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Van Meerhaeghe T, Murakami N, Le Moine A, Brouard S, Sprangers B, Degauque N. Fine-tuning tumor- and allo-immunity: advances in the use of immune checkpoint inhibitors in kidney transplant recipients. Clin Kidney J 2024; 17:sfae061. [PMID: 38606169 PMCID: PMC11008728 DOI: 10.1093/ckj/sfae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Indexed: 04/13/2024] Open
Abstract
Cancer is a common complication after kidney transplantation. Kidney transplant recipients (KTR) have a 2- to 4-fold higher risk of developing cancer compared to the general population and post-transplant malignancy is the third most common cause of death in KTR. Moreover, it is well known that certain cancer types are overrepresented after transplantation, especially non-melanoma skin cancer. Immune checkpoint inhibitors (ICI) have revolutionized the treatment of cancer, with remarkable survival benefit in a subgroup of patients. ICI are monoclonal antibodies that block the binding of specific co-inhibitory signaling molecules. Cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), programmed cell death protein 1 (PD-1), and its ligand programmed cell death ligand 1 (PD-L1) are the main targets of ICI. Solid organ transplant recipients (SOTR) have been excluded from clinical trials owing to concerns about tumor response, allo-immunity, and risk of transplant rejection. Indeed, graft rejection has been estimated as high as 48% and represents an emerging problem. The underlying mechanisms of organ rejection in the context of treatment with ICI are poorly understood. The search for restricted antitumoral responses without graft rejection is of paramount importance. This review summarizes the current knowledge of the use of ICI in KTR, the potential mechanisms involved in kidney graft rejection during ICI treatment, potential biomarkers of rejection, and how to deal with rejection in clinical practice.
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Affiliation(s)
- Tess Van Meerhaeghe
- Departement of Nephrology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Naoka Murakami
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Alain Le Moine
- Departement of Nephrology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Sophie Brouard
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, UHasselt, Diepenbeek, Belgium
- Department of Nephrology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Nicolas Degauque
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
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Zhu LJ, Lin H, Wu XT, Shi SH, Qiao X. Analysis of risk factors and prognosis of diarrhea after renal transplantation. Technol Health Care 2024:THC230579. [PMID: 38393930 DOI: 10.3233/thc-230579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND Diarrhea is a prevalent complication after renal transplantation. OBJECTIVE To examine the risk factors for diarrhea after renal transplantation, evaluate their combined predictive values, and analyze the prognosis. METHODS Clinical data of patients who underwent allogeneic renal transplantation in the Second People's Hospital of Shanxi Province from January 2019 to March 2020 were retrospectively analyzed, cases were screened and grouped, independent risk factors for diarrhea after renal transplantation were analyzed by univariate analysis and multivariate analysis, and their predictive value was evaluated by receiver operating characteristic (ROC) curve. The survival time of recipient grafts in diarrhea and non-diarrhea groups were evaluated by Kaplan-Meier and log-rank test. RESULTS We included 166 recipients in the study and the incidence of diarrhea was 25.9%; univariate and logistic regression multivariate analyses revealed that independent risk factors for diarrhea in recipients were that the type of renal transplant donor was DCD (donation after circulatory death), immunity induction was onducted with basiliximab + antithymocyte globulin (ATG), and ATG alone, the type of mycophenolic acid (MPA) used was mycophenolate mofetil capsules, and delayed graft function (DGF) occurred after transplantation. The ROC curve indicated that the combination of the four factors had good accuracy in predicting the occurrence of diarrhea in recipients. The graft survival rate two years after the operation in the diarrhea group was significantly lower than that in the non-diarrhea group. CONCLUSION Diarrhea affected the two-year survival rate of the graft. The type of donor, immunity induction scheme, and the type of MPA and DGF were independent risk factors for diarrhea in recipients, and the combination of the four factors had good prognostic prediction value.
