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Kitchens WH, Larsen CP, Badell IR. Costimulatory Blockade and Solid Organ Transplantation: The Past, Present, and Future. Kidney Int Rep 2023; 8:2529-2545. [PMID: 38106575 PMCID: PMC10719580 DOI: 10.1016/j.ekir.2023.08.037] [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: 04/03/2023] [Revised: 08/01/2023] [Accepted: 08/28/2023] [Indexed: 12/19/2023] Open
Abstract
Belatacept is the first costimulatory blockade agent clinically approved for transplant immunosuppression. Although more than 10 years of study have demonstrated that belatacept offers superior long-term renal allograft and patient survival compared to conventional calcineurin inhibitor (CNI)-based immunosuppression regimens, the clinical adoption of belatacept has continued to lag because of concerns of an early risk of acute cellular rejection (ACR) and various logistical barriers to its administration. In this review, the history of the clinical development of belatacept is examined, along with the findings of the seminal BENEFIT and BENEFIT-EXT trials culminating in the clinical approval of belatacept. Recent efforts to incorporate belatacept into novel CNI-free immunosuppression regimens are reviewed, as well as the experience of the Emory Transplant Center in using a tapered course of low-dose tacrolimus in belatacept-treated renal allograft patients to garner the long-term outcome benefits of belatacept without the short-term increased risks of ACR. Potential avenues to increase the clinical adoption of belatacept in the future are explored, including surmounting the logistical barriers of belatacept administration through subcutaneous administration or more infrequent belatacept dosing. In addition, belatacept conversion strategies and potential expanded clinical indications of belatacept are discussed for pediatric transplant recipients, extrarenal transplant recipients, treatment of antibody-mediated rejection (AMR), and in patients with failed renal allografts. Finally, we discuss the novel immunosuppressive drugs currently in the development pipeline that may aid in the expansion of costimulation blockade utilization.
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Affiliation(s)
- William H. Kitchens
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - I. Raul Badell
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Bredewold OW, Chan J, Svensson M, Bruchfeld A, de Fijter JW, Furuland H, Grinyo JM, Hartmann A, Holdaas H, Hellberg O, Jardine A, Mjörnstedt L, Skov K, Smerud KT, Soveri I, Sørensen SS, Zonneveld AJV, Fellström B. Cardiovascular Risk Following Conversion to Belatacept From a Calcineurin Inhibitor in Kidney Transplant Recipients: A Randomized Clinical Trial. Kidney Med 2022; 5:100574. [PMID: 36593877 PMCID: PMC9803830 DOI: 10.1016/j.xkme.2022.100574] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rationale & Objective In kidney transplant recipients (KTRs), a belatacept-based immunosuppressive regimen is associated with beneficial effects on cardiovascular (CV) risk factors compared with calcineurin inhibitor (CNI)-based regimens. Our objective was to compare the calculated CV risk between belatacept and CNI (predominantly tacrolimus) treatments using a validated model developed for KTRs. Study Design Prospective, randomized, open-label, parallel-group, investigator-initiated, international multicenter trial. Setting & Participants KTRs aged 18-80 years with a stable graft function (estimated glomerular filtration rate > 20 mL/min/1.73 m2), 3-60 months after transplantation, treated with tacrolimus or cyclosporine A, were eligible for inclusion. Intervention Continuation with a CNI-based regimen or switch to belatacept for 12 months. Outcomes Comparison of the change in the estimated 7-year risk of major adverse CV events and all-cause mortality, changes in traditional markers of CV health, as well as measures of arterial stiffness. Results Among the 105 KTRs randomized, we found no differences between the treatment groups in the predicted risk for major adverse CV events or mortality. Diastolic blood pressure, measured both centrally by using a SphygmoCor device and peripherally, was lower after the belatacept treatment than after the CNI treatment. The mean changes in traditional cardiovascular (CV) risk factors, including kidney transplant function, were otherwise similar in both the treatment groups. The belatacept group had 4 acute rejection episodes; 2 were severe rejections, of which 1 led to graft loss. Limitations The heterogeneous baseline estimated glomerular filtration rate and time from transplantation to trial enrollment in the participants. A limited study duration of 1 year. Conclusions We found no effects on the calculated CV risk by switching to the belatacept treatment. Participants in the belatacept group had not only lower central and peripheral diastolic blood pressure but also a higher rejection rate. Funding The trial has received a financial grant from Bristol-Myers Squibb. Trial Registration EudraCT no. 2013-001178-20.
