplant Internal Medicine, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Norihiko Goto
- Department of Transplant Internal Medicine, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Shunji Narumi
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
| | - Asami Takeda
- Department of Nephrology, Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University, School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan.
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Okada M, Watarai Y, Iwasaki K, Murotani K, Futamura K, Yamamoto T, Hiramitsu T, Tsujita M, Goto N, Narumi S, Takeda A, Morozumi K, Uchida K, Kobayashi T. Favorable results in ABO-incompatible renal transplantation without B cell-targeted therapy: Advantages and disadvantages of rituximab pretreatment. Clin Transplant 2017; 31. [PMID: 28792635 DOI: 10.1111/ctr.13071] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
The effectiveness of desensitization with rituximab in ABO-incompatible renal transplantation (ABO-I) has been widely reported. However, ABO-I outcomes are still worse than those of ABO-identical or ABO-compatible renal transplantation (ABO-Id/C). We retrospectively examined the outcomes in consecutive living donor ABO-Id/C (n = 412) and ABO-I (n = 205) cases to elucidate the causes of inferiority in ABO-I. ABO-I cases included recipients treated with rituximab (RIT, n = 131), splenectomy (SPX, n = 21), or neither because of low anti-A/B antibody titers (NoR/S, n = 53). Graft survival, infection, and de novo HLA antibody production were compared for ABO-I and ABO-Id/C, followed by stratification into RIT and NoR/S groups. Propensity score-based methods were employed to limit selection bias and potential confounders. Overall graft survival for ABO-I was significantly lower than that for ABO-Id/C (92.8% vs 97.2% after 5 years, P = .0037). Graft loss due to infection with ABO-I was significantly more frequent than that with ABO-Id/C, whereas acute antibody-mediated rejection (AMR) caused no graft failure in ABO-I recipients. Stratified analysis demonstrated significantly higher infection risk with RIT than with NoR/S. Safe reduction or avoidance of rituximab in desensitization protocols might contribute to further improvement of ABO-I outcome.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Iwasaki
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kenta Murotani
- Division of Biostatistics, Clinical Research Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan.,Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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Pankhurst L, Hudson A, Mumford L, Willicombe M, Galliford J, Shaw O, Thuraisingham R, Puliatti C, Talbot D, Griffin S, Torpey N, Ball S, Clark B, Briggs D, Fuggle SV, Higgins RM. The UK National Registry of ABO and HLA Antibody Incompatible Renal Transplantation: Pretransplant Factors Associated With Outcome in 879 Transplants. Transplant Direct 2017; 3:e181. [PMID: 28706984 PMCID: PMC5498022 DOI: 10.1097/txd.0000000000000695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/18/2017] [Accepted: 05/03/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers. METHODS The comprehensive national registry of AIT in the United Kingdom was investigated to describe the donor, recipient and transplant characteristics of AIT. Kaplan-Meier analysis was used to compare survival of AIT to all other compatible kidney transplants performed in the United Kingdom. Cox proportional hazards regression modeling was used to determine which pretransplant factors were associated with transplant survival in HLAi and ABOi separately. The primary outcome was transplant survival, taking account of death and graft failure. RESULTS For 522 HLAi and 357 ABO incompatible (ABOi) transplants, 5-year transplant survival rates were 71% (95% confidence interval [CI], 66-75%) for HLAi and 83% (95% CI, 78-87%) for ABOi, compared with 88% (95% CI, 87-89%) for 7290 standard living donor transplants, and 78% (95% CI, 77-79%) for 15 322 standard deceased donor transplants (P < 0.0001). Increased chance of transplant loss in HLAi was associated with increasing number of donor specific HLA antibodies, center performing the transplant, antibody level at the time of transplant, and an interaction between donor age and dialysis status. In ABOi, transplant loss was associated with no use of IVIg, cytomegalovirus seronegative recipient, 000 HLA donor-recipient mismatch; and increasing recipient age. CONCLUSIONS Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.
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Affiliation(s)
| | - Alex Hudson
- NHS Blood and Transplant, Bristol, United Kingdom
| | - Lisa Mumford
- NHS Blood and Transplant, Bristol, United Kingdom
| | | | - Jack Galliford
- Renal and Transplant Unit, Hammersmith Hospital, London, United Kingdom
| | - Olivia Shaw
- Clinical Transplantation Laboratory, Guy's Hospital, London, United Kingdom
| | - Raj Thuraisingham
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - Carmelo Puliatti
- Renal and Transplant Unit, Royal London Hospital, London, United Kingdom
| | - David Talbot
- Transplant Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Sian Griffin
- Renal and Transplant Unit, University Hospital of Wales, Cardiff, United Kingdom
| | - Nicholas Torpey
- Renal and Transplant Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Simon Ball
- Renal and Transplant Unit, University Hospital Birmingham, Birmingham, United Kingdom
| | - Brendan Clark
- Transplant Immunology, Leeds General Infirmary, Leeds, United Kingdom
| | - David Briggs
- Dept Histocompatibility and Immunobiology, NHSBT, Birmingham, United Kingdom
| | | | - Robert M. Higgins
- Renal and Transplant Unit, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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Abstract
BACKGROUND Desensitization therapy may enable the patient to get allograft in sensitized recipient or solve the organ shortage in ABO-incompatible relationship in kidney transplantation (KT). However, the graft outcome and morbidity remains unclear. METHODS We retrospectively analyzed 845 KT patients from January 2010 to February 2016 at Seoul National University Hospital. The patients were divided into three groups as follows: HLA-incompatible (HLAi) group, ABO-incompatible (ABOi) group, and control group. The HLAi group comprised patients who received desensitization therapy due to the presence of donor-specific antibodies (DSAs) or high panel reactive antibodies (PRAs). The ABOi group is defined as those undergoing preoperative desensitization therapy for anti-ABO antibodies. RESULTS Of the total of 845 recipients, 48 (5.6%) were HLAi KTs and 71 (13.9%) were ABOi KTs, respectively. Pre-emptive KT is done more frequently in ABOi group, therefore, they had shorter dialysis duration than the others. HLAi recipients had a higher proportion of women than the ABOi group and a higher proportion of re-transplantation. During the 38.4 (0.4-76.9) months of follow-up, there were more acute antibody-mediated rejections (AAMRs) in the HLAi (6.7%) and ABOi (8.5%) groups than in the control group (1.9%) (P = 0.001). However, there was no difference in graft survival, patient survival, and annual allograft among three groups. CONCLUSIONS Despite the higher incidence of AAMRs, HLAi and ABOi KTs showed a favorable graft and patient outcome after desensitization therapy.