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Affiliation(s)
- Li-Jun Zhu
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Hui Lin
- Department of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Xiao-Tong Wu
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Shao-Hua Shi
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Xi Qiao
- Department of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-melgar Á, Alonso J, Fernández C, García-erauzkin G, González E, González-rinne AM, Guirado L, Gutiérrez-dalmau A, Huguet J, López del Moral JL, Musquera M, Paredes D, Redondo D, Revuelta I, Van-der Hofstadt CJ, Alcaraz A, Alonso-hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-gil B, Pascual J. Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022; 42:1-128. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Tantisattamo E, Leventhal JR, Mathew JM, Gallon L. Chimerism and tolerance: past, present and future strategies to prolong renal allograft survival. Curr Opin Nephrol Hypertens 2021; 30:63-74. [PMID: 33186221 DOI: 10.1097/MNH.0000000000000666] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Immunological factors are a major cause of kidney allograft loss. Calcineurin inhibitors (CNIs) have improved short-term kidney allograft survival; however, they in turn contribute to long-term kidney allograft loss from chronic CNI nephrotoxicity. Tolerance induction in transplantation can avoid the long-term adverse effects of immunosuppressive medications. This review aims to critically discuss recent efforts in inducing transplantation tolerance. RECENT FINDINGS Tolerance induction mediated by chimerism has shown some promise in minimizing or even complete withdrawal of immunosuppressive treatments in kidney allograft recipients. There has been a number of approaches as varied as the number of centres conducting these trials. However, they can be grouped into those mediated by transient microchimerism and those facilitated by more stable macro or full donor chimerism. The success rates in terms of long-term drug-free graft survival has been limited in microchimerism-mediated tolerance induction approaches. Mixed macrochimerism of less than 50% donor may be unstable with mostly the recipient's native immune system overpowering the donor chimeric status.Tolerance induction leading to chimerism has been limited to living donor kidney transplantation and additional long-term outcomes are required. Furthermore, immune monitoring after tolerance induction has faced a limitation in studying due to a lack of sufficient study participants and appropriate study controls. SUMMARY Tolerance induction is one of several strategies used to prolong kidney allograft survival, but it has not been routinely utilized in clinical practice. However, future applications from the trials to clinical practice remain limited to living donor kidney transplantation. Once further data regarding tolerance inductions exist and practicality becomes widely accepted, tolerance induction may shift the paradigm in the field of kidney transplantation to achieve the best possible outcome of 'One Organ for Life'.
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Balani SS, Jensen CJ, Kouri AM, Kizilbash SJ. Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant 2021; 25:e14077. [PMID: 34216190 DOI: 10.1111/petr.14077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
Advances in immunosuppression have improved graft survival in pediatric kidney transplant recipients; however, treatment-related toxicities need to be balanced against the possibility of graft rejection. Several immunosuppressive agents are available for use in transplant recipients; however, the optimal combinations of agents remain unclear, resulting in variations in institutional protocols. Lymphocyte-depleting antibodies, specifically ATG, are the most common induction agent used for pediatric kidney transplantation in the US. Basiliximab may be used for induction in immunologically low-risk children; however, pediatric data are scarce. CNIs and antiproliferative agents (mostly Tac and mycophenolate in recent years) constitute the backbone of maintenance immunosuppression. Steroid-avoidance maintenance regimens remain controversial. Belatacept and mTOR inhibitors are used in children under specific circumstances such as non-adherence or CNI toxicity. This article reviews the indications, mechanism of action, efficacy, dosing, and side effect profiles of various immunosuppressive agents available for pediatric kidney transplantation.
