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Khullar D, Panigrahi DK, Bagai S, Abhishek, Singh K, Gandhi KR, Prasad P, Grover R, Chhabra G, Singh NP, Gupta AK. Comparative Efficacy and Safety of Low-Dose Versus Standard-Dose Rabbit Antithymocyte Globulin Induction Strategy in Kidney Transplant Recipients: Insights From a Single-Center Experience in North India. Cureus 2024; 16:e69770. [PMID: 39435237 PMCID: PMC11493324 DOI: 10.7759/cureus.69770] [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] [Accepted: 09/17/2024] [Indexed: 10/23/2024] Open
Abstract
Background Rabbit antithymocyte globulin (rATG) is frequently utilized as an induction therapy in kidney transplant recipients (KTRs). Full-dose rATG induction therapy (7-10 mg/kg) has been associated with increased morbidity. However, definitive data on the appropriate rATG dosage remains scarce. In this study, we evaluated the efficacy and tolerability of varying rATG doses in KTRs. Methodology A single-center, retrospective, observational study was conducted between 2009 and 2014 in a cohort of 208 KTRs who received rATG induction therapy. Patients included in the study had received two to three consecutive doses of rATG as part of their planned induction protocol. Participants were categorized into the following two groups based on the cumulative dosage of rATG received during induction therapy: group A received 2 or 2.5 mg/kg, while group B received ≥3 mg/kg. The five-year follow-up data were analyzed. Results A cumulative rATG dose of 2 or 2.5 mg/kg and ≥3 mg/kg was given to 122 and 86 patients, respectively. The incidence of delayed graft function (DGF), acute rejection episodes, total graft loss, death, and death-censored graft loss was 6.25%, 3.84%, 7.21%, 4.32%, and 2.88%, respectively. Two malignancies and 141 infectious complications were noted. There was no significant difference between the groups regarding DGF, total graft loss, death, death-censored graft loss, infectious complications, and incidence of acute rejection episodes. Deceased donor kidney transplantation was identified as a significant predictor of acute rejection episodes (odds ratio = 9.19, 95% confidence interval = 1.567-53.907; p = 0.014). Conclusions The dosage for rATG induction therapy for KTRs should be tailored based on immunological and other factors impacting graft survival, along with a comprehensive risk assessment for potential infectious complications. A cumulative dose of 2.0 or 2.5 mg/kg could be optimal, offering effective induction therapy in KTRs with excellent graft survival rates and potentially fewer infectious complications.
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Affiliation(s)
- Dinesh Khullar
- Nephrology, Max Super Speciality Hospital, Saket, New Delhi, IND
| | | | - Sahil Bagai
- Nephrology, Max Super Speciality Hospital, Saket, New Delhi, IND
| | - Abhishek
- Nephrology, Max Super Speciality Hospital, Saket, New Delhi, IND
| | - Kulwant Singh
- Nephrology, Max Super Speciality Hospital, Saket, New Delhi, IND
| | | | - Pallavi Prasad
- Nephrology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Rahul Grover
- Nephrology, Max Super Speciality Hospital, Saket, New Delhi, IND
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2
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Machado FP, Rauber N, Vicari AR, Bauer AC, Manfro RC. Single-dose antithymocyte globulin in standard immunological risk kidney transplant recipients: efficacy and kinetics of peripheral blood CD3 + T lymphocyte modulation. J Nephrol 2024; 37:1487-1496. [PMID: 37943422 DOI: 10.1007/s40620-023-01792-9] [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] [Received: 05/28/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Polyclonal anti-T cell antibodies (ATG or thymoglobulin®) are used as induction therapy in kidney transplant recipients. This study evaluates the safety, efficacy, and CD3+ T lymphocyte modulation of two ATG regimens. METHODS The trial included two cohorts of kidney transplant recipients that were followed for one year. The study group, including standard immunological risk recipients, received one 3 mg/kg dose of ATG. The comparator group, including standard and high immunological risk kidney transplant recipients, received a fractionated dose regimen (up to four 1.5 mg/kg doses). Patient and graft outcomes and the kinetics of CD3+ T lymphocyte modulation in the peripheral blood were evaluated. RESULTS One hundred kidney transplant recipients were included in each group. The one-year incidence of treated acute rejection, and patient and graft survival did not differ between groups. Bacterial infections were significantly more frequent in fractionated-dose group patients (66% versus 5%; P = 0.0001). At one-year follow-up, there was no difference in the incidence of cytomegalovirus infection (P = 0.152) or malignancies (P = 0.312). CD3+ T lymphocyte immunomodulation in the single-dose group was more effective in the first two days after transplantation. After the third post-transplant day, CD3+ T lymphocyte modulation was more efficient in the fractionated dose group. CONCLUSION Both regimens resulted in low rejection rates and equivalent survival. The single and reduced dose regimen protects from the occurrence of bacterial infections. CD3+ T lymphocyte modulation occurred with different kinetics, although it did not result in distinct outcomes.
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Affiliation(s)
| | - Nicole Rauber
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Alessandra R Vicari
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, St. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil
| | - Andrea C Bauer
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, St. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil
| | - Roberto C Manfro
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Division of Nephrology, Hospital de Clínicas de Porto Alegre, St. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
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3
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Park BH, Kim YN, Shin HS, Jung Y, Rim H. Current use of antithymoglobulin as induction regimen in kidney transplantation: A review. Medicine (Baltimore) 2024; 103:e37242. [PMID: 38428847 PMCID: PMC10906612 DOI: 10.1097/md.0000000000037242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/22/2024] [Indexed: 03/03/2024] Open
Abstract
Currently, various immunosuppressive drugs are used in organ transplantation. In particular, antithymoglobulin is a widely used drug in kidney transplantation in Korea, accounting for 20% of all induction therapy. According to existing studies, antithymoglobulin induction therapy has several advantages and disadvantages compared with other immunotherapies depending on the kidney transplant situation (dead donor, living donor, low-risk recipient, and high-risk recipient) or antithymoglobulin dose. In this review, we summarize the research conducted so far on antithymoglobulin and hope that antithymoglobulin research on kidney transplantation will be actively conducted in the future.
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Affiliation(s)
- Byung Hwa Park
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Ye Na Kim
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Ho Sik Shin
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Yeonsoon Jung
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Hark Rim
- Renal Division, Department of Internal Medicine, Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, South Korea
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4
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Montero N, Rodrigo E, Crespo M, Cruzado JM, Gutierrez-Dalmau A, Mazuecos A, Sancho A, Belmar L, Calatayud E, Mora P, Oliveras L, Solà E, Villanego F, Pascual J. The use of lymphocyte-depleting antibodies in specific populations of kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100795. [PMID: 37774445 DOI: 10.1016/j.trre.2023.100795] [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] [Received: 07/27/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Recommendations of the use of antibody induction treatments in kidney transplant recipients (KTR) are based on moderate quality and historical studies. This systematic review aims to reevaluate, based on actual studies, the effects of different antibody preparations when used in specific KTR subgroups. METHODS We searched MEDLINE and CENTRAL and selected randomized controlled trials (RCT) and observational studies looking at different antibody preparations used as induction in KTR. Comparisons were categorized into different KTR subgroups: standard, high risk of rejection, high risk of delayed graft function (DGF), living donor, and elderly KTR. Two authors independently assessed the risk of bias. RESULTS Thirty-seven RCT and 99 observational studies were finally included. Compared to anti-interleukin-2-receptor antibodies (IL2RA), anti-thymocyte globulin (ATG) reduced the risk of acute rejection at two years in standard KTR (RR 0.74, 95%CI 0.61-0.89) and high risk of rejection KTR (RR 0.55, 95%CI 0.43-0.72), but without decreasing the risk of graft loss. We did not find significant differences comparing ATG vs. alemtuzumab or different ATG dosages in any KTR group. CONCLUSIONS Despite many studies carried out on induction treatment in KTR, their heterogeneity and short follow-up preclude definitive conclusions to determine the optimal induction therapy. Compared with IL2RA, ATG reduced rejection in standard-risk, highly sensitized, and living donor graft recipients, but not in high DGF risk or elderly recipients. More studies are needed to demonstrate beneficial effects in other KTR subgroups and overall patient and graft survival.
