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Pak WLW, Brumwell NA, Kabel CC, Gutgarts V, Jaffer Sathick I, Mailankody S, Lesokhin AM, Landau HJ, Shaikh A. Chimeric Antigen Receptor (CAR) T-Cell Therapy Use in Patients with Multiple Myeloma and Kidney Failure on Maintenance Hemodialysis: A Report of 2 Cases. Kidney Med 2024; 6:100856. [PMID: 39100867 PMCID: PMC11295848 DOI: 10.1016/j.xkme.2024.100856] [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] [Indexed: 08/06/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy against B-cell maturation antigen is a new treatment modality for relapsed or refractory multiple myeloma (MM). Patients with kidney failure and MM were excluded from the pivotal CAR T-cell therapy clinical trials: KaRMMa (idecabtagene vicleucel) and CARTITUDE (ciltacabtagene autocleucel). The safety and efficacy of CAR T-cell therapy in patients with relapsed or refractory MM and kidney failure are limited to a few case reports using idecabtagene vicleucel. Here, we report the first 2 cases of ciltacabtagene autoleucel use in patients with kidney failure on maintenance hemodialysis and relapsed or refractory MM. Both patients achieved a hematologic response following ciltacabtagene autoleucel administration without serious adverse events. These findings suggest that ciltacabtagene autoleucel may be safe and effective in patients with relapsed or refractory MM and kidney failure. In this report, we review the available literature regarding the use of CAR T-cell therapy in patients with MM and kidney failure. We also discuss the modification of the lymphodepletion regimen in the kidney failure setting.
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Affiliation(s)
- Wai Lun Will Pak
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Natalie A. Brumwell
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Charlene C. Kabel
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Victoria Gutgarts
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Insara Jaffer Sathick
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Sham Mailankody
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander M. Lesokhin
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Heather J. Landau
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aisha Shaikh
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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2
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Alotaibi M, Alahmadi Z, Desai N, Brennan DC, Kant S. Twenty years in the making: tolerance in a living-related kidney transplant recipient. J Nephrol 2024:10.1007/s40620-023-01843-1. [PMID: 38175522 DOI: 10.1007/s40620-023-01843-1] [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: 08/20/2023] [Accepted: 11/18/2023] [Indexed: 01/05/2024]
Abstract
Kidney transplant recipients require lifelong immunosuppression to prevent graft rejection. However, immunosuppression is associated with adverse effects. A minority of kidney transplant recipients can be weaned off immunosuppression and maintain their graft function, a situation referred to as "functional or operational tolerance". We describe a case of a 70-year-old man who received a haploidentical hematopoietic cell transplant for lymphoma 22 years before receiving a kidney transplant from the same donor and was weaned off all immunosuppression by four months post-transplant. Tolerance was present, and there has been no graft rejection or graft vs. host disease. This case demonstrates successful long-term hematopoietic chimerism and functional tolerance after receiving a kidney transplant from the same donor.
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Affiliation(s)
- Manal Alotaibi
- Comprehensive Transplant Center and Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Umm Al-Qura University, College of Medicine, Makkah, Saudi Arabia.
| | - Ziad Alahmadi
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Niraj Desai
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel C Brennan
- Comprehensive Transplant Center and Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sam Kant
- Comprehensive Transplant Center and Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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3
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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4
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Mengrelis K, Muckenhuber M, Wekerle T. Chimerism-based Tolerance Induction in Clinical Transplantation: Its Foundations and Mechanisms. Transplantation 2023; 107:2473-2485. [PMID: 37046378 DOI: 10.1097/tp.0000000000004589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hematopoietic chimerism remains the most promising strategy to bring transplantation tolerance into clinical routine. The concept of chimerism-based tolerance aims to extend the recipient's mechanisms of self-tolerance (ie, clonal deletion, anergy, and regulation) to include the tolerization of donor antigens that are introduced through the cotransplantation of donor hematopoietic cells. For this to be successful, donor hematopoietic cells need to engraft in the recipient at least temporarily. Three pioneering clinical trials inducing chimerism-based tolerance in kidney transplantation have been published to date. Within this review, we discuss the mechanisms of tolerance that are associated with the specific therapeutic protocols of each trial. Recent data highlight the importance of regulation as a mechanism that maintains tolerance. Insufficient regulatory mechanisms are also a likely explanation for situations of tolerance failure despite persisting donor chimerism. After decades of preclinical development of chimerism protocols, mechanistic data from clinical trials have recently become increasingly important. Better understanding of the required mechanisms for tolerance to be induced in humans will be a key to design more reliable and less invasive chimerism protocols in the future.
