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Lim S, Kirkiles-Smith NC, Pober JS, Bothwell ALM, Choi JM. Regulation of human T cell responses by dNP2-ctCTLA-4 inhibits human skin and microvessel graft rejection. Biomaterials 2018; 183:128-138. [PMID: 30165256 DOI: 10.1016/j.biomaterials.2018.08.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 12/30/2022]
Abstract
Manipulation of human T cell functioning by delivery of macromolecules such as DNA, RNA, or protein is limited, unless the human T cells have been stimulated or electropermeabilized. To achieve successful adaptation and survival of a grafted organ, the alloreactive T cells that induce graft rejection must be regulated. Corticosteroids, calcineurin inhibitors, and mTOR inhibitors, which are systemic immunosuppressants, are currently used for transplantation, with significant side effects. In this study, we demonstrated that a cell-permeable peptide (CPP), dNP2, could efficiently deliver proteins into human CD4 and CD8 T cells. We confirmed regulatory functioning of the cytoplasmic domain of CTLA-4 conjugated with dNP2 (dNP2-ctCTLA-4) in human T cell activation, proliferation, and chemokine receptor expression. We utilized a human skin allograft system in SCID/beige mice to examine whether dNP2-ctCTLA-4 could inhibit allograft rejection by controlling T cell responses. The grafted skin tissue inflammation, allogeneic T cell infiltration, and blood cytokine level was markedly reduced by dNP2-ctCTLA-4, resulting in successful transplantation. In addition, it also inhibited T cell alloresponses against microvessels formed form Bcl-2-transduced human umbilical vein endothelial cells implanted into Balb/c Rag1-/-/IL-2Rγ-/- double knockout (DKO) mice, assessed as reduced T cell infiltration and granzyme B expression. These results collectively suggest that dNP2 peptide conjugation offers a valuable tool for delivering macromolecules like proteins into human T cells, and dNP2-ctCTLA-4 is a novel agent that shows potential in controlling human T cell responses to allow successful adaptation of grafted tissues.
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Affiliation(s)
- Sangho Lim
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, 04763, Korea; Research Institute for Natural Sciences, Hanyang University, Seoul, 04763, Korea
| | - Nancy C Kirkiles-Smith
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Jordan S Pober
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Alfred L M Bothwell
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Je-Min Choi
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, 04763, Korea; Research Institute for Natural Sciences, Hanyang University, Seoul, 04763, Korea.
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Abstract
Mechanisms of rejection, new pharmacologic approaches, and genomic medicine are major foci for current research in transplantation. It is hoped that these new agents and personalized immunosuppression will provide for less toxic regimens that are effective in preventing both acute and chronic allograft rejection. Until new agents are available, practitioners must use various combinations of currently approved agents to find the best regimens for improved long-term outcomes.
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Affiliation(s)
- Curtis D Holt
- Clinical Research Program, UCLA Department of Surgery, Dumont-UCLA Transplant Center, David Geffen School of Medicine at UCLA, 650 CE Young Drive South, Room 77-123CHS, Los Angeles, CA 90095-7054, USA.
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da Silva MB, da Cunha FF, Terra FF, Camara NOS. Old game, new players: Linking classical theories to new trends in transplant immunology. World J Transplant 2017; 7:1-25. [PMID: 28280691 PMCID: PMC5324024 DOI: 10.5500/wjt.v7.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/16/2016] [Accepted: 12/07/2016] [Indexed: 02/05/2023] Open
Abstract
The evolutionary emergence of an efficient immune system has a fundamental role in our survival against pathogenic attacks. Nevertheless, this same protective mechanism may also establish a negative consequence in the setting of disorders such as autoimmunity and transplant rejection. In light of the latter, although research has long uncovered main concepts of allogeneic recognition, immune rejection is still the main obstacle to long-term graft survival. Therefore, in order to define effective therapies that prolong graft viability, it is essential that we understand the underlying mediators and mechanisms that participate in transplant rejection. This multifaceted process is characterized by diverse cellular and humoral participants with innate and adaptive functions that can determine the type of rejection or promote graft acceptance. Although a number of mediators of graft recognition have been described in traditional immunology, recent studies indicate that defining rigid roles for certain immune cells and factors may be more complicated than originally conceived. Current research has also targeted specific cells and drugs that regulate immune activation and induce tolerance. This review will give a broad view of the most recent understanding of the allogeneic inflammatory/tolerogenic response and current insights into cellular and drug therapies that modulate immune activation that may prove to be useful in the induction of tolerance in the clinical setting.