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Affiliation(s)
- Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | | | - Asunción Sancho
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Lara Belmar
- Nephrology Department, Hospital Universitario Marqués de Valdecilla/IDIVAL, Santander, Spain
| | - Emma Calatayud
- Nephrology Department, Hospital Universitari Dr Peset, FISABIO, Valencia, Spain
| | - Paula Mora
- Nephrology Department, Hospital Universitario Miguel Servet, Aragon Health Research Institute, Zaragoza, Spain
| | - Laia Oliveras
- Nephrology Department, Hospital Universitari de Bellvitge, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eulalia Solà
- Nephrology Department, Consorci Sanitari del Garraf, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Shim YE, Ko Y, Lee JP, Jeon JS, Jun H, Yang J, Kim MS, Lim SJ, Kwon HE, Jung JH, Kwon H, Kim YH, Lee J, Shin S. Evaluating anti-thymocyte globulin induction doses for better allograft and patient survival in Asian kidney transplant recipients. Sci Rep 2023; 13:12560. [PMID: 37532735 PMCID: PMC10397229 DOI: 10.1038/s41598-023-39353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/24/2023] [Indexed: 08/04/2023] Open
Abstract
Anti-thymocyte globulin (ATG) is currently the most widely prescribed induction regimen for preventing acute rejection after solid organ transplantation. However, the optimal dose of ATG induction regimen in Asian kidney recipients is unclear. Using the Korean Organ Transplantation Registry, we performed a retrospective cohort study of 4579 adult patients who received renal transplantation in South Korea and divided them into three groups according to the induction regimen: basiliximab group (n = 3655), low-dose ATG group (≤ 4.5 mg/kg; n = 467), and high-dose ATG group (> 4.5 mg/kg; n = 457). We applied the Toolkit for Weighting and Analysis of Nonequivalent Groups (TWANG) package to generate high-quality propensity score weights for intergroup comparisons. During four-year follow-ups, the high-dose ATG group had the highest biopsy-proven acute rejection rate (basiliximab 20.8% vs. low-dose ATG 22.4% vs. high-dose ATG 25.6%; P < 0.001). However, the rates of overall graft failure (4.0% vs. 5.0% vs. 2.6%; P < 0.001) and mortality (1.7% vs. 2.8% vs. 1.0%; P < 0.001) were the lowest in the high-dose ATG group. Our results show that high-dose ATG induction (> 4.5 mg/kg) was superior to basiliximab and low-dose ATG induction in terms of graft and patient survival in Asian patients undergoing kidney transplant.
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Affiliation(s)
- Ye Eun Shim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Youngmin Ko
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jung Pyo Lee
- Department of Nephrology, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jin Seok Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Heungman Jun
- Department of Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jaeseok Yang
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong Jun Lim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye Eun Kwon
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Joo Hee Jung
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyunwook Kwon
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young Hoon Kim
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jungbok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Sung Shin
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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6
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Ko Y, Wee YM, Shin S, Kim MJ, Choi MY, Kim DH, Lim SJ, Jung JH, Kwon H, Kim YH, Han DJ. A prospective, randomized, non-blinded, non-inferiority pilot study to assess the effect of low-dose anti-thymocyte globulin with low-dose tacrolimus and early steroid withdrawal on clinical outcomes in non-sensitized living-donor kidney recipients. PLoS One 2023; 18:e0280924. [PMID: 36857393 PMCID: PMC9976999 DOI: 10.1371/journal.pone.0280924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/21/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND The optimal dose of anti-thymocyte globulin (ATG) as an induction regimen in Asian living-donor kidney recipients is unclear. METHODS This is a pilot study in which 36 consecutive patients undergoing living-donor kidney transplantation were randomly assigned to receive either 4.5 mg/kg (n = 19) or 6.0 mg/kg (n = 17) of ATG; all patients had corticosteroid withdrawal within 7 days. The primary end point was a composite of biopsy-proven acute rejection, de novo donor-specific antibody formation, and graft failure. RESULTS At 12 months post-transplant, biopsy-proven acute rejection was more common in the ATG4.5 group (21.1%) than in the ATG6.0 group (0%)(P = .048). Importantly, the rate of the composite end point was significantly higher in the ATG4.5 group (36.8% vs 0%)(P = .006). There were significant differences in neither the renal function nor adverse events between the two groups. One case of death-censored graft failure occurred in the ATG4.5 group and no mortality was observed overall. Compared with pre-transplantation, T cells, natural killer (NK) cells, and natural killer T (NKT) cells were significantly decreased in the first week post-transplantation except for B cells. Although T and NKT cells in both groups and NK cells in the ATG4.5 group had recovered to the pre-transplant levels, NK cells in the ATG6.0 group remained suppressed until six months post-transplant. CONCLUSIONS Compared with ATG 6.0 mg/kg, ATG 4.5 mg/kg with early corticosteroid withdrawal and low dose maintenance regimen was associated with higher rates of acute rejection in non-sensitized Asian living-donor kidney recipients. TRIAL REGISTRATION ClinicalTrials.gov: NCT02447822.
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Affiliation(s)
- Youngmin Ko
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-Mee Wee
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- * E-mail:
| | - Mi Joung Kim
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Monica Young Choi
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Kim
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Jun Lim
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunwook Kwon
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Low dose rabbit antithymocyte globulin is non-inferior to higher dose in low-risk pediatric kidney transplant recipients. Pediatr Nephrol 2022; 37:2091-2098. [PMID: 35006359 DOI: 10.1007/s00467-021-05407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/02/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Currently, there is no consensus among pediatric kidney transplant centers regarding the use and regimen for immunosuppressive induction therapy. METHODS In this single center, retrospective cohort study, pediatric kidney transplant recipients transplanted between 1 May 2013 and 1 May 2018 with rabbit antithymocyte globulin (rATG) induction were included. We stratified patients based on immunological risk, with high risk defined as those with repeat transplant, preformed donor specific antibody, current panel-reactive antibodies > 20%, 0 antigen match and/or African-American heritage. Outcome of interest was the incidence of biopsy proven acute rejection by 1 year. RESULTS A total of 166 patients met inclusion criteria. Age of patients was 12 years (11 mo-21 y), (median, range), 21.5% received a living donor transplant and 50.6% were female. Low-immunologic-risk patients were divided into 2 groups, those who received the lower cumulative rATG dose of ≤ 3.5 mg/kg (n = 52) versus the higher cumulative dose of > 3.5 mg/kg (n = 47). The median total dose in the lower dose group was 3.1 (IQR 0.3) and 4.4 (IQR 0.8) in the higher dose group, P < 0.001. Rejection rate did not differ significantly between the 2 treatment groups (7/52 vs. 6/47). None in the lower dose group developed BK nephropathy versus 3 in the higher dose group. Graft loss due to BK nephropathy occurred in 1 patient in the higher dose group. Graft loss in the whole cohort at 12 months was a rare event (n = 1) with 99.5% graft survival and 100% patient survival. CONCLUSIONS Reduced rATG dosing (≤ 3.5 mg/kg) when compared to higher dosing (> 3.5 mg/kg) is safe and effective in low-risk pediatric kidney transplant recipients without increasing risk of rejection. A higher resolution version of the Graphical abstract is available as Supplementary information.
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8
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Gassen RB, Borges TJ, Pérez-Sáez MJ, Zhang H, Al Jurdi A, Llinàs-Mallol L, Aoyama B, Lima M, Pascual J, Sage PT, Murakami N, Riella LV. T cell depletion increases humoral response by favoring T follicular helper cells expansion. Am J Transplant 2022; 22:1766-1778. [PMID: 35320600 PMCID: PMC9262847 DOI: 10.1111/ajt.17038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection is a major cause of long-term graft loss in kidney transplant patients. T follicular helper (Tfh) cells are crucial for assisting B cell differentiation and are required for an efficient antibody response. Anti-thymocyte globulin (ATG) is a widely used lymphocyte-depleting induction therapy. However, less is known about how ATG affects Tfh cell development and donor-specific antibody (DSA) formation. We observed an increase in circulating Tfh cells at 6 months after kidney transplant in patients who received ATG. Using an NP-OVA immunization model, we found that ATG-treated mice had a higher percentage of Tfh cells, germinal center B cells, and higher titers of antigen-specific antibodies compared to controls. ATG-treated animals had lower levels of IL-2, a known Bcl-6 repressor, but higher levels of IL-21, pSTAT3 and Bcl-6, favoring Tfh differentiation. In a mouse kidney transplant model, ATG-treated recipients showed an increase in Tfh cells, DSA and C4d staining in the allograft. Although ATG was effective in depleting T cells, it favored the expansion of Tfh cells following depletion. Concomitant use of IL-2, tacrolimus, or rapamycin with ATG was essential to control Tfh cell expansion. In summary, ATG depletion favors Tfh expansion, enhancing antibody-mediated response.
