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Rao M, Amouzgar M, Harden JT, Lapasaran MG, Trickey A, Armstrong B, Odim J, Debnam T, Esquivel CO, Bendall SC, Martinez OM, Krams SM. High-dimensional profiling of pediatric immune responses to solid organ transplantation. Cell Rep Med 2023; 4:101147. [PMID: 37552988 PMCID: PMC10439249 DOI: 10.1016/j.xcrm.2023.101147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/05/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023]
Abstract
Solid organ transplant remains a life-saving therapy for children with end-stage heart, lung, liver, or kidney disease; however, ∼33% of allograft recipients experience acute rejection within the first year after transplant. Our ability to detect early rejection is hampered by an incomplete understanding of the immune changes associated with allograft health, particularly in the pediatric population. We performed detailed, multilineage, single-cell analysis of the peripheral blood immune composition in pediatric solid organ transplant recipients, with high-dimensional mass cytometry. Supervised and unsupervised analysis methods to study cell-type proportions indicate that the allograft type strongly influences the post-transplant immune profile. Further, when organ-specific differences are considered, graft health is associated with changes in the proportion of distinct T cell subpopulations. Together, these data form the basis for mechanistic studies into the pathobiology of rejection and allow for the development of new immunosuppressive agents with greater specificity.
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Affiliation(s)
- Mahil Rao
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Meelad Amouzgar
- Immunology Graduate Program, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - James T Harden
- Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Immunology Graduate Program, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - M Gay Lapasaran
- Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Amber Trickey
- Department of Surgery, Division of Abdominal Transplant Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | | | - Jonah Odim
- National Institutes of Health, Bethesda, MD, USA
| | | | - Carlos O Esquivel
- Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Department of Surgery, Division of Abdominal Transplant Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Sean C Bendall
- Program in Immunology, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Department of Pathology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Olivia M Martinez
- Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Department of Surgery, Division of Abdominal Transplant Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Program in Immunology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Sheri M Krams
- Transplant Immunology Lab, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Department of Surgery, Division of Abdominal Transplant Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA; Program in Immunology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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2
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Jain A, Daoud D, Kees-Folts D, Freeman MA, Butt F, Abendroth CS, Shike H, Kadry Z. Steroid-free maintenance immunosuppression using alemtuzumab in pediatric kidney transplantation: Long-term longitudinal follow-up. Pediatr Transplant 2022; 26:e14173. [PMID: 34687570 DOI: 10.1111/petr.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/17/2021] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a scarcity of long-term data on steroid-free immunosuppression using alemtuzumab in pediatric kidney transplantation (KTx). This study examines long-term outcomes with alemtuzumab without steroid maintenance therapy in pediatric KTx. METHODS From July 2005 to June 2015, 71 pediatric KTx recipients received alemtuzumab without steroid maintenance. They were followed from 4.1 to 14.1 years post KTx. RESULTS Patient survival: One child expired with a functioning graft from post-transplant lymphoproliferative disorder (PTLD). Patient survival was 98.6%. Graft survival: Eighteen grafts were lost (16 from chronic rejection). Graft survival at 5 and 10 years was 92.3% and 61.3%, respectively. Rejection: Twenty-three (32.4%) patients were free from T-cell-mediated rejection (TCMR), 16 (22.5%) had >3 episodes. Sixteen (22.5%) were treated for antibody-mediated rejection (AMR). Infection: Twenty-three children developed Epstein-Barr virus (EBV), 5 developed cytomegalovirus (CMV), and 20 developed BK virus infection. Four (5.6%) developed PTLD. Twenty-two (31.0%) required treatment for neutropenia. Growth parameters: Mean height and weight increased by 0.56 and 0.69 SDS (standard deviation score), respectively. Body mass index increased by 5.1 kg/m2 at 10 years. Less than 40% required antihypertensive medications at all-time points. CONCLUSION Alemtuzumab, without corticosteroid maintenance, offers 98.6% patient survival at 14 years with five and 10-year graft survival of 92.3% and 61.3%, respectively. TCMR and AMR requiring treatment were 67.4% and 22.5%, respectively. CMV, EBV, and BK viremia rates were 7.0%, 32.4%, and 28.2%, respectively. Thirty-one percent were treated for neutropenia; 5.6% developed PTLD. There were improvements in growth parameters and blood pressure.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Daoud
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Kees-Folts
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Michael A Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Fauzia Butt
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Catherine S Abendroth
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hiroko Shike
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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3
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Liverman R, Chandran MM, Crowther B. Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient. Pharmacotherapy 2021; 41:77-102. [PMID: 33151553 DOI: 10.1002/phar.2483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 12/23/2022]
Abstract
Pediatric kidney transplantation has experienced considerable growth and improvement in patient and allograft outcomes over the past 20 years, in part due to advancements in immunosuppressive regimens and management. Despite this progress, care for this unique population can be challenging due to limited pediatric transplant data and trials, intricacies related to differences in children and adolescents compared with their adult counterparts, and limitations to long-term survival facing all solid organ transplant populations. Immunosuppression and infection prevention practices vary from one pediatric transplant center to another and clinical controversies exist surrounding treatment and dosing. This review aims to summarize key aspects of pharmacologic management in this population and present pertinent data that describe the influence of practice to serve as a resource for practitioners caring for this unique specialty patient population. Additionally, this review highlights select controversies that exist within pediatric kidney transplantation.