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Affiliation(s)
- Obbo W. Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands,Address for Correspondence: Obbo W. Bredewold, MD, Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Joe Chan
- Department of Renal Medicine, Akershus University Hospital, Lørenskog, Norway
| | - My Svensson
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Johan W. de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Furuland
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
| | - Josep M. Grinyo
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Hallvard Holdaas
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Olof Hellberg
- Department of Internal Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alan Jardine
- Department of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Lars Mjörnstedt
- Division of Transplantation, Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Karin Skov
- Department of Renal Medicine, Aarhus University Hospital, Denmark
| | | | - Inga Soveri
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
| | - Søren S. Sørensen
- Department of Nephrology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Bengt Fellström
- Department of Medical Science, Renal Unit, University Hospital, Uppsala, Sweden
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El Hennawy H, Safar O, Al Faifi AS, El Nazer W, Kamal A, Mahedy A, Zaitoun M, Fahmy AE. Belatacept rescue therapy of CNI-induced nephrotoxicity, meta-analysis. Transplant Rev (Orlando) 2021; 35:100653. [PMID: 34597943 DOI: 10.1016/j.trre.2021.100653] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/28/2021] [Accepted: 09/15/2021] [Indexed: 01/03/2023]
Abstract
There is growing evidence about the potential favorable effects that can be obtained from converting the administration of calcineurin inhibitors (CNIs) to Belatacept in kidney transplantation recipients. We conducted a meta-analysis to formulate strong evidence from the current literature about this effect on kidney functions, as measured by the estimated glomerular filtration rate (eGFR). Our search was conducted on the following databases: PubMed, Web of Science, Scopus, Embase, Google Scholar, Cochrane library, the clinical trials, and the International Standard Randomized Controlled Trial Number registries to obtain all studies that investigated the effect of post-transplantation CNIs conversion to Belatacept on kidney functions. Thirteen studies were finally included in the current study. The results showed a significant improvement in the eGFR following the conversion as compared to its value prior to it (MD = 10.41; 95% CI = 6.93, 13.90; P-value < 0.001). Although, there was no risk of bias among the pooled studies (P-value = 0.391), there was a significant heterogenity (I 2 = 80%; P value < 0.001). Serum creatinine levels showed no significant change following the conversion as compared to its value prior to it (MD = -1.22; 95% CI = -2.61, 0.16; P-value = 0.083). Nevertheless, a significant heterogeneity among the included studies was observed (I 2 = 87%; P-value = 0.005). Belatacept can be a good alternative to the CNI-based regimens following the kidney transplantation. The conversion to Belatacept resulted in an improvement in eGFR.
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Affiliation(s)
- Hany El Hennawy
- Surgery Department, Section of Transplantation, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia.
| | - Omar Safar
- Urology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Abdullah S Al Faifi
- Surgery Department, Section of Transplantation, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed Kamal
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed Mahedy
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Mohammad Zaitoun
- Pharmacy Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed E Fahmy
- Transplant Surgery Department, North Shore University Hospital, Northwell Health, Manhasset, NY, United States of America
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Kumar J, Reccia I, Virdis F, Podda M, Sharma AK, Halawa A. Belatacept in renal transplantation in comparison to tacrolimus and molecular understanding of resistance pattern: Meta-analysis and systematic review. World J Transplant 2021; 11:70-86. [PMID: 33816147 PMCID: PMC8009058 DOI: 10.5500/wjt.v11.i3.70] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/23/2020] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The T-cell costimulation blocking agent belatacept has been identified as a possible substitute for calcineurin inhibitors, however, no consensus has been established against its use over the standard care agent Tacrolimus.
AIM To evaluate the effectiveness of belatacept based maintenance immuno-suppressive regimens in comparison to tacrolimus in renal transplantion.
