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Oura T, Hotta K, Lei J, Markmann J, Rosales I, Dehnadi A, Kawai K, Ndishabandi D, Smith RN, Cosimi AB, Kawai T. Immunosuppression With CD40 Costimulatory Blockade Plus Rapamycin for Simultaneous Islet-Kidney Transplantation in Nonhuman Primates. Am J Transplant 2017; 17:646-656. [PMID: 27501203 PMCID: PMC5298941 DOI: 10.1111/ajt.13999] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/10/2016] [Accepted: 07/30/2016] [Indexed: 01/25/2023]
Abstract
The lack of a reliable immunosuppressive regimen that effectively suppresses both renal and islet allograft rejection without islet toxicity hampers a wider clinical application of simultaneous islet-kidney transplantation (SIK). Seven MHC-mismatched SIKs were performed in diabetic cynomolgus monkeys. Two recipients received rabbit antithymocyte globulin (ATG) induction followed by daily tacrolimus and rapamycin (ATG/Tac/Rapa), and five recipients were treated with anti-CD40 monoclonal antibody (mAb) and rapamycin (aCD40/Rapa). Anti-inflammatory therapy, including anti-interleukin-6 receptor mAb and anti-tumor necrosis factor-α mAb, was given in both groups. The ATG/Tac/Rapa recipients failed to achieve long-term islet allograft survival (19 and 26 days) due to poor islet engraftment and cytomegalovirus pneumonia. In contrast, the aCD40/Rapa regimen provided long-term islet and kidney allograft survival (90, 94, >120, >120, and >120 days), with only one recipient developing evidence of allograft rejection. The aCD40/Rapa regimen was also tested in four kidney-alone transplant recipients. All four recipients achieved long-term renal allograft survival (100% at day 120), which was superior to renal allograft survival (62.9% at day 120) with triple immunosuppressive regimen (tacrolimus, mycophenolate mofetil, and steroids). The combination of anti-CD40 mAb and rapamycin is an effective and nontoxic immunosuppressive regimen that uses only clinically available agents for kidney and islet recipients.
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Affiliation(s)
- Tetsu Oura
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kiyohiko Hotta
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ji Lei
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Abbas Dehnadi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kento Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Dorothy Ndishabandi
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rex-Neal Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Benedict Cosimi
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tatsuo Kawai
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Hirsch HH, Yakhontova K, Lu M, Manzetti J. BK Polyomavirus Replication in Renal Tubular Epithelial Cells Is Inhibited by Sirolimus, but Activated by Tacrolimus Through a Pathway Involving FKBP-12. Am J Transplant 2016; 16:821-32. [PMID: 26639422 PMCID: PMC5064607 DOI: 10.1111/ajt.13541] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/04/2015] [Accepted: 09/24/2015] [Indexed: 01/25/2023]
Abstract
BK polyomavirus (BKPyV) replication causes nephropathy and premature kidney transplant failure. Insufficient BKPyV-specific T cell control is regarded as a key mechanism, but direct effects of immunosuppressive drugs on BKPyV replication might play an additional role. We compared the effects of mammalian target of rapamycin (mTOR)- and calcineurin-inhibitors on BKPyV replication in primary human renal tubular epithelial cells. Sirolimus impaired BKPyV replication with a 90% inhibitory concentration of 4 ng/mL by interfering with mTOR-SP6-kinase activation. Sirolimus inhibition was rapid and effective up to 24 h postinfection during viral early gene expression, but not thereafter, during viral late gene expression. The mTORC-1 kinase inhibitor torin-1 showed a similar inhibition profile, supporting the notion that early steps of BKPyV replication depend on mTOR activity. Cyclosporine A also inhibited BKPyV replication, while tacrolimus activated BKPyV replication and reversed sirolimus inhibition. FK binding protein 12kda (FKBP-12) siRNA knockdown abrogated sirolimus inhibition and increased BKPyV replication similar to adding tacrolimus. Thus, sirolimus and tacrolimus exert opposite effects on BKPyV replication in renal tubular epithelial cells by a mechanism involving FKBP-12 as common target. Immunosuppressive drugs may therefore contribute directly to the risk of BKPyV replication and nephropathy besides suppressing T cell functions. The data provide rationales for clinical trials aiming at reducing the risk of BKPyV replication and disease in kidney transplantation.