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Affiliation(s)
- Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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Kirk AD, Adams AB, Durrbach A, Ford ML, Hildeman DA, Larsen CP, Vincenti F, Wojciechowski D, Woodle ES. Optimization of de novo belatacept-based immunosuppression administered to renal transplant recipients. Am J Transplant 2021; 21:1691-1698. [PMID: 33128812 PMCID: PMC8246831 DOI: 10.1111/ajt.16386] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 10/13/2020] [Accepted: 10/24/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant recipients administered belatacept-based maintenance immunosuppression present with a more favorable metabolic profile, reduced incidence of de novo donor-specific antibodies (DSAs), and improved renal function and long-term patient/graft survival relative to individuals receiving calcineurin inhibitor (CNI)-based immunosuppression. However, the rates and severity of acute rejection (AR) are greater with the approved belatacept-based regimen than with CNI-based immunosuppression. Although these early co-stimulation blockade-resistant rejections are typically steroid sensitive, the higher rate of cellular AR has led many transplant centers to adopt immunosuppressive regimens that differ from the approved label. This article summarizes the available data on these alternative de novo belatacept-based maintenance regimens. Steroid-sparing, belatacept-based immunosuppression (following T cell-depleting induction therapy) has been shown to yield AR rates comparable to those seen with CNI-based regimens. Concomitant treatment with belatacept plus a mammalian target of rapamycin inhibitor (mTORi; sirolimus or everolimus) has yielded AR rates ranging from 0 to 4%. Because the optimal induction agent and number of induction doses; blood levels of mTORi; and dose, duration, and use of corticosteroids have yet to be determined, larger prospective clinical trials are needed to establish the optimal alternative belatacept-based regimen for minimizing early cellular AR occurrence.
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Affiliation(s)
- Allan D. Kirk
- Department of SurgeryDuke UniversityDurhamNorth Carolina
| | | | - Antoine Durrbach
- Assistance Publique‐Hôpitaux de ParisNephrology and Renal Transplantation DepartmentHôpital Henri‐MondorUniversité Paris‐SaclayCreteilFrance
| | - Mandy L. Ford
- Emory Transplant CenterEmory UniversityAtlantaGeorgia
| | - David A. Hildeman
- Division of ImmunobiologyCincinnati Children's Hospital Medical Center and Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhio
| | | | - Flavio Vincenti
- Division of Transplant SurgeryUniversity of CaliforniaSan FranciscoCalifornia
| | | | - E. Steve Woodle
- Division of TransplantationDepartment of SurgeryUniversity of Cincinnati College of MedicineCincinnatiOhio
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Zhang H, Wang Z, Zhang J, Gui Z, Han Z, Tao J, Chen H, Sun L, Fei S, Yang H, Tan R, Chandraker A, Gu M. Combined Immunotherapy With Belatacept and BTLA Overexpression Attenuates Acute Rejection Following Kidney Transplantation. Front Immunol 2021; 12:618737. [PMID: 33732243 PMCID: PMC7959759 DOI: 10.3389/fimmu.2021.618737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/14/2021] [Indexed: 01/11/2023] Open
Abstract
Background Costimulatory blockade provides new therapeutic opportunities for ensuring the long-term survival of kidney grafts. The adoption of the novel immunosuppressant Belatacept has been limited, partly due to concerns regarding higher rates and grades of acute rejection in clinical trials. In this study, we hypothesized that a combined therapy, Belatacept combined with BTLA overexpression, may effectively attenuate acute rejection after kidney transplantation. Materials and Methods The rat kidney transplantation model was used to investigate graft rejection in single and combined therapy. Graft function was analyzed by detecting serum creatinine. Pathological staining was used to observe histological changes in grafts. The expression of T cells was observed by immunohistochemistry and flow cytometry. In vitro, we constructed an antigen-stimulated immune response by mixed lymphocyte culture, treated with or without Belatacept and BTLA-overexpression adenovirus, to observe the proliferation of receptor cells and the expression of cytokines. In addition, western blot and qRT-PCR analyses were performed to evaluate the expression of CTLA-4 and BTLA at various time points during the immune response. Results In rat models, combined therapy reduced the serum creatinine levels and prolonged graft survival compared to single therapy and control groups. Mixed acute rejection was shown in the allogeneic group and inhibited by combination treatment. Belatacept reduced the production of DSA and the deposition of C4d in grafts. Belatacept combined with BTLA overexpression downregulated the secretion of IL-2 and IFN-γ, as well as increasing IL-4 and IL-10 expression. We also found that Belatacept combined with BTLA overexpression inhibited the proliferation of spleen lymphocytes. The duration of the elevated expression levels of CTLA-4 and BTLA differentially affected the immune response. Conclusion Belatacept combined with BTLA overexpression attenuated acute rejection after kidney transplantation and prolonged kidney graft survival, which suggests a new approach for the optimization of early immunosuppression after kidney transplantation.