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Affiliation(s)
- Konstantinos Mengrelis
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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5
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Marquard F, Langebrake C, Janson D, Mahmud M, Dadkhah A, Kröger N, Ayuk F. Case Report: Lymphodepletion followed by CAR-T cell therapy with Idecabtagen vicleucel in a patient with severe renal impairment. Front Oncol 2023; 13:1288764. [PMID: 38033500 PMCID: PMC10682764 DOI: 10.3389/fonc.2023.1288764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Acute kidney injury and chronic kidney disease is common in multiple myeloma. Fludarabine which is part of lymphodepletion before CAR-T cell therapy is renally eliminated and its use is not recommended for patients with severe renal impairment defined as a glomerular filtration rate below 30ml/min/1.73m2. We administered fludarabine to a 58-year-old female patient with myeloma-associated severe renal impairment as part of lymphodepletion before Idecabtagen vicleucel infusion. Fludarabine was administered in reduced dose (15mg/m2) and cyclophosphamide with a dose of 300mg/m2 followed by hemodialysis over six hours using a larger filter (FX-100). The therapy was well tolerated with excellent CAR-T cell expansion and complete remission which is ongoing now beyond 12 months.
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Affiliation(s)
- Franziska Marquard
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine, Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maida Mahmud
- Department of Medicine (3rd), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine, Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Gomez-Arteaga A, Orfali N, Pasciolla M, Baptiste A, Guindine I, Hsu J, Lin J, Mayer SA, Phillips AA, Shore TB, Simonson PD, DiCarlo E, Yoon S, Muthukumar T, van Besien K. Haploidentical allogeneic stem cell transplantation with post-transplant cyclophosphamide and subsequent kidney transplant for patients with severe sickle cell disease with end-stage kidney disease (ESKD). Bone Marrow Transplant 2023; 58:835-838. [PMID: 37045941 DOI: 10.1038/s41409-023-01981-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Alexandra Gomez-Arteaga
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA.
| | - Nina Orfali
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
- Department of Haematology, St James Hospital, Dublin, Ireland
| | - Michelle Pasciolla
- Department of Pharmacy, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ayanna Baptiste
- Division of Hematology and Oncology, NewYork-Presbyterian Hospital Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Inna Guindine
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jingmei Hsu
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jonathan Lin
- Division of Nephrology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
- The Rogosin Institute, New York, NY, USA
| | - Sebastian A Mayer
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Adrienne A Phillips
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Tsiporah B Shore
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Paul D Simonson
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Edward DiCarlo
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Sung Yoon
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
- The Rogosin Institute, New York, NY, USA
| | - Koen van Besien
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
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7
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Hotta K, Hirose T, Kawai T. Clinical trials for renal allograft tolerance induction through combined hematopoietic stem cell transplantation: A narrative review. Int J Urol 2022; 29:1397-1404. [PMID: 36101964 DOI: 10.1111/iju.15035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022]
Abstract
During the last four decades, development of effective immunosuppressants has significantly improved short-term results of organ transplantation. However, long-term results have not been satisfactory due to chronic rejection or complications caused by immunosuppressive drugs. Therefore, induction of immunological tolerance of the transplanted organ is considered essential to improve the long-term results. Despite numerous tolerance strategies that have been successful in murine models, inducing hematopoietic chimerism through donor hematopoietic stem cell transplantation is the only method that reproducibly induces kidney allograft tolerance in nonhuman primates or humans. Combining kidney and hematopoietic stem cell transplantation to achieve allograft tolerance has now been attempted with different chimerism strategies. This review summarizes the status of current clinical trials on the induction of allograft tolerance. We also summarize recent studies to extend the chimerism approach to deceased donor transplant recipients.