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Young JS, Chen J, Miller ML, Vu V, Tian C, Moon JJ, Alegre ML, Sciammas R, Chong AS. Delayed Cytotoxic T Lymphocyte-Associated Protein 4-Immunoglobulin Treatment Reverses Ongoing Alloantibody Responses and Rescues Allografts From Acute Rejection. Am J Transplant 2016; 16:2312-23. [PMID: 26928966 PMCID: PMC4956497 DOI: 10.1111/ajt.13761] [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: 09/21/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection has emerged as the leading cause of late graft loss in kidney transplant recipients, and inhibition of donor-specific antibody production should lead to improved transplant outcomes. The fusion protein cytotoxic T lymphocyte-associated protein 4-immunoglobulin (CTLA4-Ig) blocks T cell activation and consequently inhibits T-dependent B cell antibody production, and the current paradigm is that CTLA4-Ig is effective with naïve T cells and less so with activated or memory T cells. In this study, we used a mouse model of allosensitization to investigate the efficacy of continuous CTLA4-Ig treatment, initiated 7 or 14 days after sensitization, for inhibiting ongoing allospecific B cell responses. Delayed treatment with CTLA4-Ig collapsed the allospecific germinal center B cell response and inhibited alloantibody production. Using adoptively transferred T cell receptor transgenic T cells and a novel approach to track endogenous graft-specific T cells, we demonstrate that delayed CTLA4-Ig minimally inhibited graft-specific CD4(+) and T follicular helper responses. Remarkably, delaying CTLA4-Ig until day 6 after transplantation in a fully mismatched heart transplant model inhibited alloantibody production and prevented acute rejection, whereas transferred hyperimmune sera reversed the effects of delayed CTLA4-Ig. Collectively, our studies revealed the unexpected efficacy of CTLA4-Ig for inhibiting ongoing B cell responses even when the graft-specific T cell response was robustly established.
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Affiliation(s)
- James S. Young
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
| | - Jianjun Chen
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
| | - Michelle L. Miller
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Vinh Vu
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
| | - Changtai Tian
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
| | - James J. Moon
- Center for Immunology and Inflammatory Diseases, and Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital; and Harvard Medical School, Boston, MA
| | - Maria-Luisa Alegre
- Section of Rheumatology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Roger Sciammas
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
| | - Anita S. Chong
- Section of Transplantation, Department of Surgery, The University of Chicago, Chicago, IL
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Paliege A, Bamoulid J, Bachmann F, Staeck O, Halleck F, Khadzhynov D, Brakemeier S, Dürr M, Budde K. [Immunosuppression and its use in kidney transplantation]. Urologe A 2016; 54:1376-84. [PMID: 26459580 DOI: 10.1007/s00120-015-3909-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current immunosuppressive protocols effectively prevent acute rejection of renal allografts. Extensive drug toxicity and the deleterious effects of long-term immunosuppression are associated with significant morbidity and mortality. OBJECTIVES The purpose of this article is to provide an overview over modern immunosuppressants and their unwanted side effects and to discuss strategies for improved long-term transplant survival. METHODS Review of the current topic-related literature and discussion of our own experience. RESULTS The use of antibody induction together with an initial combination therapy of calcineurin inhibitors, mycophenolate and steroids is recommended and results in excellent early outcomes. Detrimental effects include an increased incidence of infections, malignomas, and cardiovascular diseases. Long-term transplant survival is impaired by extensive drug toxicity and the frequent development of donor specific antibodies. Reduction of overall cumulative exposure to immunosuppressants or the reduction of specific toxic drugs such as calcineurin inhibitors and steroids may improve long-term results. Alternative immunosuppressants like mTOR inhibitors and belatacept appear to be effective and safe but their long-term effects on patient and allograft survival needs to be established in clinical trials. CONCLUSIONS Current immunosuppressants provide effective protection from renal allograft rejection. However, their use is complicated by serious side effects. In the future, development of novel immunosuppressants and optimization of minimization strategies may help to improve long-term success after kidney transplantation.
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Affiliation(s)
- A Paliege
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - J Bamoulid
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - F Bachmann
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - O Staeck
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - F Halleck
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - D Khadzhynov
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - S Brakemeier
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - M Dürr
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland
| | - K Budde
- Medizinische Klinik mit Schwerpunkt Nephrologie, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 10117, Berlin, Deutschland.
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Garcia VD, Meinerz G, Keitel E. A safety evaluation of belatacept for the treatment of kidney transplant. Expert Opin Drug Saf 2016; 15:1125-32. [PMID: 27309154 DOI: 10.1080/14740338.2016.1202236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Improving long-term survival in kidney transplantation is one of the main goals in modern immunosuppressive research. Current standard immunosuppression based in a combination of calcineurin inhibitors (CNI) and antiproliferatives, with or without steroids, has improved short-term graft survival. In the last decade, belatacept has been evaluated as a CNI free option regimen addressing better kidney transplant outcomes. AREAS COVERED This paper reviewed the indications, mechanisms of action, pharmacology and published trials using belatacept in different clinical situations. The main objective was to evaluate the safety of this immunosuppressive drug. EXPERT OPINION Kidney transplant patients receiving belatacept demonstrated improvement in renal function, less chronic allograft nephropathy, a more favorable metabolic profile and lower donor-specific antibody formation compared with cyclosporine. Based on the published data and on our personal experience, we have good expectations on belatacept use in the future. If these characteristics will translate in sustained better renal function, less chronic kidney disease-related complications and lower cardiovascular risk, improving patient and graft survival and quality of life, is still to be assessed with longer term follow-up and a larger number of exposed patients.
