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Anwar IJ, Ezekian B, DeLaura I, Manook M, Schroder P, Yoon J, Curfman V, Branum E, Messina J, Harnois M, Permar SR, Farris AB, Kwun J, Knechtle SJ. Addition of interleukin-6 receptor blockade to carfilzomib-based desensitization in a highly sensitized nonhuman primate model. Am J Transplant 2022; 22 Suppl 4:1-11. [PMID: 36239200 PMCID: PMC9722597 DOI: 10.1111/ajt.17208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Sensitized patients, those who had prior exposure to foreign human leukocyte antigens, are transplanted at lower rates due to challenges in finding suitable organs. Desensitization strategies have permitted highly sensitized patients to undergo kidney transplantation, albeit with higher rates of rejection. This study assesses targeting plasma cell and interleukin (IL)-6 receptor for desensitization in a sensitized nonhuman primate kidney transplantation model. All animals were sensitized using two sequential skin transplants from maximally major histocompatibility complex-mismatched donors. Carfilzomib (CFZ)/tocilizumab (TCZ) desensitization (N = 6) successfully decreased donor-specific antibody (DSA) titers and prevented the expansion of B cells compared to CFZ monotherapy (N = 3). Dual desensitization further delayed, but did not prevent humoral rebound, as evidenced by a delayed increase in post-kidney transplant DSA titers. Accordingly, CFZ/TCZ desensitization conferred a significant survival advantage over CFZ monotherapy. A trend toward increased T follicular helper cells was also observed in the dual therapy group along the same timeline as an increase in DSA and subsequent graft loss. Cytomegalovirus reactivation also occurred in the CFZ/TCZ group but was prevented with ganciclovir prophylaxis. In accordance with prior studies of CFZ-based dual desensitization strategies, the addition of IL-6 receptor blockade resulted in desensitization with further suppression of posttransplant humoral response compared to CFZ monotherapy.
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Affiliation(s)
- Imran J Anwar
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Brian Ezekian
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Miriam Manook
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Paul Schroder
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Janghoon Yoon
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Verna Curfman
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Evelyn Branum
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Julia Messina
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Melissa Harnois
- Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710
| | - Sallie R. Permar
- Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
| | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC 27710
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Mamode N, Bestard O, Claas F, Furian L, Griffin S, Legendre C, Pengel L, Naesens M. European Guideline for the Management of Kidney Transplant Patients With HLA Antibodies: By the European Society for Organ Transplantation Working Group. Transpl Int 2022; 35:10511. [PMID: 36033645 PMCID: PMC9399356 DOI: 10.3389/ti.2022.10511] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
This guideline, from a European Society of Organ Transplantation (ESOT) working group, concerns the management of kidney transplant patients with HLA antibodies. Sensitization should be defined using a virtual parameter such as calculated Reaction Frequency (cRF), which assesses HLA antibodies derived from the actual organ donor population. Highly sensitized patients should be prioritized in kidney allocation schemes and linking allocation schemes may increase opportunities. The use of the ENGAGE 5 ((Bestard et al., Transpl Int, 2021, 34: 1005–1018) system and online calculators for assessing risk is recommended. The Eurotransplant Acceptable Mismatch program should be extended. If strategies for finding a compatible kidney are very unlikely to yield a transplant, desensitization may be considered and should be performed with plasma exchange or immunoadsorption, supplemented with IViG and/or anti-CD20 antibody. Newer therapies, such as imlifidase, may offer alternatives. Few studies compare HLA incompatible transplantation with remaining on the waiting list, and comparisons of morbidity or quality of life do not exist. Kidney paired exchange programs (KEP) should be more widely used and should include unspecified and deceased donors, as well as compatible living donor pairs. The use of a KEP is preferred to desensitization, but highly sensitized patients should not be left on a KEP list indefinitely if the option of a direct incompatible transplant exists.
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Affiliation(s)
- Nizam Mamode
- Department of Transplantation, Guys Hospital, London, United Kingdom
- *Correspondence: Nizam Mamode,
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Frans Claas
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunology, University of Antwerp, Antwerp, Belgium
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical Gastroenterological and Oncological Sciences, University Hospital of Padua, Padua, Italy
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, United Kingdom
| | - Christophe Legendre
- Department of Nephrology and Adult Kidney Transplantation, Hôpital Necker and Université de Paris, Paris, France
| | - Liset Pengel
- Centre for Evidence in Transplantation, University of Oxford, Oxford, United Kingdom
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Anwar IJ, DeLaura IF, Gao Q, Ladowski J, Jackson AM, Kwun J, Knechtle SJ. Harnessing the B Cell Response in Kidney Transplantation - Current State and Future Directions. Front Immunol 2022; 13:903068. [PMID: 35757745 PMCID: PMC9223638 DOI: 10.3389/fimmu.2022.903068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 01/21/2023] Open
Abstract
Despite dramatic improvement in kidney transplantation outcomes over the last decades due to advent of modern immunosuppressive agents, long-term outcomes remain poor. Antibody-mediated rejection (ABMR), a B cell driven process, accounts for the majority of chronic graft failures. There are currently no FDA-approved regimens for ABMR; however, several clinical trials are currently on-going. In this review, we present current mechanisms of B cell response in kidney transplantation, the clinical impact of sensitization and ABMR, the B cell response under current immunosuppressive regimens, and ongoing clinical trials for ABMR and desensitization treatment.
