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Khan MA, Lau CL, Krupnick AS. Monitoring regulatory T cells as a prognostic marker in lung transplantation. Front Immunol 2023; 14:1235889. [PMID: 37818354 PMCID: PMC10561299 DOI: 10.3389/fimmu.2023.1235889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Lung transplantation is the major surgical procedure, which restores normal lung functioning and provides years of life for patients suffering from major lung diseases. Lung transplant recipients are at high risk of primary graft dysfunction, and chronic lung allograft dysfunction (CLAD) in the form of bronchiolitis obliterative syndrome (BOS). Regulatory T cell (Treg) suppresses effector cells and clinical studies have demonstrated that Treg levels are altered in transplanted lung during BOS progression as compared to normal lung. Here, we discuss levels of Tregs/FOXP3 gene expression as a crucial prognostic biomarker of lung functions during CLAD progression in clinical lung transplant recipients. The review will also discuss Treg mediated immune tolerance, tissue repair, and therapeutic strategies for achieving in-vivo Treg expansion, which will be a potential therapeutic option to reduce inflammation-mediated graft injuries, taper the toxic side effects of ongoing immunosuppressants, and improve lung transplant survival rates.
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Wijbenga N, Muller MM, Hoek RAS, Mathot BJ, Seghers L, Aerts JGJV, de Winter BCM, Bos D, Manintveld OC, Hellemons ME. Diagnostic accuracy of eNose 'breathprints' for therapeutic drug monitoring of Tacrolimus trough levels in lung transplantation. J Breath Res 2023; 17:046010. [PMID: 37582348 DOI: 10.1088/1752-7163/acf066] [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: 08/30/2022] [Accepted: 08/15/2023] [Indexed: 08/17/2023]
Abstract
In order to prevent long-term immunity-related complications after lung transplantation, close monitoring of immunosuppressant levels using therapeutic drug monitoring (TDM) is paramount. Novel electronic nose (eNose) technology may be a non-invasive alternative to the current invasive procedures for TDM. We investigated the diagnostic and categorization capacity of eNose breathprints for Tacrolimus trough blood plasma levels (TACtrough) in lung transplant recipients (LTRs). We performed eNose measurements in stable LTR attending the outpatient clinic. We evaluated (1) the correlation between eNose measurements and TACtrough, (2) the diagnostic capacity of eNose technology for TACtrough, and (3) the accuracy of eNose technology for categorization of TACtroughinto three clinically relevant categories (low: <7µg ml-1, medium: 7-10µg ml-1, and high: >10µg ml-1). A total of 186 measurements from 86 LTR were included. There was a weak but statistically significant correlation (r= 0.21,p= 0.004) between the eNose measurements and TACtrough. The root mean squared error of prediction for the diagnostic capacity was 3.186 in the training and 3.131 in the validation set. The accuracy of categorization ranged between 45%-63% for the training set and 52%-69% in the validation set. There is a weak correlation between eNose breathprints and TACtroughin LTR. However, the diagnostic as well as categorization capacity for TACtroughusing eNose breathprints is too inaccurate to be applicable in TDM.
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Affiliation(s)
- Nynke Wijbenga
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marjolein M Muller
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Educational program Technical Medicine; Leiden University Medical Center, Delft University of Technology & Erasmus University Medical Center, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rogier A S Hoek
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas J Mathot
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Leonard Seghers
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joachim G J V Aerts
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Merel E Hellemons
- Department of Respiratory Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Tang Y, Fakhari S, Huntemann ED, Feng Z, Wu P, Feng WY, Lei J, Yuan F, Excoffon KJ, Wang K, Limberis MP, Kolbeck R, Yan Z, Engelhardt JF. Immunosuppression reduces rAAV2.5T neutralizing antibodies that limit efficacy following repeat dosing to ferret lungs. Mol Ther Methods Clin Dev 2023; 29:70-80. [PMID: 36950451 PMCID: PMC10025970 DOI: 10.1016/j.omtm.2023.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
The efficacy of redosing the recombinant adeno-associated virus (rAAV) vector rAAV2.5T to ferret lung is limited by AAV neutralizing antibody (NAb) responses. While immunosuppression strategies have allowed for systemic rAAV repeat dosing, their utility for rAAV lung-directed gene therapy is largely unexplored. To this end, we evaluated two immunosuppression (IS) strategies to improve repeat dosing of rAAV2.5T to ferret lungs: (1) a combination of three IS drugs (Tri-IS) with broad coverage against cellular and humoral responses (methylprednisolone [MP], azathioprine, and cyclosporine) and (2) MP alone, which is typically used in systemic rAAV applications. Repeat dosing utilized AAV2.5T-SP183-fCFTRΔR (recombinant ferret CFTR transgene), followed 28 days later by AAV2.5T-SP183-gLuc (for quantification of transgene expression). Both the Tri-IS and MP strategies significantly improved transgene expression following repeat dosing and reduced AAV2.5T NAb responses in the bronchioalveolar lavage fluid (BALF) and plasma, while AAV2.5T binding antibody subtypes and cellular immune responses by ELISpot were largely unchanged by IS. One exception was the reduction in plasma AAV2.5T binding immunoglobulin G (IgG) in both IS groups. Only the Tri-IS strategy significantly suppressed splenocyte expression of IFNA (interferon α [IFN-α]) and IL4. Our studies suggest that IS strategies may be useful in clinical application of rAAV targeting lung genetic diseases such as cystic fibrosis.