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Affiliation(s)
- Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Takayuki Hirose
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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8
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Miller KC, Hall AC, Cohen-Bucay A, Chen YBA. Delayed Kidney Transplantation after HLA-Haploidentical Hematopoietic Cell Transplantation in a Young Woman with Myelodysplastic Syndrome. Leuk Res Rep 2022; 17:100302. [PMID: 35360511 PMCID: PMC8961207 DOI: 10.1016/j.lrr.2022.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/16/2022] [Indexed: 11/02/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) are often excluded from potentially curative allogeneic hematopoietic cell transplantation (alloHCT). Our institution pioneered simultaneous living donor kidney transplantation in patients undergoing alloHCT from the same donor for hematologic malignancies. Herein, we present the case of a 31-year-old woman diagnosed with myelodysplastic syndrome who developed ESRD during cytoreductive induction therapy. She achieved disease control, then successfully underwent a human leukocyte antigen (HLA)-haploidentical alloHCT while on hemodialysis. After rapidly tapering off graft-versus-host disease prophylaxis, fourteen months from her alloHCT she received a kidney transplant from her same haploidentical sibling donor, which obviated the need for further systemic immunosuppression.
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9
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Hunter BD, Hoda D, Nguyen A, Gouw L, Huber B, Jensen RR, Preedit J, Evens A, Huang E, Park J, Cooper DL. Successful administration of chimeric antigen receptor (CAR) T-cell therapy in patients requiring hemodialysis. Exp Hematol Oncol 2022; 11:10. [PMID: 35227310 PMCID: PMC8883625 DOI: 10.1186/s40164-022-00266-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/19/2022] [Indexed: 11/21/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of relapsed/refractory B-cell malignancies. However, there is no data on the safety and efficacy of CAR T-cell therapy in patients with end stage renal disease (ESRD) requiring dialysis. In this report, we present two patients with DLBCL and ESRD who were successfully treated with different CAR T-cell products. Patient #1 is a 66 year-old woman with a history of HIV who was treated to complete response with axicabtagene ciloleucel with treatment complicated by grade 1 cytokine release syndrome (CRS) and grade 2 immune effector cell-associated neurolotoxicity syndrome (ICANS). Patient #2 is 52 year old woman whose ESRD was caused by ifosphamide toxicity and was treated to complete response with lisocabtagene maraleucel and did not experience either CRS or ICANS. Both patients received lymphodepletion chemotherapy with fludarabine and cyclophosphamide, which was dose-adjusted for ESRD with scheduled dialysis 12 h after each dose of lymphodepletion chemotherapy. Patients with DLBCL and ESRD can be safely administered both lymphodepletion chemotherapy and CAR T-cell therapy. Additionally, the fact that both patients achieved complete response to therapy suggests that CAR T-cell therapy should be strongly considered in patients with ESRD. Long-term follow up is needed to determine if therapy in this setting is of curative intent.
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Affiliation(s)
- Bradley D Hunter
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States.
