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Horn ET, Xu Q, Dibridge JN, Huston JH, Hickey GW, Kaczorowski DJ, Keebler ME, Zeevi A. Reduction of HLA donor specific antibodies in heart transplant patients treated with proteasome inhibitors for antibody mediated rejection. Clin Transplant 2023; 37:e15132. [PMID: 37705362 DOI: 10.1111/ctr.15132] [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] [Received: 06/19/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
In this project, we describe proteasome inhibitor (PI) treatment of antibody-mediated rejection (AMR) in heart transplantation (HTX). From January 2018 to September 2021, 10 patients were treated with PI for AMR: carfilzomib (CFZ) n = 8; bortezomib (BTZ) n = 2. Patients received 1-3 cycles of PI. All patients had ≥1 strong donor-specific antibody (DSA) (mean fluorescence intensity [MFI] > 8000) in undiluted serum. Most DSAs (20/21) had HLA class II specificity. The MFI of strong DSAs had a median reduction of 56% (IQR = 13%-89%) in undiluted serum and 92% (IQR = 53%-95%) at 1:16 dilution. Seventeen DSAs in seven patients were reduced > 50% at 1:16 dilution after treatment. Four DSAs from three patients did not respond. DSA with MFI > 8000 at 1:16 dilution was less responsive to treatment. 60% (6/10) patients presented with graft dysfunction; 4/6 recovered ejection fraction > 40% after treatment. Pathologic AMR was resolved in 5/7 (71.4%) of patients within 1 year after treatment. 9/10 (90%) patients survived to 1 year after AMR diagnosis. Using PI in AMR resulted in significant DSA reduction with some resolution of graft dysfunction. Larger studies are needed to evaluate PI for AMR.
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Affiliation(s)
- Edward T Horn
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julie N Dibridge
- UPMC Presbyterian Hospital, Department of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jessica H Huston
- Department of Cardiology, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Department of Cardiology, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Mary E Keebler
- Department of Cardiology, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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2
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Magnetta DA, Hoch VL, Pinelli D, Monge M, Pahl E, Thrush PT. Donor-specific antibodies after heart transplantation for Fontan-associated protein-losing enteropathy. Pediatr Transplant 2023:e14458. [PMID: 36591815 DOI: 10.1111/petr.14458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/22/2022] [Accepted: 10/04/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite ubiquitous exposure to sensitizing events, most Fontan PLE patients have low panel reactive antibodies (PRA). To assess whether they are at risk for donor-specific antibody (DSA) memory response following heart transplantation (HT) when their PLE resolves, DSA profiles, incidence of rejection, and graft outcomes in Fontan recipients with and without PLE were compared. METHODS Patient characteristics, appearance of newly detected DSA (nDSA), and graft outcomes were compared between patients with and without PLE using Wilcoxon rank-sum and Chi-squared tests. DSA burden was quantified using titers and time to nDSA, incidence of rejection, and graft outcomes were compared using Kaplan-Meier curves and the log-rank test. RESULTS Characteristics of patients with and without PLE were similar. Lymphocyte and albumin levels were lower in the PLE group, and flow PRA were comparable. Graft failure, CAV, and ACR were similar between the two groups, but AMR occurred more frequently in the PLE group (p = .03). Nearly 50% of PLE patients experienced class II nDSA by 1-year post-HT, compared to 30% of non-PLE patients, but this difference was statistically not significant. Antibody burden did not differ between groups. CONCLUSIONS In this cohort, PLE was associated with AMR within the first-year post-HT, despite no significant difference in nDSA. Small patient numbers limited statistical comparison of nDSA in this cohort. PLE may be a risk factor for AMR post-HT, and the possibility of a clinically important DSA memory response remains. Larger studies are necessary to better understand these preliminary findings.