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Affiliation(s)
- Yinghua Tang
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Shahab Fakhari
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Eric D. Huntemann
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Zehua Feng
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Peipei Wu
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - William Y. Feng
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Junying Lei
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Feng Yuan
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | | | - Kai Wang
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA 52242, USA
| | | | | | - Ziying Yan
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - John F. Engelhardt
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Sharma D, Krishnan GS, Sharma N, Chandrashekhar A. Current perspective of immunomodulators for lung transplant. Indian J Thorac Cardiovasc Surg 2022; 38:497-505. [PMID: 36050971 PMCID: PMC9424406 DOI: 10.1007/s12055-022-01388-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022] Open
Abstract
Lung transplantation is an effective treatment option for selected patients suffering from end-stage lung disease. More intensive immunosuppression is enforced after lung transplants owing to a greater risk of rejection than after any other solid organ transplants. The commencing of lung transplantation in the modern era was in 1983 when the Toronto Lung Transplant Group executed the first successful lung transplant. A total of 43,785 lung transplants and 1365 heart-lung transplants have been performed from 1 Jan 1988 until 31 Jan 2021. The aim of this review article is to discuss the existing immunosuppressive strategies and emerging agents to prevent acute and chronic rejection in lung transplantation.
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Affiliation(s)
- Dhruva Sharma
- Department of Cardiothoracic and Vascular Surgery, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, 302001 Rajasthan India
| | - Ganapathy Subramaniam Krishnan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil Nadu India
| | - Neha Sharma
- Department of Pharmacology, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, 302001 Rajasthan India
| | - Anitha Chandrashekhar
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil Nadu India
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Bos S, Daniëls L, Michaux L, Vanden Bempt I, Vermeer S, Woei-A-Jin FSH, Schöffski P, Weynand B, Sciot R, Declercq S, Ceulemans LJ, Godinas L, Verleden GM, Van Raemdonck DE, Dupont LJ, Vos R. Case Report: An Unusual Course of Angiosarcoma After Lung Transplantation. Front Immunol 2022; 12:789851. [PMID: 35046948 PMCID: PMC8761760 DOI: 10.3389/fimmu.2021.789851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022] Open
Abstract
A 35-year-old woman underwent bilateral lung transplantation for primary ciliary dyskinesia and developed vascular tumors over a slow time course. Initial presentation of non-specific vascular tumors in the lungs and liver for up to 6 years after transplantation evolved toward bilateral ovarian angiosarcoma. Tumor analysis by haplotyping and human leukocyte antigen typing showed mixed donor chimerism, proving donor origin of the tumoral lesions. In retrospect, the donor became brain dead following neurosurgical complications for a previously biopsy-proven cerebral hemangioma, which is believed to have been a precursor lesion of the vascular malignancy in the recipient. Donor-transmitted tumors should always be suspected in solid organ transplant recipients in case of uncommon disease course or histology, and proper tissue-based diagnosis using sensitive techniques should be pursued.
