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Heeger PS, Haro MC, Jordan S. Translating B cell immunology to the treatment of antibody-mediated allograft rejection. Nat Rev Nephrol 2024; 20:218-232. [PMID: 38168662 DOI: 10.1038/s41581-023-00791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 01/05/2024]
Abstract
Antibody-mediated rejection (AMR), including chronic AMR (cAMR), causes ~50% of kidney allograft losses each year. Despite attempts to develop well-tolerated and effective therapeutics for the management of AMR, to date, none has obtained FDA approval, thereby highlighting an urgent unmet medical need. Discoveries over the past decade from basic, translational and clinical studies of transplant recipients have provided a foundation for developing novel therapeutic approaches to preventing and treating AMR and cAMR. These interventions are aimed at reducing donor-specific antibody levels, decreasing graft injury and fibrosis, and preserving kidney function. Innovative approaches emerging from basic science findings include targeting interactions between alloreactive T cells and B cells, and depleting alloreactive memory B cells, as well as donor-specific antibody-producing plasmablasts and plasma cells. Therapies aimed at reducing the cytotoxic antibody effector functions mediated by natural killer cells and the complement system, and their associated pro-inflammatory cytokines, are also undergoing evaluation. The complexity of the pathogenesis of AMR and cAMR suggest that multiple approaches will probably be required to treat these disease processes effectively. Definitive answers await results from large, double-blind, multicentre, randomized controlled clinical trials.
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Affiliation(s)
- Peter S Heeger
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA
| | - Maria Carrera Haro
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY, USA
| | - Stanley Jordan
- Comprehensive Transplant Center, Department of Medicine, Division of Nephrology Cedars-Sinai Medical Center Los Angeles, Los Angeles, CA, USA.
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2
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Nakano R, Ohira M, Ishiyama K, Ide K, Kobayashi T, Tahara H, Shimizu S, Arihiro K, Imamura M, Chayama K, Tanaka Y, Ohdan H. Acute Graft Rejection and Formation of De Novo Donor-Specific Antibodies Triggered by Low Cyclosporine Levels and Interferon Therapy for Recurrent Hepatitis C Infection After Liver Transplantation: A Case Report. Transplant Proc 2018; 49:1634-1638. [PMID: 28838454 DOI: 10.1016/j.transproceed.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/13/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND We report a case of acute rejection of a liver graft, together with the occurrence of de novo donor-specific antibodies (DSAs), in a 53-year-old Japanese man who had undergone deceased-donor liver transplantation. METHODS The graft rejection was triggered by low cyclosporine levels and pegylated interferon treatment for the recurrence of hepatitis C virus (HCV) infection 18 months after transplantation. Although the graft was ABO-compatible, pre-formed DSA B51 was detected; therefore, total plasma exchange was performed and intravenous rituximab (500 mg/body) was administered before transplantation. RESULTS DSA was absent 6 months after transplantation. HCV recurrence was treated with pegylated interferon-α-2a. Renal function deteriorated with this anti-HCV therapy, with serum cyclosporine levels decreasing to 50 ng/mL. A rapid virologic response was achieved, but liver function deteriorated after 3 months of anti-HCV therapy, with histologic evidence of acute cellular rejection and formation of de novo DSAs. Anti-thymocyte globulin was administered for 5 days, which led to immediate improvement in liver function. However, renal function declined, warranting hemodialysis. The patient recovered 2 months after acute rejection, although de novo DSAs persisted. CONCLUSIONS Careful immunologic monitoring may be required for patients receiving interferon therapy for HCV infection to maintain sufficient blood levels of immunosuppressive agents and to prevent acute liver graft rejection.