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Affiliation(s)
- Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mary Moss Chandran
- Department of Pharmacy, Childeren's Hospital Colorado, Aurora, Colorado, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Hospital, Aurora, Colorado, USA
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4
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Puliyanda DP, Pizzo H, Rodig N, Somers MJG. Early outcomes comparing induction with antithymocyte globulin vs alemtuzumab in two steroid-avoidance protocols in pediatric renal transplantation. Pediatr Transplant 2020; 24:e13685. [PMID: 32112514 DOI: 10.1111/petr.13685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
Steroid avoidance in pediatric kidney transplants was found effective with extended daclizumab induction. Upon discontinuation of daclizumab, lymphocyte-depleting agents became used, with little comparative data. We assessed outcomes in children undergoing low immunologic-risk deceased donor (DD) kidney transplants using induction with antithymocyte globulin (ATG) compared to alemtuzumab. We reviewed consecutive DD kidney transplants from January 2015 to September 2017 at two pediatric centers that used different lymphocyte-depleting agents in steroid-avoidance protocols: ATG (Center A) and alemtuzumab (Center B), with tacrolimus and MMF as maintenance immunosuppression. Anti-infective prophylaxis was based on center protocol. Over the first year post-tx, there were similar rates of infections. EBV and BK viremia were comparable though Center A manifested more low-grade CMV viremia (A 46% vs B 0%; P = .0009) at median onset 1.8 months, followed by early seroconversion. Reduction of immunosuppression did not differ between groups. DSA at 1 year was similar (A 8% vs 13%) with low rates of BPAR. Need for steroid-based conversion was low. There were no graft losses and no differences in median eGFR at 30, 90, 180, and 365 days. (a) 1-year graft outcomes are excellent in steroid-avoidance regimens using ATG or alemtuzumab induction; (b) conversion to steroid-based therapy is low; (c) alemtuzumab/high-dose MMF is associated with lower WBC and more GCSF use; (d) alemtuzumab/higher dose MMF results in more diarrhea and azathioprine conversion than ATG/lower dose MMF; (e) CMV viremia is seen more often with ATG use with infection prophylaxis reduction; however, seroconversion occurs promptly.