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Affiliation(s)
- Rodrigo Benedetti Gassen
- Center of Transplantation Science, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thiago J Borges
- Center of Transplantation Science, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - María José Pérez-Sáez
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Hengcheng Zhang
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ayman Al Jurdi
- Center of Transplantation Science, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Bruno Aoyama
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Maurício Lima
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Peter T Sage
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Naoka Murakami
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonardo V. Riella
- Center of Transplantation Science, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, MA, USA
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9
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Cremoni M, Massa F, Sicard A. Overcoming barriers to widespread use of CAR-Treg therapy in organ transplant recipients. HLA 2022; 99:565-572. [PMID: 35233971 DOI: 10.1111/tan.14591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/27/2022] [Indexed: 11/30/2022]
Abstract
Preventing allograft rejection has been the main challenge of transplantation medicine since the discovery of immune responses against foreign HLA molecules in the mid-20th century. Prevention of rejection currently relies on immunosuppressive drugs, which lack antigen specificity and therefore increase the risk for infections and cancers. Adoptive cell therapy with donor-reactive regulatory T cells (Tregs) has progressively emerged as a promising approach to reduce the need for pan-immunosuppressive drugs and minimize morbidity and mortality in solid-organ transplant recipients. Chimeric antigen receptor (CAR) technology has recently been used successfully to generate Tregs specific for donor HLA molecules and overcome the limitations of Tregs enrichment protocols based on repetitive stimulations with alloantigens. While this novel approach opens new possibilities to make Tregs therapy more feasible, it also creates additional challenges. It is essential to determine which source of therapeutic Tregs, CAR constructs, target alloantigens, safety strategies, patients and immunosuppressive regimens are optimal for the success of CAR Treg therapy. Here, we discuss unmet needs and strategies to bring donor-specific CAR Treg therapy to the clinic and make it as accessible as possible.
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Affiliation(s)
- Marion Cremoni
- Department of Nephrology, Dialysis, Transplantation, Nice University Hospital, Nice, France.,Clinical Research Unit, University Côte d'Azur (UR2CA), Nice, France
| | - Filippo Massa
- Department of Nephrology, Dialysis, Transplantation, Nice University Hospital, Nice, France.,Laboratory of Molecular Physio Medicine (LP2M), University Côte d'Azur, Nice, France
| | - Antoine Sicard
- Department of Nephrology, Dialysis, Transplantation, Nice University Hospital, Nice, France.,Laboratory of Molecular Physio Medicine (LP2M), University Côte d'Azur, Nice, France
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Abouzid Z, Amar MA, Abdessater M, Alioubane M, Benjaafar A, Ouzeddoun N, Benamar L, Bayahia R, Bouattar T. [Thymoglobulin as induction treatment in kidney transplantants with low immunological risk: a Moroccan experience]. Pan Afr Med J 2022; 41:138. [PMID: 35519161 PMCID: PMC9034569 DOI: 10.11604/pamj.2022.41.138.23091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 01/24/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Thymoglobulin® is a polyclonal antibody indicated for induction treatment in kidney transplantation. The purpose of this study is to estimate the effectiveness of Thymoglobulin® as induction treatment in kidney transplant patients with low immune risk. Methods we conducted a retrospective study between January 2012 and September 2017. Patients with low immunological risk, defined as the absence of previous transplantation and donor-specific antibodies (DSA), were included and received Thymoglobulin® induction therapy. Demographic and clinical characteristics, biological parameters and post-renal transplant complications were studied. Results we enrolled 55 kidney transplant patients with an average follow-up period of 38 ± 16 months. The average age of patients was 39,1 ± 12,1 years with a male predominance (58.2%). No patient had DSA prior to transplant. Cumulative dose of Thymoglobulin® was 4,26 ± 0,87 mg/kg, with an average duration of 5 ± 0,82 days. Lymphocyte depletion was maximal on the first day of infusion. Three patients had delayed graft function, at least one episode of bacterial infection in 56,4% of patients, 7 cases of CMV infections (12,7%) and 2 cases of CMV disease (3,6%). Graft survival rate was calculated for all patients with an average serum creatinine of 11,7 ± 3,6 mg/l during the last visit. Conclusion although it is not indicated for first line treatment in patients with low immunological risk, Thymoglobulin® can nevertheless be prescribed at a lower dose, with similar efficacy and without exposure to a higher risk of rejection.
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Affiliation(s)
- Zineb Abouzid
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Service d´Urologie, Centre Hospitalier René Dubos, Pontoise, France
| | - Mohamed Anass Amar
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Maher Abdessater
- Service d´Urologie, Centre Hospitalier René Dubos, Pontoise, France
| | - Meryem Alioubane
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Anissa Benjaafar
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Naima Ouzeddoun
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Loubna Benamar
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Rabia Bayahia
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Tarik Bouattar
- Service de Néphrologie-Dialyse-Transplantation Rénale, Centre Hospitalier Universitaire Ibn Sina, Rabat, Maroc
- Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
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11
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Gao Q, Davis R, Fitch Z, Mulvihill M, Ezekian B, Schroder P, Schmitz R, Song M, Leopardi F, Ribeiro M, Miller A, Moris D, Shaw B, Samy K, Reimann K, Williams K, Collins B, Kirk AD. Anti-thymoglobulin induction improves neonatal porcine xenoislet engraftment and survival. Xenotransplantation 2021; 28:e12713. [PMID: 34951057 PMCID: PMC8715890 DOI: 10.1111/xen.12713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/13/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
Porcine islet xenotransplantation is a viable strategy to treat diabetes. Its translation has been limited by the pre-clinical development of a clinically available immunosuppressive regimen. We tested two clinically relevant induction agents in a non-human primate (NHP) islet xenotransplantation model to compare depletional versus nondepletional induction immunosuppression. Neonatal porcine islets were isolated from GKO or hCD46/GKO transgenic piglets and transplanted via portal vein infusion in diabetic rhesus macaques. Induction therapy consisted of either basiliximab (n = 6) or rhesus-specific anti-thymocyte globulin (rhATG, n = 6), combined with a maintenance regimen using B7 costimulation blockade, tacrolimus with a delayed transition to sirolimus, and mycophenolate mofetil. Xenografts were monitored by blood glucose levels and porcine C-peptide measurements. Of the six receiving basiliximab induction, engraftment was achieved in 4 with median graft survival of 14 days. All six receiving rhATG induction engrafted with significantly longer xenograft survival at 40.5 days (P = 0.03). These data suggest that depletional induction provides superior xenograft survival to nondepletional induction, in the setting of a costimulation blockade-based maintenance regimen.
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Affiliation(s)
- Qimeng Gao
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Robert Davis
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Zachary Fitch
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Michael Mulvihill
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Brian Ezekian
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Paul Schroder
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Robin Schmitz
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Mingqing Song
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Frank Leopardi
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Marianna Ribeiro
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Allison Miller
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Brian Shaw
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Kannan Samy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Keith Reimann
- MassBiologics, University of Massachusetts Medical School, Worcester, Massachusetts, 01655, USA
| | - Kyha Williams
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Bradley Collins
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
| | - Allan D Kirk
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, 27710, USA
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12
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Landwehr-Kenzel S, Zobel A, Schmitt-Knosalla I, Forke A, Hoffmann H, Schmueck-Henneresse M, Klopfleisch R, Volk HD, Reinke P. Cyclosporine A but Not Corticosteroids Support Efficacy of Ex Vivo Expanded, Adoptively Transferred Human Tregs in GvHD. Front Immunol 2021; 12:716629. [PMID: 34707604 PMCID: PMC8543016 DOI: 10.3389/fimmu.2021.716629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/02/2021] [Indexed: 11/13/2022] Open
Abstract
Reshaping the immune balance by adoptive transfer of regulatory T-cells (Tregs) has emerged as a promising strategy to combat undesired immune reactions, including in Graft-versus-Host Disease (GvHD), which is the most lethal non-relapse complication of allogeneic hematopoietic stem cell transplantation. Currently however, little is known about the potentially inhibitory in vivo effects of conventional immunosuppressive drugs, which are routinely used to treat GvHD, on adoptively transferred Tregs. Here we demonstrate drug-specific effects of the conventional immunosuppressive drugs Cyclosporine A, Mycophenolate mofetil and methylprednisolone on adoptively transferred Tregs in a humanized NOD/SCID/IL2Rgamma-/- GvHD mouse model. The clinical course of GvHD and postmortem organ histology, including cellular organ infiltration, showed that co-administration of Cyclosporine A and Tregs is highly beneficial as it enhanced Treg accumulation at inflammatory sites like lung and liver. Similarly, co-administration of Mycophenolate mofetil and Tregs improved clinical signs of GvHD. In contrast, co-administration of methylprednisolone and Tregs resulted in reduced Treg recruitment to inflammatory sites and the fast deterioration of some animals. Consequently, when clinical trials investigating safety and efficacy of adjunctive Treg therapy in GvHD are designed, we suggest co-administering Cyclosporine A, whereas high doses of glucocorticosteroids should be avoided.