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Affiliation(s)
- R Nakano
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - M Ohira
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - K Ishiyama
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Ide
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - T Kobayashi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - H Tahara
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - S Shimizu
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Arihiro
- Department of Pathology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - M Imamura
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - K Chayama
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Y Tanaka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - H Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Ejaz NS, Alloway RR, Halleck F, Dürr M, Budde K, Woodle ES. Review of bortezomib treatment of antibody-mediated rejection in renal transplantation. Antioxid Redox Signal 2014; 21:2401-18. [PMID: 24635140 DOI: 10.1089/ars.2014.5892] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
SIGNIFICANCE Development of donor-specific antibodies (DSA) after kidney transplantation is associated with reduced allograft survival. A few strategies have been tested in controlled clinical trials for the treatment of antibody-mediated rejection (AMR), and no therapies are approved by regulatory authorities. Thus development of antihumoral therapies that provide prompt elimination of DSA and improve allograft survival is an important goal. RECENT ADVANCES Proteasome inhibitor (PI)-based regimens provide a promising new approach for treating AMR. To date, experiences have been limited to off-label bortezomib use in AMR. Key findings with PI-based therapy are that they provide effective primary and rescue therapy for AMR by prompt reduction in immunodominant DSA and improvements in histologic and renal function. Early and late AMR differ immunologically and in response to PI therapy. Bortezomib-related toxicities in renal transplant recipients are similar to those observed in the multiple myeloma population. CRITICAL ISSUES Although preliminary evidence with PI therapy for AMR is encouraging, the evidence is limited. Larger, prospective, randomized controlled trials with long-term follow up are needed. Advancement in endpoints of clinical trial designs and rigorous clinical trials with more standardized adjunct therapies are also required to explore the risks and benefits of AMR treatment modalities. FUTURE DIRECTIONS In the next few years, new PIs are likely to be introduced and new approaches would be developed for achieving synergy with PIs. The ultimate goal will be to develop a regimen that delivers reliable, rapid, complete, and durable elimination of DSA with an acceptable safety profile.
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Affiliation(s)
- Nicole S Ejaz
- 1 Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
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4
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Sadaka B, Alloway RR, Woodle ES. Management of antibody-mediated rejection in transplantation. Surg Clin North Am 2013; 93:1451-66. [PMID: 24206861 DOI: 10.1016/j.suc.2013.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite intensive traditional immunosuppressive therapy, rates of graft loss have approximated 15% to 20% at 1 year following antibody-mediated rejection (AMR) in solid organ transplant recipients. Therefore, the development of antihumoral therapies that provide prompt elimination of donor-specific anti-HLA antibodies and improve allograft survival is an important goal. Traditional treatment modalities for AMR deplete B-cell populations but not the cell at the source of antibody production, the mature plasma cell. Plasma cell-targeted therapies using proteasome inhibition is a novel approach to treating AMR. This review discusses current and emerging treatment modalities used for AMR.
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Affiliation(s)
- Basma Sadaka
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 558, Cincinnati, OH 45267-0558, USA
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5
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Puttarajappa C, Shapiro R, Tan HP. Antibody-mediated rejection in kidney transplantation: a review. J Transplant 2012; 2012:193724. [PMID: 22577514 PMCID: PMC3337620 DOI: 10.1155/2012/193724] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 01/09/2012] [Indexed: 01/12/2023] Open
Abstract
Antibody mediated rejection (AMR) poses a significant and continued challenge for long term graft survival in kidney transplantation. However, in the recent years, there has emerged an increased understanding of the varied manifestations of the antibody mediated processes in kidney transplantation. In this article, we briefly discuss the various histopathological and clinical manifestations of AMRs, along with describing the techniques and methods which have made it easier to define and diagnose these rejections. We also review the emerging issues of C4d negative AMR, its significance in long term allograft survival and provide a brief summary of the current management strategies for managing AMRs in kidney transplantation.
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Affiliation(s)
- Chethan Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213-2582, USA
| | - Ron Shapiro
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213-2582, USA
| | - Henkie P. Tan
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213-2582, USA
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Kihm LP, Zeier M, Morath C. Emerging drugs for the treatment of transplant rejection. Expert Opin Emerg Drugs 2011; 16:683-95. [DOI: 10.1517/14728214.2011.641012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Kahan BD. Forty years of publication of Transplantation Proceedings--the fourth decade: Globalization of the enterprise. Transplant Proc 2011; 43:3-29. [PMID: 21335147 DOI: 10.1016/j.transproceed.2010.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Barry D Kahan
- Division of Immunology and Organ Transplantation, The University of Texas-Health Science Center at Houston Medical School, Houston, Texas 77030, USA.