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Affiliation(s)
- Defne A Magnetta
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Virginia L Hoch
- Internal Medicine-Pediatrics, ChristianaCare Health System, Newark, Delaware, USA
| | - David Pinelli
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Monge
- Pediatric Cardiothoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Elfriede Pahl
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Philip T Thrush
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Jaiswal A, Bell J, DeFilippis EM, Kransdorf EP, Patel J, Kobashigawa JA, Kittleson MM, Baran DA. Assessment and management of allosensitization following heart transplant in adults. J Heart Lung Transplant 2022; 42:423-432. [PMID: 36702686 DOI: 10.1016/j.healun.2022.12.011] [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: 09/23/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Immunological injury to the allograft, specifically by antibodies to de novo donor specific human leukocyte antigen (dnDSA) and antibody mediated injury and rejection are the major limitations to graft survival after heart transplantation (HT). As such, our approach to allosensitization remains limited by the inability of contemporaneous immunoassays to unravel pathogenic potential of dnDSA. Additionally, the role of dnDSA is continuously evaluated with emerging methods to detect rejection. Moreover, the timing and frequency of dnDSA monitoring for early detection and risk mitigation as well as management of dnDSA remain challenging. A strategic approach to dnDSA employs diagnostic assays to determine relevant antibodies in conjunction with clinical presentation and injury/rejection of allograft to tailor therapeutics. In this review, we aim to outline contemporary knowledge involving detection, monitoring and management of dnDSA after HT. Subsequently, we propose a diagnostic and therapeutic approach that may mitigate morbidity and mortality while balancing adverse reactions from pharmacotherapy.
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Affiliation(s)
- Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Jennifer Bell
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan P Kransdorf
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart, Vascular and Thoracic Institute, Advanced Heart Failure Program, Weston, Florida
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Konda P, Golamari R, Eisen HJ. Novel Immunosuppression in Solid Organ Transplantation. Handb Exp Pharmacol 2022; 272:267-285. [PMID: 35318509 DOI: 10.1007/164_2021_569] [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: 06/14/2023]
Abstract
Solid organ transplantation and survival has improved tremendously in the last few decades, much of the success has been attributed to the advancements in immunosuppression. While steroids are being replaced and much of the immunosuppressive strategies focus on steroid free regimens, novel agents have introduced in the induction, maintenance, and treatment of acute rejection phase. MTOR inhibitors have helped with the renal sparing side effect from the calcineurin inhibitors, newer agents such as rituximab have decreased the incidence of donor-specific antibodies which led to decreased incidence of acute rejection reactions. In this chapter we discuss the newer therapies directed specifically for solid organ transplantation.
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Affiliation(s)
- Prasad Konda
- Heart and Vascular Institute, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Reshma Golamari
- Department of Hospital Medicine, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA, USA.
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5
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Assessment of Carfilzomib Treatment Response in Lung Transplant Recipients With Antibody-mediated Rejection. Transplant Direct 2021; 7:e680. [PMID: 33748409 PMCID: PMC7969244 DOI: 10.1097/txd.0000000000001131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 01/31/2023] Open
Abstract
Supplemental Digital Content is available in the text. Data supporting the use of carfilzomib (CFZ) for treatment of antibody-mediated rejection (AMR) in lung transplantation in combination with plasmapheresis and intravenous immunoglobulin suggest positive outcomes through donor-specific antibody (DSA) depletion or conversion to noncomplement-activating antibodies. Herein, we describe our center’s experience treating AMR with CFZ.
