mTOR-Inhibition and COVID-19 in Kidney Transplant Recipients: Focus on Pulmonary Fibrosis

The changing landscape of thyroid eye disease: current clinical advances and future outlook

AIMS

This review aims to provide an overview of the current understanding of TED and its pathophysiology. To describe the evidence base for current consensus treatment recommendations and newer biological therapies available as well as to present future therapeutic research.

METHODS

We reviewed and assessed the peer-reviewed literature placing particular emphasis on recent studies evaluating the pathophysiology of TED, landmark trials forming the basis of current management and recent clinical trials informing future therapeutics. Searched were made in MEDLINE Ovid, Embase Ovid, US National Institutes of Health Ongoing Trials Register and EU Clinical Trials Register. Keywords included: "Thyroid Eye Disease", "Graves Orbitopathy", "Thyroid Orbitopathy" and "Graves' Ophthalmopathy".

RESULTS AND CONCLUSIONS

The pathophysiology of TED involves a complex array of cellular and humoral based autoimmune dysfunction. Previous therapies have been broad-based acting as a blunt instrument on this mechanism with varying efficacy but often accompanied with a significant side effect profile. The recent development of targeted therapy, spearheaded by Teprotumumab has led to an array of treatments focusing on specific components of the molecular pathway optimising their impact whilst possibly minimising their side effect profile. Future challenges involve identifying the most effective target for each patient rather than any single agent being a panacea. Long-term safety profiles will require clarification as unintended immunological consequence downstream may become manifest as seen in other diseases. Finally, future novel therapeutics will entail significant expenditure and may lead to a divergence of available treatment modalities between healthcare systems due to funding disparities.

COVID-19 in a pregnant kidney transplant recipient - what we need to know: A case report

BACKGROUND

In the era of the coronavirus disease 2019 (COVID-19) pandemic, kidney transplant recipients are more susceptible to severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection, developing severe morbidity and graft impairment. Pregnant women are also more likely to develop severe COVID-19 disease, causing pregnancy complications such as preterm births and acute kidney injury.

CASE SUMMARY

Herein, we report the case of a pregnant woman with a third kidney transplantation who developed COVID-19 disease. The reduction of immunosuppressive drugs and strict monitoring of trough blood levels were needed to avoid severe SARS-CoV-2-related complications, and permitted to continue a healthy pregnancy and maintain good graft function. In such a complex scenario, the concomitance of COVID-19-related morbidity, the risk of acute rejection in the hyperimmune recipient, graft dysfunction and pregnancy complications make the management of immunosuppression a very difficult task and clinicians must be aware.

CONCLUSION

Tailoring the immunosuppressive regimen is a key factor affecting both the graft outcome and pregnancy safety.

COVID-19 in kidney transplant recipients; a DALMATIAN single-center experience

INTRODUCTION

We aimed to explore COVID-19 severity, complications, and outcome predictors in the Dalmatian population of kidney transplant recipients (KTRs).

METHODS

KTRs confirmed with acute COVID-19 infection until May 2021 were included and followed up for 6 months.

RESULTS

Out of 50 KTRs average aged 63 years, 36 (72%) were men. Nine (18%) KTRs had no pulmonary infiltration, and twenty-nine (58%) did not require oxygen supplementation. Bilateral pulmonary infiltrates had 29 (58%) while high-flow nasal cannula or mechanical ventilation required 8 (16%) KTRs. The mortality rate was 16%. Acute kidney injury developed in 18 (36%), and acute renal replacement therapy required 2 (4%) KTRs. Nine (18%) KTRs were subsequently rehospitalized. Chronic COVID-19 syndrome reported 23 (58%) KTRs.

CONCLUSIONS

D-dimers were found to be the key prognostic factor of clinical complications, emphasizing the importance of underlying thrombotic microangiopathy. Optimal immunosuppressant adjusting in KTRs with acute COVID-19 infection remains to be clarified.

mTOR inhibitors improve both humoral and cellular response to SARS-CoV-2 messenger RNA BNT16b2 vaccine in kidney transplant recipients

Kidney transplant recipients (KTRs) have been considered as patients at higher risk of SARS-CoV-2-related disease severity, thus COVID-19 vaccination was highly recommended. However, possible interferences of different immunosuppression with development of both humoral and T cell-mediated immune response to COVID-19 vaccination have not been determined. Here we evaluated the association between mTOR-inhibitors (mTOR-I) and immune response to mRNA BNT162b2 (Pfizer-BioNTech) vaccine in KTR. To this aim 132 consecutive KTR vaccinated against COVID-19 in the early 2021 were enrolled, and humoral and T cell-mediated immune response were assessed after 4-5 weeks. Patients treated with mTOR-I showed significantly higher anti-SARS-CoV-2 IgG titer (p = .003) and higher percentages of anti-SARS-CoV-2 S1/RBD Ig (p = .024), than those without. Moreover, SARS-CoV-2-specific T cell-derived IFNγ release was significantly increased in patients treated with mTOR-I (p < .001), than in those without. Multivariate analysis confirmed that therapy with mTOR-I gained better humoral (p = .005) and T cell-mediated immune response (p = .005) in KTR. The presence of mTOR-I is associated with a better immune response to COVID-19 vaccine in KTR compared to therapy without mTOR-I, not only by increasing vaccine-induced antibodies but also by stimulating anti-SARS-CoV-2 T cell response. These finding are consistent with a potential beneficial role of mTOR-I as modulators of immune response to COVID-19 vaccine in KTR.

Immunogenicity and Adverse Effects of the 2-Dose BNT162b2 Messenger RNA Vaccine Among Liver Transplantation Recipients

The BNT162b2 messenger RNA (mRNA) vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to be safe and effective in immunocompetent patients. The safety and efficacy of this vaccine in liver transplantation (LT) recipients is still under evaluation. The objective of this study was to assess the safety and efficacy of the BNT162b2 vaccine among transplant recipients. The immune responses of 76 LT recipients receiving 2 doses of the vaccine were compared with those of 174 age-matched immunocompetent controls. Postvaccination immunoglobulin G (IgG) antibodies against the receptor-binding domain (RBD) of SARS-CoV-2 and neutralizing antibodies (NA) to the BNT162b2 mRNA vaccine were determined at least 14 days after the second dose of the vaccine. IgG antibody titers ≥1.1 were defined as positive antibodies. Adverse effects were monitored during the study period. Following administration of the second dose, transplant recipients showed reduced immune responses compared with controls (72% versus 94.2%; P < 0.001). At a median time of 38 days after the second vaccination, the geometric mean of RBD IgG and NA titers were 2.1 (95% confidence interval [CI], 1.6-2.6) and 150 (95% CI, 96-234) among transplant recipients and 4.6 (95% CI, 4.1-5.1) and 429 (95% CI, 350-528) in the control group, respectively (P < 0.001). Antibody responses were lower in transplant recipients who were receiving combined immunosuppression therapy and in those with impaired renal function. Among the LT recipients with negative antibody responses, 1 became infected with SARS-CoV-2, but no recipients with positive antibody responses became infected. Overall, most (n = 39 [51%]) adverse effects self-reported by transplant recipients were mild and occurred more often in women than in men. Compared with patients who were immunocompetent, LT recipients had lower immune responses. The durability of immune responses to the BNT162b2 vaccine among LT recipients requires further investigation.