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Affiliation(s)
- Dechu P Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Helen Pizzo
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Nancy Rodig
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael J G Somers
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Traitanon O, Mathew JM, Shetty A, Bontha SV, Maluf DG, El Kassis Y, Park SH, Han J, Ansari MJ, Leventhal JR, Mas V, Gallon L. Mechanistic analyses in kidney transplant recipients prospectively randomized to two steroid free regimen-Low dose Tacrolimus with Everolimus versus standard dose Tacrolimus with Mycophenolate Mofetil. PLoS One 2019; 14:e0216300. [PMID: 31136582 PMCID: PMC6538151 DOI: 10.1371/journal.pone.0216300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/17/2019] [Indexed: 01/05/2023] Open
Abstract
Calcineurin inhibitors (CNI), the cornerstone of immunosuppression after transplantation are implicated in nephrotoxicity and allograft dysfunction. We hypothesized that combined low doses of CNI and Everolimus (EVR) may result in better graft outcomes and greater tolerogenic milieu. Forty adult renal transplant recipients were prospectively randomized to (steroid free) low dose Tacrolimus (TAC) and EVR or standard dose TAC and Mycophenolate (MMF) after Alemtuzumab induction. Baseline characteristics were statistically similar. EVR levels were maintained at 3-8 ng/ml. TAC levels were 4.5±1.9 and 6.4±1.5 ng/ml in the TAC+EVR and TAC+MMF group respectively. Follow up was 14±4 and 17±5 months respectively and included protocol kidney biopsies at 3 and 12 months post-transplantation. Rejection-rate was lower in the TAC+EVR group. However patient and overall graft survival, eGFR and incidence of adverse events were similar. TAC+EVR induced expansion of CD4+CD25hiFoxp3+ regulatory T cells as early as 3 months and expansion of IFN-γ+CD4+CD25hiFoxp3+ regulatory T cells at 12 months post-transplant. Gene expression profile showed a trend toward decreased inflammation, angiogenesis and connective tissue growth in the TAC+EVR Group. Thus, greater tolerogenic mechanisms were found to be operating in patients with low dose TAC+EVR and this might be responsible for the lower rejection-rate than in patients on standard dose TAC+MMF. However, further studies with longer follow up and evaluating impact on T regulatory cells are warranted.
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Affiliation(s)
- Opas Traitanon
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
- Department of Medicine-Nephrology, Thammasart University Hospital, Pathumthani, Thailand
| | - James M. Mathew
- Department of Surgery, Northwestern University, Chicago, IL, United States of America
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, United States of America
- Department of Microbiology-Immunology, Northwestern University, Chicago, IL, United States of America
- * E-mail: (LG); (JMM)
| | - Aneesha Shetty
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
| | - Sai Vineela Bontha
- Methodist University Transplant Institute; University of Tennessee Health Science Center; Memphis, TN, United States of America
| | - Daniel G. Maluf
- Methodist University Transplant Institute; University of Tennessee Health Science Center; Memphis, TN, United States of America
| | - Yvonne El Kassis
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
| | - Sook H. Park
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
| | - Jing Han
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, United States of America
| | - M. Javeed Ansari
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, United States of America
| | - Joseph R. Leventhal
- Department of Surgery, Northwestern University, Chicago, IL, United States of America
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, United States of America
| | - Valeria Mas
- Methodist University Transplant Institute; University of Tennessee Health Science Center; Memphis, TN, United States of America
| | - Lorenzo Gallon
- Department of Medicine-Nephrology, Northwestern University, Chicago, IL, United States of America
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, United States of America
- * E-mail: (LG); (JMM)
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6
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Nemes B, Barta A, Ivádi G, Kárai B, Szánthó E, Hevessy Z, Szabó RP, Szilvási A, Sipka S, Baráth S. T Cell Subset Profile and Appearance of Donor-specific Antibodies in Primary and Retransplanted Kidney Recipients. Transplant Proc 2019; 51:1215-1225. [DOI: 10.1016/j.transproceed.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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7
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Chen J, Bhattacharya S, Sirota M, Laiudompitak S, Schaefer H, Thomson E, Wiser J, Sarwal MM, Butte AJ. Assessment of Postdonation Outcomes in US Living Kidney Donors Using Publicly Available Data Sets. JAMA Netw Open 2019; 2:e191851. [PMID: 30977847 PMCID: PMC6481454 DOI: 10.1001/jamanetworkopen.2019.1851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 02/12/2019] [Indexed: 12/30/2022] Open
Abstract