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Sriwattanakomen R, Xu Q, Demehin M, Shullo MA, Mangiola M, Hickey GW, Sciortino CM, Horn ET, Keebler ME, Zeevi A. Impact of carfilzomib-based desensitization on heart transplantation of sensitized candidates. J Heart Lung Transplant 2021; 40:595-603. [PMID: 33785250 DOI: 10.1016/j.healun.2021.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/14/2021] [Accepted: 03/02/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Allosensitization in heart transplant candidates is associated with longer transplant wait times and post-transplant complications. We summarize our experience with desensitization using carfilzomib, an irreversible proteasome inhibitor that causes plasma cell apoptosis. METHODS One cycle of desensitization consisted of plasmapheresis and carfilzomib 20 mg/m2 on days 1, 2, 8, 9, 15, and 16 with intravenous immune globulin 2 g/kg after carfilzomib on day 16. Patients underwent repeat cycles as indicated. We compare calculated panel-reactive antibody (cPRA) for neat combined Class I and II IgG and C1q pre- and post-treatment using a cutoff for cPRA entry of ≥ 4000 and 500 MFI, respectively. RESULTS From June 2013 to October 2019, 9 patients underwent 20 cycles of carfilzomib-based desensitization. Each cycle resulted in an average cPRA decrease of 24% (95% CI: 6-42) for IgG and 36% (95% CI: 17-55) for C1q. From treatment start to finish, mean cPRA fell from 76% to 40% (p = 0.01) for IgG and 56% to 4% (p = 0.017) for C1q. Six of 9 patients have been transplanted with 5 of the transplanted hearts crossing preoperative donor-specific antibodies. During a median follow-up of 35.1 months, all transplanted patients have survived with only 1 occurrence of treated rejection. Side effects of desensitization included acute kidney injury (67%) and thrombocytopenia (33%) with all episodes self-resolving. CONCLUSIONS A carfilzomib-based desensitization strategy among heart transplant candidates reduces the level of HLA antibodies and complement binding, facilitates successful transplantation, and is associated with excellent outcomes at 3 years.
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Affiliation(s)
| | - Qingyong Xu
- Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Moses Demehin
- University of Maryland Medical Center, Baltimore, Maryland
| | | | | | - Gavin W Hickey
- Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Edward T Horn
- Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary E Keebler
- Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adriana Zeevi
- Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:15-30. [PMID: 36263111 PMCID: PMC9536714 DOI: 10.36628/ijhf.2020.0034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022]
Abstract
Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.
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Jambon F, Merville P, Guidicelli G, Taton B, De Précigout V, Couzi L, Moreau K, Visentin J. Efficacy of plasmapheresis and semi-selective immunoadsorption for removal of anti-HLA antibodies. J Clin Apher 2020; 36:291-298. [PMID: 33253430 DOI: 10.1002/jca.21858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/10/2020] [Accepted: 11/12/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND In organ transplantation, apheresis is frequently used for removal of anti-HLA antibodies. However, it is unclear whether plasmapheresis (PP) or semi-selective immunoadsorption (IA) should be employed, and the optimal number of apheresis sessions required to reach post-treatment objectives is also unknown. METHODS We enrolled 43 patients from Bordeaux University Hospital who were treated with PP (n = 29) or IA (n = 14) for antibody-mediated rejection or pre-transplant desensitization. Using Luminex single-antigen flow beads, we assessed the initial mean fluorescence intensity (MFI) of 1416 positive beads with MFIs obtained after 7 to 8 apheresis sessions (extended protocol) and, if a serum was available, after the first four sessions (short protocol). RESULTS MFI reduction after extended apheresis protocol was stronger with IA [87% (61%-100%)] than with PP [73% (22%-100%)] (P < .001). Indeed, 59% of the beads had a final MFI < 2000 with IA, whereas only 38% with PP (P < .001). The efficacy of removal depended on initial MFI but not on HLA specificity. A short protocol of apheresis showed excellent results without superiority of IA over PP for antibodies with an initial MFI < 3000. For antibodies showing MFI ≥2000 after four sessions, the residual MFI predicted the effectiveness of four additional sessions. CONCLUSION Monitoring the MFI of anti-HLA antibodies before and during apheresis protocol can guide physicians in the selection of apheresis technique and the number of sessions to be performed.
