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Park BH, Kim YN, Shin HS. New treatment for antibody-mediated rejection: interleukin-6 inhibitors. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:1-6. [PMID: 38725179 PMCID: PMC11075910 DOI: 10.4285/ctr.23.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 05/14/2024]
Abstract
Following kidney transplantation, antibody-mediated rejection (AMR) occurs when the antibodies of the immune system attack the transplanted organ, leading to damage of the kidney tissue. De novo human leukocyte antigen donor-specific antibodies (HLA-DSAs) play a key role in AMR. Current therapeutic approaches include intravenous immunoglobulin, anti-CD20 antibodies, and plasmapheresis. In cases resistant to treatment, proteasome inhibitors and C5 inhibitors may be employed. Nevertheless, a pressing need exists for new medications to improve transplant survival and reduce complications. In the context of AMR, interleukin (IL)-6 is instrumental in the development and maturation of B cells into plasma cells, which then produce HLA-DSAs targeting the allograft. IL-6 inhibitors are currently under investigation and show promise due to the essential role of IL-6 in the immune response; however, additional research is necessary.
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Affiliation(s)
- Byung Hwa Park
- Division of Nephrology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, Korea
| | - Ye Na Kim
- Division of Nephrology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, Korea
| | - Ho Sik Shin
- Division of Nephrology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
- Transplantation Research Institute, Kosin University College of Medicine, Busan, Korea
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Bekbolsynov D, Waack A, Buskey C, Bhadkamkar S, Rengel K, Petersen W, Brown ML, Sparkle T, Kaw D, Syed FJ, Chattopadhyay S, Chakravarti R, Khuder S, Mierzejewska B, Rees M, Stepkowski S. Differences in Responses of Immunosuppressed Kidney Transplant Patients to Moderna mRNA-1273 versus Pfizer-BioNTech. Vaccines (Basel) 2024; 12:91. [PMID: 38250904 PMCID: PMC10819652 DOI: 10.3390/vaccines12010091] [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: 10/16/2023] [Revised: 12/21/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
Immunosuppressed kidney transplant (KT) recipients produce a weaker response to COVID-19 vaccination than immunocompetent individuals. We tested antiviral IgG response in 99 KT recipients and 66 healthy volunteers who were vaccinated with mRNA-1273 Moderna or BNT162b2 Pfizer-BioNTech vaccines. A subgroup of participants had their peripheral blood leukocytes (PBLs) evaluated for the frequency of T helper 1 (Th1) cells producing IL-2, IFN-γ and/or TNF-α, and IL-10-producing T-regulatory 1 (Tr) cells. Among KT recipients, 45.8% had anti-SARS-CoV-2 IgG compared to 74.1% of healthy volunteers (p = 0.009); also, anti-viral IgG levels were lower in recipients than in volunteers (p = 0.001). In terms of non-responders (≤2000 U/mL IgG), Moderna's group had 10.8% and Pfizer-BioNTech's group had 34.3% of non-responders at 6 months (p = 0.023); similarly, 15.7% and 31.3% were non-responders in Moderna and Pfizer-BioNTech groups at 12 months, respectively (p = 0.067). There were no non-responders among controls. Healthy volunteers had higher Th1 levels than KT recipients, while Moderna produced a higher Th1 response than Pfizer-BioNTech. In contrast, the Pfizer-BioNTech vaccine induced a higher Tr1 response than the Moderna vaccine (p < 0.05); overall, IgG levels correlated with Th1(fTTNF-α)/Tr1(fTIL-10) ratios. We propose that the higher number of non-responders in the Pfizer-BioNTech group than the Moderna group was caused by a more potent activity of regulatory Tr1 cells in KT recipients vaccinated with the Pfizer-BioNTech vaccine.
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Affiliation(s)
- Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Andrew Waack
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Camryn Buskey
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Shalmali Bhadkamkar
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Keegan Rengel
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Winnifer Petersen
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Mary Lee Brown
- Department of Urology, University of Toledo, Toledo, OH 43614, USA;
| | - Tanaya Sparkle
- Department of Anesthesiology, University of Toledo, Toledo, OH 43614, USA;
| | - Dinkar Kaw
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA; (D.K.); (S.K.)
| | - Fayeq Jeelani Syed
- Department of Electrical Engineering and Computer Science, University of Toledo, Toledo, OH 43614, USA;
| | - Saurabh Chattopadhyay
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Ritu Chakravarti
- Department of Physiology, University of Toledo, Toledo, OH 43614, USA;
| | - Sadik Khuder
- Department of Internal Medicine, University of Toledo, Toledo, OH 43614, USA; (D.K.); (S.K.)
| | - Beata Mierzejewska
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
| | - Michael Rees
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
- Department of Urology, University of Toledo, Toledo, OH 43614, USA;
| | - Stanislaw Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo, Toledo, OH 43614, USA; (D.B.); (A.W.); (C.B.); (S.B.); (K.R.); (W.P.); (S.C.); (B.M.); (M.R.)
