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Garcia J, Vianna R. B-Cell Induction Therapies in Intestinal Transplantation. Gastroenterol Clin North Am 2024; 53:343-357. [PMID: 39067999 DOI: 10.1016/j.gtc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Despite advancements in short-term outcomes since the inception of intestinal transplant, significant long-term graft failure persists. Early successes are attributed to the utilization of tacrolimus for maintenance therapy, coupled with T-cell modulating induction regimens, which effectively reduce the incidence of acute cellular rejection. However, the challenge of chronic allograft injury remains unresolved. There is increasing evidence indicating a correlation between donor-specific antibodies and the survival of visceral allografts. Strategies aimed at reducing the presence or load of these antibodies may potentially enhance long-term outcomes. Consequently, our focus is now turning toward B-cell induction therapies as a possible solution.
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Affiliation(s)
- Jennifer Garcia
- Adult and Pediatric Intestinal Transplant, Miami Transplant Institute, University of Miami-Jackson Memorial Hospital, 1801 Northwest 9th Avenue, MTI 7th Floor, Jackson Professional Building, Miami, FL 33136, USA.
| | - Rodrigo Vianna
- Adult and Pediatric Intestinal Transplant, Miami Transplant Institute, University of Miami-Jackson Memorial Hospital, 1801 Northwest 9th Avenue, MTI 7th Floor, Jackson Professional Building, Miami, FL 33136, USA
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2
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Hickey MJ, Singh G, Lum EL. Continuation of immunosuppression vs. immunosuppression weaning in potential repeat kidney transplant candidates: a care management perspective. FRONTIERS IN NEPHROLOGY 2023; 3:1163581. [PMID: 37746029 PMCID: PMC10513023 DOI: 10.3389/fneph.2023.1163581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/17/2023] [Indexed: 09/26/2023]
Abstract
Management of immunosuppression in patients with a failing or failed kidney transplant requires a complete assessment of their clinical condition. One of the major considerations in determining immunosuppression is whether or not such an individual is considered a candidate for re-transplantation. Withdrawal of immunosuppression in a re-transplant candidate can result in allosensitization and markedly reduce the chances of a repeat transplant. In this review, we summarize the effects of immunosuppression reduction on HLA sensitization, discuss the impacts of allosensitization in these patients, and explore reduction protocols and future directions. Risks of chronic immunosuppression, medical management of the failing allograft, and the effect of nephrectomy are covered elsewhere in this issue.
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Affiliation(s)
- Michelle J. Hickey
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Immunogenetics Center, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Gurbir Singh
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
| | - Erik L. Lum
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
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Wilson N, Reese S, Ptak L, Aziz F, Parajuli S, Jucaud V, Denham S, Mishra A, Cascalho M, Platt JL, Hematti P, Djamali A. Ixazomib for Desensitization (IXADES) in Highly Sensitized Kidney Transplant Candidates: A Phase II Clinical Trial. KIDNEY360 2023; 4:e796-e808. [PMID: 36951387 PMCID: PMC10371382 DOI: 10.34067/kid.0000000000000113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Key Points Ixazomib treatment resulted in decreases in B-cell subsets and bone marrow lymphocytes. Ixazomib treatment resulted in modest decreases in certain anti-HLA antibody specificities. Ixazomib treatment was tolerated, with modest adverse events. Background Ixazomib is a second-generation oral proteasome inhibitor approved for treatment of refractory multiple myeloma. We conducted an open-label phase II trial, IXAzomib for DESensitization (IXADES), testing the safety of ixazomib treatment as an approach to decreasing the level and diversity of specificities of anti-HLA antibodies in subjects awaiting kidney transplantation. The trial (NCT03213158 ) enrolled highly sensitized kidney transplant candidates, defined as subjects with calculated panel reactive antibodies (cPRA) >80%, awaiting kidney transplantation >24 months. The subjects were treated with 12 monthly cycles of ixazomib 3 mg+dexamethasone 20 mg. Efficacy was defined as a decrease of cPRA >20% or kidney transplantation. The safety end point was tolerability. Methods In ten enrolled subjects, no grade IV, five grade III, 11 grade II, and 43 grade I adverse events were noted. The adverse events included infection, transient paresthesia, nausea, vomiting, and diarrhea. The IXADES regimen was not associated with significant change in levels or diversity of anti-HLA antibodies (cPRA). Results Although the IXADES regimen did not exhibit a clear impact on levels and diversity of anti-HLA antibodies in this small cohort, the prolonged half-life of IgG could necessitate a longer duration of treatment for accurate evaluation of efficacy. Conclusions In conclusion, treatment with ixazomib/dexamethasone engendered mild-to-moderate toxicity. The impact on anti-HLA was modest and paradoxical in the case of anti-HLA-DR. Clinical trials combining ixazomib with other immunosuppressive agents may be more effective in addressing antibody-mediated processes in kidney transplantation.
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Affiliation(s)
- Nancy Wilson
- Department of Pathology and Laboratory Medicine, AVRL, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shannon Reese
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lucy Ptak
- Department of Administration, Division of Clinical Trials, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Fahad Aziz
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | | | | | - Ameet Mishra
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Marilia Cascalho
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey L. Platt
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, Michigan
| | - Peiman Hematti
- Department of Medicine, Division of Hematology and Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Arjang Djamali
- Department of Medicine, Maine Medical Center, Portland, Maine
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Rodriguez-Ramirez S, Al Jurdi A, Konvalinka A, Riella LV. Antibody-mediated rejection: prevention, monitoring and treatment dilemmas. Curr Opin Organ Transplant 2022; 27:405-414. [PMID: 35950887 PMCID: PMC9475491 DOI: 10.1097/mot.0000000000001011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) has emerged as the leading cause of late graft loss in kidney transplant recipients. Donor-specific antibodies are an independent risk factor for AMR and graft loss. However, not all donor-specific antibodies are pathogenic. AMR treatment is heterogeneous due to the lack of robust trials to support clinical decisions. This review provides an overview and comments on practical but relevant dilemmas physicians experience in managing kidney transplant recipients with AMR. RECENT FINDINGS Active AMR with donor-specific antibodies may be treated with plasmapheresis, intravenous immunoglobulin and corticosteroids with additional therapies considered on a case-by-case basis. On the contrary, no treatment has been shown to be effective against chronic active AMR. Various biomarkers and prediction models to assess the individual risk of graft failure and response to rejection treatment show promise. SUMMARY The ability to personalize management for a given kidney transplant recipient and identify treatments that will improve their long-term outcome remains a critical unmet need. Earlier identification of AMR with noninvasive biomarkers and prediction models to assess the individual risk of graft failure should be considered. Enrolling patients with AMR in clinical trials to assess novel therapeutic agents is highly encouraged.
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Affiliation(s)
- Sonia Rodriguez-Ramirez
- Department of Medicine, Division of Nephrology
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana Konvalinka
- Department of Medicine, Division of Nephrology
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network
- Institute of Medical Science, University of Toronto
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kim SG, Hong S, Lee H, Eum SH, Kim YS, Jin K, Han S, Yang CW, Park WY, Chung BH. Impact of delayed graft function on clinical outcomes in highly sensitized patients after deceased-donor kidney transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:149-160. [PMID: 35769252 PMCID: PMC9235446 DOI: 10.4285/kjt.21.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/18/2021] [Accepted: 09/18/2021] [Indexed: 11/24/2022] Open
Abstract
Background We investigated whether the development of delayed graft function (DGF) in pre-sensitized patients affects the clinical outcomes after deceased-donor kidney transplantation (DDKT). Methods The study included 709 kidney transplant recipients (KTRs) from three transplant centers. We divided KTRs into four subgroups (highly sensitized DGF, highly sensitized non-DGF, low-sensitized DGF, and low-sensitized non-DGF) according to panel reactive antibody level of 50%, or DGF development. We compared post-transplant clinical outcomes among the four subgroups. Results Incidence of biopsy-proven acute rejection (BPAR) was higher in two highly sensitized subgroups than in low-sensitized subgroups. It tended to be higher in highly sensitized DGF subgroups than in the highly sensitized non-DGF subgroups. In addition, the highly sensitized DGF subgroup showed the highest risk for BPAR (hazard ratio, 3.051; P=0.005) and independently predicted BPAR. Allograft function was lower in the two DGF subgroups than in the non-DGF subgroup until one month after transplantation, but thereafter it was similar. Death-censored graft loss rates and patient mortality tended to be low when DGF developed, but it did not reach statistical significance. Conclusions DGF development in highly sensitized patients increases the risk for BPAR in DDKT compared with patients without DGF, suggesting the need for strict monitoring and management of such cases.
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Affiliation(s)
- Seong Gyu Kim
- Division of Nephrology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Suyeon Hong
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hanbi Lee
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hun Eum
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Soo Kim
- Division of Nephrology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyubok Jin
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeop Han
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chul Woo Yang
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo Yeong Park
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Byung Ha Chung
- Transplantation Research Center, Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Goesch TR, Wilson NA, Zeng W, Verhoven BM, Zhong W, Coumbe Gitter MM, Fahl WE. Suppression of Inflammation-Associated Kidney Damage Post-Transplant Using the New PrC-210 Free Radical Scavenger in Rats. Biomolecules 2021; 11:1054. [PMID: 34356678 PMCID: PMC8301928 DOI: 10.3390/biom11071054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 01/10/2023] Open
Abstract
Allograft kidney transplantation, which triggers host cellular- and antibody-mediated rejection of the kidney, is a major contributor to kidney damage during transplant. Here, we asked whether PrC-210 would suppress damage seen in allograft kidney transplant. Brown Norway (BN) rat kidneys were perfused in situ (UW Solution) with or without added 30 mM PrC-210, and then immediately transplanted into Lewis (LEW) rats. 20 h later, the transplanted BN kidneys and LEW rat plasma were analyzed. Kidney histology, and kidney/serum levels of several inflammation-associated cytokines, were measured to assess mismatch-related kidney pathology, and PrC-210 protective efficacy. Twenty hours after the allograft transplants: (i) significant histologic kidney tubule damage and mononuclear inflammatory cell infiltration were seen in allograft kidneys; (ii) kidney function metrics (creatinine and BUN) were significantly elevated; (iii) significant changes in key cytokines, i.e., TIMP-1, TNF-alpha and MIP-3A/CCL20, and kidney activated caspase levels were seen. In PrC-210-treated kidneys and recipient rats, (i) kidney histologic damage (Banff Scores) and mononuclear infiltration were reduced to untreated background levels; (ii) creatinine and BUN were significantly reduced; and (iii) activated caspase and cytokine changes were significantly reduced, some to background. In conclusion, the results suggest that PrC-210 could provide broadly applicable organ protection for many allograft transplantation conditions; it could protect transplanted kidneys during and after all stages of the transplantation process-from organ donation, through transportation, re-implantation and the post-operative inflammation-to minimize acute and chronic rejection.