Importance There are limited resources providing postdonation conditions that can occur in living donors (LDs) of solid-organ transplant. Consequently, it is difficult to visualize and understand possible postdonation outcomes in LDs. Objective To assemble an open access resource that is representative of the demographic characteristics in the US national registry, maintained by the Organ Procurement and Transplantation Network and administered by the United Network for Organ Sharing, but contains more follow-up information to help to examine postdonation outcomes in LDs. Design, Setting, and Participants Cohort study in which the data for the resource and analyses stemmed from the transplant data set derived from 27 clinical studies from the ImmPort database, which is an open access repository for clinical studies. The studies included data collected from 1963 to 2016. Data from the United Network for Organ Sharing Organ Procurement and Transplantation Network national registry collected from October 1987 to March 2016 were used to determine representativeness. Data analysis took place from June 2016 to May 2018. Data from 20 ImmPort clinical studies (including clinical trials and observational studies) were curated, and a cohort of 11 263 LDs was studied, excluding deceased donors, LDs with 95% or more missing data, and studies without a complete data dictionary. The harmonization process involved the extraction of common features from each clinical study based on categories that included demographic characteristics as well as predonation and postdonation data. Main Outcomes and Measures Thirty-six postdonation events were identified, represented, and analyzed via a trajectory network analysis. Results The curated data contained 10 869 living kidney donors (median [interquartile range] age, 39 [31-48] years; 6175 [56.8%] women; and 9133 [86.6%] of European descent). A total of 9558 living kidney donors with postdonation data were analyzed. Overall, 1406 LDs (14.7%) had postdonation events. The 4 most common events were hypertension (806 [8.4%]), diabetes (190 [2.0%]), proteinuria (171 [1.8%]), and postoperative ileus (147 [1.5%]). Relatively few events (n = 269) occurred before the 2-year postdonation mark. Of the 1746 events that took place 2 years or more after donation, 1575 (90.2%) were nonsurgical; nonsurgical conditions tended to occur in the wide range of 2 to 40 years after donation (odds ratio, 38.3; 95% CI, 4.12-1956.9). Conclusions and Relevance Most events that occurred more than 2 years after donation were nonsurgical and could occur up to 40 years after donation. Findings support the construction of a national registry for long-term monitoring of LDs and confirm the value of secondary reanalysis of clinical studies.
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Affiliation(s)
- Jieming Chen
- Bakar Computational Health Sciences Institute, University of California, San Francisco
- Department of Pediatrics, University of California, San Francisco
- Now with the Department of Bioinformatics and Computational Biology, Genentech, Inc, South San Francisco, California
| | - Sanchita Bhattacharya
- Bakar Computational Health Sciences Institute, University of California, San Francisco
- Department of Pediatrics, University of California, San Francisco
| | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco
- Department of Pediatrics, University of California, San Francisco
| | - Sunisa Laiudompitak
- Bakar Computational Health Sciences Institute, University of California, San Francisco
| | | | | | - Jeff Wiser
- Northrop Grumman Information Systems Health IT, Rockville, Maryland
| | - Minnie M. Sarwal
- Department of Pediatrics, University of California, San Francisco
- Division of MultiOrgan Transplant, Department of Surgery and Medicine, University of California, San Francisco
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco
- Department of Pediatrics, University of California, San Francisco
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8
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van der Zwan M, Baan CC, van Gelder T, Hesselink DA. Review of the Clinical Pharmacokinetics and Pharmacodynamics of Alemtuzumab and Its Use in Kidney Transplantation. Clin Pharmacokinet 2018; 57:191-207. [PMID: 28669130 PMCID: PMC5784003 DOI: 10.1007/s40262-017-0573-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52 and causes depletion of T and B lymphocytes, monocytes, and NK cells. Alemtuzumab is registered for the treatment of multiple sclerosis (MS) and is also used in chronic lymphocytic leukemia (CLL). Alemtuzumab is used off-label in kidney transplantation as induction and anti-rejection therapy. The objective of this review is to present a review of the pharmacokinetics, pharmacodynamics, and use of alemtuzumab in kidney transplantation. A systematic literature search was conducted using Ovid Medline, Embase, and Cochrane Central Register of controlled trials. No pharmacokinetic or dose-finding studies of alemtuzumab have been performed in kidney transplantation. Although such studies were conducted in patients with CLL and MS, these findings cannot be directly extrapolated to transplant recipients, because CLL patients have a much higher load of CD52-positive cells and, therefore, target-mediated clearance will differ between these two indications. Alemtuzumab used as induction therapy in kidney transplantation results in a lower incidence of acute rejection compared to basiliximab therapy and comparable results as compared with rabbit anti-thymocyte globulin (rATG). Alemtuzumab used as anti-rejection therapy results in a comparable graft survival rate compared with rATG, although infusion-related side effects appear to be less. There is a need for pharmacokinetic and dose-finding studies of alemtuzumab in kidney transplant recipients to establish the optimal balance between efficacy and toxicity. Furthermore, randomized controlled trials with sufficient follow-up are necessary to provide further evidence for the treatment of severe kidney transplant rejection.