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Affiliation(s)
- Hengcheng Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Zijie Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiayi Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zeping Gui
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhijian Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Tao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Sun
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuang Fei
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Haiwei Yang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ruoyun Tan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Min Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ulloa CE, Anglicheau D, Snanoudj R, Scemla A, Martinez F, Timsit MO, Legendre C, Sberro-Soussan R. Conversion From Calcineurin Inhibitors to Belatacept in HLA-sensitized Kidney Transplant Recipients With Low-level Donor-specific Antibodies. Transplantation 2019; 103:2150-6. [PMID: 30720681 DOI: 10.1097/TP.0000000000002592] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Belatacept could be the treatment of choice in renal-transplant recipients with renal dysfunction attributed to calcineurin inhibitor (CNI) nephrotoxicity. Few studies have described its use in patients with donor-specific antibody (DSA). METHODS We retrospectively evaluated conversion from CNIs to belatacept in 29 human leukocyte antigen-immunized renal-transplant recipients. Data about acute rejection, DSA, and renal function were collected. These patients were compared with 42 nonimmunized patients treated with belatacept. RESULTS Patients were converted from CNIs to belatacept a median of 444 days (interquartile range, 85-1200) after transplantation and were followed up after belatacept conversion, for a median of 308 days (interquartile range, 125-511). At conversion, 16 patients had DSA. Nineteen DSA were observed in these 16 patients, of which 11/19 were <1000 mean fluorescence intensity (MFI), 7/19 were between 1000 and 3000 MFI, and one was >3000 MFI. At last follow-up, preexisting DSA had decreased or stabilized. Seven patients still had DSA with a mean MFI of 1298 ± 930 at the last follow-up. No patient developed a de novo DSA in the DSA-positive group. In the nonimmunized group, one patient developed de novo DSA (A24-MFI 970; biopsy for cause did not show biopsy-proven acute rejection or microinflammation score). After belatacept conversion, one antibody-mediated rejection was diagnosed. The mean estimated glomerular filtration rate improved from 31.7 ± 14.2 mL/min/1.73 m to 40.7 ± 12.3 mL/min/1.73 m (P < 0.0001) at 12 months after conversion. We did not find any significant difference between groups in terms of renal function, proteinuria, or biopsy-proven acute rejection. CONCLUSIONS We report on a safe conversion to belatacept in human leukocyte antigen-immunized patients with low DSA levels.
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Perez CP, Patel N, Mardis CR, Meadows HB, Taber DJ, Pilch NA. Belatacept in Solid Organ Transplant: Review of Current Literature Across Transplant Types. Transplantation 2018; 102:1440-52. [PMID: 29787522 DOI: 10.1097/TP.0000000000002291] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Calcineurin inhibitors (CNIs) have been the backbone immunosuppressant for solid organ transplant recipients for decades. Long-term use of CNIs unfortunately is associated with multiple toxicities, with the biggest concern being CNI-induced nephrotoxicity. Belatacept is a novel agent approved for maintenance immunosuppression in renal transplant recipients. In the kidney transplant literature, it has shown promise as being an alternative agent by preserving renal function and having a minimal adverse effect profile. There are emerging studies of its use in other organ groups, particularly liver transplantation, as well as using with other alternative immunosuppressive strategies. The purpose of this review is to analyze the current literature of belatacept use in solid organ transplantation and discuss its use in current practice.