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Affiliation(s)
- Frédéric Jambon
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Pierre Merville
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Gwendaline Guidicelli
- CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France
| | - Benjamin Taton
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Valérie De Précigout
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Lionel Couzi
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France.,CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France
| | - Karine Moreau
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Jonathan Visentin
- CNRS UMR 5164, ImmunoConcEpT, Univ. Bordeaux, Bordeaux, France.,CHU de Bordeaux, Laboratoire d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France
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9
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Pinelli DF, Zachary AA, Friedewald JJ, Gjertson DW, Evans MA, Chatroop EN, Leffell MS, Vo AA, Jordan SC, Montgomery RA, Tambur AR. Prognostic tools to assess candidacy for and efficacy of antibody-removal therapy. Am J Transplant 2019; 19:381-390. [PMID: 29981209 DOI: 10.1111/ajt.15007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/20/2018] [Accepted: 07/01/2018] [Indexed: 01/25/2023]
Abstract
Currently, the ability to predict or monitor the efficacy of HLA antibody-removal therapies is deficient. We previously reported that titration studies are a consistent and accurate means of assessing antibody strength. To test whether titration studies can also predict which patients are better candidates for desensitization, we studied 38 patients from 3 centers (29 receiving plasmapheresis/low-dose intravenous immunoglobulin [IVIg]; 9 patients receiving high-dose IVIg). For patients undergoing plasmapheresis/low-dose IVIg, antibody titer reduction correlated with number of treatment cycles for both class I and II antibodies but only up to approximately 4 cycles. Reduction in titer slowed with additional cycles, suggesting a limit to the efficacy of this approach. Furthermore, initial titer (predesensitization) can guide the selection of candidates for successful antibody-removal treatment. In our experience, patients with antibodies at an initial titer >1:512 could not be reduced to the goal of a negative lymphocyte crossmatch, corresponding to a 1:16 titer, despite a significant increase in the number of treatment cycles. Change in mean fluorescence intensity (MFI) value did not correlate with success of treatment if initial MFI values were >10 000, likely due to single antigen bead saturation. Overall, we present a potential prognostic tool to predict candidacy and a monitoring tool to assess efficacy of desensitization treatment.
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Affiliation(s)
- David F Pinelli
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Andrea A Zachary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John J Friedewald
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Gjertson
- Division of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, CA, USA
| | - Michelle A Evans
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Erik N Chatroop
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
| | - Mary S Leffell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashley A Vo
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Robert A Montgomery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anat R Tambur
- Division of Transplant Surgery, Northwestern University Feinberg School of Medicine, Comprehensive Transplant Center, Chicago, IL, USA
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11
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Abstract
PURPOSE OF REVIEW Pediatric heart transplants continue to be the therapy of choice for children with end stage heart failure. The interplay of limited donor supply, improvement in ventricular assist device (VAD) technology and utilization, and a focus on optimizing long-term outcomes make it critically important for practitioners to be aware of an evolving diagnostic and therapeutic arsenal. RECENT FINDINGS Data suitable to define best practices for pediatric heart transplantation consist of an amalgam of small single center series, registry reviews and judicious inference from adult studies. Large-scale prospective pediatric studies are essentially nonexistent; the pediatric heart transplant study group continues to be highly productive while new collaboratives are emerging. SUMMARY Outcomes for pediatric transplants continue to improve. Technology and innovation continue to drive shifts in management. Improvements in VAD support along with refinement of solid-phase assays require clinicians to develop a deeper understanding of pre and post transplant management of donor-specific antibodies and antibody-mediated rejection. Expertise in retransplantation and the care of adults with congenital heart disease will be critical in the future.