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Affiliation(s)
| | | | | | | | | | | | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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Huang E, Jordan SC. Rationalizing Incompatible Living Donor Kidney Transplantation for Highly Sensitized Candidates. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schmitz R, Fitch ZW, Schroder PM, Choi AY, Jackson AM, Knechtle SJ, Kwun J. B cells in transplant tolerance and rejection: friends or foes? Transpl Int 2021; 33:30-40. [PMID: 31705678 DOI: 10.1111/tri.13549] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/14/2022]
Abstract
Our understanding of the role of B cells in organ transplantation remains incomplete and continues to grow. The majority of research has focused on the detrimental role of antibodies that drive the development of pathogenesis of the transplanted organ. However, it has been shown that not all donor-specific antibodies are harmful and in some circumstances can even promote tolerance through the mechanism of accommodation. Furthermore, B cells can have effects on transplanted organs through their interaction with T cells, namely antigen presentation, cytokine production, and costimulation. More recently, the role and importance of Bregs was introduced to the field of transplantation. Due to this functional and ontogenetic heterogeneity, targeting B cells in transplantation may bring undesired immunologic side effects including increased rejection. Therefore, the selective control of B cells that contribute to the humoral response against donor antigens will continue to be an important and challenging area of research and potentially lead to improved long-term transplant outcomes.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Zachary W Fitch
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Paul M Schroder
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Ashley Y Choi
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Annette M Jackson
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
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Keith DS. Parsing the 100% calculated panel reactive antibody kidney transplant candidates: Who gets transplanted? HLA 2019; 95:23-29. [PMID: 31515960 DOI: 10.1111/tan.13692] [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: 07/10/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 11/27/2022]
Abstract
The new kidney allocation system in the United States has improved deceased donor transplant rates among candidates with high calculated panel reactive antibodies (CPRAs). Probability analysis predicts a very low transplant rate as the CPRA approaches 100%. This study sought to determine if the rate of deceased donor kidney transplant based on the actual CPRA in the cohort of 100% qualifying candidates behaved as predicted by probability analysis. Nine thousand two hundred and twenty eight patients were identified on the waiting list on or after December 2014 that had at least one CPRA greater than or equal to 99.5%. The distribution of the 100% CPRA group was highly skewed toward 100% (Median CPRA 99.98%). The decile group within the 100% CPRA qualifying population was by far the most important factor determining kidney transplantation. The highest two deciles of CPRA had a very low rate of transplantation. Options to improve the prospects of deceased donor transplant include intelligently lowering the CPRA by reducing unacceptable antigens, expanding the donor pool by listing candidates for higher risk donors, or through desensitization. The CPRA calculator should display the non-integer CPRA out to several decimal points so that informed decisions can be made for these candidates regarding their prospects of receiving a deceased donor offer.
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How the definition of acceptable antigens and epitope analysis can facilitate transplantation of highly sensitized patients with excellent long-term graft survival. Curr Opin Organ Transplant 2018; 23:493-499. [DOI: 10.1097/mot.0000000000000545] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Heidt S, Claas FHJ. Transplantation in highly sensitized patients: challenges and recommendations. Expert Rev Clin Immunol 2018; 14:673-679. [PMID: 30004800 DOI: 10.1080/1744666x.2018.1498335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Highly sensitized patients awaiting a kidney transplant accrue on the transplant waiting list. The breadth of HLA antibodies in this subpopulation of patients precludes receiving a compatible organ offer through regular allocation within an acceptable time-frame. Areas covered: Several alternative options to receive a transplant exist for these patients, including additional priority in regular allocation, special programs based on allocation through acceptable antigens, kidney paired donation programs, desensitization protocols, or a combination of the latter two. In this review, these options and their outcomes are discussed as well as some possibilities to further enhance transplantation of this disadvantaged group of patients. Expert commentary: For highly sensitized patients, special attention is required, for which several strategies may apply. A step-wise approach may be the optimal strategy to facilitate successful transplantation of highly sensitized patients.
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Affiliation(s)
- Sebastiaan Heidt
- a Department of Immunohematology and Blood Transfusion , Leiden University Medical Center , Leiden , the Netherlands
| | - Frans H J Claas
- a Department of Immunohematology and Blood Transfusion , Leiden University Medical Center , Leiden , the Netherlands
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Huang E, Jordan SC. Immunoglobulin G-Degrading Enzyme of Streptococcus pyogenes (IdeS), Desensitization, and the Kidney Allocation System: Complementary Approaches to Increase Transplantation in Highly HLA Sensitized Patients. Clin J Am Soc Nephrol 2018; 13:799-801. [PMID: 29523676 PMCID: PMC5969484 DOI: 10.2215/cjn.12031017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Edmund Huang
- Department of Medicine, Division of Nephrology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, West Hollywood, California
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Woodle ES, Tremblay S, Driscoll JJ. IgG Endopeptidase in Highly Sensitized Patients Undergoing Transplantation. N Engl J Med 2017; 377:1693-4. [PMID: 29069556 DOI: 10.1056/nejmc1711335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- E Steve Woodle
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Simon Tremblay
- University of Cincinnati College of Medicine, Cincinnati, OH
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Gebel HM, Kamoun M. The new KAS: Challenges and opportunities. Hum Immunol 2016; 78:54-56. [PMID: 27845172 DOI: 10.1016/j.humimm.2016.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA, United States.
| | - Malek Kamoun
- Dept of Pathology, University of Pennsylvania, Philadelphia, PA, United States
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Gebel HM, Kamoun M. The new KAS: It takes a village. Hum Immunol 2016; 78:1-3. [PMID: 27845171 DOI: 10.1016/j.humimm.2016.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA, United States.
| | - Malek Kamoun
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, United States
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