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Affiliation(s)
- Sybille Landwehr-Kenzel
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
- Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anne Zobel
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Isabela Schmitt-Knosalla
- Institute of Medical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anne Forke
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Henrike Hoffmann
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Michael Schmueck-Henneresse
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
- Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Klopfleisch
- Department of Veterinary Medicine, Institute of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Hans-Dieter Volk
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
- Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Medical Immunology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Petra Reinke
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, BIH-Center for Regenerative Therapies (BCRT), Berlin, Germany
- Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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13
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Mohammadi K, Khajeh B, Dashti-Khavidaki S, Shab-Bidar S. Association between cumulative rATG induction doses and kidney graft outcomes and adverse effects in kidney transplant patients: a systematic review and meta-analysis. Expert Opin Biol Ther 2021; 21:1265-1279. [PMID: 34304664 DOI: 10.1080/14712598.2021.1960978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND This systematic review and meta-analysis were performed to explore the association between rabbit thymoglobulin (rATG) doses and transplant-related efficacy and safety outcomes. METHODS We searched PubMed and Scopus databases from inception up to June 2020. The primary efficacy and safety endpoints in kidney transplant recipients were evaluated. RESULTS Data of 23 cohort studies (3457 patients) and three RCTs (154 patients) were extracted and analyzed. rATG doses of ≤4.5 m/kg was associated with lower rates of biopsy proven acute rejection, cytomegalovirus infection, BK virus infection, and malignancy with a comparable rate of delayed graft function, patients' mortality, and death-censored graft loss compared to rATG total doses of 4.5-6 mg/kg or more than 6 mg/kg. The rATG doses of 3-4.5 mg/kg was associated with better outcomes in dose-response analysis. EXPERT OPINION Cumulative rATG induction doses as much as 3-4.5 mg/kg is as effective as higher doses regarding to allograft and patient outcomes while minimizing potential adverse effects in kidney transplant recipients.
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Affiliation(s)
- Keyhan Mohammadi
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Behrouz Khajeh
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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14
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Wei S, Peng W, Zhang C, Su L, Zhang Z, Wang J, Huang C, Chu Z. Cordyceps sinensis aqueous extract regulates the adaptive immunity of mice subjected to 60 Co γ irradiation. Phytother Res 2021; 35:5163-5177. [PMID: 34236103 DOI: 10.1002/ptr.7186] [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: 11/29/2020] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022]
Abstract
Cordyceps sinensis (CS) is a traditional Chinese medicine that is known for treating various diseases, and particularly for exerting therapeutic effects in immune disorders. The adaptive immunoregulatory effects of CS aqueous extract (CSAE) on γ-irradiated mice have not been reported previously. The study aimed to evaluate the therapeutic effects of CSAE in mice immunosuppressed by irradiation. We observed that CSAE administration significantly increased body weight and spleen index, as well as the number of white blood cells, lymphocytes, and platelets in peripheral blood, T and B lymphocytes in spleen tissue, and total serum immunoglobulins in irradiated mice, whereas total serum pro-inflammatory cytokine levels were decreased. Collectively, CSAE maintained the structural integrity of spleen tissue and repaired its damage in irradiated mice as shown by hematoxylin and eosin staining, and decreased the number of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive splenocytes. Mechanistically, CSAE upregulated Bcl-2, and downregulated Bax and cleaved caspase-3 in spleen of irradiated mice. However, there were no significant differences in red blood cells and neutrophils in different groups. The results revealed that CSAE had protective effects against irradiation-induced immunosuppression, which was likely associated with an antiapoptotic effect and the regulation of adaptive immunity.
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Affiliation(s)
- Shanshan Wei
- School of Pharmacy, Jiangxi University of Traditional Chinese Medicine, Nanchang, China.,Naval Medical Research Institute, Naval Medical University, Shanghai, China
| | - Weibiao Peng
- School of Pharmacy, Jiangxi University of Traditional Chinese Medicine, Nanchang, China.,Naval Medical Research Institute, Naval Medical University, Shanghai, China
| | - Chenxi Zhang
- Institute of Translational Medicine, Shanghai University, Shanghai, China
| | - Li Su
- Institute of Translational Medicine, Shanghai University, Shanghai, China
| | - Zhenzhen Zhang
- Naval Medical Research Institute, Naval Medical University, Shanghai, China
| | - Jiachun Wang
- Naval Medical Research Institute, Naval Medical University, Shanghai, China
| | - Caiguo Huang
- Department of Biochemistry and Molecular Biology, the Faculty of Basic Medical Science, Naval Medical University, Shanghai, China
| | - Zhiyong Chu
- School of Pharmacy, Jiangxi University of Traditional Chinese Medicine, Nanchang, China.,Naval Medical Research Institute, Naval Medical University, Shanghai, China
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15
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Ashoor IF, Beyl RA, Gupta C, Jain A, Kiessling SG, Moudgil A, Patel HP, Sherbotie J, Weaver DJ, Zahr RS, Dharnidharka VR. Low-Dose Antithymocyte Globulin Has No Disadvantages to Standard Higher Dose in Pediatric Kidney Transplant Recipients: Report From the Pediatric Nephrology Research Consortium. Kidney Int Rep 2021; 6:995-1002. [PMID: 33912749 PMCID: PMC8071617 DOI: 10.1016/j.ekir.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/14/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Rabbit antithymocyte globulin (rATG) dosing strategies for induction in pediatric kidney transplantation vary between centers. It is not known whether a lower rATG induction dose provides safe and effective immunosuppression compared with a "standard" higher dose. METHODS We performed a retrospective multicenter study of all isolated first-time kidney transplant recipients <21 years old who received rATG induction between 1 January 2010 and 31 December 2014 at 9 pediatric centers. An a priori cutoff of a 4.5-mg/kg cumulative rATG dose was used to identify low (≤ 4.5 mg/kg) and standard (> 4.5 mg/kg) exposure groups. Outcomes examined included 12 months posttransplant graft function (estimated glomerular filtration rate [eGFR]); the occurrence of acute rejection, donor-specific antibody (DSA), neutropenia, and viral infection (cytomegalovirus [CMV], Epstein-Barr virus [EBV], and BK virus); and 24-month outcomes of posttransplant lymphoproliferative disorder (PTLD) occurrence and patient and graft survival. RESULTS Two hundred thirty-five patients were included. Baseline features of the low and standard rATG dose groups were similar. By 12 months, the rATG dose group had no significant impact on the occurrence of neutropenia, positive DSA, or viral polymerase chain reaction (PCR). Graft function was similar. Acute rejection rates were similar at 17% (low dose) versus 19% (standard dose) (P = 0.13). By 24 months, graft survival (96.4% vs. 94.6%) and patient survival (100% vs. 99.3%) were similar between the low- and standard-dose groups (P = 0.54 and 0.46), whereas the occurrence of PTLD trended higher in the standard-dose group (0% vs. 2.6%, P = 0.07). CONCLUSION A low rATG induction dose ≤ 4.5 mg/kg provided safe and effective outcomes in this multicenter low immunologic risk pediatric cohort. Prospective studies are warranted to define the optimal rATG induction dose in pediatric kidney transplantation.
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Affiliation(s)
- Isa F. Ashoor
- Division of Nephrology, Department of Pediatrics, LSU Health New Orleans, New Orleans, Louisiana, USA
| | - Robbie A. Beyl
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Charu Gupta
- Children’s National Hospital, Washington, DC, USA
| | - Amrish Jain
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | | | - Asha Moudgil
- Children’s National Hospital, Washington, DC, USA
| | | | - Joseph Sherbotie
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Rima S. Zahr
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University and St. Louis Children’s Hospital, St. Louis, Missouri, USA
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16
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Boucquemont J, Foucher Y, Masset C, Legendre C, Scemla A, Buron F, Morelon E, Garrigue V, Pernin V, Albano L, Sicard A, Girerd S, Ladrière M, Giral M, Dantal J. Induction therapy in kidney transplant recipients: Description of the practices according to the calendar period from the French multicentric DIVAT cohort. PLoS One 2020; 15:e0240929. [PMID: 33091057 PMCID: PMC7580969 DOI: 10.1371/journal.pone.0240929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background There is extensive literature with comparisons between Anti-Thymocyte Globulin (ATG) and Basiliximab (BSX) as induction therapy in kidney transplant recipients. The purpose of our benchmarking study was to describe the consequences in terms of practices in 6 transplantation centers of a French prospective cohort. Methods We included adult patients who received a first or second kidney graft between 2013 and 2019 (n = 4157). We used logistic regressions to identify characteristics associated with the use of ATG or BSX. Results Use of ATG between the centers ranged from 41% to 75%. We observed different factors associated with the treatment decision. Compared to a first transplant, performing a second graft was the only factor significantly associated with the choice of ATG in all centers. The AUC ranged from 0.67 to 0.91, indicating that the centers seemed to define their own rules. As a result, for patients with the same low immunological risk, the probability of receiving ATG varied from 7% to 36%. We stratified the analyses according to two periods, from 2013 to 2015 and from 2016 to 2019. A similar heterogeneity was observed, and in some cases ATG indications between the centers were inverted. Conclusions The heterogeneity of induction therapy practices did not decrease in France, even if the reated literature is prolific. This illustrates the necessity to improve the literature by using meta-analyses of recent studies stratified by graft and patient profiles.