| | - Daanish Hoda
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Andy Nguyen
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Launce Gouw
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Bryan Huber
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Ryan R Jensen
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Justine Preedit
- Blood and Marrow Transplant, Intermountain Healthcare, LDS Hospital, 8th Avenue and C Street, E8 BMT, Salt Lake City, UT, United States
| | - Andrew Evens
- Blood and Marrow Transplantation, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Esther Huang
- Blood and Marrow Transplantation, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Jiyeon Park
- Blood and Marrow Transplantation, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Dennis L Cooper
- Blood and Marrow Transplantation, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
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10
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Hadjis AD, Nunes NS, Khan SM, Fletcher RE, Pohl ADP, Venzon DJ, Eckhaus MA, Kanakry CG. Post-Transplantation Cyclophosphamide Uniquely Restrains Alloreactive CD4 + T-Cell Proliferation and Differentiation After Murine MHC-Haploidentical Hematopoietic Cell Transplantation. Front Immunol 2022; 13:796349. [PMID: 35242129 PMCID: PMC8886236 DOI: 10.3389/fimmu.2022.796349] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/06/2022] [Indexed: 12/25/2022] Open
Abstract
Post-transplantation cyclophosphamide (PTCy) reduces the incidence and severity of graft-versus-host disease (GVHD), thereby improving the safety and accessibility of allogeneic hematopoietic cell transplantation (HCT). We have shown that PTCy works by inducing functional impairment and suppression of alloreactive T cells. We also have identified that reduced proliferation of alloreactive CD4+ T cells at day +7 and preferential recovery of CD4+CD25+Foxp3+ regulatory T cells (Tregs) at day +21 are potential biomarkers associated with optimal PTCy dosing and timing in our B6C3F1→B6D2F1 MHC-haploidentical murine HCT model. To understand whether the effects of PTCy are unique and also to understand better the biology of GVHD prevention by PTCy, here we tested the relative impact of cyclophosphamide compared with five other optimally dosed chemotherapeutics (methotrexate, bendamustine, paclitaxel, vincristine, and cytarabine) that vary in mechanisms of action and drug resistance. Only cyclophosphamide, methotrexate, and cytarabine were effective in preventing fatal GVHD, but cyclophosphamide was superior in ameliorating both clinical and histopathological GVHD. Flow cytometric analyses of blood and spleens revealed that these three chemotherapeutics were distinct in constraining conventional T-cell numerical recovery and facilitating preferential Treg recovery at day +21. However, cyclophosphamide was unique in consistently reducing proliferation and expression of the activation marker CD25 by alloreactive CD4+Foxp3- conventional T cells at day +7. Furthermore, cyclophosphamide restrained the differentiation of alloreactive CD4+Foxp3- conventional T cells at both days +7 and +21, whereas methotrexate and cytarabine only restrained differentiation at day +7. No chemotherapeutic selectively eliminated alloreactive T cells. These data suggest that constrained alloreactive CD4+Foxp3- conventional T-cell numerical recovery and associated preferential CD4+CD25+Foxp3+ Treg reconstitution at day +21 may be potential biomarkers of effective GVHD prevention. Additionally, these results reveal that PTCy uniquely restrains alloreactive CD4+Foxp3- conventional T-cell proliferation and differentiation, which may explain the superior effects of PTCy in preventing GVHD. Further study is needed to determine whether these findings also hold true in clinical HCT.
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Affiliation(s)
- Ashley D. Hadjis
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Natalia S. Nunes
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Shanzay M. Khan
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Rochelle E. Fletcher
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Alessandra de Paula Pohl
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - David J. Venzon
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Michael A. Eckhaus
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, MD, United States
| | - Christopher G. Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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11
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Yu J, Sherburne B, Chen YB, Kutzler HL, Tremaglio J, Rochon C, Sheiner P, Serrano OK. Acute Myeloid Leukemia Presenting Less Than 3 Weeks After Living Donor Kidney Transplant: A Case Report. Transplant Proc 2021; 53:1360-1364. [PMID: 33888344 DOI: 10.1016/j.transproceed.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/28/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
Acute myeloid leukemia (AML) is a rare malignancy with increased incidence in the kidney transplantation (KT) population for which immunosuppression has been implicated as a putative cause. The average time interval from KT to AML development is 5 years. We present the case of a 61-year-old man who was found to have peripheral blood blasts on a postoperative day 20 routine blood draw after an uneventful unrelated living donor kidney transplant. He subsequently had a bone marrow biopsy and next-generation sequencing (NGS)-based molecular testing, which demonstrated AML characterized by SMC1A and TET2 mutations. He received induction chemotherapy followed by hematopoietic cell transplantation (HCT) from the kidney donor, who happened to be matched at one haplotype. At 12 months after his HCT and 15 months after his KT, his AML remained in remission, normal renal function was preserved, no active graft-versus-host disease was present, and immunosuppression was tapering. With full donor-derived hematopoietic chimerism, we expect to be able to discontinue immunosuppression shortly, thereby achieving tolerance. The short time interval between KT and development of AML suggests the malignancy was likely present before KT. Modern NGS-based analysis offers a promising method of identifying transplant candidates with unexplained hematologic abnormalities on pre-KT testing who may benefit from formal hematologic evaluation.