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Desensitization protocol enabling pediatric crossmatch-positive renal transplantation: successful HLA-antibody-incompatible renal transplantation of two highly sensitized children. Pediatr Nephrol 2017; 32:359-364. [PMID: 27585679 PMCID: PMC5203834 DOI: 10.1007/s00467-016-3489-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/31/2016] [Accepted: 08/05/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Renal transplantation improves quality of life (QoL) and survival in children requiring renal replacement therapy (RRT). Sensitization with development of a broad-spectrum of anti-HLA antibodies as a result of previous transplantation or after receiving blood products is an increasing problem. There are no published reports of desensitization protocols in children allowing renal transplantation from HLA-antibody-incompatible living donors. METHODS We adopted our well-established adult desensitization protocol for this purpose and undertook HLA antibody-incompatible living donor renal transplants in two children: a 14-year-old girl and a 13-year-old boy. RESULTS After 2 and 1.5 years of follow-up, respectively, both patients have stable renal allograft function despite a rise in donor-specific antibodies in one case. CONCLUSIONS HLA-incompatible transplantation should be considered in selected cases for sensitized children.
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Kleinclauss F, Frontczak A, Terrier N, Thuret R, Timsit MO. [Immunology and immunosuppression in kidney transplantation. ABO and HLA incompatible kidney transplantation]. Prog Urol 2016; 26:977-992. [PMID: 27670824 DOI: 10.1016/j.purol.2016.08.015] [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: 07/15/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To perform a state of the art about immunological features in renal transplantation, immunosuppressive drugs and their mechanisms of action and immunologically high risk transplantations such as ABO and HLA-incompatible transplantation. MATERIAL AND METHODS An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "allogenic response; allograft; immunosuppression; ABO incompatible transplantation; donor specific antibodies; HLA incompatible; desensitization; kidney transplantation". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 4717 articles. After reading titles and abstracts, 141 were included in the text, based on their relevance. RESULTS The considerable step in comprehension and knowledge allogeneic response this last few years allowed a better used of immunosuppression and the discover of news immunosuppressive drugs. In the first part of this article, the allogeneic response will be described. The different classes of immunosuppressive drugs will be presented and the actual management of immunosuppression will be discussed. Eventually, the modalities and results of immunologically high-risk transplantations such as ABO and HLA incompatible transplantations will be reported. CONCLUSIONS The knowledge and the control of allogeneic response to allogeneic graft allowed the development of renal transplantation.
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Affiliation(s)
- F Kleinclauss
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France.
| | - A Frontczak
- Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France
| | - N Terrier
- Service d'urologie et transplantation rénale, CHU de Grenoble, 38700 Grenoble, France
| | - R Thuret
- Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34000 Montpellier, France
| | - M-O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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Rostaing L, Karam B, Congy-Jolivet N, Hage V, Sallusto F, Esposito L, Doumerc N, Debiol B, Guilbeau-Frugier C, Game X, Allal A, Kamar N. Successful Transplantation in ABO- and HLA-Incompatible Living Kidney Transplant Patients: A Report on 12 Cases. Ther Apher Dial 2016; 20:507-516. [DOI: 10.1111/1744-9987.12408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 01/25/2023]
Affiliation(s)
- Lionel Rostaing
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
- CHU Purpan, INSERM01043, IFR-BMT; Toulouse France
- Université Toulouse 3 Paul Sabaiter; Toulouse France
| | | | - Nicolas Congy-Jolivet
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- CHU Rangueil, Laboratory of Immunology; Toulouse France
| | - Valérie Hage
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Federico Sallusto
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Laure Esposito
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Nicolas Doumerc
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Bénédicte Debiol
- CHU Purpan, Etablissement Français du Sang de Midi-Pyrénées; Toulouse France
| | | | - Xavier Game
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- CHU Rangueil; Department of Urology, Andrology and Transplantation; Toulouse France
| | - Asma Allal
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
| | - Nassim Kamar
- CHU Rangueil, Nephrology, Dialysis, Transplantation; Toulouse France
- Université Toulouse 3 Paul Sabaiter; Toulouse France
- IFB-BMT - CHU Purpan, INSERM U563; Toulouse France
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