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Affiliation(s)
- Julie Boucquemont
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- * E-mail: (JD); (JB)
| | - Yohann Foucher
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Christophe Masset
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS « Centaure », Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Anne Scemla
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS « Centaure », Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Fanny Buron
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Valérie Garrigue
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Vincent Pernin
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Laetitia Albano
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Antoine Sicard
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Sophie Girerd
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Marc Ladrière
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Magali Giral
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
- Centre d’Investigation Clinique en Biothérapie, Nantes, France
| | - Jacques Dantal
- Centre Hospitalier Universitaire de Nantes, Nantes, France
- CRTI UMR 1064, Inserm, Université de Nantes; ITUN, CHU Nantes; RTRS « Centaure », Nantes, France
- * E-mail: (JD); (JB)
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17
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Reassessing Rabbit Antithymocyte Globulin Induction in Kidney Transplantation (RETHINK): An Analysis of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Registry. Transplant Direct 2020; 6:e598. [PMID: 32903852 PMCID: PMC7447457 DOI: 10.1097/txd.0000000000001042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 01/29/2023] Open
Abstract
Supplemental Digital Content is available in the text. Background. There is no consensus on rabbit antithymocyte globulin (rATG) dose used for induction immunosuppression in pediatric kidney transplants. We aimed to identify whether a lower rATG dose provides safe and effective immunosuppression compared with a higher dose. Methods. We retrospectively analyzed all first-time kidney transplant recipients (aged <21 y) in the North American Pediatric Renal Trials and Collaborative Studies registry since 1998 on mycophenolate mofetil– and tacrolimus-based immunosuppression with rATG induction. An a priori cutoff of 7.5 mg/kg cumulative rATG dose was used to identify low (<7.5 mg/kg) and high (≥7.5 mg/kg) exposure groups. Primary outcome was time to first-acute rejection episode. Secondary outcomes included graft function, patient survival, hospitalizations due to infections, and time to first-posttransplant lymphoproliferative disorder episode. Results. Four hundred fifty-five patients met inclusion criteria (59% male, 49% whites, 26% blacks, 38% living donor source). Median cumulative rATG dose was 6.8 mg/kg with a median of 5 doses and a median 1.5 mg/kg/dose introduced at a median of postoperative 0 days. Sixty-four percent received <7.5 mg/kg total rATG. There was no difference in age at transplant, gender, race, end-stage renal disease causes, or HLA mismatch among groups. Time to first-acute rejection was similar (P = 0.07). There was no significant difference in graft or patient survival or time to posttransplant lymphoproliferative disorder. Hospitalization for infection rates was similar. Conclusions. These data demonstrate a wide variation in cumulative rATG induction dose. A smaller rATG dose <7.5 mg/kg may provide effective and safe immunosuppression compared with a higher dose.
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18
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Jalalonmuhali M, Ng KP, Ong CS, Lee YW, Wan Md Adnan WAH, Lim SK. Low Immunologic Risk Living Related Renal Transplant Using Very Low-Dose Antithymocyte Globulin as Induction Therapy: A Single Tertiary Hospital Experience. Transplant Proc 2020; 52:1709-1714. [PMID: 32448669 DOI: 10.1016/j.transproceed.2020.02.139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/05/2020] [Indexed: 11/18/2022]
Abstract
The aim of induction therapy in the management of kidney transplant is to reduce the incidence of acute rejection and delayed graft function after kidney transplant. The agent for induction therapy differs depending on the recipient risks. The regimen can be either polyclonal (rabbit antithymocyte globulin [rATG]) or monoclonal antibody (basiliximab). Basiliximab is commonly used in patients with low immunologic risk. However, to date we know that the use of rATG on T cell depletion is dose dependent and more potent antirejection therapy. Therefore, we would like to look at 1-year graft function of very low-dose rATG in low immunologic risk recipients. All low immunologic risk patients who received low-dose rATG (0.5 mg/kg of body weight daily) during transplant (day 0) and on days 1 and 2 were recruited. Their renal function, HLA donor-specific antibodies, lymphocyte counts, protocol biopsy results, and cytomegalovirus (CMV) polymerase chain reaction were monitored as per clinical practice. All 10 patients had immediate graft function. Low-dose rATG caused lymphocyte counts to deplete immediately on day 0, and the effect lasted about 1 month post-transplant. All the patients had stable graft function without any significance episode of rejection. Only one patient had de novo HLA-DQ antibody. It is good to know that without prophylaxis antiviral in CMV+ donor to CMV+ recipient, the incidence of CMV viremia is considerably low in our cohort. Very low-dose rATG is an effective induction immunosuppression in low immunologic risk patients with acceptable infection risk.
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Affiliation(s)
- Maisarah Jalalonmuhali
- Division of Nephrology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Kok Peng Ng
- Division of Nephrology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chun Seong Ong
- Division of Nephrology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yee Wan Lee
- Division of Nephrology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | | | - Soo Kun Lim
- Division of Nephrology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
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Outcome Comparison between Low-Dose Rabbit Anti-Thymocyte Globulin and Basiliximab in Low-Risk Living Donor Kidney Transplantation. J Clin Med 2020; 9:jcm9051320. [PMID: 32370265 PMCID: PMC7290680 DOI: 10.3390/jcm9051320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/09/2023] Open
Abstract
The objective of this study was to compare outcomes between basiliximab and low-dose r-ATG in living donor kidney transplantation recipients with low immunological risk. Patients in the low-dose r-ATG group received 1.5 mg/kg of r-ATG for 3 days (total 4.5 mg/kg). Graft survival, patient survival, acute rejection, de novo donor specific antibody (DSA), estimated glomerular filtration rate (e-GFR) changes, and infection status were compared. Among 268 patients, 37 received r-ATG, and 231 received basiliximab. There was no noticeable difference in the graft failure rate (r-ATG vs. basiliximab: 2.7% vs. 4.8%) or rejection (51.4% vs. 45.9%). de novo DSA was more frequent in the r-ATG group (11.4% vs. 2.4%, p = 0.017). e-GFR changes did not differ noticeably between groups. Although most infections showed no noticeable differences between groups, more patients in the r-ATG group had cytomegalovirus (CMV) antigenemia and serum polyomavirus (BK virus) (73.0% vs. 51.9%, p = 0.032 in CMV; 37.8% vs. 15.6%, p = 0.002 in BK), which did not aggravate graft failure. Living donor kidney transplantation patients who received low-dose r-ATG and patients who received basiliximab showed comparable outcomes in terms of graft survival, function, and overall infections. Although CMV antigenemia, BK viremia were more frequent in the r-ATG group, those factors didn’t change the graft outcomes.
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Ko EJ, Yu JH, Yang CW, Chung BH. Usefulness of valacyclovir prophylaxis for cytomegalovirus infection after anti-thymocyte globulin as rejection therapy. Korean J Intern Med 2019; 34:375-382. [PMID: 29237252 PMCID: PMC6406088 DOI: 10.3904/kjim.2017.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/15/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND/AIMS Anti-thymocyte globulin (ATG) treatment for acute T-cell mediated rejection (TCMR) can increase the risk of cytomegalovirus (CMV) infection. We aimed to evaluate the effect of valacyclovir prophylaxis against CMV infection after ATG administration as anti-rejection therapy. METHODS We retrospectively analyzed 55 kidney transplant recipients (KTRs) receiving ATG for steroid resistant TCMR. In all KTRs, we used intravenous ganciclovir during ATG injection. In 34 KTRs treated before July 2013, we performed preemptive therapy for CMV infection after ATG therapy. They were regarded as the historic control group (CONT). After July 2013, we used valacyclovir maintenance for 1 month after ATG therapy in 21 patients (VAL). The primary outcome was the incidence of CMV infection, and the secondary outcomes were subsequent acute rejection, and graft and patient outcome. RESULTS Valacyclovir prophylaxis significantly reduced the incidence of CMV infection (VAL, 9.6% vs. CONT, 67.6%; p < 0.001), and CMV-free survival rate was higher in the VAL group compared to the CONT group (p = 0.009). In the VAL group, two cases of CMV infection were limited to CMV viremia, but CMV disease or syndrome (n = 3) was detected in the CONT group. There was no difference in graft failure (CONT, 70.5% vs. VAL, 47.6%; p = 0.152), incidence of subsequent rejection after ATG treatment (CONT, 41.1% vs. VAL, 33.3%; p = 0.776), and graft or patient survival between the two groups. There were no major adverse events associated with valacyclovir prophylaxis. CONCLUSION In conclusion, valacyclovir prophylaxis is effective in the prevention of CMV infection after ATG treatment for steroid resistant TCMR.