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Affiliation(s)
- Valter Duro Garcia
- a Head of Renal and Pancreas Transplant Department , Santa Casa de Misericórdia de Porto Alegre (ISCMPA) , Porto Alegre , Brazil
| | - Gisele Meinerz
- b Post-Graduation Program in Pathology , Universidade Federal de Ciências da Saúde de Porto Alegre (UFSCPA) , Porto Alegre , Brazil.,c Renal and Pancreas Transplant Department , ISCMPA , Porto Alegre , Brazil
| | - Elizete Keitel
- b Post-Graduation Program in Pathology , Universidade Federal de Ciências da Saúde de Porto Alegre (UFSCPA) , Porto Alegre , Brazil.,c Renal and Pancreas Transplant Department , ISCMPA , Porto Alegre , Brazil
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Moraes-Vieira PM, Castoldi A, Aryal P, Wellenstein K, Peroni OD, Kahn BB. Antigen Presentation and T-Cell Activation Are Critical for RBP4-Induced Insulin Resistance. Diabetes 2016; 65:1317-27. [PMID: 26936962 PMCID: PMC4839203 DOI: 10.2337/db15-1696] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/20/2016] [Indexed: 02/06/2023]
Abstract
Adipose tissue (AT) inflammation contributes to impaired insulin action, which is a major cause of type 2 diabetes. RBP4 is an adipocyte- and liver-derived protein with an important role in insulin resistance, metabolic syndrome, and AT inflammation. RBP4 elevation causes AT inflammation by activating innate immunity, which elicits an adaptive immune response. RBP4-overexpressing mice (RBP4-Ox) are insulin resistant and glucose intolerant and have increased AT macrophages and T-helper 1 cells. We show that high-fat diet-fed RBP4(-/-) mice have reduced AT inflammation and improved insulin sensitivity versus wild type. We also elucidate the mechanism for RBP4-induced macrophage antigen presentation and subsequent T-cell activation. In RBP4-Ox, AT macrophages display enhanced c-Jun N-terminal kinase, extracellular signal-related kinase, and p38 phosphorylation. Inhibition of these pathways and of NF-κB reduces activation of macrophages and CD4 T cells. MyD88 is an adaptor protein involved in proinflammatory signaling. In macrophages from MyD88(-/-) mice, RBP4 fails to stimulate secretion of tumor necrosis factor, IL-12, and IL-6 and CD4 T-cell activation. In vivo blockade of antigen presentation by treating RBP4-Ox mice with CTLA4-Ig, which blocks costimulation of T cells, is sufficient to reduce AT inflammation and improve insulin resistance. Thus, MyD88 and downstream mitogen-activated protein kinase and NF-κB pathways are necessary for RBP4-induced macrophage antigen presentation and subsequent T-cell activation. Also, blocking antigen presentation with CTLA4-Ig improves RBP4-induced insulin resistance and macrophage-induced T-cell activation.
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Affiliation(s)
- Pedro M Moraes-Vieira
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Angela Castoldi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Pratik Aryal
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Kerry Wellenstein
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Odile D Peroni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Barbara B Kahn
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Rogers J, Katari R, Gifford S, Tamburrini R, Edgar L, Voigt MR, Murphy SV, Igel D, Mancone S, Callese T, Colucci N, Mirzazadeh M, Peloso A, Zambon JP, Farney AC, Stratta RJ, Orlando G. Kidney transplantation, bioengineering and regeneration: an originally immunology-based discipline destined to transition towards ad hoc organ manufacturing and repair. Expert Rev Clin Immunol 2015; 12:169-82. [PMID: 26634874 DOI: 10.1586/1744666x.2016.1112268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Kidney transplantation (KT), as a modality of renal replacement therapy (RRT), has been shown to be both economically and functionally superior to dialysis for the treatment of end-stage renal disease (ESRD). Progress in KT is limited by two major barriers: a) a chronic and burgeoning shortage of transplantable organs and b) the need for chronic immunosuppression following transplantation. Although ground-breaking advances in transplant immunology have improved patient survival and graft durability, a new pathway of innovation is needed in order to overcome current obstacles. Regenerative medicine (RM) holds the potential to shift the paradigm in RRT, through organ bioengineering. Manufactured organs represent a potentially inexhaustible source of transplantable grafts that would bypass the need for immunosuppressive drugs by using autologous cells to repopulate extracellular matrix (ECM) scaffolds. This overview discusses the current status of renal transplantation while reviewing the most promising innovations in RM therapy as applied to RRT.
