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Clinical Correlates and Outcomes of Dual Basiliximab and Antithymocyte Globulin Induction in Kidney Transplant Recipients: A National Study. Transplant Direct 2021; 7:e736. [PMID: 35836670 PMCID: PMC9276156 DOI: 10.1097/txd.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022] Open
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Ruggenenti P, Cravedi P, Gotti E, Plati A, Marasà M, Sandrini S, Bossini N, Citterio F, Minetti E, Montanaro D, Sabadini E, Tardanico R, Martinetti D, Gaspari F, Villa A, Perna A, Peraro F, Remuzzi G. Mycophenolate mofetil versus azathioprine in kidney transplant recipients on steroid-free, low-dose cyclosporine immunosuppression (ATHENA): A pragmatic randomized trial. PLoS Med 2021; 18:e1003668. [PMID: 34166370 PMCID: PMC8224852 DOI: 10.1371/journal.pmed.1003668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/23/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We compared protection of mycophenolate mofetil (MMF) and azathioprine (AZA) against acute cellular rejection (ACR) and chronic allograft nephropathy (CAN) in kidney transplant recipients on steroid-free, low-dose cyclosporine (CsA) microemulsion maintenance immunosuppression. METHODS AND FINDINGS ATHENA, a pragmatic, prospective, multicenter trial conducted by 6 Italian transplant centers, compared the outcomes of 233 consenting recipients of a first deceased donor kidney transplant induced with low-dose thymoglobulin and basiliximab and randomized to MMF (750 mg twice/day, n = 119) or AZA (75 to 125 mg/day, n = 114) added-on maintenance low-dose CsA microemulsion and 1-week steroid. In patients without acute clinical or subclinical rejections, CsA dose was progressively halved. Primary endpoint was biopsy-proven CAN. Analysis was by intention to treat. Participants were included between June 2007 and July 2012 and followed up to August 2016. Between-group donor and recipient characteristics, donor/recipient mismatches, and follow-up CsA blood levels were similar. During a median (interquartile range (IQR)) follow-up of 47.7 (44.2 to 48.9) months, 29 of 87 biopsied patients on MMF (33.3%) versus 31 of 88 on AZA (35.2%) developed CAN (hazard ratio (HR) [95% confidence interval (CI)]: 1.147 (0.691 to 1.904, p = 0.595). Twenty and 21 patients on MMF versus 34 and 14 on AZA had clinical [HR (95% CI): 0.58 (0.34 to 1.02); p = 0.057) or biopsy-proven subclinical [HR (95% CI): 1.49 (0.76 to 2.92); p = 0.249] ACR, respectively. Combined events [HR (95% CI): 0.85 (0.56 to 1.29); p = 0.438], patient and graft survival, delayed graft function (DGF), 3-year glomerular filtration rate (GFR) [53.8 (40.6;65.7) versus 49.8 (36.8;62.5) mL/min/1.73 m2, p = 0.50], and adverse events (AEs) were not significantly different between groups. Chronicity scores other than CAN predict long-term graft outcome. Study limitations include small sample size and unblinded design. CONCLUSIONS In this study, we found that in deceased donor kidney transplant recipients on low-dose CsA and no steroids, MMF had no significant benefits over AZA. This finding suggests that AZA, due to its lower costs, could safely replace MMF in combination with minimized immunosuppression. TRIAL REGISTRATION ClinicalTrials.gov NCT00494741; EUDRACT 2006-005604-14.
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Affiliation(s)
- Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Cravedi
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Eliana Gotti
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Annarita Plati
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maddalena Marasà
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Silvio Sandrini
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Nicola Bossini
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Franco Citterio
- Unit of Kidney Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Enrico Minetti
- Unit of Nephrology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Domenico Montanaro
- SOC di Nefrologia, Dialisi e Trapianto Renale della Azienda Ospedaliero Universitaria “S. Maria della Misericordia,” Udine, Italy
| | - Ettore Sabadini
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Regina Tardanico
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Davide Martinetti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Flavio Gaspari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessandro Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco Peraro
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- * E-mail:
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Casiraghi F, Perico N, Remuzzi G. Mesenchymal stromal cells for tolerance induction in organ transplantation. Hum Immunol 2017; 79:304-313. [PMID: 29288697 DOI: 10.1016/j.humimm.2017.12.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/06/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022]
Abstract
The primary challenge in organ transplantation continues to be the need to suppress the host immune system long-term to ensure prolonged allograft survival. Long-term non-specific immunosuppression can, however, result in life-threatening complications. Thus, efforts have been pursued to explore novel strategies that would allow minimization of maintenance immunosuppression, eventually leading to transplant tolerance. In this scenario, bone marrow-derived mesenchymal stromal cells (MSC), given their unique immunomodulatory properties to skew the balance between regulatory and memory T cells, have emerged as potential candidates for cell-based therapy to promote immune tolerance. Here, we review our initial clinical experience with bone marrow-derived MSC in living-donor kidney transplant recipients and provide an overview of the available results of other clinical programs with MSC in kidney and liver transplantation, highlighting hurdles and success of this innovative cell-based therapy.
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Affiliation(s)
| | - Norberto Perico
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Giuseppe Remuzzi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale (ASST), Papa Giovanni XXIII, Bergamo, Italy; L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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