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Affiliation(s)
- Marieke van der Zwan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Carla C Baan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun van Gelder
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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9
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Safety and Efficacy of Alemtuzumab Induction in Highly Sensitized Pediatric Renal Transplant Recipients. Transplantation 2017; 101:883-889. [PMID: 27495773 DOI: 10.1097/tp.0000000000001416] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Studies show that alemtuzumab, a potent lymphocyte-depleting agent, is well tolerated in pediatric renal transplantation. We report on the use of alemtuzumab induction in highly HLA sensitized (HS) pediatric kidney transplant patients. METHODS Fifty pediatric renal transplants were performed from 1/2009-12/2014. 15 HS patients received IVIG (2 g/kg ×2 doses)/rituximab (375 mg/m ×1) for desensitization with alemtuzumab induction (15-30 mg, 1 dose, subcutaneous), whereas 35 nonsensitized patients received anti-IL-2R. Graft survival and infections were compared between 2 groups. RESULTS All HS patients had received a prior transplant and were older with lower risk for viral infections due to serostatus. Patient survival was 100%, and graft outcomes were similar with mean 1-year creatinine of 1.03 ± 0.45 versus 0.99 ± 0.6 (P = 0.48). Although a higher incidence of acute cellular rejection was seen in HS patients receiving alemtuzumab (P = 0.001), there was a nonsignificant difference in antibody-mediated rejection. White blood cell and absolute lymphocyte count were significantly lower in alemtuzumab group at 30 days (P < 0.0001) and at 1 year (P = 0.026 and P = 0.001), respectively. There was no significant difference in bacterial, viral, or fungal infections after transplant. CONCLUSIONS Alemtuzumab induction with desensitization led to nearly equivalent graft survival and functional outcomes in HS pediatric patients as nonsensitized patients receiving anti-IL-2R induction. With this small sample size, we observed significant reduction of white blood cell and absolute lymphocyte count up to 1 year posttransplant. The risk of infection was comparable between the 2 groups; however, patients who received alemtuzumab were older and at lower risk of viral infection due to serostatus.
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10
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Pediatric kidney transplantation: a historical review. Pediatr Res 2017; 81:259-264. [PMID: 27732587 DOI: 10.1038/pr.2016.207] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/30/2016] [Indexed: 01/10/2023]
Abstract
Successful renal transplantation is the optimal treatment for chronic kidney failure, but this was not always so for children. Beginning with the first kidney transplants in the 1950s, children experienced poorer patient and graft survival rates than adult patients. But over the last 6 decades, an improved understanding of the immune system which has steered pediatric multi-center clinical/pharmacokinetic and mechanistic studies that have sculpted our immunosuppression with markedly better patient and graft survivals. In addition, uniquely pediatric issues related to growth, development, neurocognitive maturation, increased complications from primary viral infections, and comorbid congenital/inherited disorders, are now diagnosed and effectively managed in these children. Refined pretransplant preparation (vaccinations for preventable diseases, attention to cognitive delays, effective dialysis and nutrition) improved donor selection, and more potent immunosuppression have all contributed to enhanced outcomes. Similarly, improvements in pediatric surgical techniques, postoperative care and better antiviral prophylaxis have all shortened hospitalizations and reduced morbidity. Today pediatric kidney transplant outcomes are markedly improved and younger children today experience better long-term graft survival than adults! While difficult problems remain, we have made tremendous progress and anticipate even more advances in the future of pediatric kidney transplantation.