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Affiliation(s)
- Eun Jeong Ko
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ji Hyun Yu
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Byung Ha Chung, M.D. Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6066 Fax: +82-2-536-3589 E-mail:
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Landwehr-Kenzel S, Zobel A, Hoffmann H, Landwehr N, Schmueck-Henneresse M, Schachtner T, Roemhild A, Reinke P. Ex vivo expanded natural regulatory T cells from patients with end-stage renal disease or kidney transplantation are useful for autologous cell therapy. Kidney Int 2018; 93:1452-1464. [PMID: 29792274 DOI: 10.1016/j.kint.2018.01.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 02/08/2023]
Abstract
Novel concepts employing autologous, ex vivo expanded natural regulatory T cells (nTreg) for adoptive transfer has potential to prevent organ rejection after kidney transplantation. However, the impact of dialysis and maintenance immunosuppression on the nTreg phenotype and peripheral survival is not well understood, but essential when assessing patient eligibility. The current study investigates regulatory T-cells in dialysis and kidney transplanted patients and the feasibility of generating a clinically useful nTreg product from these patients. Heparinized blood from 200 individuals including healthy controls, dialysis patients with end stage renal disease and patients 1, 5, 10, 15, 20 years after kidney transplantation were analyzed. Differentiation and maturation of nTregs were studied by flow cytometry in order to compare dialysis patients and kidney transplanted patients under maintenance immunosuppression to healthy controls. CD127 expressing CD4+CD25highFoxP3+ nTregs were detectable at increased frequencies in dialysis patients with no negative impact on the nTreg end product quality and therapeutic usefulness of the ex vivo expanded nTregs. Further, despite that immunosuppression mildly altered nTreg maturation, neither dialysis nor pharmacological immunosuppression or previous acute rejection episodes impeded nTreg survival in vivo. Accordingly, the generation of autologous, highly pure nTreg products is feasible and qualifies patients awaiting or having received allogenic kidney transplantation for adoptive nTreg therapy. Thus, our novel treatment approach may enable us to reduce the incidence of organ rejection and reduce the need of long-term immunosuppression.
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Affiliation(s)
- Sybille Landwehr-Kenzel
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany; Berlin-Brandenburg School for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany; Department of Pediatrics, Division of Pneumonology and Immunology, Charité University Medicine Berlin, Berlin, Germany.
| | - Anne Zobel
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany; Renal and Transplant Research Unit, Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Henrike Hoffmann
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany
| | - Niels Landwehr
- Leibniz-Institute for Agricultural Engineering and Bioeconomy, Potsdam, Germany; University of Potsdam, Department for Computer Science, Potsdam, Germany
| | - Michael Schmueck-Henneresse
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany; Renal and Transplant Research Unit, Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany; Institute of Medical Immunology, Charité University Medicine Berlin, 13353 Berlin, Germany
| | - Thomas Schachtner
- Renal and Transplant Research Unit, Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Andy Roemhild
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany
| | - Petra Reinke
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine Berlin, Berlin, Germany; Renal and Transplant Research Unit, Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
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Dopazo C, Charco R, Caralt M, Pando E, Lázaro JL, Gómez-Gavara C, Castells L, Bilbao I. Low Total Dose of Anti-Human T-Lymphocyte Globulin (ATG) Guarantees a Good Glomerular Filtration Rate after Liver Transplant in Recipients with Pretransplant Renal Dysfunction. Can J Gastroenterol Hepatol 2018; 2018:1672621. [PMID: 30186817 PMCID: PMC6116465 DOI: 10.1155/2018/1672621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/04/2018] [Indexed: 02/08/2023] Open
Abstract
We aimed to evaluate the safety and efficacy of low doses of anti-T-lymphocyte globulin (ATG)-based immunosuppression in preserving renal function and preventing liver rejection in liver transplant (LT) recipients with pretransplant renal dysfunction. We designed a prospective single-center cohort study analyzing patients with pre-LT renal dysfunction defined as eGFR<60 mL/min/1.73m2, who underwent induction therapy with ATG (ATG group, n=20). This group was compared with a similar retrospective cohort treated with basiliximab (BAS group, n=20). An economic analysis between both induction therapies was also undertaken. In the ATG group, 45% and 50% of patients had recovered their renal function without acute cellular rejection (ACR) episodes at day 7 and 1 month after LT, respectively, versus 40% and 55% of patients in the BAS group (p=1). Renal function improved in both groups over time and no differences between groups were observed regarding one-year eGRF and one-year probability of ACR. Cost per patient of the ATG course was 403€ (r: 126-756) versus 2,524€ of the basiliximab course (p=0.001). In conclusion, induction with low dose of ATG or basiliximab in patients with pretransplant renal dysfunction is a good strategy for preserving posttransplant renal function; however the use of low-dose ATG resulted in a substantial reduction in drug costs. This trail is registered with ClinicalTrials.gov number: NCT01453218.
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Affiliation(s)
- Cristina Dopazo
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ramón Charco
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mireia Caralt
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - José Luis Lázaro
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Concepción Gómez-Gavara
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Lluis Castells
- Hepatology Unit, Department of Internal Medicine, Hospital Vall d'Hebron, CIBERehd, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Itxarone Bilbao
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
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Does Rabbit Antithymocyte Globulin (Thymoglobuline®) Have a Role in Avoiding Delayed Graft Function in the Modern Era of Kidney Transplantation? J Transplant 2018; 2018:4524837. [PMID: 30112193 PMCID: PMC6077603 DOI: 10.1155/2018/4524837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
Delayed graft function (DGF) increases the risk of graft loss by up to 40%, and recent developments in kidney donation have increased the risk of its occurrence. Lowering the risk of DGF, however, is challenging due to a complicated etiology in which ischemia-reperfusion injury (IRI) leads to acute tubular necrosis. Among various strategies explored, the choice of induction therapy is one consideration. Rabbit antithymocyte globulin (rATG [Thymoglobuline]) has complex immunomodulatory effects that are relevant to DGF. In addition to a rapid and profound T-cell depletion, rATG inhibits leukocyte migration and adhesion. Experimental studies of rATG have demonstrated attenuated IRI-related tissue damage in reperfused tissues, consistent with histological evidence from transplant recipients. Starting rATG intraoperatively instead of postoperatively can improve kidney graft function and reduce the incidence of DGF. rATG is effective in preventing acute rejection in kidney transplant recipients at high immunological risk, supporting delayed calcineurin inhibitor (CNI) introduction which protects the graft from early insults. A reduced rate of DGF has been reported with rATG (started intraoperatively) and delayed CNI therapy compared to IL-2RA induction with immediate CNI in patients at high immunological risk, but not in lower-risk patients. Overall, induction with rATG induction is the preferred choice for supporting delayed introduction of CNI therapy to avoid DGF in high-risk patients but shows no benefit versus IL-2RA in lower-risk individuals. Evidence is growing that intraoperative rATG ameliorates IRI, and it seems reasonable to routinely start rATG before reperfusion.