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Affiliation(s)
| | - Nancy A. Wilson
- Department of Surgery, Division of Organ Transplant, University of Wisconsin-Madison, Madison, WI 53706, USA; (N.A.W.); (W.Z.); (B.M.V.); (W.Z.)
| | - Weifeng Zeng
- Department of Surgery, Division of Organ Transplant, University of Wisconsin-Madison, Madison, WI 53706, USA; (N.A.W.); (W.Z.); (B.M.V.); (W.Z.)
| | - Bret M. Verhoven
- Department of Surgery, Division of Organ Transplant, University of Wisconsin-Madison, Madison, WI 53706, USA; (N.A.W.); (W.Z.); (B.M.V.); (W.Z.)
| | - Weixiong Zhong
- Department of Surgery, Division of Organ Transplant, University of Wisconsin-Madison, Madison, WI 53706, USA; (N.A.W.); (W.Z.); (B.M.V.); (W.Z.)
| | - Maya M. Coumbe Gitter
- Department of Oncology, Wisconsin Institutes for Medical Research, University of Wisconsin-Madison, Madison, WI 53706, USA;
| | - William E. Fahl
- Obvia Pharmaceuticals Ltd., Madison, WI 53719, USA;
- Department of Oncology, Wisconsin Institutes for Medical Research, University of Wisconsin-Madison, Madison, WI 53706, USA;
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Park Y, Ko EJ, Chung BH, Yang CW. Kidney transplantation in highly sensitized recipients. Kidney Res Clin Pract 2021; 40:355-370. [PMID: 34233438 PMCID: PMC8476304 DOI: 10.23876/j.krcp.21.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/02/2021] [Indexed: 11/04/2022] Open
Abstract
In kidney transplantation (KT), overcoming donor shortage is particularly challenging in patients with preexisting donor-specific antibodies (DSAs) against human leukocyte antigen (HLA), called HLA-incompatible KT (HLAi KT), carrying the risk of rejection and allograft loss. Thus, it is necessary to accurately evaluate the degree of sensitization before HLAi KT, and undertake appropriate pretreatment strategies. To determine the degree of sensitization, complement-dependent cytotoxicity has been the only method employed; the development of a method using flow cytometry further improved the test sensitivity. However, these tests present disadvantages, including the need for living cells, with a solid-phase assay developed to resolve this problem. Currently, the method using Luminex (Luminex Corp.) is widely used in clinical practice. As this method measures DSAs using single antigen beads, it is possible to classify immunological risks by measuring the type and amount of DSAs. Furthermore, there have been major advances in methods that involve DSA removal before HLAi KT. In the early stages of desensitization, plasmapheresis and intravenous immunoglobulins were the main treatment methods employed; however, the introduction of CD20 monoclonal antibody and proteasome inhibitors further increased the success rate of desensitization. Currently, HLAi KT has been established as an important transplant method, but an understanding of DSAs and a novel desensitization treatment are warranted.
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Affiliation(s)
- Yohan Park
- Division of Nephrology, Department of Internal Medicine and Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Ko
- Division of Nephrology, Department of Internal Medicine and Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine and Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine and Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Park Y, Lee H, Ko EJ, Lee S, Ban TH, Min JW, Yoon HE, Oh EJ, Yang CW, Chung BH. Impact of high body mass index on allograft outcomes in kidney transplant recipients with presensitization to human leukocyte antigen. Kidney Res Clin Pract 2021; 40:304-316. [PMID: 34024089 PMCID: PMC8237112 DOI: 10.23876/j.krcp.20.216] [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: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to investigate whether high body mass index (BMI) and presensitization to human leukocyte antigen (HLA) in kidney transplant recipients (KTRs) affected allograft outcomes. Methods From January 2010 to December 2018, 1,290 kidney transplantations (KTs) were performed at the Seoul St Mary’s Hospital. Of these, 682 cases of ABO-compatible living donor KT patients were enrolled. They were divided into four groups (low BMI-non-sensitized, high BMI-non-sensitized, low BMI-sensitized, and high BMI-sensitized) according to the median BMI value (22.7 kg/m2) and HLA presensitization status (anti-HLA antibody mean fluorescence intensity > 3,000). Short-term and long-term allograft outcomes were compared between groups. Results In the high BMI-sensitized group, the decline in allograft function was higher than that in the other three groups. Death-censored graft loss (DCGL) rates were highest in the high BMI-sensitized group (4 of 21 [19.0%], p = 0.04). In the multivariable Cox regression hazard regression model analysis, the hazard ratio (HR) for DCGL was intensified when high BMI and presensitization statuses were combined (HR, 3.75; p = 0.03); these statuses significantly interacted with each other (p-value for interaction = 0.008). Conclusion Our results suggest that presensitization to HLA and high BMI might have an interactive adverse impact on allograft outcomes in KTRs.
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Affiliation(s)
- Yohan Park
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hanbi Lee
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Ko
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sua Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye-Eun Yoon
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Woo Yang
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Ha Chung
- Transplantation Research Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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10
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Redfield RR, Jordan SC, Busque S, Vincenti F, Woodle ES, Desai N, Reed EF, Tremblay S, Zachary AA, Vo AA, Formica R, Schindler T, Tran H, Looney C, Jamois C, Green C, Morimoto A, Rajwanshi R, Schroeder A, Cascino MD, Brunetta P, Borie D. Safety, pharmacokinetics, and pharmacodynamic activity of obinutuzumab, a type 2 anti-CD20 monoclonal antibody for the desensitization of candidates for renal transplant. Am J Transplant 2019; 19:3035-3045. [PMID: 31257724 PMCID: PMC6899639 DOI: 10.1111/ajt.15514] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/28/2019] [Accepted: 06/18/2019] [Indexed: 01/25/2023]
Abstract
The limited effectiveness of rituximab plus intravenous immunoglobulin (IVIG) in desensitization may be due to incomplete B cell depletion. Obinutuzumab is a type 2 anti-CD20 antibody that induces increased B cell depletion relative to rituximab and may therefore be more effective for desensitization. This open-label phase 1b study assessed the safety, pharmacokinetics, and pharmacodynamics of obinutuzumab in highly sensitized patients with end-stage renal disease. Patients received 1 (day 1, n = 5) or 2 (days 1 and 15; n = 20) infusions of 1000-mg obinutuzumab followed by 2 doses of IVIG on days 22 and 43. Eleven patients received additional obinutuzumab doses at the time of transplant and/or at week 24. The median follow-up duration was 9.4 months. Obinutuzumab was well tolerated, and most adverse events were grade 1-2 in severity. There were 11 serious adverse events (SAEs) in 9 patients (36%); 10 of these SAEs were infections and 4 occurred after kidney transplant. Obinutuzumab plus IVIG resulted in profound peripheral B cell depletion and appeared to reduce B cells in retroperitoneal lymph nodes. Reductions in anti-HLA antibodies, number of unacceptable antigens, and the calculated panel reactive antibody score as centrally assessed using single-antigen bead assay were limited and not clinically meaningful for most patients (NCT02586051).
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Affiliation(s)
| | | | | | | | | | - Niraj Desai
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Elaine F. Reed
- David Geffen School of MedicineUniversity of CaliforniaLos AngelesCalifornia
| | - Simon Tremblay
- University of Cincinnati College of MedicineCincinnatiOhio
| | | | - Ashley A. Vo
- Cedars‐Sinai Medical CenterLos AngelesCalifornia
| | | | | | - Ha Tran
- Genentech, Inc.South San FranciscoCalifornia
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Ezekian B, Schroder PM, Mulvihill MS, Barbas A, Collins B, Freischlag K, Yoon J, Yi JS, Smith F, Olaso D, Saccoccio FM, Permar S, Farris AB, Kwun J, Knechtle SJ. Pretransplant Desensitization with Costimulation Blockade and Proteasome Inhibitor Reduces DSA and Delays Antibody-Mediated Rejection in Highly Sensitized Nonhuman Primate Kidney Transplant Recipients. J Am Soc Nephrol 2019; 30:2399-2411. [PMID: 31658991 DOI: 10.1681/asn.2019030304] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/17/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with broad HLA sensitization have poor access to donor organs, high mortality while waiting for kidney transplant, and inferior graft survival. Although desensitization strategies permit transplantation via lowering of donor-specific antibodies, the B cell-response axis from germinal center activation to plasma cell differentiation remains intact. METHODS To investigate targeting the germinal center response and plasma cells as a desensitization strategy, we sensitized maximally MHC-mismatched rhesus pairs with two sequential skin transplants. We administered a proteasome inhibitor (carfilzomib) and costimulation blockade agent (belatacept) to six animals weekly for 1 month; four controls received no treatment. We analyzed blood, lymph node, bone marrow cells, and serum before desensitization, after desensitization, and after kidney transplantation. RESULTS The group receiving carfilzomib and belatacept exhibited significantly reduced levels of donor-specific antibodies (P=0.05) and bone marrow plasma cells (P=0.02) compared with controls, with a trend toward reduced lymph node T follicular helper cells (P=0.06). Compared with controls, carfilzomib- and belatacept-treated animals had significantly prolonged graft survival (P=0.02), and renal biopsy at 1 month showed significantly reduced antibody-mediated rejection scores (P=0.02). However, four of five animals with long-term graft survival showed gradual rebound of donor-specific antibodies and antibody-mediated rejection. CONCLUSIONS Desensitization using proteasome inhibition and costimulation blockade reduces bone marrow plasma cells, disorganizes germinal center responses, reduces donor-specific antibody levels, and prolongs allograft survival in highly sensitized nonhuman primates. Most animals experienced antibody-mediated rejection with humoral-response rebound, suggesting desensitization must be maintained after transplantation using ongoing suppression of the B cell response.