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11
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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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12
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Min SI, Han A, Choi C, Kim SY, Kang HG, Ha IS, Ha J. Immunosuppression in Pediatric Kidney Transplant Patients. KOREAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.4285/jkstn.2015.29.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Sang-il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chanjoong Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Song Yi Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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13
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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14
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Rosenblum JM, Kirk AD. Recollective homeostasis and the immune consequences of peritransplant depletional induction therapy. Immunol Rev 2015; 258:167-82. [PMID: 24517433 DOI: 10.1111/imr.12155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
One's cellular immune repertoire is composed of lymphocytes in multiple stages of maturation - the dynamic product of their responses to antigenic challenges and the homeostatic contractions necessary to accommodate immune expansions within physiologic norms. Given that alloreactivity is predominantly a cross-reactive phenomenon that is stochastically distributed throughout the overall T-cell repertoire, one's allospecific repertoire is similarly made up of cells in a variety of differentiation states. As such, the continuous expansion and elimination of activated memory populations, producing a 'recollective homeostasis' of sorts, has the potential over time to alter the maturation state and effector composition of both ones protective and alloreactive T-cell repertoire. Importantly, a T cell's maturation state significantly influences its response to numerous immunomodulatory therapies used in organ transplantation, including depletional antibody induction. In this review, we discuss clinically utilized depletional induction strategies, how their use alters a transplant recipient's cellular immune repertoire, and how a recipient's repertoire influences the clinical effects of induction therapy.
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Bhattacharya S, Andorf S, Gomes L, Dunn P, Schaefer H, Pontius J, Berger P, Desborough V, Smith T, Campbell J, Thomson E, Monteiro R, Guimaraes P, Walters B, Wiser J, Butte AJ. ImmPort: disseminating data to the public for the future of immunology. Immunol Res 2015; 58:234-9. [PMID: 24791905 DOI: 10.1007/s12026-014-8516-1] [Citation(s) in RCA: 540] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The immunology database and analysis portal (ImmPort) system is the archival repository and dissemination vehicle for clinical and molecular datasets created by research consortia funded by the National Institute of Allergy and Infectious Diseases Division of Allergy, Immunology, and Transplantation. With nearly 100 datasets now publicly available and hundreds of downloads per month, ImmPort is an important source for raw data and protocols from clinical trials, mechanistic studies, and novel methods for cellular and molecular measurements. To facilitate data transfer, templates for data representation and standard operating procedures have also been created and are also publicly available. ImmPort facilitates transparency and reproducibility in immunology research, serves as an important resource for education, and enables newly generated hypotheses and data-driven science.
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Affiliation(s)
- Sanchita Bhattacharya
- Division of Systems Medicine, Department of Pediatrics, Stanford University School of Medicine, 1265 Welch Road MSOB X163, Stanford, CA, 94305-5415, USA
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16
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Peruzzi L, Amore A, Coppo R. Challenges in pediatric renal transplantation. World J Transplant 2014; 4:222-228. [PMID: 25540732 PMCID: PMC4274593 DOI: 10.5500/wjt.v4.i4.222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/20/2014] [Accepted: 12/10/2014] [Indexed: 02/05/2023] Open
Abstract
Transplantation in children is the best option to treat renal failure. Over the last 25 years the improvements in therapy have dramatically reduced the risk of early acute rejection and graft loss, however the long term results in terms of graft survival and morbidity still require search for new immunosuppressive regimens. Tolerance of the graft and minimization of side effects are the challenges for improving the outcome of children with a grafted kidney. Notwithstanding the difficulties in settling in children large multicenter trials to derive statistically useful data, many important contributions in the last years brought important modifications in the immunosuppressive therapy, including minimization protocols of steroids and calcineurin inhibitors and new induction drugs. New methods for diagnosis of anti HLA antibodies and some new protocols to improve both chance and outcome of transplantation in immunized subjects represent area of ongoing research of extreme interest for children.