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12
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Ensor CR, Yousem SA, Marrari M, Morrell MR, Mangiola M, Pilewski JM, D'Cunha J, Wisniewski SR, Venkataramanan R, Zeevi A, McDyer JF. Proteasome Inhibitor Carfilzomib-Based Therapy for Antibody-Mediated Rejection of the Pulmonary Allograft: Use and Short-Term Findings. Am J Transplant 2017; 17:1380-1388. [PMID: 28173620 DOI: 10.1111/ajt.14222] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/08/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
We present this observational study of lung transplant recipients (LTR) treated with carfilzomib (CFZ)-based therapy for antibody-mediated rejection (AMR) of the lung. Patients were considered responders to CFZ if complement-1q (C1q)-fixing ability of their immunodominant (ID) donor-specific anti-human leukocyte antibody (DSA) was suppressed after treatment. Treatment consisted of CFZ plus plasma exchange and immunoglobulins. Fourteen LTRs underwent CFZ for 20 ID DSA AMR. Ten (71.4%) of LTRs responded to CFZ. DSA IgG mean fluorescence intensity (MFI) fell from 7664 (IQR 3230-11 874) to 1878 (653-7791) after therapy (p = 0.001) and to 1400 (850-8287) 2 weeks later (p = 0.001). DSA C1q MFI fell from 3596 (IQR 714-14 405) to <30 after therapy (p = 0.01) and <30 2 weeks later (p = 0.02). Forced expiratory volume in 1s ( FEV1 ) fell from mean 2.11 L pre-AMR to 1.92 L at AMR (p = 0.04). FEV1 was unchanged after CFZ (1.91 L) and subsequently rose to a maximum of 2.13 L (p = 0.01). Mean forced expiratory flow during mid forced vital capacity (25-75) (FEF25-75 ) fell from mean 2.5 L pre-AMR to 1.95 L at AMR (p = 0.01). FEF25-75 rose after CFZ to 2.54 L and reached a maximum of 2.91 L (p = 0.01). Responders had less chronic lung allograft dysfunction or progression versus nonresponders (25% vs. 83%, p = 0.04). No deaths occurred within 120 days and 7 patients died post CFZ therapy of allograft failure. Larger prospective interventional studies are needed to further describe the benefit of CFZ-based therapy for pulmonary AMR.
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Affiliation(s)
- C R Ensor
- School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S A Yousem
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M Marrari
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M R Morrell
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - M Mangiola
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J M Pilewski
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J D'Cunha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S R Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R Venkataramanan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J F McDyer
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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13
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Mangiola M, Marrari M, Feingold B, Zeevi A. Significance of Anti-HLA Antibodies on Adult and Pediatric Heart Allograft Outcomes. Front Immunol 2017; 8:4. [PMID: 28191005 PMCID: PMC5269448 DOI: 10.3389/fimmu.2017.00004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/03/2017] [Indexed: 12/17/2022] Open
Abstract
As methods for human leukocyte antigens (HLA) antibody detection have evolved and newer solid phase assays are much more sensitive, the last 15 years has seen a renewed focus on the importance of HLA antibodies in solid organ transplant rejection. However, there is still much controversy regarding the clinical significance of antibody level as depicted by the mean fluorescence intensity of a patient’s neat serum. Emerging techniques, including those that identify antibody level and function, show promise for the detection of individuals at risk of allograft rejection, determination of the effectiveness of desensitization prior to transplant, and for monitoring treatment of rejection. Here, we review current publications regarding the relevance of donor-specific HLA antibodies (DSA) in adult and pediatric heart transplantation (HT) with graft survival, development of antibody-mediated rejection and cardiac allograft vasculopathy (CAV). The negative impact of DSA on patient and allograft survival is evident in adult and pediatric HT recipients. Many questions remain regarding the most appropriate frequency of assessment of pre- and posttransplant DSA as well as the phenotype of DSA memory vs. true de novo antibody using large multicenter adult and pediatric cohorts and state-of-the-art methodologies for DSA detection and characterization.