METHODS We did extensive search of all the available literature comparing the role of belatacept to tacrolimus in renal transplant recipients by searching the PubMed, Embase, Cochrane, Crossref, Scopus, clinical trials registry on October 5, 2020.
RESULTS The literature search identified four randomized controlled trials (n = 173 participants) comparing belatacept with tacrolimus. There was no significant difference in estimated renal function at 12 mo [mean difference 4.12 mL/min/1.73 m2, confidence interval (CI): -2.18 to 10.42, P = 0.20]. Further, belatacept group was associated with significant increase in biopsy proven acute rejection [relative risk (RR) = 3.27, CI: 0.88 to 12.11, P = 0.08] and worse 12 mo allograft survival (RR = 4.51, CI: 1.23 to 16.58, P = 0.02). However, incidence of new onset diabetes mellitus was lower with belatacept at 12 mo (RR = 0.26, CI: 0.07 to 0.99, P = 0.05).
CONCLUSION The evidence reviewed in this meta-analysis suggested that belatacept-based maintenance immunosuppression regimens were associated with an increased risk allograft loss in renal transplant recipients with equivalent renal functioning against standard tacrolimus; however, observed significantly reduced new onset diabetes mellitus after transplantation incidence and lower serum low density lipid profile levels in belatacept group. In addition, the adaptation of belatacept in renal transplantation has been forestalled by increased rates of rejection and resistance owing to development of various effector memory T cells through, parallel differentiation and immunological plasticity.
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Affiliation(s)
- Jayant Kumar
- Department of Cancer and Surgery, Imperial College, London W12 0HS, United Kingdom
| | - Isabella Reccia
- Department of Cancer and Surgery, Imperial College, London W12 0HS, United Kingdom
| | - Francesco Virdis
- Department of Emergency General Surgery, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Mauro Podda
- Department of Surgery, General, Emergency and Robotic Surgical Unit, San Francesco Hospital, Nuoro 08100, Italy
| | - Ajay Kumar Sharma
- Department of Transplantation, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
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Perrier Q, Portais A, Terrec F, Cerba Y, Romanet T, Malvezzi P, Bedouch P, Tetaz R, Rostaing L. A Case of Pneumocystis jirovecii Pneumonia under Belatacept and Everolimus: Benefit-Risk Balance between Renal Allograft Function and Infection. Case Rep Nephrol Dial 2021; 11:10-15. [PMID: 33708795 PMCID: PMC7923707 DOI: 10.1159/000510842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 11/20/2022] Open
Abstract
Pneumocystis jirovecii pneumonia is an opportunistic disease usually prevented by trimethoprim-sulfamethoxazole. A 49-year-old HLA-sensitized male with successful late conversion from tacrolimus-based to belatacept-based immunosuppression developed P. jirovecii pneumonia for which he presented several risks factors: low lymphocyte count with no CD4+ T cells detected since 2 years, hypogammaglobulinemia, history of acute cellular rejection 3 years before, and immunosuppressive treatment (belatacept, everolimus). Because of respiratory gravity in the acute phase, the patient was given oxygen, corticosteroids, and trimethoprim-sulfamethoxazole. Thanks to the improvement of respiratory status, and because of the renal impairment, trimethoprim-sulfamethoxazole was converted to atovaquone for 21 days. Indeed, after 1 week on intensive treatment, the benefit-risk balance favored preserving renal function according to respiratory improvement status. P. jirovecii pneumonia prophylaxis for the next 6 months was monthly aerosol of pentamidine. Long-term safety studies or early/late conversion to belatacept did not report on P. jirovecii pneumonia. Four other cases of P. jirovecii pneumonia under belatacept therapy were previously described in patients having no P. jirovecii pneumonia prophylaxis. Studies on the reintroduction of P. jiroveciipneumonia prophylaxis after conversion to belatacept would be of interest. It could be useful to continue regular evaluation within the second-year post-transplantation regarding immunosuppression: T-cell subsets and immunoglobulin G levels.