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Gallon L, Traitanon O, Sustento-Reodica N, Leventhal J, Ansari MJ, Gehrau RC, Ariyamuthu V, De Serres SA, Alvarado A, Chhabra D, Mathew JM, Najafian N, Mas V. Cellular and molecular immune profiles in renal transplant recipients after conversion from tacrolimus to sirolimus. Kidney Int 2014; 87:828-38. [PMID: 25354238 PMCID: PMC4382402 DOI: 10.1038/ki.2014.350] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 02/01/2023]
Abstract
Tacrolimus and Sirolimus are commonly used maintenance immunesuppressants in kidney transplantation. Since their effects on immune cells and allograft molecular profiles have not been elucidated, we characterized the effects of Tacrolimus to Sirolimus conversion on frequency and function of T cells, and on graft molecular profiles. Samples from renal transplant patients in a randomized trial of 18 patients with late Sirolimus conversion and 12 on Tacrolimus maintenance were utilized. Peripheral blood was collected at 0, 6, 12 and 24-months post-randomization with T cell subpopulations analyzed by flow cytometry and T cell alloreactivity tested by IFN-γ ELISPOT. Graft biopsy samples obtained 24-months post-randomization were used for gene expression analysis. Sirolimus conversion led to an increase in CD4+25+++Foxp3+ regulatory T cells. While Tacrolimus-maintained patients showed a decrease in indirect alloreactivity over time post-transplant, Sirolimus conversion increased indirect alloreactive T cell frequencies compared to Tacrolimus-maintained patients. No histological differences were found in graft biopsies, but molecular profiles showed activation of the antigen presentation, IL-12 signaling, oxidative stress, macrophage-derived production pathways, and increased inflammatory and immune response in Sirolimus-converted patients. Thus, chronic immune alterations are induced after Sirolimus conversion. Despite the molecular profile being favorable to calcineurin inhibitor-based regimen, there was no impact in renal function over 30 months of follow-up.
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Affiliation(s)
- Lorenzo Gallon
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Opas Traitanon
- 1] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Thammasart University Hospital, Pathumthani, Thailand
| | | | - Joseph Leventhal
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - M Javeed Ansari
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Ricardo C Gehrau
- University of Virginia, Department of Surgery, Charlottesville, Virginia, USA
| | - Venkatesh Ariyamuthu
- Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Sacha A De Serres
- 1] Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Nephrology, Cleveland Clinic Florida, Cleveland, Florida, USA
| | - Antonio Alvarado
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Darshika Chhabra
- Advocate Christ Medical Center, Kidney Transplant, Oak Lawn, Illinois, USA
| | - James M Mathew
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - Nader Najafian
- 1] Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Nephrology, Cleveland Clinic Florida, Cleveland, Florida, USA
| | - Valeria Mas
- University of Virginia, Department of Surgery, Charlottesville, Virginia, USA
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Affiliation(s)
- Vikas R Dharnidharka
- From the Division of Pediatric Nephrology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis (V.R.D.); the Division of Nephrology, Boston Children's Hospital and Harvard Medical School, Boston (P.F., W.E.H.); and the Division of Transplant Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan (P.F.)
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Piotti G, Ma J, Adams E, Cobbold S, Waldmann H. Guiding postablative lymphocyte reconstitution as a route toward transplantation tolerance. Am J Transplant 2014; 14:1678-89. [PMID: 24840180 DOI: 10.1111/ajt.12756] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 02/28/2014] [Accepted: 03/22/2014] [Indexed: 01/25/2023]
Abstract
Anti-lymphocyte-depleting antibodies have increasingly been utilized in the clinic as induction therapy aiming to improve transplantation outcomes by reducing the need for long-term immunosuppression. However, maintenance immunosuppression is still required as lymphocyte reconstitution through homeostatic proliferation, partially driven by IL-7, continues to replenish tolerance-refractory immune cells capable of rejection. In murine models of MHC mismatched skin grafting, we investigated whether it is feasible to control the lymphocyte reconstitution process to delay rejection and favor tolerance processes. We found that a short course of anti-IL-7 receptor blocking antibody following T cell depletion, combined with the mammalian target of rapamycin inhibitor Rapamycin, could significantly delay graft rejection in one mouse strain, and achieve transplantation tolerance in another. The combination treatment was found to delay T cell reconstitution and, in the short term, enriched for Foxp3+ regulatory T cells (Tregs), at the expense of effector cells. Extended graft survival and tolerance were dependent on TGF-ß, indicating a role for induced Tregs. These findings point to the feasibility of building on lympholytic induction by guiding early lymphocyte reconstitution to favor endogenous regulatory mechanisms.