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Affiliation(s)
- Jeffrey Rogers
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Ravi Katari
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sheyna Gifford
- c Annenberg School for Communication & Journalism , University of Southern California , Los Angeles , CA , USA
| | | | - Lauren Edgar
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Marcia R Voigt
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sean V Murphy
- d Wake Forest Institute for Regenerative Medicine , Winston Salem , NC , USA
| | - Daniel Igel
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sara Mancone
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Tyler Callese
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Nicola Colucci
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Majid Mirzazadeh
- e Department of Urology , Wake Forest University , Winston Salem , NC , USA
| | - Andrea Peloso
- f Department of General Surgery , University of Pavia , Pavia , Italy
| | - Joao Paulo Zambon
- d Wake Forest Institute for Regenerative Medicine , Winston Salem , NC , USA
| | - Alan C Farney
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Robert J Stratta
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Giuseppe Orlando
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
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Matz M, Fabritius K, Liu J, Lorkowski C, Brakemeier S, Unterwalder N, Dürr M, Mashreghi MF, Neumayer HH, Budde K. Conversion to Belatacept based regimen does not change T-cell phenotype and function in renal transplantation. Transpl Immunol 2015; 33:176-84. [PMID: 26478531 DOI: 10.1016/j.trim.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/08/2015] [Accepted: 10/13/2015] [Indexed: 11/19/2022]
Abstract
Belatacept offers a new option for renal allograft recipients who are suffering from side effects of calcineurin inhibitors or mTOR inhibitors,which may result in renal and extrarenal benefits.We prospectively performed flow cytometric immunophenotyping with a T-cell panel. In total we were able to fully investigate the immunophenotypic change in 8 patients before and after conversion from calcineurin inhibitor (n = 5) or mTOR inhibitor (n=2) to Belatacept or additional administration (n=1). Cells were analysed pre conversion, 1 month, 3 months, 6 months and 12 months after first Belatacept administration. The percentage of central memory, naïve, effector memory and terminally differentiated effector memory CD4+ and CD4− T-cells was determined. CD28, CD25 and CD69 expression on CD4+ and CD4− T-cells was measured ex vivo and also after 3 days of mitogen stimulation. Intracellular cytokines IFNgamma and IL-2 were measured after polyclonal cellular stimulation. The expression of activation markers and intracellular cytokines as well as the percentage of T-cell subsets did not change significantly during the observation period compared to the time-point pre conversion. Therefore the conversion of calcineurin inhibitor or mTOR inhibitor to Belatacept seems to have no obvious impact on the immunophenotype of T-cells in patients after kidney transplantation.
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Affiliation(s)
- Mareen Matz
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany.
| | - Katharina Fabritius
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Juan Liu
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Christine Lorkowski
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Nadine Unterwalder
- Labor Berlin GmbH, Immunology Department, Universitätsmedizin Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Michael Dürr
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Hans-H Neumayer
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Universitätsmedizin Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Brakemeier S, Dürr M, Budde K. The need for minimization strategies: current problems of immunosuppression. Transpl Int 2015; 28:891-900. [PMID: 25752992 DOI: 10.1111/tri.12553] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/30/2014] [Accepted: 02/27/2015] [Indexed: 12/31/2022]
Abstract
New immunosuppressants and the better use of immunosuppressant combination therapy have led to significant improvements in renal allograft outcomes over the last decades. Yet, despite dramatic reduction in rejection rates and improvement in 1-year graft survival, long-term graft attrition rates remained rather constant. Current immunosuppressant combinations are frequently leading to overimmunosuppression and are increasing cardiovascular risk. Importantly, calcineurin inhibitors are nephrotoxic, contribute to cardiovascular risk and chronic allograft dysfunction. Furthermore, immunosuppressant-associated toxicities aggravate immune-mediated nephron injury and side effects lead to nonadherence, an identified important reason for late acute and chronic antibody-mediated rejections. The frequent development of a chronic humoral response indicates rather insufficient immunosuppression of current combinations than simple under-immunosuppression. While there is no evidence that increasing immunosuppressive doses will improve outcomes or reduce de novo HLA-antibody formation, there is clear evidence that adequate minimization strategies will reduce side effect burden. Because of low rejection risk, but frequent side effects, drug minimization is particularly relevant for the many maintenance patients. In summary, new therapeutic strategies need to be developed from adequately powered clinical trials for reduction of the many side effects of immunosuppressants. Such evidence-based and time-dependent immunosuppressive minimization strategies are needed to achieve better long-term outcomes in the future.
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Affiliation(s)
- Jamal Bamoulid
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dmytri Khadzhynov
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Dürr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
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