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Affiliation(s)
- Saskia Bos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetics Laboratory (HILA), Red Cross-Flanders, Mechelen, Belgium
| | - Lucienne Michaux
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | | | - Sascha Vermeer
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Fj Sherida H Woei-A-Jin
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Patrick Schöffski
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Birgit Weynand
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Raf Sciot
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Sabine Declercq
- Department of Pathology, ZNA Middelheim Hospital, Antwerp, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Laurent Godinas
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Lieven J Dupont
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
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Rizk JG, Lazo JG, Quan D, Gabardi S, Rizk Y, Streja E, Kovesdy CP, Kalantar-Zadeh K. Mechanisms and management of drug-induced hyperkalemia in kidney transplant patients. Rev Endocr Metab Disord 2021; 22:1157-1170. [PMID: 34292479 DOI: 10.1007/s11154-021-09677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Hyperkalemia is a common and potentially life-threatening complication following kidney transplantation that can be caused by a composite of factors such as medications, delayed graft function, and possibly potassium intake. Managing hyperkalemia after kidney transplantation is associated with increased morbidity and healthcare costs, and can be a cause of multiple hospital admissions and barriers to patient discharge. Medications used routinely after kidney transplantation are considered the most frequent culprit for post-transplant hyperkalemia in recipients with a well-functioning graft. These include calcineurin inhibitors (CNIs), pneumocystis pneumonia (PCP) prophylactic agents, and antihypertensives (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers). CNIs can cause hyperkalemic renal tubular acidosis. When hyperkalemia develops following transplantation, the potential offending medication may be discontinued, switched to another agent, or dose-reduced. Belatacept and mTOR inhibitors offer an alternative to calcineurin inhibitors in the event of hyperkalemia, however should be prescribed in the appropriate patient. While trimethoprim/sulfamethoxazole (TMP/SMX) remains the gold standard for prevention of PCP, alternative agents (e.g. dapsone, atovaquone) have been studied and can be recommend in place of TMP/SMX. Antihypertensives that act on the Renin-Angiotensin-Aldosterone System are generally avoided early after transplant but may be indicated later in the transplant course for patients with comorbidities. In cases of mild to moderate hyperkalemia, medical management can be used to normalize serum potassium levels and allow the transplant team additional time to evaluate the function of the graft. In the immediate post-operative setting following kidney transplantation, a rapidly rising potassium refractory to medical therapy can be an indication for dialysis. Patiromer and sodium zirconium cyclosilicate (ZS-9) may play an important role in the management of chronic hyperkalemia in kidney transplant patients, although additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.
| | - Jose G Lazo
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - David Quan
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Youssef Rizk
- Department of Internal Medicine, Division of Family Medicine, Lebanese American University Medical Center - St. John's Hospital, Beirut, Lebanon
| | - Elani Streja
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
- Department of Epidemiology, University of California, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities. Int J Mol Sci 2019; 20:ijms20133210. [PMID: 31261959 PMCID: PMC6651704 DOI: 10.3390/ijms20133210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023] Open
Abstract
Although transplantation procedures have been developed for patients with end-stage hepatic insufficiency or other diseases, allograft rejection still threatens patient health and lifespan. Over the last few decades, the emergence of immunosuppressive agents such as calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors have strikingly increased graft survival. Unfortunately, immunosuppressive agent-related neurotoxicity commonly occurs in clinical practice, with the majority of neurotoxicity cases caused by CNIs. The possible mechanisms through which CNIs cause neurotoxicity include increasing the permeability or injury of the blood–brain barrier, alterations of mitochondrial function, and alterations in the electrophysiological state. Other immunosuppressants can also induce neuropsychiatric complications. For example, mTOR inhibitors induce seizures, mycophenolate mofetil induces depression and headaches, methotrexate affects the central nervous system, the mouse monoclonal immunoglobulin G2 antibody (used against the cluster of differentiation 3) also induces headaches, and patients using corticosteroids usually experience cognitive alteration. Therapeutic drug monitoring, individual therapy based on pharmacogenetics, and early recognition of symptoms help reduce neurotoxic events considerably. Once neurotoxicity occurs, a reduction in the drug dosage, switching to other immunosuppressants, combination therapy with drugs used to treat the neuropsychiatric manifestation, or blood purification therapy have proven to be effective against neurotoxicity. In this review, we summarize recent topics on the mechanisms of immunosuppressive drug-related neurotoxicity. In addition, information about the neuroprotective effects of several immunosuppressants is also discussed.
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