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Affiliation(s)
- H. H. Hirsch
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland,Division Infection DiagnosticsDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland,Infectious Diseases & Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
| | - K. Yakhontova
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
| | - M. Lu
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
| | - J. Manzetti
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
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Mandelbrot DA, Alberú J, Barama A, Marder BA, Silva HT, Flechner SM, Flynn A, Healy C, Li H, Tortorici MA, Schulman SL. Effect of Ramipril on Urinary Protein Excretion in Maintenance Renal Transplant Patients Converted to Sirolimus. Am J Transplant 2015; 15:3174-84. [PMID: 26176342 DOI: 10.1111/ajt.13384] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 05/17/2015] [Accepted: 05/17/2015] [Indexed: 01/25/2023]
Abstract
This prospective, randomized, double-blind, placebo-controlled study evaluated the effects of ramipril on urinary protein excretion in renal transplant patients treated with sirolimus following conversion from a calcineurin inhibitor. Patients received ramipril or placebo for up to 6 weeks before conversion and 52 weeks thereafter. Doses were increased if patients developed proteinuria (urinary protein/creatinine ratio ≥0.5); losartan was given as rescue therapy for persistent proteinuria. The primary end point was time to losartan initiation. Of 295 patients randomized, 264 met the criteria for sirolimus conversion (ramipril, 138; placebo, 126). At 52 weeks, the cumulative rate of losartan initiation was significantly lower with ramipril (6.2%) versus placebo (23.2%) (p < 0.001). No significant differences were observed between ramipril and placebo for change in glomerular filtration rate from baseline (p = 0.148) or in the number of patients with biopsy-confirmed acute rejection (13 vs. 5, respectively; p = 0.073). One patient in the placebo group died due to cerebrovascular accident. Treatment-emergent adverse events were consistent with the known safety profile of sirolimus and were not potentiated by ramipril co-administration. Ramipril was effective in reducing the incidence of proteinuria for up to 1 year following conversion to sirolimus in maintenance renal transplant patients.
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Affiliation(s)
- D A Mandelbrot
- Department of Medicine, University of Wisconsin Hospital, Madison, WI
| | - J Alberú
- Transplantation Department, Instituto Nacional de Ciencias Médicas y Nutrición SZ, Mexico City, Mexico
| | - A Barama
- Department of Surgery, University of Montréal, Quebec, Canada
| | - B A Marder
- Internal Medicine/Nephrology, Presbyterian/St Luke's Medical Center, Denver, CO
| | - H T Silva
- Nephrology Division, Hospital do Rim-Universidade Federal de São Paulo, São Paulo, Brazil
| | - S M Flechner
- Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - A Flynn
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | - C Healy
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | - H Li
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | | | - S L Schulman
- Global Innovative Pharma, Pfizer, Collegeville, PA
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Yanik EL, Gustafson SK, Kasiske BL, Israni AK, Snyder JJ, Hess GP, Engels EA, Segev DL. Sirolimus use and cancer incidence among US kidney transplant recipients. Am J Transplant 2015; 15:129-36. [PMID: 25522018 DOI: 10.1111/ajt.12969] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/04/2014] [Indexed: 01/25/2023]
Abstract
Sirolimus has anti-carcinogenic properties and can be included in maintenance immunosuppressive therapy following kidney transplantation. We investigated sirolimus effects on cancer incidence among kidney recipients. The US transplant registry was linked with 15 population-based cancer registries and national pharmacy claims. Recipients contributed sirolimus-exposed time when sirolimus claims were filled, and unexposed time when other immunosuppressant claims were filled without sirolimus. Cox regression was used to estimate associations with overall and specific cancer incidence, excluding nonmelanoma skin cancers (not captured in cancer registries). We included 32,604 kidney transplants (5687 sirolimus-exposed). Overall, cancer incidence was suggestively lower during sirolimus use (hazard ratio [HR] = 0.88, 95% confidence interval [CI] = 0.70-1.11). Prostate cancer incidence was higher during sirolimus use (HR = 1.86, 95% CI = 1.15-3.02). Incidence of other cancers was similar or lower with sirolimus use, with a 26% decrease overall (HR = 0.74, 95% CI = 0.57-0.96, excluding prostate cancer). Results were similar after adjustment for demographic and clinical characteristics. This modest association does not provide strong evidence that sirolimus prevents posttransplant cancer, but it may be advantageous among kidney recipients with high cancer risk. Increased prostate cancer diagnoses may result from sirolimus effects on screen detection.
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Affiliation(s)
- E L Yanik
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
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