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Ensor CR, Goehring KC, Iasella CJ, Moore CA, Lendermon EA, McDyer JF, Morrell MR, Sciortino CM, Venkataramanan R, Wiland AM. Belatacept for maintenance immunosuppression in cardiothoracic transplantation: The potential frontier. Clin Transplant 2018; 32:e13363. [PMID: 30058177 DOI: 10.1111/ctr.13363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 01/18/2023]
Abstract
Current immunosuppressive regimens with calcineurin inhibitors have improved the management of patients after transplantation. However, their adverse effects are linked to increased morbidity and limit the long-term survival of heart and lung transplant recipients. Belatacept, a costimulation inhibitor interfering with the interaction between CD28 on T cells and the B7 ligands on antigen presenting cells, has shown success and is currently approved for use in renal transplant recipients. Furthermore, it lacks many of the cardiovascular, metabolic, neurologic, and renal adverse of effects of calcineurin inhibitors that have the largest impact on long-term survival in cardiothoracic transplant. Additionally, it requires no therapeutic drug monitoring and is only administered once a month. Limitations to belatacept use have been observed that must be considered when comparing immunosuppression options. Despite this, maintenance immunosuppression with belatacept has the potential to improve outcomes in cardiothoracic transplant recipients, as it has with kidney transplant recipients. However, no large clinical trials investigating belatacept for maintenance immunosuppression in heart and lung transplant recipients exist. There is a large need for focused research of belatacept in cardiothoracic transplantation. Belatacept is a viable treatment option for maintenance immunosuppression, and it is reasonable to pursue more evidence in cardiothoracic transplant recipients.
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Affiliation(s)
- Christopher R Ensor
- Division of Pulmonary Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Carlo J Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Cody A Moore
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Elizabeth A Lendermon
- Division of Pulmonary Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Morrell
- Division of Pulmonary Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher M Sciortino
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Anne M Wiland
- Norvartis Pharmaceuticals Corporation, Baltimore, Maryland
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Bray RA, Gebel HM, Townsend R, Roberts ME, Polinsky M, Yang L, Meier‐Kriesche H, Larsen CP. Posttransplant reduction in preexisting donor-specific antibody levels after belatacept- versus cyclosporine-based immunosuppression: Post hoc analyses of BENEFIT and BENEFIT-EXT. Am J Transplant 2018; 18:1774-1782. [PMID: 29573335 PMCID: PMC6055813 DOI: 10.1111/ajt.14738] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/02/2018] [Accepted: 03/07/2018] [Indexed: 01/25/2023]
Abstract
BENEFIT and BENEFIT-EXT were phase III studies of cytotoxic T-cell crossmatch-negative kidney transplant recipients randomized to belatacept more intense (MI)-based, belatacept less intense (LI)-based, or cyclosporine-based immunosuppression. Following study completion, presence/absence of HLA-specific antibodies was determined centrally via solid-phase flow cytometry screening. Stored sera from anti-HLA-positive patients were further tested with a single-antigen bead assay to determine antibody specificities, presence/absence of donor-specific antibodies (DSAs), and mean fluorescent intensity (MFI) of any DSAs present. The effect of belatacept-based and cyclosporine-based immunosuppression on MFI was explored post hoc in patients with preexisting DSAs enrolled to BENEFIT and BENEFIT-EXT. In BENEFIT, preexisting DSAs were detected in 4.6%, 4.9%, and 6.3% of belatacept MI-treated, belatacept LI-treated, and cyclosporine-treated patients, respectively. The corresponding values in BENEFIT-EXT were 6.0%, 5.7%, and 9.2%. In both studies, most preexisting DSAs were of class I specificity. Over the first 24 months posttransplant, a greater proportion of preexisting DSAs in belatacept-treated versus cyclosporine-treated patients exhibited decreases or no change in MFI. MFI decline was more apparent with belatacept MI-based versus belatacept LI-based immunosuppression in both studies and more pronounced in BENEFIT-EXT versus BENEFIT. Although derived post hoc, these data suggest that belatacept-based immunosuppression decreases preexisting DSAs more effectively than cyclosporine-based immunosuppression.