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Affiliation(s)
- Quentin Perrier
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Portais
- Infectious Diseases Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Yann Cerba
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Thierry Romanet
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble-Alpes, Grenoble, France
| | - Pierrick Bedouch
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble Alpes, CNRS TIMC-IMAG, UMR 5525, Grenoble, France
| | - Rachel Tetaz
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble-Alpes, Grenoble, France
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Bertrand D, Terrec F, Etienne I, Chavarot N, Sberro R, Gatault P, Garrouste C, Bouvier N, Grall-Jezequel A, Jaureguy M, Caillard S, Thervet E, Colosio C, Golbin L, Rerolle JP, Thierry A, Sayegh J, Janbon B, Malvezzi P, Jouve T, Rostaing L, Noble J. Opportunistic Infections and Efficacy Following Conversion to Belatacept-Based Therapy after Kidney Transplantation: A French Multicenter Cohort. J Clin Med 2020; 9:jcm9113479. [PMID: 33126667 PMCID: PMC7693007 DOI: 10.3390/jcm9113479] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022] Open
Abstract
Conversion from calcineurin-inhibitors (CNIs) to belatacept can help kidney-transplant (KT) recipients avoid CNI-related nephrotoxicity. The risk of associated opportunistic infections (OPIs) is ill-defined. We conducted a multicentric cohort study across 15 French KT-centers in a real-life setting. Between 07-2010 and 07-2019, 453 KT recipients were converted from CNI- to belatacept-based therapy at 19 [0.13-431] months post-transplantation. Most patients, i.e., 332 (79.3%), were converted after 6-months post-transplantation. Follow-up time after conversion was 20.1 +/- 13 months. OPIs developed in 42(9.3%) patients after 14 +/- 12 months post-conversion. Eight patients (19%) had two OPI episodes during follow-up. Incidences of CMV DNAemia and CMV disease were significantly higher in patients converted before 6-months post-KT compared to those converted later (i.e., 31.6% vs. 11.5%; p < 0.001; and 11.6% vs. 2.4%, p < 0.001, respectively). Cumulative incidence of OPIs was 6.5 OPIs/100 person-years. Incidence of CMV disease was 2.8/100 person-years, of pneumocystis pneumonia 1.6/100 person-years, and of aspergillosis 0.2/100 person-years. Multivariate analyses showed that estimated glomerular filtration (eGFR) < 25 mL/min/1.73 m2 at conversion was independently associated with OPIs (HR = 4.7 (2.2 - 10.3), p < 0.001). The incidence of EBV DNAemia was 17.3 events /100 person-years. At 1-year post-conversion, mean eGFR had significantly increased from 32.0 +/- 18 mL/min/1.73 m2 to 42.2 +/- 18 mL/min/1.73 m2 (p < 0.0001). Conversion to belatacept is an effective strategy with a low infectious risk.
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Affiliation(s)
- Dominique Bertrand
- Department of Nephrology and Transplantation, Rouen University Hospital, 76000 Rouen, France; (D.B.); (I.E.)
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Isabelle Etienne
- Department of Nephrology and Transplantation, Rouen University Hospital, 76000 Rouen, France; (D.B.); (I.E.)
| | - Nathalie Chavarot
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Rebecca Sberro
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Philippe Gatault
- Department of Nephrology, Tours University Hospital, 37000 Tours, France;
| | - Cyril Garrouste
- Department of Nephrology, Clermont Ferrand University Hospital, 63000 Clermont Ferrand, France;
| | - Nicolas Bouvier
- Department of Nephrology, Caen University Hospital, 14000 Caen, France;
| | | | - Maïté Jaureguy
- Department of Nephrology, Amiens University Hospital, 80000 Amiens, France;
| | - Sophie Caillard
- Department of Nephrology, Strasbourg University Hospital, 67000 Strasbourg, France;
| | - Eric Thervet
- Department of Nephrology, European Georges Pompidou University Hospital, 75000 Paris, France;
| | - Charlotte Colosio
- Department of Nephrology, Reims University Hospital, 51100 Reims, France;
| | - Leonard Golbin
- Department of Nephrology, Rennes University Hospital, 35000 Rennes, France;
| | | | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, 86000 Poitiers, France;
| | - Johnny Sayegh
- Department of Nephrology, Angers University Hospital, 49000 Angers, France;
| | - Bénédicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, 75000 Paris, France; (N.C.); (R.S.)