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Affiliation(s)
| | | | | | | | | | | | | | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina; and
| | | | - Danae Olaso
- Department of Surgery, Duke Transplant Center
| | - Frances M Saccoccio
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Sallie Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center,
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12
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Association Between Peripheral Blood CD19-Positive Rate and Antibody-Mediated Rejection Following Rituximab Administration in Kidney Transplant Recipients. Transplant Direct 2019; 5:e467. [PMID: 31334341 PMCID: PMC6616141 DOI: 10.1097/txd.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 11/26/2022] Open
Abstract
Background. Rituximab is used widely for desensitization in ABO-incompatible and donor-specific antibody-positive kidney transplantation. However, data about the effects of individual differences in rituximab-induced B-cell suppression on antibody-mediated rejection (AMR) remain unknown. We aimed to assess the association between CD19-positive rate and AMR following rituximab administration after kidney transplantation. Methods. Overall, 42 patients who underwent rituximab therapy for pretransplant desensitization in ABO-incompatible (n = 33) and donor-specific antibody-positive (n = 15) kidney transplantation were observed retrospectively. To predict AMR incidence, the peripheral blood CD19-positive rate was determined and classified into short- and long-acting groups. AMR incidence, allograft function, complications, and rituximab dose were compared. Results. Eight patients (19%) had AMR within 39.2 months after transplantation. The CD19-positive rate cutoff value to predict AMR incidence was 4.4%, 6.4%, and 7.7% at 6, 12, and 18 months after transplantation, respectively. When comparing the short- and long-acting groups stratified according to the CD19-positive rate cutoff value, AMR incidence was significantly higher in the short-acting group than in the long-acting group at 6 (71.4% vs 8.6%), 12 (70.0% vs 3.1%), and 18 (58.3% vs 3.3%) months after transplantation. The CD19-positive rate for all patients with AMR exceeded the cutoff value 6, 12, or 18 months. Conversely, serum creatinine level, tacrolimus trough-level, cytomegalovirus antigenemia-positive rate, neutropenia incidence rate, and total dose of rituximab before transplantation showed no significant differences between the 2 groups. Conclusions. The risk of AMR was higher in patients with short-term B-cell suppression following rituximab administration. Additional rituximab administration after transplantation may prevent AMR in patients with a CD19-positive rate higher than the cutoff value.
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Kwun J, Matignon M, Manook M, Guendouz S, Audard V, Kheav D, Poullot E, Gautreau C, Ezekian B, Bodez D, Damy T, Faivre L, Menouch D, Yoon J, Park J, Belhadj K, Chen D, Bilewski AM, Yi JS, Collins B, Stegall M, Farris AB, Knechtle S, Grimbert P. Daratumumab in Sensitized Kidney Transplantation: Potentials and Limitations of Experimental and Clinical Use. J Am Soc Nephrol 2019; 30:1206-1219. [PMID: 31227636 DOI: 10.1681/asn.2018121254] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Donor-specific antibodies are associated with increased risk of antibody-mediated rejection and decreased allograft survival. Therefore, reducing the risk of these antibodies remains a clinical need in transplantation. Plasma cells are a logical target of therapy given their critical role in antibody production. METHODS To target plasma cells, we treated sensitized rhesus macaques with daratumumab (anti-CD38 mAb). Before transplant, we sensitized eight macaques with two sequential skin grafts from MHC-mismatched donors; four of them were also desensitized with daratumumab and plerixafor (anti-CXCR4). We also treated two patients with daratumumab in the context of transplant. RESULTS The animals treated with daratumumab had significantly reduced donor-specific antibody levels compared with untreated controls (57.9% versus 13% reduction; P<0.05) and prolonged renal graft survival (28.0 days versus 5.2 days; P<0.01). However, the reduction in donor-specific antibodies was not maintained because all recipients demonstrated rapid rebound of antibodies, with profound T cell-mediated rejection. In the two clinical patients, a combined heart and kidney transplant recipient with refractory antibody-mediated rejection and a highly sensitized heart transplant candidate, we also observed a significant decrease in class 1 and 2 donor-specific antibodies that led to clinical improvement of antibody-mediated rejection and to heart graft access. CONCLUSIONS Targeting CD38 with daratumumab significantly reduced anti-HLA antibodies and anti-HLA donor-specific antibodies in a nonhuman primate model and in two transplant clinical cases before and after transplant. This supports investigation of daratumumab as a potential therapeutic strategy; however, further research is needed regarding its use for both antibody-mediated rejection and desensitization.
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Affiliation(s)
| | - Marie Matignon
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | | | - Soulef Guendouz
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | - Vincent Audard
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - David Kheav
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Chantal Gautreau
- Department of Immunology and Histocompatibility, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Diane Bodez
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | - Thibault Damy
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France
| | | | - Dehbia Menouch
- Department of Apheresis, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France; and
| | | | | | - Karim Belhadj
- Haematology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Dongfeng Chen
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Alyssa M Bilewski
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham, North Carolina
| | | | - Mark Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alton B Farris
- Department of Pathology, Emory School of Medicine, Atlanta, Georgia
| | | | - Philippe Grimbert
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France;
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14
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Durdu MS, Cakici M, Gumus F, Deniz GC, Bozdag SC, Ozcinar E, Yaman ND, Ilhan O, Ucanok K. Promising utilization areas of therapeutic plasmapheresis in cardiovascular surgery practice. Transfus Apher Sci 2018; 57:762-767. [PMID: 30249533 DOI: 10.1016/j.transci.2018.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/10/2018] [Accepted: 09/16/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Apheresis is performed for treatment of numerous diseases by removing auto-antibodies, antigen-antibody complexes, allo-antibodies, paraproteins, non-Ig proteins, toxins, exogenous poisons. In current study, we present our experience of using therapeutic plasma exchange (TPE) in patients with different types of clinical scenarios. METHODS Between January 2013 and May 2016, we retrospectively presented the results of 64 patients in whom postoperative TPE was performed in ICU setting after cardiac surgery. Patients were grouped into four as; 1-sepsis (n = 26), 2-hepatorenal syndrome(n = 24), 3-antibody mediated rejection(AMR) following heart transplantation(n = 4) and 4-right heart failure(RHF) after left ventricular asist device(LVAD)(n = 10). Hemodynamic parameters were monitored constantly, pre- and post-procedure peripheral blood tests including renal and liver functions and daily complete blood count (CBC), sedimentation, C-reactive protein and procalcitonin (ng/ml) levels were studied. RESULTS The mean age was 61 ± 17.67 years old and 56.25% (n = 36) were male. Mean Pre TPE left ventricular ejection fraction (LVEF) (%), central venous pressure (CVP)(mmHg) pulmonary capillary wedge pressure (PCWP)(mmHg) and pulmonary arterial pressure (PAP)(mmHg) were measured as 41.8 ± 8.1, 15.5 ± 4.4, 17.3 ± 3.24 and 39.9 ± 5.4, respectively. Procalcitonin (ng/ml) level of patients undergoing TPE due to sepsis was significantly reduced from 873 ± 401 ng/ml to 248 ± 132 ng/ml. Seventeen (26.5%) patients died in hospital during treatment, mean length of intensive care unit (ICU) stay(days) was 13.2 ± 5.1. CONCLUSION This study shows that TEP is a safe and feasible treatment modality in patients with different types of complications after cardiac surgery and hopefully this study will lead to new utilization areas.
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Affiliation(s)
- Mustafa Serkan Durdu
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Cakici
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey.
| | - Fatih Gumus
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | | | - Sinem Civriz Bozdag
- Department of Hematology, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Ozcinar
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Nur Dikmen Yaman
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Osman Ilhan
- Department of Hematology, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
| | - Kemalettin Ucanok
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara, Turkey
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15
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Zhang Z, Wilson NA, Chinnadurai R, Panzer SE, Redfield RR, Reese SR, Galipeau J, Djamali A. Autologous Mesenchymal Stromal Cells Prevent Transfusion-elicited Sensitization and Upregulate Transitional and Regulatory B Cells. Transplant Direct 2018; 4:e387. [PMID: 30234156 PMCID: PMC6133404 DOI: 10.1097/txd.0000000000000827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/14/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We hypothesized that immunomodulatory properties of mesenchymal stromal cells (MSC) may be considered for desensitization. METHODS Autologous or allogeneic bone marrow derived MSC were infused via tail vein at 0.5 M (0.5 × 106), 1 M, or 2 M cells/dose on days -2, 3, 6, 9, 12 (prevention) or 14, 17, 20, 23, 26 (treatment) relative to transfusion in a Brown Norway to Lewis rat model (10 groups total, n = 6 per group). RESULTS At 4 weeks, pooled analyses demonstrated that autologous and allogeneic MSC were equally effective in reducing IgG1 and IgG2a de novo donor-specific antibody (dnDSA, P < 0.001). Dose-response studies indicated that moderate-dose MSC (5 M total) was most effective in reducing IgG1, IgG2a, and IgG2c dnDSA (P ≤ 0.01). Time course studies determined that preventive and treatment strategies were equally effective in reducing IgG1 and IgG2a dnDSA (P ≤ 0.01). However, individual group analyses determined that moderate-dose (5 M) treatment with autologous MSC was most effective in reducing IgG1, IgG2a, and IgG2c dnDSA (P ≤ 0.01). In this group, dnDSA decreased after 1 week of treatment; regulatory B cells increased in the spleen and peripheral blood mononuclear cells; and transitional B cells increased in the spleen, peripheral blood mononuclear cells, and bone marrow (P < 0.05 for all). CONCLUSIONS Our findings indicate that autologous MSC prevent transfusion-elicited sensitization and upregulate transitional, and regulatory B cells. Additional studies are needed to determine the biological relevance of these changes after kidney transplantation.
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Affiliation(s)
- Zijian Zhang
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI
- Department of Urology, Beijing Chao-Yang Hospital, China Capital Medical University, Beijing, China
| | - Nancy A. Wilson
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI
| | - Raghavan Chinnadurai
- Division of Hematology-Oncology, Department of Medicine, University of Wisconsin, Madison, WI
| | - Sarah E. Panzer
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI
| | - Robert R. Redfield
- Division of Transplant, Department of Surgery, University of Wisconsin, Madison, WI
| | - Shannon R. Reese
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI
| | - Jacques Galipeau
- Division of Hematology-Oncology, Department of Medicine, University of Wisconsin, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI
- Division of Transplant, Department of Surgery, University of Wisconsin, Madison, WI
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16
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Shao LN, Yang Y, Zhang ST, Zhou SH, Duan Y, Meng QL, Liang XH, Yu WJ. Association between the polymorphism of HLA and ESRD in Dalian Han population located in north of China. Immunol Invest 2017; 47:212-219. [PMID: 29257902 DOI: 10.1080/08820139.2017.1416397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD), the last stage of chronic renal failure, is a global health problem. The number of ESRD patients worldwide is increasing faster than the number of kidneys available per year for renal transplantation. Most of the ESRD patients are awaiting renal transplantation. The immune response to the transplanted kidney is directed mainly against mismatched human leukocyte antigen (HLA) glycoproteins expressed on donor tissues. Thus, the analysis of HLA allele and haplotype polymorphisms is valuable not only for identifying ESRD susceptibility factors but also to improve graft survival. METHODS In this study, 163 Han ESRD patients were recruited to participate. The blood samples were genotyped by sequence-specific oligonucleotide method. A group of 14,529 healthy Chinese Han individuals registered at the Dalian Blood Center as bone marrow donors, living in the same region and of the same ethnicity, were used as controls. RESULTS We found that only one allele, HLA-DRB1*12, showed a positive association with ESRD (p = 0.004, pc = 0.028, odds ratio = 1.530, 95% confidence interval = 1.147-2.041); A*02-B*40-DRB1*09, A*02-B*40-DRB1*12, A*24-B*15-DRB1*12, and B*40-DRB1*12 were significantly more frequent in ESRD patients after Bonferroni correction (pc < 0.05). CONCLUSION They were potentially valuable predictors for evaluating the risk of ESRD in the Dalian Han population.