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Affiliation(s)
- Jielin Yu
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Bradford Sherburne
- Transfusion Medicine, Clinical Laboratory, Hartford Hospital, Hartford, Connecticut; Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut
| | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Heather L Kutzler
- Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut
| | - Joseph Tremaglio
- Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut
| | - Caroline Rochon
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut; Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut
| | - Patricia Sheiner
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut; Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut
| | - Oscar K Serrano
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut; Hartford Hospital Transplant and Comprehensive Liver Center, Hartford, Connecticut.
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12
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Liu Y, Wang X, Zhu Y, Zhang M, Nasri U, Sun SS, Forman SJ, Riggs AD, Zhang X, Zeng D. Haploidentical mixed chimerism cures autoimmunity in established type 1 diabetic mice. J Clin Invest 2020; 130:6457-6476. [PMID: 32817590 DOI: 10.1172/jci131799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/13/2020] [Indexed: 12/21/2022] Open
Abstract
Clinical trials are currently testing whether induction of haploidentical mixed chimerism (Haplo-MC) induces organ transplantation tolerance. Whether Haplo-MC can be used to treat established autoimmune diseases remains unknown. Here, we show that established autoimmunity in euthymic and adult-thymectomized NOD (H-2g7) mice was cured by induction of Haplo-MC under a non-myeloablative anti-thymocyte globulin-based conditioning regimen and infusion of CD4+ T cell-depleted hematopoietic graft from H-2b/g7 F1 donors that expressed autoimmune-resistant H-2b or from H-2s/g7 F1 donors that expressed autoimmune-susceptible H-2s. The cure was associated with enhanced thymic negative selection, increased thymic Treg (tTreg) production, and anergy or exhaustion of residual host-type autoreactive T cells in the periphery. The peripheral tolerance was accompanied by expansion of donor- and host-type CD62L-Helios+ tTregs as well as host-type Helios-Nrp1+ peripheral Tregs (pTregs) and PD-L1hi plasmacytoid DCs (pDCs). Depletion of donor- or host-type Tregs led to reduction of host-type PD-L1hi pDCs and recurrence of autoimmunity, whereas PD-L1 deficiency in host-type DCs led to reduction of host-type pDCs and Helios-Nrp1+ pTregs. Thus, induction of Haplo-MC reestablished both central and peripheral tolerance through mechanisms that depend on allo-MHC+ donor-type DCs, PD-L1hi host-type DCs, and the generation and persistence of donor- and host-type tTregs and pTregs.