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8
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Kotlan B, Stroncek DF, Marincola FM. Intravenous immunoglobulin-based immunotherapy: an arsenal of possibilities for patients and science. Immunotherapy 2011; 1:995-1015. [PMID: 20635915 DOI: 10.2217/imt.09.67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The use of intravenous immunoglobulin (IVIG) concentrated from pooled healthy donors' plasma has gained increasing popularity. IVIG therapy has become important as a replacement therapy in primary and acquired humoral immunodeficiencies, and it has been extended to autoimmune, neurodegenerative and inflammatory conditions and transplantation therapy. Recurrent pregnancy failure and cancer are rather new platforms, where IVIG has shown its beneficial effects. This manuscript is focused on these two off-labelled usages. The immunomodulatory mechanisms of IVIG therapy appear as a coordinated orchestration of different functions, resulting in a synergistic effect. Treatment monitoring and detailed molecular analyses reveal how such treatments may interfere with disease pathogenesis. These finding may foster the development of novel therapeutic and/or preventive strategies. Studying this field with bidirectional bench-to-bedside and bedside-to-bench approaches fit well into 'the two-way road' paradigm of translational medicine.
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Affiliation(s)
- Beatrix Kotlan
- Center of Surgical & Molecular Tumorpathology National Institute of Oncology, Rath Gy street 7-9, Budapest 1122, Hungary.
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High-Dose Intravenous Immunoglobulin and Rituximab Treatment for Antibody-Mediated Rejection After Kidney Transplantation: A Cost Analysis. Transplant Proc 2008; 40:3393-6. [DOI: 10.1016/j.transproceed.2008.08.131] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Accepted: 08/29/2008] [Indexed: 11/15/2022]
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Hoetzenecker K, Hacker S, Hoetzenecker W, Sadeghi K, Sachet M, Pollreisz A, Mangold A, Wliszczak T, Bielek E, Muehlbacher F, Klepetko W, Ankersmit HJ. Cytomegalovirus hyperimmunoglobulin: mechanisms in allo-immune response in vitro. Eur J Clin Invest 2007; 37:978-86. [PMID: 18036032 DOI: 10.1111/j.1365-2362.2007.01881.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cytomegalovirus hyperimmunoglobulin (CMVIg) containing drugs are routinely administered in cardiac transplantation for prophylaxis against CMV disease. Yet little is known about their influence on transplant relevant immune functions. The aim of this study was to evaluate the effect of CMVIg on cellular immunity in in vitro experiments and to define their role in tolerance inducing mechanisms. MATERIALS AND METHODS/RESULTS CMVIg reduces proliferation in mixed lymphocyte reactions and anti-CD3 blastogenesis assays and is related to decreased production of immune modulating cytokines interleukin (IL)-2, interferonr (IFNgamma), IL-10. This antiproliferative effect is associated with a cell-cycle arrest in the G0/G1 phase and induction of apoptosis in CD8+ and natural killer cells. Co-incubation with CMVIg causes down-regulation of cell bound immunoglobulin and FcgammaRIII surface expression on natural killer cells and leads to attenuation of antibody dependent cellular cytotoxicity effector functions. CONCLUSIONS We conclude that CMVIg induces immunological features on leukocytes in vitro that are known to be related to tolerance induction. Our observations extend the current concept of CMVIg as passive CMV prophylaxis to a therapeutic drug compound capable of reducing allogeneic immune response.
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Affiliation(s)
- K Hoetzenecker
- Department of Surgery, Medical University of Vienna, Austria
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Darabi K, Abdel-Wahab O, Dzik WH. Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature. Transfusion 2006; 46:741-53. [PMID: 16686841 DOI: 10.1111/j.1537-2995.2006.00792.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous immune globulin (IVIG) has been approved by the Food and Drug Administration (FDA) for use in 6 conditions: immune thrombocytopenic purpura (ITP), primary immunodeficiency, secondary immunodeficiency, pediatric HIV infection, Kawasaki disease, prevention of graft versus host disease (GVHD) and infection in bone marrow transplant recipients. However, most usage is for off-label indications, and for some of these comprehensive guidelines have been published. STUDY DESIGN AND METHODS We retrospectively reviewed all approved IVIG transfusions at Massachusetts General Hospital in 2004 to identify the current usage pattern and completed a literature review. RESULTS IVIG was most commonly used in the treatment of chronic neuropathy, which included chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy. For such patients, the annual cost of IVIG can exceed 50,000 dollars per patient. Other common indications were the treatment of hypogammaglobulinemia, ITP, renal transplant rejection, myasthenia gravis, Guillain-Barre syndrome, necrotizing fasciitis, autoimmune hemolytic anemia, and Kawasaki disease. IVIG was administered in a variety of other indications each representing <3% of the total treated patients. CONCLUSION Only a few indications account for most of the usage for IVIG. Reports concerning IVIG continue to grow at a tremendous pace but few high-quality randomized controlled trials have been reported. Randomized trials are especially needed for conditions such as CIDP, which consume large quantities of product.