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Affiliation(s)
- Lin-Nan Shao
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Yang Yang
- b The Third Department of Urology (Renal Transplant) , Dalian Friendship Hospital , Dalian , Liaoning , China
| | - Shu-Ting Zhang
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Shi-Hang Zhou
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Ying Duan
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Qing-Li Meng
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Xiao-Hua Liang
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
| | - Wei-Jian Yu
- a Blood Group Research Department, Dalian Blood Center , Dalian , Liaoning , China
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17
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Porcine to Human Heart Transplantation: Is Clinical Application Now Appropriate? J Immunol Res 2017; 2017:2534653. [PMID: 29238731 PMCID: PMC5697125 DOI: 10.1155/2017/2534653] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/08/2017] [Indexed: 11/24/2022] Open
Abstract
Cardiac xenotransplantation (CXTx) is a promising solution to the chronic shortage of donor hearts. Recent advancements in immune suppression have greatly improved the survival of heterotopic CXTx, now extended beyond 2 years, and life-supporting kidney XTx. Advances in donor genetic modification (B4GALNT2 and CMAH mutations) with proven Gal-deficient donors expressing human complement regulatory protein(s) have also accelerated, reducing donor pig organ antigenicity. These advances can now be combined and tested in life-supporting orthotopic preclinical studies in nonhuman primates and immunologically appropriate models confirming their efficacy and safety for a clinical CXTx program. Preclinical studies should also allow for organ rejection to develop xenospecific assays and therapies to reverse rejection. The complexity of future clinical CXTx presents a substantial and unique set of regulatory challenges which must be addressed to avoid delay; however, dependent on these prospective life-supporting preclinical studies in NHPs, it appears that the scientific path forward is well defined and the era of clinical CXTx is approaching.
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18
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Successful desensitization with proteasome inhibition and costimulation blockade in sensitized nonhuman primates. Blood Adv 2017; 1:2115-2119. [PMID: 29296858 DOI: 10.1182/bloodadvances.2017010991] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/16/2017] [Indexed: 11/20/2022] Open
Abstract
The detrimental effects of donor-directed antibodies in sensitized transplant patients remain a difficult immunologic barrier to successful organ transplantation. Antibody removal is often followed by rebound. Proteasome inhibitors (PIs) deplete antibody-producing plasma cells (PCs) but have shown marginal benefit for desensitization. In an allosensitized nonhuman primate (NHP) model, we observed increased germinal center (GC) formation after PI monotherapy, suggesting a compensatory PC repopulation mediated via GC activation. Here we show that costimulation blockade (CoB) targets GC follicular helper T (Tfh) cells in allosensitized NHPs. Combined PI and CoB significantly reduces bone marrow PCs (CD19+CD20-CD38+), Tfh cells (CD4+ICOS+PD-1hi), and GC B cells (BCL-6+CD20+); controls the homeostatic GC response to PC depletion; and sustains alloantibody decline. Importantly, dual PC and CoB therapy prolongs rejection-free graft survival in major histocompatibility complex incompatible kidney transplantation without alloantibody rebound. Our study illustrates a translatable desensitization method and provides mechanistic insight into maintenance of alloantibody sensitization.
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19
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Ixtlapale-Carmona X, Arvizu A, De-Santiago A, González-Tableros N, López M, Castelán N, Marino LA, Uribe-Uribe NO, Contreras AG, Vilatobá M, Morales-Buenrostro LE, Alberú J. Graft immunologic events in deceased donor kidney transplant recipients with preformed HLA-donor specific antibodies. Transpl Immunol 2017; 46:8-13. [PMID: 28974434 DOI: 10.1016/j.trim.2017.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pretransplant donor-specific HLA alloantibodies detected with the Single Antigen Bead (SAB) assay reflect an increased risk for acute antibody-mediated rejection (AMR). We herein report the incidence of both acute AMR and acute cellular rejection (ACR) during the first year posttransplantation, in a cohort of kidney transplant recipients (KTR) of deceased donor (DD) grafts, according to their DSA status. Pretransplant DSA do not preclude DD-KT in negative CDC-XM recipients at our center. PATIENTS AND METHODS 246 KT were performed at our center between 01/2012 and 12/2015 and 100 KTR obtained from a DD were analyzed; 24% harbored DSA by SAB assay, MFI values >500 were considered positive. All recipients received thymoglobulin induction and generic tacrolimus-based maintenance therapy. Graft biopsies were performed by protocol on months 3 and 12 as well as per indication. The incidence of AMR and ACR was correlated with the existence of pretransplant DSA. RESULTS Overall, 34% of patients developed an acute rejection episode, 54.2% in the DSA group versus 27.6% in the non-DSA group (p=0.032), and most of these events were detected as subclinical conditions in protocol biopsies. AMR events developed in 33.3% and 19.7% (p=0.176) in the DSA and the non-DSA groups, respectively. ACR events were found in 16.6% and 6.6% (p=0.127) in the DSA and non-DSA groups, respectively. Graft function was similar between groups at the end of the 1st year posttransplant and no immunological graft loss occurred. CONCLUSION Despite the use of depleting induction therapy and adequate tacrolimus trough levels along with MMF and steroids, a high rate of rejection events was observed during the first year post-transplantation.
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Affiliation(s)
- Xicohténcatl Ixtlapale-Carmona
- Department of Transplantation, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Adriana Arvizu
- Histocompatibility Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Adrian De-Santiago
- Histocompatibility Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Norma González-Tableros
- Histocompatibility Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Mayra López
- Histocompatibility Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Natalia Castelán
- Histocompatibility Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Lluvia A Marino
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Norma O Uribe-Uribe
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Alan G Contreras
- Department of Transplantation, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Mario Vilatobá
- Department of Transplantation, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico
| | - Luis E Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico.
| | - Josefina Alberú
- Department of Transplantation, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Mexico City 14080, Mexico.
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Arreola-Guerra JM, Morales-Buenrostro LE, Granados J, Castelán N, de Santiago A, Arvizu A, Gonzalez-Tableros N, López M, Vilatobá M, Alberú J. Anti-HLA-DQ antibodies are highly and independently related to the C1q-binding capacity of HLA antibodies. Transpl Immunol 2017; 41:10-16. [DOI: 10.1016/j.trim.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/28/2022]
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Parajuli S, Redfield RR, Astor BC, Djamali A, Kaufman DB, Mandelbrot DA. Outcomes in the highest panel reactive antibody recipients of deceased donor kidneys under the new kidney allocation system. Clin Transplant 2017; 31. [PMID: 27988992 DOI: 10.1111/ctr.12895] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology; Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - Robert R. Redfield
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Brad C. Astor
- Division of Nephrology; Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison WI USA
- Department of Population Health Sciences; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - Arjang Djamali
- Division of Nephrology; Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - Dixon B. Kaufman
- Division of Transplant Surgery; University of Wisconsin Hospital and Clinics; Madison WI USA
| | - Didier A. Mandelbrot
- Division of Nephrology; Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison WI USA
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Karahan GE, Claas FHJ, Heidt S. B Cell Immunity in Solid Organ Transplantation. Front Immunol 2017; 7:686. [PMID: 28119695 PMCID: PMC5222792 DOI: 10.3389/fimmu.2016.00686] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/22/2016] [Indexed: 01/03/2023] Open
Abstract
The contribution of B cells to alloimmune responses is gradually being understood in more detail. We now know that B cells can perpetuate alloimmune responses in multiple ways: (i) differentiation into antibody-producing plasma cells; (ii) sustaining long-term humoral immune memory; (iii) serving as antigen-presenting cells; (iv) organizing the formation of tertiary lymphoid organs; and (v) secreting pro- as well as anti-inflammatory cytokines. The cross-talk between B cells and T cells in the course of immune responses forms the basis of these diverse functions. In the setting of organ transplantation, focus has gradually shifted from T cells to B cells, with an increased notion that B cells are more than mere precursors of antibody-producing plasma cells. In this review, we discuss the various roles of B cells in the generation of alloimmune responses beyond antibody production, as well as possibilities to specifically interfere with B cell activation.
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Affiliation(s)
- Gonca E Karahan
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
| | - Frans H J Claas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
| | - Sebastiaan Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center , Leiden , Netherlands
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Dello Strologo L, Murer L, Guzzo I, Morolli F, Pipicelli AMV, Benetti E, Longo G, Testa S, Ricci A, Ginevri F, Ghio L, Cardillo M, Piazza A, Nanni Costa A. Renal transplantation in sensitized children and young adults: a nationwide approach. Nephrol Dial Transplant 2017; 32:191-195. [PMID: 27742824 DOI: 10.1093/ndt/gfw369] [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: 06/11/2016] [Accepted: 08/18/2016] [Indexed: 11/14/2022] Open
Abstract
Background High levels of preformed anti-HLA antibodies dramatically diminish renal transplant outcomes. Most desensitization programmes guarantee good intermediate outcomes but quite disappointing long-term prognosis. The search for a fully compatible kidney increases time on the waiting list. Methods In February 2011, a nationwide hyperimmune programme (NHP) was begun in Italy: all available kidneys are primarily proposed to highly sensitized patients with a panel reactive antibody above 80%. In this manuscript, we evaluate the outcome of paediatric patients transplanted with this approach. Results Twenty-one patients were transplanted. Complete data are available for 20 patients. Mean age at transplantation was 14.5 years [standard deviation (SD) ± 5.5)]. Mean time on the waiting list was 29.3 months (SD ± 27.5). Median follow-up was 29.2 months (range: 11.2-59.3). The average number of HLA mismatches in these patients was 2.3 versus 3.7 in 48 standard patients transplanted in the same period (P < 0.001). Only one graft was lost. Two cases of humoral rejection occurred and were successfully treated. No cellular rejection was reported. Median creatinine clearance was 84, 88, 77 and 77 mL/min/1.73 m 2 respectively 1, 6, 12 and 24 months after transplant. Conclusions Transplantation of sensitized patients avoiding prohibited antigens is feasible, at least in a selected cohort of patients. In order to be able to further improve this approach, which in our opinion is very successful, it would be necessary to expand the donor pool, possibly increasing the number of countries participating in the programme. In this series, time on the waiting list did not increase significantly. This allocation policy should ideally lead to an outcome comparable to that expected in standard patients, which is particularly desirable in young patients who have the longest life expectancy. Since long-term results of desensitization programmes are not (yet) convincing, we suggest that these programmes should be reserved for selected cases where compatible organs cannot be found within a reasonable time span.