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Cremaschi L, von Versen R, Benzing T, Wiesener M, Zink N, Milkovich G, Paivanas T, Gallagher M, Thaiss F. Induction therapy with rabbit antithymocyte globulin versus basiliximab after kidney transplantation: a health economic analysis from a German perspective. Transpl Int 2017; 30:1011-1019. [DOI: 10.1111/tri.12991] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/20/2017] [Accepted: 05/20/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Liana Cremaschi
- Department of Nephrology; University Hospital Eppendorf UKE; Hamburg Germany
| | - Regina von Versen
- Nephrology, Rheumatology, Diabetology and General Internal Medicine; University Hospital Cologne; Cologne Germany
| | - Thomas Benzing
- Nephrology, Rheumatology, Diabetology and General Internal Medicine; University Hospital Cologne; Cologne Germany
| | - Michael Wiesener
- Department of Nephrology and Hypertension; University Hospital Erlangen; Erlangen Germany
| | - Nikolai Zink
- Department of Nephrology and Hypertension; University Hospital Erlangen; Erlangen Germany
| | | | | | - Meghan Gallagher
- Global Health Economics & Outcomes Research; Sanofi-Aventis US; Cambridge MA USA
| | - Friedrich Thaiss
- Department of Nephrology; University Hospital Eppendorf UKE; Hamburg Germany
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Willicombe M, Goodall D, McLean AG, Taube D. Alemtuzumab dose adjusted for body weight is associated with earlier lymphocyte repletion and less infective episodes in the first year post renal transplantation - a retrospective study. Transpl Int 2017; 30:1110-1118. [DOI: 10.1111/tri.12978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 05/05/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Michelle Willicombe
- Imperial College Renal and Transplant Centre; Imperial College NHS Trust; Hammersmith Hospital; London UK
| | - Dawn Goodall
- Imperial College Renal and Transplant Centre; Imperial College NHS Trust; Hammersmith Hospital; London UK
| | - Adam G McLean
- Imperial College Renal and Transplant Centre; Imperial College NHS Trust; Hammersmith Hospital; London UK
| | - David Taube
- Imperial College Renal and Transplant Centre; Imperial College NHS Trust; Hammersmith Hospital; London UK
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Camirand G, Riella LV. Treg-Centric View of Immunosuppressive Drugs in Transplantation: A Balancing Act. Am J Transplant 2017; 17:601-610. [PMID: 27581661 DOI: 10.1111/ajt.14029] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/15/2016] [Accepted: 08/18/2016] [Indexed: 01/25/2023]
Abstract
Regulatory CD4+ Foxp3+ T cells (Tregs) are critical in controlling immunity and tolerance. Thus, preserving Treg numbers and function in transplanted patients is essential for the successful minimization of maintenance immunosuppression. Multiple cellular signals control the development, differentiation, and function of Tregs. Many of these signals are shared with conventional Foxp3- T cells (Tconv) and are targeted by immunosuppressive drugs, negatively affecting both Tregs and Tconv. Because intracellular signals vary in optimal intensity in different T cell subsets, improved specificity in immunosuppressive regimens must occur to benefit long-term transplant outcomes. In this regard, recent advances are gradually uncovering differences in the signals required in Tregs and Tconv biology, opening the door to new potential therapeutic approaches to either enhance or spare Tregs. In this review, we will explain the prominent cell signaling pathways critical for Treg maintenance and function, while reporting the effects of immunosuppressive drugs targeting these signaling pathways in clinical transplantation settings.
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Affiliation(s)
- G Camirand
- Department of Surgery, University of Pittsburgh Medical School, The Thomas E. Starzl Transplantation Institute, Pittsburgh, PA
| | - L V Riella
- Renal Division, Schuster Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Hill P, Cross NB, Barnett ANR, Palmer SC, Webster AC. Polyclonal and monoclonal antibodies for induction therapy in kidney transplant recipients. Cochrane Database Syst Rev 2017; 1:CD004759. [PMID: 28073178 PMCID: PMC6464766 DOI: 10.1002/14651858.cd004759.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prolonging kidney transplant survival is an important clinical priority. Induction immunosuppression with antibody therapy is recommended at transplantation and non-depleting interleukin-2 receptor monoclonal antibodies (IL2Ra) are considered first line. It is suggested that recipients at high risk of rejection should receive lymphocyte-depleting antibodies but the relative benefits and harms of the available agents are uncertain. OBJECTIVES We aimed to: evaluate the relative and absolute effects of different antibody preparations (except IL2Ra) when used as induction therapy in kidney transplant recipients; determine how the benefits and adverse events vary for each antibody preparation; determine how the benefits and harms vary for different formulations of antibody preparation; and determine whether the benefits and harms vary in specific subgroups of recipients (e.g. children and sensitised recipients). SEARCH METHODS Randomised controlled trials (RCTs) comparing monoclonal or polyclonal antibodies with placebo, no treatment, or other antibody therapy in adults and children who had received a kidney transplant. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing monoclonal or polyclonal antibodies with placebo, no treatment, or other antibody therapy in adults and children who had received a kidney transplant. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) together with their 95% confidence intervals (CI). MAIN RESULTS We included 99 studies (269 records; 8956 participants; 33 with contemporary agents). Methodology was incompletely reported in most studies leading to lower confidence in the treatment estimates.Antithymocyte globulin (ATG) prevented acute graft rejection (17 studies: RR 0.63, 95% CI 0.51 to 0.78). The benefits of ATG on graft rejection were similar when used with (12 studies: RR 0.61, 0.49 to 0.76) or without (5 studies: RR 0.65, 0.43 to 0.98) calcineurin inhibitor (CNI) treatment. ATG (with CNI therapy) had uncertain effects on death (3 to 6 months, 3 studies: RR 0.41, 0.13 to 1.22; 1 to 2 years, 5 studies: RR 0.75, 0.27 to 2.06; 5 years, 2 studies: RR 0.94, 0.11 to 7.81) and graft loss (3 to 6 months, 4 studies: RR 0.60, 0.34 to 1.05; 1 to 2 years, 3 studies: RR 0.65, 0.36 to 1.19). The effect of ATG on death-censored graft loss was uncertain at 1 to 2 years and 5 years. In non-CNI studies, ATG had uncertain effects on death but reduced death-censored graft loss (6 studies: RR 0.55, 0.38 to 0.78). When CNI and older non-CNI studies were combined, a benefit was seen with ATG at 1 to 2 years for both all-cause graft loss (7 studies: RR 0.71, 0.53 to 0.95) and death-censored graft loss (8 studies: RR 0.55, 0.39 to 0.77) but not sustained longer term. ATG increased cytomegalovirus (CMV) infection (6 studies: RR 1.55, 1.24 to 1.95), leucopenia (4 studies: RR 3.86, 2.79 to 5.34) and thrombocytopenia (4 studies: RR 2.41, 1.61 to 3.61) but had uncertain effects on delayed graft function, malignancy, post-transplant lymphoproliferative disorder (PTLD), and new onset diabetes after transplantation (NODAT).Alemtuzumab was compared to ATG in six studies (446 patients) with early steroid withdrawal (ESW) or steroid minimisation. Alemtuzumab plus steroid minimisation reduced acute rejection compared to ATG at one year (4 studies: RR 0.57, 0.35 to 0.93). In the two studies with ESW only in the alemtuzumab arm, the effect of alemtuzumab on acute rejection at 1 year was uncertain compared to ATG (RR 1.27, 0.50 to 3.19). Alemtuzumab had uncertain effects on death (1 year, 2 studies: RR 0.39, 0.06 to 2.42; 2 to 3 years, 3 studies: RR 0.67, 95% CI 0.15 to 2.95), graft loss (1 year, 2 studies: RR 0.39, 0.13 to 1.30; 2 to 3 years, 3 studies: RR 0.98, 95% CI 0.47 to 2.06), and death-censored graft loss (1 year, 2 studies: RR 0.38, 0.08 to 1.81; 2 to 3 years, 3 studies: RR 2.45, 95% CI 0.67 to 8.97) compared to ATG. Creatinine clearance was lower with alemtuzumab plus ESW at 6 months (2 studies: MD -13.35 mL/min, -23.91 to -2.80) and 2 years (2 studies: MD -12.86 mL/min, -23.73 to -2.00) compared to ATG plus triple maintenance. Across all 6 studies, the effect of alemtuzumab versus ATG was uncertain on all-cause infection, CMV infection, BK virus infection, malignancy, and PTLD. The effect of alemtuzumab with steroid minimisation on NODAT was uncertain, compared to ATG with steroid maintenance.Alemtuzumab plus ESW compared with triple maintenance without induction therapy had uncertain effects on death and all-cause graft loss at 1 year, acute rejection at 6 months and 1 year. CMV infection was increased (2 studies: RR 2.28, 1.18 to 4.40). Treatment effects were uncertain for NODAT, thrombocytopenia, and malignancy or PTLD.Rituximab had uncertain effects on death, graft loss, acute rejection and all other adverse outcomes compared to placebo. AUTHORS' CONCLUSIONS ATG reduces acute rejection but has uncertain effects on death, graft survival, malignancy and NODAT, and increases CMV infection, thrombocytopenia and leucopenia. Given a 45% acute rejection risk without ATG induction, seven patients would need treatment to prevent one having rejection, while incurring an additional patient experiencing CMV disease for every 12 treated. Excluding non-CNI studies, the risk of rejection was 37% without induction with six patients needing treatment to prevent one having rejection.In the context of steroid minimisation, alemtuzumab prevents acute rejection at 1 year compared to ATG. Eleven patients would require treatment with alemtuzumab to prevent 1 having rejection, assuming a 21% rejection risk with ATG.Triple maintenance without induction therapy compared to alemtuzumab combined with ESW had similar rates of acute rejection but adverse effects including NODAT were poorly documented. Alemtuzumab plus steroid withdrawal would cause one additional patient experiencing CMV disease for every six patients treated compared to no induction and triple maintenance, in the absence of any clinical benefit. Overall, ATG and alemtuzumab decrease acute rejection at a cost of increased CMV disease while patient-centred outcomes (reduced death or lower toxicity) do not appear to be improved.