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (F.T.); (B.J.); (P.M.); (T.J.); (J.N.)
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Choi M, Bachmann F, Wu K, Lachmann N, Schmidt D, Brakemeier S, Duerr M, Kahl A, Eckardt KU, Budde K, Nickel P. Microvascular inflammation is a risk factor in kidney transplant recipients with very late conversion from calcineurin inhibitor-based regimens to belatacept. BMC Nephrol 2020; 21:354. [PMID: 32819287 PMCID: PMC7439694 DOI: 10.1186/s12882-020-01992-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/29/2020] [Indexed: 01/05/2023] Open
Abstract
Background In de novo kidney transplant recipients (KTR) treatment with belatacept has been established as a comparable option as maintenance immunosuppression, preferably as a strategy to convert from calcineurin inhibitor (CNI)- to belatacept-based immunosuppression. Switch to belatacept demonstrated improved renal function in patients with CNI-induced nephrotoxicity, but risk of transplant rejection and the development of donor-specific antibodies (DSA) are still a matter of debate. Only few data are available in patients at increased immunological risk and late after transplantation. Methods We analyzed 30 long-term KTR (including 2 combined pancreas-KTR) converted from CNI to belatacept > 60 months after transplantation with moderate to severe graft dysfunction (GFR ≤ 45 mL/min). Biopsies were classified according to the Banff 2015 criteria. Group differences were assessed in a univariate analysis using Mann Whitney U or Chi square test, respectively. Multivariate analysis of risk factors for treatment failure was performed using a binary logistic regression model including significant predictors from univariate analysis. Fifty-six KTR matched for donor and recipient characteristics were used as a control cohort remaining under CNI-treatment. Results Patient survival in belatacept cohort at 12/24 months was 96.7%/90%, overall graft survival was 76.7 and 60.0%, while graft survival censored for death was 79.3%/66.7%. In patients with functioning grafts, median GFR improved from 22.5 mL/min to 24.5 mL/min at 24 months. Positivity for DSA at conversion was 46.7%. From univariate analysis of risk factors for graft loss, GFR < 25 mL/min (p = 0.042) and Banff microvascular inflammation (MVI) sum score ≥ 2 (p = 0.023) at conversion were significant at 24 months. In the analysis of risk factors for treatment failure, a MVI sum score ≥ 2 was significant univariately (p = 0.023) and in a bivariate (p = 0.037) logistic regression at 12 months. DSA-positivity was neither associated with graft loss nor treatment failure. The control cohort had comparable graft survival outcomes at 24 months, albeit without increase of mean GFR in patients with functioning grafts (ΔGFR of − 3.6 ± 8.5 mL/min). Conclusion Rescue therapy with conversion to belatacept is feasible in patients with worsening renal function, even many years after transplantation. The benefit in patients with MVI and severe GFR impairment remains to be investigated.
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Affiliation(s)
- Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Lachmann
- Tissue Typing Laboratory, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Abstract
Costimulation between T cells and antigen-presenting cells is essential for the regulation of an effective alloimmune response and is not targeted with the conventional immunosuppressive therapy after kidney transplantation. Costimulation blockade therapy with biologicals allows precise targeting of the immune response but without non-immune adverse events. Multiple costimulation blockade approaches have been developed that inhibit the alloimmune response in kidney transplant recipients with varying degrees of success. Belatacept, an immunosuppressive drug that selectively targets the CD28-CD80/CD86 pathway, is the only costimulation blockade therapy that is currently approved for kidney transplant recipients. In the last decade, belatacept therapy has been shown to be a promising therapy in subgroups of kidney transplant recipients; however, the widespread use of belatacept has been tempered by an increased risk of acute kidney transplant rejection. The purpose of this review is to provide an overview of the costimulation blockade therapies that are currently in use or being developed for kidney transplant indications.
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9
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Noble J, Jouve T, Janbon B, Rostaing L, Malvezzi P. Belatacept in kidney transplantation and its limitations. Expert Rev Clin Immunol 2019; 15:359-367. [DOI: 10.1080/1744666x.2019.1574570] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
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