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Affiliation(s)
- Luca Dello Strologo
- Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy
| | - Isabella Guzzo
- Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Federica Morolli
- Nephrology and Transplant Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy
| | - Germana Longo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, AziendaOspedaliera-University of Padova, Padova, Italy
| | - Sara Testa
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Ricci
- Italian National Transplant Centre, Italian National Institute of Health (ISS), Rome, Italy
| | | | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Organ and Tissue Transplant Immunology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonina Piazza
- National Research Council, IFT Unit of Rome S. Camillo Hospital, Regional Transplant Center Lazio (CRTL), S. Camillo Hospital, Rome, Italy
| | - Alessandro Nanni Costa
- Italian National Transplant Centre, Italian National Institute of Health (ISS), Rome, Italy
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Mujtaba MA, Komocsar WJ, Nantz E, Samaniego MD, Henson SL, Hague JA, Lobashevsky AL, Higgins NG, Czader M, Book BK, Anderson MD, Pescovitz MD, Taber TE. Effect of Treatment With Tabalumab, a B Cell-Activating Factor Inhibitor, on Highly Sensitized Patients With End-Stage Renal Disease Awaiting Transplantation. Am J Transplant 2016; 16:1266-75. [PMID: 26780484 DOI: 10.1111/ajt.13557] [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: 07/22/2015] [Revised: 09/23/2015] [Accepted: 09/28/2015] [Indexed: 01/25/2023]
Abstract
B cell-activation factor (BAFF) is critical for B cell maturation. Inhibition of BAFF represents an appealing target for desensitization of sensitized end-stage renal disease (ESRD) patients. We conducted a Phase 2a, single-arm, open-label exploratory study investigating the effect of tabalumab (BAFF inhibitor) in patients with ESRD and calculated panel reactive antibodies (cPRAs) >50%. The treatment period duration was 24 weeks. Eighteen patients received tabalumab, at doses of 240-mg subcutaneous (SC) at Week 0 followed by 120-mg SC monthly for 5 additional months. Patients were followed for an additional 52 weeks. Immunopharmacologic effects were characterized through analysis of blood for HLA antibodies, BAFF concentrations, immunoglobulins, T and B cell subsets, as well as pre- and posttreatment tonsil and bone marrow biopsies. Significant reductions in cPRAs were observed at Weeks 16 (p = 0.043) and 36 (p = 0.004); however, absolute reductions were small (<5%). Expected pharmacologic changes in B cell subsets and immunoglobulin reductions were observed. Two tabalumab-related serious adverse events occurred (pneumonia, worsening of peripheral neuropathy), while the most common other adverse events were injection-site pain and hypotension. Three patients received matched deceased donor transplants during follow-up. Treatment with a BAFF inhibitor resulted in statistically significant, but not clinically meaningful reduction in the cPRA from baseline (NCT01200290, Clinicaltrials.gov).
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Affiliation(s)
- M A Mujtaba
- Division of Nephrology, University of Texas Medical Branch, Galveston, TX
| | - W J Komocsar
- Bio-Medicines Business Unit, Eli Lilly and Company, Indianapolis, IN
| | - E Nantz
- Bio-Medicines Business Unit, Eli Lilly and Company, Indianapolis, IN
| | - M D Samaniego
- Department of Internal Medicine-Nephrology, University of Michigan Health System, Ann Arbor, MI
| | - S L Henson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - J A Hague
- Clinical Trial Management, Eli Lilly and Company, Indianapolis, IN
| | - A L Lobashevsky
- Transplant Immunology, Indiana University Health, Indianapolis, IN
| | - N G Higgins
- Transplant Immunology, Indiana University Health, Indianapolis, IN
| | - M Czader
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - B K Book
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - M D Anderson
- Department of Medicine-Nephrology, Indiana University School of Medicine, Indianapolis, IN
| | | | - T E Taber
- Department of Medicine-Nephrology, Indiana University School of Medicine, Indianapolis, IN
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25
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Cuadrado A, San Segundo D, López-Hoyos M, Crespo J, Fábrega E. Clinical significance of donor-specific human leukocyte antigen antibodies in liver transplantation. World J Gastroenterol 2015; 21:11016-11026. [PMID: 26494958 PMCID: PMC4607901 DOI: 10.3748/wjg.v21.i39.11016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/29/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Antibody-mediated rejection (AMR) caused by donor-specific anti-human leukocyte antigen antibodies (DSA) is widely accepted to be a risk factor for decreased graft survival after kidney transplantation. This entity also plays a pathogenic role in other solid organ transplants as it appears to be an increasingly common cause of heart graft dysfunction and an emerging issue in lung transplantation. In contrast, the liver appears relatively resistant to DSA-mediated injury. This “immune-tolerance” liver property has been sustained by a low rate of liver graft loss in patients with preformed DSA and by the intrinsic liver characteristics that favor the absorption and elimination of DSA; however, alloantibody-mediated adverse consequences are increasingly being recognized, and several cases of acute AMR after ABO-compatible liver transplant (LT) have been reported. Furthermore, the availability of new solid-phase assays, allowing the detection of low titers of DSA and the refinement of objective diagnostic criteria for AMR in solid organ transplants and particularly in LT, have improved the recognition and management of this entity. A cost-effective strategy of DSA monitoring, avoidance of class II human leukocyte antigen mismatching, judicious immunosuppression attached to a higher level of clinical suspicion of AMR, particularly in cases unresponsive to conventional anti-rejection therapy, can allow a rational approach to this threat.
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26
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Mehrotra S, Sharma R, Mayya M, Gupta A, Prasad N, Kaul A, Bhadauria D. Pre transplant PRA (penal reactive antibody) and DSA (donor specific antibody) screening status and outcome after renal transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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27
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Gao B, Moore C, Porcheray F, Rong C, Abidoglu C, DeVito J, Paine R, Girouard TC, Saidman SL, Schoenfeld D, Levin B, Wong W, Elias N, Schuetz C, Rosales IA, Fu Y, Zorn E. Pretransplant IgG reactivity to apoptotic cells correlates with late kidney allograft loss. Am J Transplant 2014; 14:1581-91. [PMID: 24935695 PMCID: PMC4120834 DOI: 10.1111/ajt.12763] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 02/03/2014] [Accepted: 02/20/2014] [Indexed: 01/25/2023]
Abstract
Preexisting serum antibodies have long been associated with graft loss in transplant recipients. While most studies have focused on HLA-specific antibodies, the contribution of non-HLA-reactive antibodies has been largely overlooked. We have recently characterized mAbs secreted by B cell clones derived from kidney allograft recipients with rejection that bind to apoptotic cells. Here, we assessed the presence of such antibodies in pretransplant serum from 300 kidney transplant recipients and examined their contribution to the graft outcomes. Kaplan-Meier survival analysis revealed that patients with high pretransplant IgG reactivity to apoptotic cells had a significantly increased rate of late graft loss. The effect was only apparent after approximately 1 year posttransplant. Moreover, the association between pretransplant IgG reactivity to apoptotic cells and graft loss was still significant after excluding patients with high reactivity to HLA. This reactivity was almost exclusively mediated by IgG1 and IgG3 with complement fixing and activating properties. Overall, our findings support the view that IgG reactive to apoptotic cells contribute to presensitization. Taking these antibodies into consideration alongside anti-HLA antibodies during candidate evaluation would likely improve the transplant risk assessment.
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Affiliation(s)
- Baoshan Gao
- Transplant Center, The First Hospital of Jilin University, Changchun, China,Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolina Moore
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Fabrice Porcheray
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chunshu Rong
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China
| | - Cem Abidoglu
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie DeVito
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rosemary Paine
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy C. Girouard
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan L. Saidman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Waichi Wong
- Division of Nephrology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Nahel Elias
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Schuetz
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ivy A. Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yaowen Fu
- Transplant Center, The First Hospital of Jilin University, Changchun, China
| | - Emmanuel Zorn
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Corresponding author: Emmanuel Zorn, Massachusetts General Hospital, Transplant Center, Thier 807, 55 Fruit Street, Boston, MA 02114, , Tel: (617) 643-3675, Fax: (617) 724-3471
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28
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Identification of patients with increased immunological risk among potential kidney recipients in the Polish population. Hum Immunol 2014; 75:650-5. [DOI: 10.1016/j.humimm.2014.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/14/2014] [Accepted: 04/06/2014] [Indexed: 01/02/2023]
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29
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Kahwaji J, Najjar R, Kancherla D, Villicana R, Peng A, Jordan S, Vo A, Haas M. Histopathologic features of transplant glomerulopathy associated with response to therapy with intravenous immune globulin and rituximab. Clin Transplant 2014; 28:546-53. [PMID: 24579925 DOI: 10.1111/ctr.12345] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2014] [Indexed: 01/11/2023]
Abstract
Transplant glomerulopathy (TG) is associated with poor long-term allograft survival and is often accompanied by microcirculation inflammation. Histopathologic scoring may inform prognosis and help guide therapy. We retrospectively assessed 33 patients with biopsy-proven TG. All biopsies were given a glomerulitis (g) and peritubular capillaritis (ptc) score. We determined allograft survival and serum creatinine stability in three different score groups: g < 2 and ≥ 2, ptc < 2 and ≥ 2, and (g + ptc) < 4 and ≥ 4. We assessed the impact of treatment with intravenous immune globulin (IVIG) and rituximab on outcomes. Graft survival and serum creatinine stability did not differ in each of the histopathologic score groups. Higher-score groups were associated with the presence of concomitant antibody-mediated rejection and were more likely to receive IVIG and rituximab. Treatment with IVIG and rituximab resulted in stability of serum creatinine within the higher-score groups, but not in the lower-score groups. Stabilization of serum creatinine was associated with an improvement in donor-specific antibody. Histopathologic scoring in kidney allograft biopsies with TG may help guide treatment. The combination of IVIG and rituximab appears to be beneficial in patients whose biopsies have moderate or severe microvascular injury.