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Affiliation(s)
- Kamran Darabi
- Harvard University Joint Program in Transfusion Medicine, Boston, Massachusetts, USA.
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Crew RJ, Ratner LE. Overcoming Immunologic Incompatibility: Transplanting the Difficult to Transplant Patient. Semin Dial 2005; 18:474-81. [PMID: 16398709 DOI: 10.1111/j.1525-139x.2005.00092.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Immunologic incompatibilities between donor and recipient have limited the access to renal transplantation for many patients. Previously the presence of donor-specific alloantibodies directed against donor major histocompatibility complex (MHC) antigens or natural antibodies directed against donor ABO blood group antigens was considered an absolute contraindication to renal transplantation. However, with the current understanding of humoral immune responses, superior immunosuppressive agents, and improved diagnosis and treatment of antibody-mediated rejection, renal transplantation can be safely performed with outstanding results despite the presence of donor-specific antibody. In this review we discuss the biology of antibody-mediated rejection and sensitization. We discuss the diagnostic tests necessary to characterize the type, affinity, and avidity of the donor-directed antibodies. Current methods for performing renal transplants across ABO and human leukocyte antigen (HLA)-sensitized barriers are covered, including the potential morbidities. The rest of the review focuses on advances in managing these antibodies to increase the likelihood of receiving a deceased donor kidney or allow transplantation from a living donor against whom one has a prohibitive antibody.
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Affiliation(s)
- R John Crew
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Tan J, Yang S, Wu W. Basiliximab (Simulect) reduces acute rejection among sensitized kidney allograft recipients. Transplant Proc 2005; 37:903-5. [PMID: 15848570 DOI: 10.1016/j.transproceed.2005.01.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIMS Our goal was to evaluate the efficacy and safety of basiliximab (Simulect) as immunosuppressive induction therapy for the prevention of acute allograft rejection among sensitized kidney recipients. METHODS Fifty-six adult recipients receiving cadaveric kidney transplant with panel reactive antibody class I ranging from 30% to 50% and or class II 30% to 80% were randomized at about a 2:1 ratio to the Simulect group (36 patients) or matching control group (20 patients). All patients received baseline triple immunosuppressive therapy with cyclosporine (Neoral), mycophenolate mofetil, and steroids. Simulect was given in two doses of 20 mg each on day 0 (2 hours before operation) and day 4 after transplantation. RESULTS There was no hyperacute rejection in either group and delayed graft function occurred in three control patients. The incidence of acute rejection during the first 3 months was 11.1% in the Simulect group compared with 50% in the placebo group (77.8% reduction, P < .01). No apparent adverse and toxic events were recorded in the Simulect group. The mean daily dose of steroids was significantly higher in the control group 2 to 4 weeks posttransplantation. No clinically meaningful differences in the mean dose of cyclosporine were observed between the two groups; in addition, there were no statistically significant differences in the rate of patient or graft survival. CONCLUSIONS On the basis of appropriate selection of the donor and recipient, Simulect is effective and safety for the sensitized recipients as immunosuppressive induction therapy.
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Affiliation(s)
- J Tan
- Organ Transplant Institute, Fujian Orient Hospital, Fuzhou, PR China.
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Hardinger KL, Koch MJ, Brennan DC. Current and future immunosuppressive strategies in renal transplantation. Pharmacotherapy 2004; 24:1159-76. [PMID: 15460177 DOI: 10.1592/phco.24.13.1159.38094] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The past decade has witnessed the introduction of several new immunosuppressive agents. The availability of these new pharmacologic offerings has not diminished the challenge of achieving a balance of adequate graft protection while minimizing the consequences of excessive immunosuppression. For renal transplant recipients, maintenance immunosuppression generally consists of a calcineurin inhibitor in combination with an antiproliferative agent and a corticosteroid; more recently, mammalian target of rapamycin inhibitors have been used. Excellent results have been achieved at many transplant centers with combinations of these agents in a variety of protocols. Regimens designed to limit or eliminate calcineurin inhibitor and/or corticosteroid therapy are actively being pursued in the transplant community. Allograft tolerance and xenotransplantation are being studied, and the knowledge gained from the effort may help in the development of innovative strategies and new immunosuppressive agents.
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Affiliation(s)
- Karen L Hardinger
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Affiliation(s)
- Irina Knezevic-Maramica
- Division of Laboratory and Transfusion Medicine, Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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