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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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Parajuli S, Zhong W, Pantha M, Sokup M, Aziz F, Garg N, Mohamed M, Mandelbrot D. The Trend of Serum Creatinine Does Not Predict Follow-Up Biopsy Findings Among Kidney Transplant Recipients With Antibody-Mediated Rejection. Transplant Direct 2023; 9:e1489. [PMID: 37250486 PMCID: PMC10212615 DOI: 10.1097/txd.0000000000001489] [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: 03/07/2023] [Accepted: 03/23/2023] [Indexed: 05/31/2023] Open
Abstract
Traditionally, antibody-mediated rejection (AMR) has been suspected mainly by a rise in serum creatinine (Scr) and confirmed by allograft biopsy. There is limited literature describing the trend of Scr after treatment, and how that trend might differ between patients with histological response and with no response to treatment. Methods We included all cases of AMR at our program between March 2016 and July 2020 who had a follow-up biopsy after the index biopsy, with initial diagnosis of AMR. We trended the Scr and change in Scr (delta Scr) and its association with being a responder (microvascular inflammation, MVI ≤1) or nonresponder (MVI >1), as well as graft failure. Results A total of 183 kidney transplant recipients were included, 66 in the responder group and 177 in the nonresponder group. The MVI scores and sum chronicity scores, along with transplant glomerulopathy scores, were higher in the nonresponder group. However, Scr at index biopsy was similar in responders (1.74 ± 0.70) versus nonresponders (1.83 ± 0.65; P = 0.39), as were the delta Scr at various time points. After adjustment for multiple variables, delta Scr was not associated with being a nonresponder. Also, delta Scr value at follow-up biopsy compared with index biopsy among responders was 0 ± 0.67 (P = 0.99) and among nonresponders was -0.01 ± 0.61 (P = 0.89). Being a nonresponder was significantly associated with an increased risk of graft failure at the last follow-up in univariate analysis but was not in multivariate analysis (hazard ratio 1.35; 95% confidence interval, 0.58-3.17; P = 0.49). Conclusions We found that Scr is not a good predictor of the resolution of MVI, supporting the utility of follow-up biopsies after treatment of AMR.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Weixiong Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Monika Pantha
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Megan Sokup
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Reese SR, Wilson NA, Huang Y, Ptak L, Degner KR, Xiang D, Redfield RR, Zhong W, Panzer SE. B-cell Deficiency Attenuates Transplant Glomerulopathy in a Rat Model of Chronic Active Antibody-mediated Rejection. Transplantation 2021; 105:1516-1529. [PMID: 33273321 PMCID: PMC8106694 DOI: 10.1097/tp.0000000000003530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transplant glomerulopathy (TG) is a pathological feature of chronic active antibody-mediated rejection (cAMR) and is associated with renal allograft failure. The specific role of B cells in the pathogenesis of TG is unclear. METHODS We used a minor mismatched rat kidney transplant model with B cell-deficient recipients, generated by clustered regularly interspaced short palindromic repeats/Cas9 technology, to investigate the impact of B-cell depletion on the pathogenesis of TG. We hypothesized that B-cell deficiency would prevent TG in the rat kidney transplant model of cAMR. Treatment groups included syngeneic, allogeneic, sensitized allogeneic, and B cell-deficient allogeneic transplant recipients. RESULTS B cell-deficient recipients demonstrated reduced TG lesions, decreased microvascular inflammation, reduced allograft infiltrating macrophages, and reduced interferon gamma transcripts within the allograft. Allograft transcript levels of interferon gamma, monocyte chemoattractant protein-1, and interleukin-1β correlated with numbers of intragraft macrophages. B cell-deficient recipients lacked circulating donor-specific antibodies and had an increased splenic regulatory T-cell population. CONCLUSIONS In this model of cAMR, B-cell depletion attenuated the development of TG with effects on T cell and innate immunity.
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Affiliation(s)
- Shannon R. Reese
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Nancy A. Wilson
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Yabing Huang
- Department of Pathology, Renmin Hospital of Wuhan University, China
| | - Lucille Ptak
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenna R. Degner
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Ding Xiang
- Department of Organ Transplantation, Xiangya Hospital, Central South University, China
| | - Robert R. Redfield
- Department of Surgery, Division of Transplant Surgery, University of Wisconsin, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI, United States
| | - Sarah E. Panzer
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
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Donor-specific antibodies in kidney transplantation: the University of Wisconsin experience. Curr Opin Organ Transplant 2020; 25:543-548. [PMID: 33044350 DOI: 10.1097/mot.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (ABMR) is the leading cause of allograft failure in kidney transplant recipients. This article provides a summary of the clinical research relating to donor-specific antibodies (DSA) and ABMR in kidney transplant recipients at the University of Wisconsin-Madison Transplant Center. RECENT FINDINGS Over 40% of the kidney transplant candidates on the UNOS waitlist are sensitized, and both preformed and de novo DSA are associated with increased risk of rejection and graft loss. We have developed graded induction-desensitization treatment and monitoring protocols based on the degree of immunologic risk. We have also implemented standard treatment and surveillance strategies for patients with ABMR. Additional important observations from our studies include high rates of ABMR in patients with positive C4d staining in postreperfusion biopsies and rise in DSA at 1 week after transplant, and increased risk of kidney allograft failure in patients with de novo DSA and ABMR, as well as in patients with HLA-DSA undetectable ABMR. We also found worse outcomes with de novo DSA following simultaneous pancreas--kidney and liver--kidney transplantation. Notably, favorable long-term graft outcomes were observed in patients with DSA who do not present the classic histopathological findings of ABMR. SUMMARY In order to improve long-term outcomes for kidney transplant recipients, further research focusing on the pathogenic mechanisms elicited by HLA and non-HLA DSA, and novel therapies targeting these pathways is needed.
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