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Affiliation(s)
- Massimo Mangiola
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Marilyn Marrari
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Brian Feingold
- Pediatric Cardiology, The Children's Hospital of Pittsburgh of UPMC , Pittsburgh, PA , USA
| | - Adriana Zeevi
- Division of Transplant Pathology, Department of Pathology, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
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14
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Pearl MH, Nayak AB, Ettenger RB, Puliyanda D, Palma Diaz MF, Zhang Q, Reed EF, Tsai EW. Bortezomib may stabilize pediatric renal transplant recipients with antibody-mediated rejection. Pediatr Nephrol 2016; 31:1341-8. [PMID: 27048228 PMCID: PMC5590841 DOI: 10.1007/s00467-016-3319-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Current therapeutic strategies to effectively treat antibody-mediated rejection (AMR) are insufficient. Thus, we aimed to determine the benefit of a therapeutic protocol using bortezomib for refractory C4d + AMR in pediatric kidney transplant patients. METHODS We examined seven patients with treatment-refractory C4d + AMR. Immunosuppression included antithymocyte globulin or anti-CD25 monoclonal antibody for induction therapy with maintenance corticosteroids, calcineurin inhibitor, and anti-metabolite. Estimated glomerular filtration rate (eGFR) calculated by the Schwartz equation, biopsy findings assessed by 2013 Banff criteria, and human leukocyte antigen (HLA) donor-specific antibodies (DSA) performed using the Luminex single antigen bead assay were monitored pre- and post- bortezomib therapy. RESULTS Seven patients (86 % male, 86 % with ≥6/8 HLA mismatch, and 14 % with pre-formed DSA) age 5 to 19 (median 15) years developed refractory C4d + AMR between 1 and 145 (median 65) months post-transplantation. All patients tolerated bortezomib. One patient had allograft loss. Of the six patients with surviving grafts (86 %), mean pre-bortezomib eGFR was 42 ml/min/1.73 m(2) and the mean 1 year post-bortezomib eGFR was 53 ml/min/1.73 m(2). Five of seven (71 %) had improvement of histological findings of AMR, C4d staining, and/or acute cellular rejection. Reduction in HLA DSAs was more effective for class I than class II. CONCLUSIONS Bortezomib appears safe and may correlate with stabilization of eGFR in pediatric kidney transplant patients with refractory C4d + AMR.
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Affiliation(s)
- Meghan H Pearl
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA.
| | - Anjali B Nayak
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Robert B Ettenger
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
| | - Dechu Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Miguel Fernando Palma Diaz
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, PO Box 951752, Los Angeles, CA, USA
| | - Eileen W Tsai
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at UCLA, University of California Los Angeles, PO Box 951752, Los Angeles, CA, 90095, USA
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Chih S, Patel J. Desensitization strategies in adult heart transplantation-Will persistence pay off? J Heart Lung Transplant 2016; 35:962-72. [PMID: 27216504 DOI: 10.1016/j.healun.2016.03.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/25/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022] Open
Abstract
Strategies are needed to enable successful heart transplantation in highly sensitized patients. Immunologic challenges from sensitization to human leukocyte antigen (HLA) reduce access to compatible donors, extend waiting times to transplant, and increase the risks of antibody-mediated rejection and cardiac allograft vasculopathy after transplant. The prime goal of desensitization is to increase access to transplantation through expansion of the donor organ pool. Existing therapies are directed at key components of the humoral immune response with newer biologically based regimens able to target plasma cells as the source of antibody production, as well as complement activation that has a central role in antibody-mediated injury. Despite the emergence of early promising results for these agents, a significant knowledge gap remains with the current data for desensitization, extrapolated mostly from non-heart solid-organ transplants and small observational studies. Notably, no approach has demonstrated significant and sustainable reductions in HLA antibody pre-transplant, and the ideal desensitization strategy remains elusive. In addition, clinical tools to evaluate the humoral response and efficacy of therapy are limited, focusing almost exclusively on HLA antibody detection. Importantly, desensitization is associated with significant costs and potential risks, and overall long-term outcomes and cost-effectiveness have not been sufficiently evaluated. Investigation is ongoing into the development of a clinically effective desensitization strategy in heart transplantation.
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Affiliation(s)
- Sharon Chih
- Heart Failure and Transplant, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Jignesh Patel
- Heart Transplant Program, Cedars-Sinai Heart Institute, Los Angeles, California, USA
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