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Affiliation(s)
- G Piotti
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
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20
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Abstract
Immunosuppressive therapy in pediatrics continues to evolve. Over the past decade, newer immunosuppressive agents have been introduced into adult and pediatric transplant patients with the goal of improving patient and allograft survival. Unfortunately, large-scale randomized clinical trials are not commonly performed in children. The purpose of this review is to discuss the newer immunosuppressive agents available for induction therapy, maintenance immunosuppression, and the treatment of rejection.
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Affiliation(s)
- Christina Nguyen
- Division of Pediatric Nephrology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Ron Shapiro
- Division of Transplant Surgery, UPMC Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, United States
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Sung J, Barry JM, Jenkins R, Rozansky D, Iragorri S, Conlin M, Al-Uzri A. Alemtuzumab induction with tacrolimus monotherapy in 25 pediatric renal transplant recipients. Pediatr Transplant 2013; 17:718-25. [PMID: 24164824 DOI: 10.1111/petr.12159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 12/12/2022]
Abstract
ALA induction in transplantation has been shown to reduce the need for maintenance immunosuppression. We report the outcome of 25 pediatric renal transplants between 2007 and 2010 using ALA induction followed by tacrolimus maintenance monotherapy. Patient ages were 1-19 yr (mean 14 ± 4.1 yr). Time of follow-up was 7-51 months (mean 26 ± 13 months). Tacrolimus monotherapy was maintained in 48% of patients, and glucocorticoids were avoided in 80% of recipients. Mean plasma creatinine and GFR at one yr post-transplant were 0.88 ± 0.3 mg/dL and 104.4 ± 25 mL/min/1.73m(2) , respectively. One, two, and three-yr actuarial patient and graft survival rates were 100%. The incidence of early AR (<12 months after transplantation) was 12%, while the incidence of late AR (after 12 months) was 16%. Forty-four percent of the recipients recovered normal, baseline renal function after an episode of AR, and 44% had persistent renal dysfunction (plasma creatinine 1.0-1.8 mg/dL). One graft was lost four yr after transplantation due to medication non-compliance. Four (16%) patients developed BK or CMV infection. In our experience, ALA induction with tacrolimus monotherapy resulted in excellent short- and mid-term patient and graft survival in low-immunologic risk pediatric renal transplant recipients.
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Affiliation(s)
- Jennifer Sung
- Department of Urology, Oregon Health and Science University, Portland, OR, USA
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Wang XJ, Leveson-Gower D, Golab K, Wang LJ, Marek-Trzonkowska N, Krzystyniak A, Wardowska A, Millis JM, Trzonkowski P, Witkowski P. Influence of pharmacological immunomodulatory agents on CD4(+)CD25(high)FoxP3(+) T regulatory cells in humans. Int Immunopharmacol 2013; 16:364-70. [PMID: 23499512 DOI: 10.1016/j.intimp.2013.02.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 02/18/2013] [Indexed: 12/24/2022]
Abstract
T regulatory cells (Tregs) play a critical role in the immunologic tolerance to the graft in transplantation. Thus, due to their immunosuppressive capability, ex vivo expanded Tregs may be used as a cellular therapy and an attractive novel strategy to control chronic rejection and eliminate need for lifelong pharmacological immunosuppression. Since Treg therapy is still in its infancy, initially Tregs still need to be applied in combination with pharmacological agents to prevent rejection. Fortunately, some of the medications have been shown to enhance the function and number of Tregs. In the clinic, different immunosuppressive regimens are used for individual patients for different types of organ transplantation. In this review, we present the most commonly used pharmacological agents for immunosuppression and discuss how they affect the Treg population. It is extremely difficult to dissect the effect of single agent on Tregs population in clinical settings since usually the combination of several medications is applied at the same time for graft protection. Nevertheless, experimental and clinical data indicate that thymoglobulin as immunosuppressive induction and mTOR inhibitors as immunosuppressive maintenance agents have the most beneficial effect on Treg population in the blood. Among supplemental agents promoting Tregs, anti-TNFα preparations have been in clinical use (in autoimmune diseases) for many years, so they are optimal candidates for testing in transplant settings in combination with Treg based cellular therapy.
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Affiliation(s)
- Xiao-Jun Wang
- Department of Surgery, Section of Transplantation, University of Chicago, IL 60637, USA
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