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Affiliation(s)
- Penny Hill
- Christchurch Public HospitalDepartment of NephrologyChristchurchNew Zealand
| | - Nicholas B Cross
- Christchurch Public HospitalDepartment of NephrologyChristchurchNew Zealand
| | | | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Abstract
Immunosuppression strategies that selectively inhibit effector T cells while preserving and even enhancing CD4FOXP3 regulatory T cells (Treg) permit immune self-regulation and may allow minimization of immunosuppression and associated toxicities. Many immunosuppressive drugs were developed before the identity and function of Treg were appreciated. A good understanding of the interactions between Treg and immunosuppressive agents will be valuable to the effective design of more tolerable immunosuppression regimens. This review will discuss preclinical and clinical evidence regarding the influence of current and emerging immunosuppressive drugs on Treg homeostasis, stability, and function as a guideline for the selection and development of Treg-friendly immunosuppressive regimens.
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Affiliation(s)
- Akiko Furukawa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Steven A Wisel
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Qizhi Tang
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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Naesens M, Berger S, Biancone L, Crespo M, Djamali A, Hertig A, Öllinger R, Portolés J, Zuckermann A, Pascual J. Lymphocyte-depleting induction and steroid minimization after kidney transplantation: A review. Nefrologia 2016; 36:469-480. [DOI: 10.1016/j.nefro.2016.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/12/2016] [Accepted: 03/28/2016] [Indexed: 12/28/2022] Open
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A Proposal for Early Dosing Regimens in Heart Transplant Patients Receiving Thymoglobulin and Calcineurin Inhibition. Transplant Direct 2016; 2:e81. [PMID: 27500271 PMCID: PMC4946520 DOI: 10.1097/txd.0000000000000594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 12/19/2022] Open
Abstract
There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.
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Opelz G, Unterrainer C, Süsal C, Döhler B. Efficacy and safety of antibody induction therapy in the current era of kidney transplantation. Nephrol Dial Transplant 2016; 31:1730-8. [PMID: 27190386 DOI: 10.1093/ndt/gfw086] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/19/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Antibody induction with polyclonal rabbit-antithymocyte globulin (rATG) or an interleukin-2 receptor antagonist (IL-2RA) is widely used in kidney transplantation. METHODS Collaborative Transplant Study data from 38 311 first deceased-donor kidney transplants (2004-13) were analysed. Transplants were classified as 'normal risk' or 'increased risk' according to current guidelines. Cox regression analysis was applied to subpopulations of propensity score-matched recipients. RESULTS rATG or IL-2RA induction was given to 64% of increased-risk and 53% of normal-risk patients, respectively. rATG and IL-2RA induction were each associated with reduced risk for graft loss versus no induction in increased-risk patients [hazard ratio (HR) 0.85, P = 0.046 and HR 0.89, P = 0.011, respectively]. The HR values for incidence of treated rejection in increased-risk patients for rATG and IL-2RA versus no induction were 0.75 (P = 0.037) and 0.77 (P < 0.001), respectively. In the normal risk subpopulation, neither induction therapy significantly affected the risk of graft loss or treated rejection. Hospitalization for infection was increased by rATG (P < 0.001) and IL-2RA (P < 0.001) induction. In contrast to patients transplanted during 1994-2003, among patients transplanted during 2004-13, rATG did not significantly affect the risk of non-Hodgkin's lymphoma versus no induction (P = 0.68). CONCLUSION Induction therapy following kidney transplantation should be targeted to increased-risk transplants. In this analysis, a beneficial effect of antibody induction in normal-risk transplants could not be demonstrated.
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Affiliation(s)
- Gerhard Opelz
- Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Christian Unterrainer
- Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
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Wang DC, Wang X, Chen C. Effects of anti-human T lymphocyte immune globulins in patients: new or old. J Cell Mol Med 2016; 20:1796-9. [PMID: 27084794 PMCID: PMC4988288 DOI: 10.1111/jcmm.12860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/29/2016] [Indexed: 02/06/2023] Open
Abstract
Multiple studies demonstrated that anti‐human T lymphocyte immune globulins (ATG) can decrease the incidence of acute and chronic graft rejection in cell or organ transplants. However, further in‐depth study indicates that different subgroups may benefit from either different regimes or alteration of them. Studies among renal transplant patients indicate that low immunological risk patients may not gain the same amount of benefit and thus tilt the risk versus benefit consideration. This may hold true for low immunological risk patients receiving other organ transplants and would be worth further investigation. The recovery time of T cells and natural killer (NK) cells also bears consideration and the impact that it has on the severity and incidence of opportunistic infections closely correlated with the dosage of ATG. The use of lower doses of ATG in combination with other induction medications may offer a solution. The finding that ATG may lose efficacy in cases of multiple transplants or re‐transplants in the case of heart transplants may hold true for other transplantations. This may lead to reconsideration of which induction therapies would be most beneficial in the clinical setting. These studies on ATG done on different patient groups will naturally not be applicable to all, but the evidence accrued from them as a whole may offer us new and different perspectives on how to approach and potentially solve the clinical question of how to best reduce the mortality associated with chronic host‐versus‐graft disease.
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Affiliation(s)
- Diane C Wang
- Department of Respiratory Medicine, The First Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiangdong Wang
- Department of Respiratory Medicine, The First Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengshui Chen
- Department of Respiratory Medicine, The First Hospital of Wenzhou Medical University, Wenzhou, China
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Pratschke J, Dragun D, Hauser IA, Horn S, Mueller TF, Schemmer P, Thaiss F. Immunological risk assessment: The key to individualized immunosuppression after kidney transplantation. Transplant Rev (Orlando) 2016; 30:77-84. [DOI: 10.1016/j.trre.2016.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/10/2016] [Indexed: 12/18/2022]
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Malvezzi P, Jouve T, Rostaing L. Induction by anti-thymocyte globulins in kidney transplantation: a review of the literature and current usage. J Nephropathol 2015; 4:110-5. [PMID: 26457257 PMCID: PMC4596294 DOI: 10.12860/jnp.2015.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 07/25/2015] [Indexed: 01/28/2023] Open
Abstract
Context: Preventing acute rejection (AR) after kidney transplantation is of utmost importance because an AR can have a negative impact on long-term allograft survival.
Evidence Acquisition: Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO, and Web of Science have been searched.
Results: At the moment this can be done by using rabbit anti-thymocyte globulins (rATGs) as an induction therapy. However, because rATGs are associated with some deleterious side-effects, such as the opportunistic infections cytomegalovirus (CMV) and
de novo
post-transplant cancer, it is very important they are used optimally, i.e., at minimal doses that avoid many side-effects but still retain optimal treatment efficacy. Recent data show that the risk of CMV infection can be minimized using tacrolimus plus everolimus, and not tacrolimus plus mycophenolic acid, as the maintenance immunosuppression. The use of rATG is particularly valuable in; (a) sensitized patients;
(b)
in recipients from an expanded-criteria donor, thus enabling the introduction of calcineurin inhibitors at reduced doses; and
(c)
for patients where steroid avoidance is contemplated. However, we also need to consider that rATG may increase the risk of
de novo
cancer, even though recent data indicate this is unlikely and that any risk can be reduced by using mammalian target of rapamycin (mTOR) inhibitors instead of mycophenolic acid combined with low-dose calcineurin inhibitors.
Conclusions: Even though rATGs do not improve long-term kidney-allograft survival, they may help reduce calcineurin-inhibitor dosage during the early post-transplant period and minimize the risk of AR.
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Affiliation(s)
- Paolo Malvezzi
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Thomas Jouve
- Clinique de Néphrologie, University Hospital, Grenoble, France
| | - Lionel Rostaing
- Department of Nephrology, Dialysis, and Organ Transplantation, CHU Rangueil, Toulouse University Hospital, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France ; Université Paul Sabatier, Toulouse, France
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