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Affiliation(s)
- Joseph Kahwaji
- Kidney and Pancreas Transplant Program, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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30
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Djamali A, Kaufman DB, Ellis TM, Zhong W, Matas A, Samaniego M. Diagnosis and management of antibody-mediated rejection: current status and novel approaches. Am J Transplant 2014; 14:255-71. [PMID: 24401076 PMCID: PMC4285166 DOI: 10.1111/ajt.12589] [Citation(s) in RCA: 260] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 11/12/2013] [Indexed: 01/25/2023]
Abstract
Advances in multimodal immunotherapy have significantly reduced acute rejection rates and substantially improved 1-year graft survival following renal transplantation. However, long-term (10-year) survival rates have stagnated over the past decade. Recent studies indicate that antibody-mediated rejection (ABMR) is among the most important barriers to improving long-term outcomes. Improved understanding of the roles of acute and chronic ABMR has evolved in recent years following major progress in the technical ability to detect and quantify recipient anti-HLA antibody production. Additionally, new knowledge of the immunobiology of B cells and plasma cells that pertains to allograft rejection and tolerance has emerged. Still, questions regarding the classification of ABMR, the precision of diagnostic approaches, and the efficacy of various strategies for managing affected patients abound. This review article provides an overview of current thinking and research surrounding the pathophysiology and diagnosis of ABMR, ABMR-related outcomes, ABMR prevention and treatment, as well as possible future directions in treatment.
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Affiliation(s)
- A Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - D B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - T M Ellis
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
| | - W Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public HealthMadison, WI
- Pathology and Laboratory Services, William S. Middleton Memorial Veterans HospitalMadison, WI
| | - A Matas
- Division of Transplantation, Department of Surgery, University of MinnesotaMinneapolis, MN
| | - M Samaniego
- Division of Nephrology, Department of Medicine, University of MichiganAnn Arbor, MI
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31
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Coulthard MG, Crosier J, Griffiths C, Smith J, Drinnan M, Whitaker M, Beckwith R, Matthews JNS, Flecknell P, Lambert HJ. Haemodialysing babies weighing <8 kg with the Newcastle infant dialysis and ultrafiltration system (Nidus): comparison with peritoneal and conventional haemodialysis. Pediatr Nephrol 2014; 29:1873-81. [PMID: 25125229 PMCID: PMC4167433 DOI: 10.1007/s00467-014-2923-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 06/26/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND To compare the efficacy of the Newcastle infant dialysis and ultrafiltration system (Nidus) with peritoneal dialysis (PD) and conventional haemodialysis (HD) in infants weighing <8 kg. METHODS We compared the urea, creatinine and phosphate clearances, the ultrafiltration precision, and the safety of the Nidus machine with PD in 7 piglets weighing 1-8 kg, in a planned randomised cross-over trial in babies, and in babies for whom no other therapy existed, some of whom later graduated to conventional HD. RESULTS Two babies entered the randomised trial; 1 recovered rapidly on PD, the other remained on the Nidus as PD failed. Additionally, 9 babies were treated on the Nidus on humanitarian grounds: 3 because of failed PD, and 3 with permanent kidney failure later converted to conventional HD. We haemodialysed 10 babies weighing between 1.8 and 5.9 kg for 2,475 h during 354 Nidus sessions without any clinically important incidents, and without detectable haemolysis. Single-lumen vascular access was used with no blood priming of circuits. The urea, creatinine and phosphate clearances using the Nidus were around 1.5 to 2.0 ml/min in piglets and babies, and were consistently higher than PD clearances, which ranged from about 0.2 to 0.8 ml/min (p ≤ 0.0002 for each chemical). Ultrafiltration was achieved to microlitre precision by the Nidus, but varied widely with PD. Fluid removal using conventional HD was imprecise and resulted in some hypovolaemic episodes requiring correction. CONCLUSION The Nidus can provide HD in the Pediatric Intensive Care Unit (PICU) and outpatient intermittent HD without blood priming for babies weighing <8 kg, It generates higher dialysis clearances than PD, and delivers more precise ultrafiltration control than either PD or conventional HD.
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Affiliation(s)
- Malcolm G. Coulthard
- Department of Paediatric Nephrology, Great North Children’s Hospital, Newcastle, NE1 4LP UK ,South Park House, South Park, Hexham, NE46 1BS UK
| | - Jean Crosier
- Department of Paediatric Nephrology, Great North Children’s Hospital, Newcastle, NE1 4LP UK
| | - Clive Griffiths
- Clinical Measurement and Engineering Unit, Department of Medical Physics, Freeman Hospital, Newcastle, NE7 7DN UK
| | - Jon Smith
- Department of Paediatric Anaesthesia, Freeman Hospital, Newcastle, NE7 7DN UK
| | - Michael Drinnan
- Clinical Measurement and Engineering Unit, Department of Medical Physics, Freeman Hospital, Newcastle, NE7 7DN UK
| | - Mike Whitaker
- Clinical Measurement and Engineering Unit, Department of Medical Physics, Freeman Hospital, Newcastle, NE7 7DN UK
| | - Robert Beckwith
- Clinical Measurement and Engineering Unit, Department of Medical Physics, Freeman Hospital, Newcastle, NE7 7DN UK
| | - John N. S. Matthews
- School of Mathematics and Statistics, Newcastle University, Newcastle, NE1 7RU UK
| | - Paul Flecknell
- Comparative Biology Centre, Medical School, University of Newcastle upon Tyne, Newcastle, NE2 4HH UK
| | - Heather J. Lambert
- Department of Paediatric Nephrology, Great North Children’s Hospital, Newcastle, NE1 4LP UK
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Abstract
Late kidney transplant dysfunction may be a harbinger of graft failure. For many years, calcineurin inhibitor toxicity was felt to be the main cause for graft dysfunction with fibrosis and transplant loss. Recently this idea has come into question. With the observation that peritubular capillary C4d staining in kidney allografts may indicate antibody-mediated injury in conjunction with biopsy study findings, an appreciation for antibody-mediated rejection as a major cause of late graft dysfunction and loss has emerged. Twenty percent to 30% of patients develop de novo donor-specific antibodies after kidney transplantation. There are no US Food and Drug Administration-approved treatments for antibody-mediated rejection, nor have any randomized controlled trials assessed efficacy. Off-label treatment strategies include some combination of plasma exchange, intravenous immunoglobulin, and rituximab. Other approaches, including splenectomy, bortezomib, and eculizumab, have also been tried.
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Won D, Choe W, Kim HJ, Kwon SW, Han DJ, Park SK. Significance of isoagglutinin titer in ABO-incompatible kidney transplantation. J Clin Apher 2013; 29:243-50. [PMID: 24375675 DOI: 10.1002/jca.21312] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/27/2013] [Indexed: 01/30/2023]
Abstract
ABO-incompatible (ABO-i) kidney transplantation (KT) has emerged for overcoming the shortage of organ donors. Although this technique initially achieved only low graft survival due to isoagglutinin, recently developed desensitization protocols have improved survival to levels that are comparable to ABO-compatible KT. However, isoagglutinin is still regarded as a major obstacle to ABO-i KT. In this study, we evaluate the impact of isoagglutinin titer on clinical outcomes as well as factors that may influence isoagglutinin titers. In total, data from 95 patients who underwent ABO-i KT were analyzed. Preoperatively, rituximab administration and plasmapheresis were performed until the titer was reduced to ≤1:4. Retrospective analysis included blood group; timing and dosage of rituximab; isoagglutinin titer; number of plasmapheresis; and clinical outcomes including graft survival and serum creatinine. Graft survival was 95.8% (n = 91) and average serum creatinine at 1- and 1.5-year post-ABOi-KT was 1.3. Three patients died of sepsis. The identified predictors of titer-rebound after transplant were short interval (<7 days) between rituximab and first plasmapheresis (P = 0.004); high initial titer (≥256) (P = 0.023); low titer-reduction rate (P < 0.001); and blood group O (P < 0.001). One patient who experienced a rebound developed antibody-mediated rejection. With low-dose (200 mg) rituximab, the change in isoagglutinin titer-rebound was not significant and the infection rate was significantly decreased (P = 0.001). In conclusion, isoagglutinin titer-rebound within the first 2 weeks after KT may be a risk factor for rejection. The factors identified as affecting titer-rebound after KT were high initial isoagglutinin titer, low titer-reduction rate, short interval, and blood group O.
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Affiliation(s)
- Dahae Won
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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34
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Abstract
Over the last 6 decades, organ transplantation has achieved great success to become standard therapy for the treatment of patients with end-stage organ failure. With this success has emerged candidate wait lists that greatly outnumber the current supply of deceased donor organs. The increasing number of candidates and transplants performed has resulted in an organ allocation process that occurs at a local, regional, and sometimes national level. A brief description of the history is presented as well as the methodologies involved in allocation of a donor organ to a single recipient.
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Affiliation(s)
- Praveen Kandula
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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35
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Niederhaus SV, Leverson GE, Lorentzen DF, Robillard DJ, Sollinger HW, Pirsch JD, Torrealba JR, Odorico JS. Acute cellular and antibody-mediated rejection of the pancreas allograft: incidence, risk factors and outcomes. Am J Transplant 2013; 13:2945-55. [PMID: 24102905 DOI: 10.1111/ajt.12443] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) after pancreas transplantation is a recently identified entity. We describe the incidence of, risk factors for, and outcomes after AMR, and the correlation of C4d immunostaining and donor-specific antibody (DSA) in the diagnosis of AMR. We retrospectively analyzed 162 pancreas transplants in 159 patients who underwent 94 pancreas allograft biopsies between 2006 and 2009. Univariate and multivariate analyses were performed to evaluate risk factors for pancreas graft AMR. One-year rejection rates and survival after rejection were calculated by Kaplan-Meier methods. AMR occurred in 10% of patients by 1-year posttransplant. Multivariate risk factors identified for AMR include nonprimary simultaneous pancreas-kidney (SPK) transplant, primary solitary pancreas (PAN) transplant and race mismatch. After pancreas rejection, patient survival was 100% but 20% (8 of 41) of pancreas grafts failed within 1 year. Graft survival after acute cellular rejection (ACR), AMR and mixed rejection was similar. Of biopsies that stained >5% C4d, 80% were associated with increased Class I DSA. In summary, AMR occurs at a measurable rate after pancreas transplantation, and the diagnosis should be actively sought using C4d staining and DSA levels in patients with graft dysfunction, especially after nonprimary SPK and primary PAN transplantation.
