Application of Immune Checkpoint Inhibitors in Solid Organ Transplantation Recipients: A Systematic Review

Immune-checkpoint expression in antigen-presenting cells (APCs) of cytomegaloviruses infection after transplantation: as a diagnostic biomarker

Cytomegalovirus (CMV), a member of the Herpesviridae family, mostly causes only slight feverish symptoms or can be asymptomatic in immunocompetent individuals. However, it is known to be particularly a significant cause of morbidity in immunocompromised patients, including transplant recipients, whose immune system has been weakened due to the consumption of immunosuppressor drugs. Therefore, the diagnosis of CMV infection after transplantation is crucial. New diagnostic methods for the quick detection of CMV have been developed as a result of understanding the clinical importance of invasive CMV. Antigen-presenting cells (APCs) and T cells are important components of the immune system and it may be possible to diagnose viral infections using immunological markers, such as lymphocytosis, cytotoxic T lymphocytes (CTL), and serum cytokine levels. Moreover, PD-1, CTLA 4, and TIGIT, which are expressed on certain T cells and antigen-presenting cells, are over-expressed during the infection. The assessment of CMV infection based on T cell and APC activity, and the expression of immunological checkpoints, can be helpful for the diagnosis of transplant patients at risk for CMV infection. In this review, we will investigate how immune checkpoints affect immune cells and how they impair organ transplantation after CMV infection.

Immune Checkpoint Inhibitors in Solid Organ Transplant Recipients With Advanced Skin Cancers-Emerging Strategies for Clinical Management

Use of immune checkpoint inhibitors (ICIs) in solid organ transplant recipients (SOTRs) with advanced skin cancers presents a significant clinical management dilemma. SOTRs and other immunosuppressed patients have been routinely excluded from ICI clinical trials with good reason: immune checkpoints play an important role in self- and allograft-tolerance and risk of acute allograft rejection reported in retrospective studies affects 10% to 65% of cases. These reports also confirm that cutaneous squamous cell carcinoma and melanoma respond to ICI therapy, although response rates are generally lower than those observed in immunocompetent populations. Prospective trials are now of critical importance in further establishing ICI efficacy and safety. However, based on current knowledge, we recommend that ICIs should be offered to kidney transplant recipients with advanced cutaneous squamous cell carcinoma, melanoma, or Merkel cell carcinoma if surgery and/or radiotherapy have failed. For kidney transplant recipients, this should be first line ahead of chemotherapy and targeted therapies. In SOTRs, the use of ICIs should be carefully considered with the benefits of ICIs versus risks of allograft rejection weighed up on a case-by-case basis as part of shared decision-making with patients. In all cases, parallel management of immunosuppression may be key to ICI responsiveness. We recommend maintaining immunosuppression before ICI initiation with a dual immunosuppressive regimen combining mammalian target of rapamycin inhibitors and either corticosteroids or calcineurin inhibitors. Such modification of immunosuppression must be considered in the context of allograft risk (both rejection and also its subsequent treatment) and risk of tumor progression. Ultimately, a multidisciplinary approach should underpin all clinical decision-making in this challenging scenario.

Experience with solid organ transplantation in patients with previous immunotherapy treatment is still limited but this is changing: The survey-based view of the global transplant society

BACKGROUND

The use of immunotherapy for cancer is increasing and is expected to continue growing. The outcomes after solid organ transplantation(SOT) in patients who received immunotherapy before SOT remain unclear. We evaluated the global transplant surgery community's attitude towards and experience with patients who received immunotherapy for malignancy before SOT.

METHODS

An online-based survey was sent to North American transplant program directors in December-2020 and members of the International Liver Transplant Society in November-2021 evaluating experiences with and attitudes towards SOT in recipients with previous immunotherapy for cancer.

RESULTS

A total of 119 respondents completed the survey(119/175;completion rate:68%), representing centers from North America, South America, Europe, Asia, and Australia. Seventy-one(62%) respondents would consider SOT in patients with a previous history of immunotherapy for cancer, whereas thirty-nine(34%) were aware of such immunotherapy-treated recipients being transplanted, with an increasing trend over the last few years(2016[n = 1]-2020[n = 14]). Institutional clinical management policies in this setting were lacking in most centers(n = 85[75%]).

CONCLUSIONS

The international transplant community is receptive to transplanting transplant candidates previously treated with immunotherapy for cancer, although experience is still limited. In this context, more centers have started to offer SOT to patients with a history of immunotherapy for cancer in recent years. However, support from clear and robust institutional policies in this endeavor is scant. Therefore, there is a high need for consensus guidelines to inform future clinical management, especially as immunotherapy for cancer is likely to continue to increase in the coming years.

Prompt response of advanced cutaneous squamous cell carcinoma to cemiplimab in a kidney transplant patient under everolimus treatment

Immune checkpoint inhibitors (ICI) are increasingly used in numerous advanced solid cancers. Nevertheless, the safety and efficacy of ICI in solid organ transplant recipients (SOTR) are unclear, since SOTR are usually excluded from clinical investigations due to their high risk for irreversible allograft rejection.^1-4.