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Affiliation(s)
- Yuqing Liu
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA.,Medical Center of Hematology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xiaoqi Wang
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA.,Medical Center of Hematology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Yongping Zhu
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA.,Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Mingfeng Zhang
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Ubaydah Nasri
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Sharne S Sun
- Eugene and Ruth Roberts Summer Student Academy of City of Hope, Duarte, California, USA
| | - Stephen J Forman
- Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA
| | | | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Defu Zeng
- Diabetes and Metabolism Research Institute, and.,Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute of City of Hope, Duarte, California, USA
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13
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Allogeneic hematopoietic cell transplantation (allo-HCT) outcomes in myeloma patients on renal replacement therapy: a report from the Chronic Malignancy Working Party (CMWP) of the European Society of Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 56:529-531. [PMID: 32741961 DOI: 10.1038/s41409-020-01010-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/02/2020] [Accepted: 07/21/2020] [Indexed: 11/08/2022]
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14
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Kato K, Takeuchi A, Akashi K, Eto M. Cyclophosphamide-Induced Tolerance in Allogeneic Transplantation: From Basic Studies to Clinical Application. Front Immunol 2020; 10:3138. [PMID: 32082305 PMCID: PMC7005582 DOI: 10.3389/fimmu.2019.03138] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/24/2019] [Indexed: 01/02/2023] Open
Abstract
Immune tolerance against alloantigens plays an important role in the success of clinical organ and allogeneic hematopoietic stem cell transplantation. The mechanisms of immune tolerance to alloantigens have gradually been elucidated over time. Although there have been numerous reports to date on the induction of tolerance to alloantigens, the establishment of mixed chimerism is well-known to be crucial in the induction and maintenance of immune tolerance for either of the methods. Since the early 1980s, the murine system of cyclophosphamide (Cy)-induced tolerance has also been examined extensively. The present review focuses on studies conducted on Cy-induced immune tolerance. Clinical data of patients with allogeneic transplantation suggest that the posttransplant Cy method to induce immune tolerance has been successfully translated from basic studies into clinical practice.
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Affiliation(s)
- Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Ario Takeuchi
- Department of Urology, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Urology, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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15
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Nunes NS, Kanakry CG. Mechanisms of Graft-versus-Host Disease Prevention by Post-transplantation Cyclophosphamide: An Evolving Understanding. Front Immunol 2019; 10:2668. [PMID: 31849930 PMCID: PMC6895959 DOI: 10.3389/fimmu.2019.02668] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/28/2019] [Indexed: 11/13/2022] Open
Abstract
Post-transplantation cyclophosphamide (PTCy) has been highly successful at preventing severe acute and chronic graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT). The clinical application of this approach was based on extensive studies in major histocompatibility complex (MHC)-matched murine skin allografting models, in which cyclophosphamide was believed to act via three main mechanisms: (1) selective elimination of alloreactive T cells; (2) intrathymic clonal deletion of alloreactive T-cell precursors; and (3) induction of suppressor T cells. In these models, cyclophosphamide was only effective in very specific contexts, requiring particular cell dose, cell source, PTCy dose, and recipient age. Achievement of transient mixed chimerism also was required. Furthermore, these studies showed differences in the impact of cyclophosphamide on transplanted cells (tumor) versus tissue (skin grafts), including the ability of cyclophosphamide to prevent rejection of the former but not the latter after MHC-mismatched transplants. Yet, clinically PTCy has demonstrated efficacy in MHC-matched or partially-MHC-mismatched HCT across a wide array of patients and HCT platforms. Importantly, clinically significant acute GVHD occurs frequently after PTCy, inconsistent with alloreactive T-cell elimination, whereas PTCy is most active against severe acute GVHD and chronic GVHD. These differences between murine skin allografting and clinical HCT suggest that the above-mentioned mechanisms may not be responsible for GVHD prevention by PTCy. Indeed, recent work by our group in murine HCT has shown that PTCy does not eliminate alloreactive T cells nor is the thymus necessary for PTCy's efficacy. Instead, other mechanisms appear to be playing important roles, including: (1) reduction of alloreactive CD4+ effector T-cell proliferation; (2) induced functional impairment of surviving alloreactive CD4+ and CD8+ effector T cells; and (3) preferential recovery of CD4+ regulatory T cells. Herein, we review the history of cyclophosphamide's use in preventing murine skin allograft rejection and our evolving new understanding of the mechanisms underlying its efficacy in preventing GVHD after HCT. Efforts are ongoing to more fully refine and elaborate this proposed new working model. The completion of this effort will provide critical insight relevant for the rational design of novel approaches to improve outcomes for PTCy-treated patients and for the induction of tolerance in other clinical contexts.
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Affiliation(s)
- Natalia S Nunes
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Christopher G Kanakry
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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