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Affiliation(s)
- S V Niederhaus
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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36
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Al-Mohaissen MA, Virani SA. Allosensitization in heart transplantation: an overview. Can J Cardiol 2013; 30:161-72. [PMID: 24373761 DOI: 10.1016/j.cjca.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 10/01/2013] [Accepted: 10/16/2013] [Indexed: 01/29/2023] Open
Abstract
Transplant candidates might manifest circulating antibodies against human leukocyte antigens and nonhuman leukocyte antigens, a condition termed allosensitization. The presence of these antibodies decreases a given candidate's possible donor pool, thereby prolonging the time to transplantation. They are also associated with poorer posttransplant outcomes including increased morbidity and mortality. With the increasing use of ventricular assist devices as a bridge to transplantation, the prevalence of allosensitized transplant candidates has increased. This has implications for transplant programs in terms of donor-recipient matching and managing transplant-related complications, which are more common in this high risk cohort. Controversy exists as to the best approach in managing sensitized patients, before and after transplantation. Transplant centres have used various strategies to reduce antibody loads with mixed results being reported; moreover, it remains unclear as to whether attempts at desensitization translate into better posttransplant outcomes. As an alternative management approach, some centres participate in large organ sharing strategies and allocate organs based on the probability of finding a successful donor-recipient match. In this article, the immunological basis of allosensitization, its causes, implications, and therapeutic strategies to manage sensitized patients are reviewed. The literature in relation to desensitization therapies in heart transplant candidates is also reviewed.
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Affiliation(s)
- Maha A Al-Mohaissen
- Division of Cardiology Adult Heart Transplant Program, St Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Sean A Virani
- Division of Cardiology Adult Heart Transplant Program, St Paul's Hospital, University of British Columbia, Vancouver, Canada.
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Klein K, Süsal C, Schäfer SM, Becker LE, Beimler J, Schwenger V, Zeier M, Schemmer P, Macher-Goeppinger S, Scherer S, Opelz G, Morath C. Living donor kidney transplantation in patients with donor-specific HLA antibodies enabled by anti-CD20 therapy and peritransplant apheresis. ATHEROSCLEROSIS SUPP 2013; 14:199-202. [PMID: 23357165 DOI: 10.1016/j.atherosclerosissup.2012.10.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Due to increasing waiting times for deceased donor kidneys, living donor kidney transplantation is increasingly performed in the presence of donor-specific antibodies (DSA). METHODS Twenty-three patients with Luminex-detected DSA were successfully desensitized by anti-CD20 therapy and immunoadsorption (N = 19) or plasmapheresis (N = 4) and received a kidney transplant from a living donor. Twelve of the 23 patients (52%) had a positive CDC and/or ELISA crossmatch result before desensitization. Six patients were negative in CDC as well as ELISA screening but positive in Luminex for DSA. RESULTS The 23 patients received a median of 8 apheresis treatments before and 5 treatments after transplantation. Induction therapy was performed with either thymoglobulin (N = 11) or basiliximab (N = 12). The 2-year graft survival rate was 100%. At last follow up, a median of 12 months after transplantation, median serum creatinine was 1.42 mg/dL, median MDRD-GFR 59.5 mL/min/1.73 m(2), and median urinary protein-to-creatinine ratio 0.12. Ten out of fourteen patients (71%) who had completed the first year after transplantation by the time of analysis had no DSA by day 360. Acute T-cell mediated rejection was diagnosed in one patient (4%), and antibody-mediated changes were found in 5 patients (22%). Four out of these 5 patients showed evidence of persistent (N = 2) or reemerging plus/minus de novo DSA (N = 2) on day 360, and the 2 patients with persistent DSA lost their allograft subsequently on days 750 and 810, respectively. Infectious complications were infrequent. CONCLUSIONS Our previously described treatment algorithm for desensitization of living donor kidney transplant recipients with DSA results in good graft outcomes with a low rate of side effects.
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Affiliation(s)
- Katrin Klein
- Department of Nephrology, University of Heidelberg, INF 162, 69120 Heidelberg, Germany
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38
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Shang W, Dong L, Feng G, Wang Y, Pang X, Li J, Liu L, Zhang W. Panel-reactive antibody levels and renal transplantation rates in sensitized patients after desensitization and human leucocyte antigen amino acid residue matching. J Int Med Res 2013; 41:1333-41. [PMID: 23780877 DOI: 10.1177/0300060513485896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether a new desensitization protocol (mycophenolate mofetil [MMF], plasmapheresis and antithymocyte globulin [ATG], complemented with human leucocyte antigen [HLA] amino acid residue matching) could reduce panel-reactive antibody (PRA) levels in sensitized patients, to facilitate successful renal transplantation. METHODS Patients awaiting transplantation with PRA levels >10% received treatment with MMF; those with PRA levels >30% were also treated with plasmapheresis. Patients whose PRA level was <20% after desensitization were eligible for transplantation. When a donor became available, traditional HLA matching and HLA amino acid residue matching were performed. All patients received ATG induction therapy postoperatively. RESULTS Thirty-two sensitized patients were enrolled. Desensitization produced a significant decrease in PRA levels; 27 patients (84.4%) became eligible for transplantation and 26 (81.2%) subsequently underwent successful transplantation. Residue matching improved the proportion with a mismatch number of 0-1 from 7.7% to 65.4%, compared with traditional HLA matching. Postoperatively, all patients showed immediate graft function. Acute rejection occurred in three patients (11.5%) and infections in seven patients (25.9%); all were treated successfully. CONCLUSION The combination of a desensitization protocol (MMF, plasmapheresis and ATG) and residue matching appears to be an effective strategy for sensitized patients awaiting renal transplantation.
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Affiliation(s)
- Wenjun Shang
- Department of Renal Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Bostock IC, Alberú J, Arvizu A, Hernández-Mendez EA, De-Santiago A, González-Tableros N, López M, Castelán N, Contreras AG, Morales-Buenrostro LE, Gabilondo B, Vilatobá M. Probability of deceased donor kidney transplantation based on % PRA. Transpl Immunol 2013; 28:154-8. [PMID: 23684945 DOI: 10.1016/j.trim.2013.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/26/2013] [Accepted: 05/01/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Sensitization to HLA antigens creates an obstacle for the accessibility and success of kidney transplantation (KT). Highly sensitized patients have longer waiting times and some may never receive a KT. AIM To determine the probability of patients on the deceased donor (DD) waiting list to receive a KT based on the panel reactive antibody percentage (% PRA) in our center. METHODS The DD waiting list from our institution was analyzed from 01/05 to 08/12 documenting the clinical variables from donor and potential recipients (ABO blood group), lymphocyte cross-match [CxM (CDC-AHG)] results, highest % PRA determination, and time on the waiting list. The patients were classified into 4 groups based on the % PRA: 0%, 1-19%, 20-79% and 80-100%. The data was analyzed using odds ratio and logistic regression (significant p<0.05). RESULTS 58 DD (F:M 34:24, ABO group O=35, A=13, B=10) and 179 potential recipients were analyzed (F:M 98:81, ABO group O=127, A=33, B=19, participating 4.2 ± 3.8 times with different donors to receive KT). The mean PRA for the whole group was 22 ± 32%, median [md] 0 (0-98). A total of 100 patients received KT (mean waiting time 2.2 ± 1.7 years, 12 days-7 years) and their mean % PRA was 11.6 ± 24, md 0 (0-94) vs. 31.4 ± 37 md 8.5 (0-98) in those who have not received a KT. An association between the % PRA group and KT (p<0.003) was observed. The probability of receiving KT with a 0% PRA vs. >0% was higher (OR 2.12, 1.17-3.84). There was no difference between the 0% vs. 1-19% group (OR 1); differences were observed between 0% vs. 20-79% (OR 2.5, 1.18-5.3) and 0% vs. 80-100% (OR 5, 1.67-14.9). For every percent increase in the PRA above 20%, the risk of not receiving a KT increased by 5% (1-9, p<0.01). CONCLUSIONS The probability of receiving a DD kidney transplant is inversely related to the % PRA although a higher risk for not receiving a KT becomes evident with a PRA >20%.
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Affiliation(s)
- I C Bostock
- Department of Transplantation, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
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Park KT, Jung CW, Kim MG. Update on the Treatment of Acute and Chronic Antibody-mediated Rejection. KOREAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.4285/jkstn.2013.27.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kwan-Tae Park
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Cheol-Woong Jung
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Myung-Gyu Kim
- Department of Nephrology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Trevizol AP, David AI, Dias ER, Mantovani D, Pécora R, D'Albuquerque LAC. Intestinal and multivisceral transplantation immunosuppression protocols--literature review. Transplant Proc 2013; 44:2445-8. [PMID: 23026616 DOI: 10.1016/j.transproceed.2012.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Currently the most used techniques for small bowel transplant are isolated intestinal transplantation, multivisceral transplantation (MVT), and modified multivisceral transplantation. One important factor is early diagnosis of acute cellular rejection (ACR). In addition, improvements in immunosuppression have recently reduced the number and enhanced treatment of ACR episodes, enabling graft recovery. OBJECTIVE We analyzed immunosuppression protocols of leading transplantation centers in the last 5 years. METHOD We reviewed papers published in PubMed from major multivisceral and intestinal transplantation centers from 2006 to 2010 in adult recipients. The 211 adults transplanted in seven centers were divided into three groups according to the immunosuppression protocol used: protocol 1: daclizumab induction with tacrolimus and steroid maintenance; protocol 2: alemtuzumab and tacrolimus; and protocol 3: thymoglobulin and rituximab and tacrolimus. RESULTS Protocol 2 showed the lowest rate of ACR (34%). Protocols 1 and 3 displayed 54% and 48% ACR rates; respectively. However, protocol 1 patients developed only mild ACR, whereas those in protocols 2 and 3 developed moderate ACR in 26.3% and 11.7%, and severe ACR in 7.9% and 47% of cases, respectively. The infection rate was considerably lower in protocol 3 (7.4%). Protocols 1 and 2 showed infection rates of 62.5% and 52%, respectively. One-year patient survival rates were 70%, 79% and 81%, respectively. Three-year patient survival rates were 62%, 56%, and 78% for protocols 1, 2 and 3, respectively. CONCLUSION Protocol 2 was the strongest immunosuppressive regimen capable of reducing ACR rates when compared with the other protocols, but the strong effect resulted in high infection rate that impacts 1-year patient survival. Protocol 3 seems to be the best available one balancing ACR and infection rates.
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Affiliation(s)
- A P Trevizol
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
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Increased C4d in post-reperfusion biopsies and increased donor specific antibodies at one-week post transplant are risk factors for acute rejection in mild to moderately sensitized kidney transplant recipients. Kidney Int 2013; 83:1185-92. [PMID: 23447068 PMCID: PMC3672254 DOI: 10.1038/ki.2013.44] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In order to define the intensity of immunosuppression, we examined risk factors for acute rejection in desensitization protocols that use baseline donor specific antibody levels measured as mean fluorescence intensity (MFImax). The study included 146 patients transplanted with a negative flow crossmatch and a mean follow-up of 18 months with the majority (83%) followed for at least 1 year. At the time of transplant, mean calculated panel reactive antibody and MFImax ranged from 10.3% to 57.2%, and 262 to 1691, respectively, between low and high-risk protocols. Mean MFImax increased significantly from transplant to one-week and one-year. The incidence of acute rejection (mean 1.65 months) as a combination of clinical and subclinical rejection was 32% including 14% cellular, 12% antibody-mediated and 6% mixed rejection. In regression analyses, only C4d staining in post-reperfusion biopsies (hazard ratio 3.3, confidence interval 1.71 to 6.45) and increased donor specific antibodies at 1 week post-transplant were significant predictors of rejection. A rise in MFImax by 500 was associated with a 2.8-fold risk of rejection. Thus, C4d staining in post-reperfusion biopsies and an early rise in donor specific antibodies after transplantation are risk factors for rejection in moderately sensitized patients.
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Goldfarb-Rumyantzev AS, Yoon JH, Patibandla BK, Narra A, Sandhu GS, DeSilva R. The role of initial hemodialysis vascular access in the outcome of subsequent kidney transplantation. Clin Transplant 2012; 27:210-6. [DOI: 10.1111/ctr.12049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - Joo Heung Yoon
- Department of Medicine; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Bhanu K. Patibandla
- Division of Nephrology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston; MA; USA
| | - Akshita Narra
- Division of Nephrology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston; MA; USA
| | - Gurprataap S. Sandhu
- Division of Nephrology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston; MA; USA
| | - Ranil DeSilva
- Division of Nephrology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston; MA; USA
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A sterile elastic exsanguination tourniquet is effective in preventing blood loss during hemodialysis access surgery. J Vasc Access 2012; 14:116-9. [PMID: 23080335 PMCID: PMC6159822 DOI: 10.5301/jva.5000107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2012] [Indexed: 12/03/2022] Open
Abstract
Purpose We report the first use of a sterile elastic exsanguination tourniquet (SET) in performing hemodialysis vascular access procedures in 27 patients. The main advantages of this tourniquet are the reduction of blood loss and need for possible transfusions. Additional benefits are the near-perfect exsanguination and excellent exposure of the operative field. Methods This SET is a sterile elastic stockinet device that rolls up the arm starting from the hand by pulling on two handles. The elastic silicone ring provides sufficient pressure (220 ± 30 mmHg) to block arterial flow into the limb. The stockinet can be cut to provide access to the incision area while providing an additional sterile cover over the rest of the limb. Results No transfusions were required in any patients. Minor adverse effects occurred in four patients, including a twisted vessel, a bleeding vascular branch, a tear in atrophic arm skin, and pain, all of which had resolved on subsequent follow-up. Operational recommendations to avoid these adverse effects are outlined. Conclusions We conclude that this sterile elastic exsanguination tourniquet is effective and safe in preventing bleeding during upper extremity hemodialysis vascular access procedures.
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Ferrari-Lacraz S, Tiercy JM, Villard J. Detection of anti-HLA antibodies by solid-phase assay in kidney transplantation: friend or foe? ACTA ACUST UNITED AC 2012; 79:315-25. [PMID: 22489941 DOI: 10.1111/j.1399-0039.2012.01853.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pre-formed and de novo anti-human leukocyte antigen (HLA) antibodies induce antibody-mediated rejection and are also involved in mechanisms leading to chronic graft nephropathy. The detection of anti-HLA antibodies by solid-phase assay (SPA) has revolutionized the management of immunized patients before and after kidney transplantation. Characterized by high sensitivity and specificity, the clinical relevance of anti-HLA antibodies by SPA has to be clarified. The presence of donor-specific antibody at the epitope level, their titer, and the use of different crossmatch technologies could help to determine which of the anti-HLA antibodies are friends and which are foes in kidney transplantation. In this review, we summarize the current state of the art on this debated topic, and give clinical guidelines for the management of antibody detection pre- and post-transplantation, based on these evidences and our own clinical expertise.
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Affiliation(s)
- S Ferrari-Lacraz
- Transplant Immunology Unit and National Reference Laboratory for Histocompatibility-LNRH, Division of Immunology, Allergy and Laboratory Medicine, Department of Medicine, Genetics and Laboratory Medicine, Geneva University Hospital and Medical School, Geneva, Switzerland
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Abstract
Many factors limit short- and long-term survival after pediatric heart transplantation. Historically, attention had been directed toward T-cell responses and acute cellular rejection. Presence of pretransplant antibodies against HLA is associated with increased donor wait times and poor post-transplant outcomes. Therapies aimed to mitigate circulating antibodies include plasmapheresis, protein A immunoadsorption columns, intravenous immune globulin, rituximab, and bortezomib. The negative effects of B cells, HLA antibodies, and AMR and potential interventions are the focus of this review article.
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Affiliation(s)
- Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Page EK, Dar WA, Knechtle SJ. Tolerogenic therapies in transplantation. Front Immunol 2012; 3:198. [PMID: 22826708 PMCID: PMC3399382 DOI: 10.3389/fimmu.2012.00198] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 06/22/2012] [Indexed: 01/08/2023] Open
Abstract
Since the concept of immunologic tolerance was discovered in the 1940s, the pursuit of tolerance induction in human transplantation has led to a rapid development of pharmacologic and biologic agents. Short-term graft survival remains an all-time high, but successful withdrawal of immunosuppression to achieve operational tolerance rarely occurs outside of liver transplantation. Collaborative efforts through the NIH sponsored Immune Tolerance Network and the European Commission sponsored Reprogramming the Immune System for Establishment of Tolerance consortia have afforded researchers opportunity to evaluate the safety and efficacy of tolerogenic strategies, investigate mechanisms of tolerance, and identify molecular and genetic markers that distinguish the tolerance phenotype. In this article, we review traditional and novel approaches to inducing tolerance for organ transplantation, with an emphasis on their translation into clinical trials.
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Song YH, Huh KH, Kim YS, Lee HS, Kim MS, Kim SJ, Kim HJ, Kim SI, Joo DJ. Impact of pretransplant rituximab induction on highly sensitized kidney recipients: comparison with non-rituximab group. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 82:335-9. [PMID: 22708094 PMCID: PMC3373982 DOI: 10.4174/jkss.2012.82.6.335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 04/05/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Highly sensitized patients with a high level of panel reactive antibody (PRA) experience more episodes of antibody-mediated rejection (AMR) and poorer graft survival than non-sensitized patients. Rituximab is a well-known monoclonal anti-CD20 antibody that causes the depletion of B lymphocytes. The aim of this study was to compare a rituximab-administered and a non-administered group of highly sensitized recipients. METHODS Forty-three kidney recipients with a PRA level of ≥50% were included. Sixteen (group R) received one dose of rituximab at 2 days prior to transplantation and 27 patients (group NR) did not. RESULTS Patients' demographics, such as age, sex, dialysis duration, and type of immunosuppressive agent were not different in the two groups. No side effects due to rituximab administration were observed in group R. Class I PRA of group R (75.6 ± 37.7%) was higher than that of group NR (45.7 ± 35.8%, P = 0.013). More acute rejection episodes occurred within 1 year after transplantation in group NR but the difference between the groups was not significant (18.8% in group R vs. 29.6% in group NR, P = 0.631). However, two AMR episodes occurred only in group NR. Renal functions were not different in the two groups. In group R, CD19 and CD20 rapidly decreased 2 days after rituximab infusion. Furthermore, the administration of rituximab was not linked to acute rejection. CONCLUSION To confirm the long-term anti-rejection and beneficial effects of rituximab, further studies should be performed with a larger cohort. In conclusion, rituximab administration 2 days prior to transplantation is both effective and safe.
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Affiliation(s)
- Young Hae Song
- Department of Surgery, Yonsei University Health System, Seoul, Korea
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Rödl S, Marschitz I, Mache CJ, Nagel B, Koestenberger M, Zobel G. Hemodiafiltration in infants with complications during peritoneal dialysis. Artif Organs 2012; 36:590-3. [PMID: 22428733 DOI: 10.1111/j.1525-1594.2011.01434.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
End-stage renal disease (ESRD) in neonates still has a high mortality, particularly in the first year of life. We present the combination of peritoneal dialysis (PD) with intermittent hemodiafiltration (iHDF) in neonates with ESRD. Four infants younger than 28 days were treated with PD and iHDF. Renal diagnoses leading to ESRD were cortical necrosis, prune belly syndrome, neonatal hemolytic uremic syndrome, and autosomal recessive polycystic kidney disease. Initially, three patients were on iHDF until PD was started. At the time when complications occurred during PD, patients were switched back to iHDF. iHDF was used five times as a bridge to PD in case of abdominal surgery. Two of the four patients were switched to iHDF because of peritoneal ultrafiltration failure due to recurrent peritoneal leaks. Once, iHDF became necessary due to refractory peritonitis. All four patients survived the first year of life. Two patients were transplanted successfully at an age of 35 and 22 months, respectively. The others are on renal replacement therapy, one on PD at the age of 28 months and one on iHDF at the age of 25 months, respectively. In case of PD complications, iHDF may be an appropriate bridge to achieve long-term survival until kidney transplantation.
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Affiliation(s)
- Siegfried Rödl
- Pediatric Intensive Care Unit, Department of Pediatrics, Medical University of Graz, Graz, Austria.
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50
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Morath C, Beimler J, Opelz G, Scherer S, Schmidt J, Macher-Goeppinger S, Klein K, Sommerer C, Schwenger V, Zeier M, Süsal C. Living donor kidney transplantation in crossmatch-positive patients enabled by peritransplant immunoadsorption and anti-CD20 therapy. Transpl Int 2012; 25:506-17. [PMID: 22372718 DOI: 10.1111/j.1432-2277.2012.01447.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Living donor kidney transplantation in crossmatch-positive patients is a challenge that requires specific measures. Ten patients with positive crossmatch results (n = 9) or negative crossmatch results but strong donor-specific antibodies (DSA; n = 1) were desensitized using immunoadsorption (IA) and anti-CD20 antibody induction. IA was continued after transplantation and accompanied by HLA antibody monitoring and protocol biopsies. After a median of 10 IA treatments, all patients were desensitized successfully and transplanted. Median levels of mean fluorescence intensity (MFI) of Luminex-DSA before desensitization were 6203 and decreased after desensitization and immediately before transplantation to 891. Patients received a median of seven post-transplant IA treatments. At last visit, after a median follow-up of 19 months, 9 of 10 patients had a functioning allograft and a median Luminex-DSA of 149 MFI; serum creatinine was 1.6 mg/dl, and protein to creatinine ratio 0.1. Reversible acute antibody-mediated rejection was diagnosed in three patients. One allograft was lost after the second post-transplant year in a patient with catastrophic antiphospholipid syndrome. We describe a treatment algorithm for desensitization of living donor kidney transplant recipients that allows the rapid elimination of DSA with a low rate of side effects and results in good graft outcome.
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Affiliation(s)
- Christian Morath
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
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