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Affiliation(s)
| | | | | | | | | | - L. Yang
- Bristol‐Myers SquibbLawrencevilleNJUSA
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Bray RA, Gebel HM, Townsend R, Roberts ME, Polinsky M, Yang L, Meier‐Kriesche H, Larsen CP. De novo donor-specific antibodies in belatacept-treated vs cyclosporine-treated kidney-transplant recipients: Post hoc analyses of the randomized phase III BENEFIT and BENEFIT-EXT studies. Am J Transplant 2018; 18:1783-1789. [PMID: 29509295 PMCID: PMC6055714 DOI: 10.1111/ajt.14721] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/14/2018] [Accepted: 02/19/2018] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSAs) are associated with an increased risk of antibody-mediated rejection and graft failure. In BENEFIT and BENEFIT-EXT, kidney-transplant recipients were randomized to receive belatacept more intense (MI)-based, belatacept less intense (LI)-based, or cyclosporine-based immunosuppression for up to 7 years (84 months). The presence/absence of HLA-specific antibodies was determined at baseline, at months 6, 12, 24, 36, 48, 60, and 84, and at the time of clinically suspected episodes of acute rejection, using solid-phase flow-cytometry screening. Samples from anti-HLA-positive patients were further tested with a single-antigen bead assay to determine antibody specificities, presence/absence of DSAs, and mean fluorescence intensity (MFI) of any DSAs present. In BENEFIT, de novo DSAs developed in 1.4%, 3.5%, and 12.1% of belatacept MI-treated, belatacept LI-treated, and cyclosporine-treated patients, respectively. The corresponding values in BENEFIT-EXT were 3.8%, 1.1%, and 11.2%. Per Kaplan-Meier analysis, de novo DSA incidence was significantly lower in belatacept-treated vs cyclosporine-treated patients over 7 years in both studies (P < .01). In patients who developed de novo DSAs, belatacept-based immunosuppression was associated with numerically lower MFI vs cyclosporine-based immunosuppression. Although derived post hoc, these data suggest that belatacept-based immunosuppression suppresses de novo DSA development more effectively than cyclosporine-based immunosuppression.
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Affiliation(s)
| | | | | | | | | | - L. Yang
- Bristol‐Myers SquibbLawrencevilleNJUSA
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14
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Florman S, Vincenti F, Durrbach A, Abouljoud M, Bresnahan B, Garcia VD, Mulloy L, Rice K, Rostaing L, Zayas C, Calderon K, Meier-Kriesche U, Polinsky M, Yang L, Medina Pestana J, Larsen CP. Outcomes at 7 years post-transplant in black vs nonblack kidney transplant recipients administered belatacept or cyclosporine in BENEFIT and BENEFIT-EXT. Clin Transplant 2018; 32:e13225. [PMID: 29461660 DOI: 10.1111/ctr.13225] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 11/28/2022]
Abstract
Clinical outcomes are generally worse for black vs nonblack renal allograft recipients. In BENEFIT and BENEFIT-EXT, recipients were randomized to belatacept more intense-based, belatacept less intense-based, or cyclosporine-based immunosuppression. At year 7, belatacept was associated with superior graft survival vs cyclosporine in BENEFIT (recipients of living or standard criteria deceased donor kidneys); belatacept was associated with similar graft survival vs cyclosporine in BENEFIT-EXT (recipients of extended criteria donor kidneys). In both studies, renal function was superior for belatacept-treated vs cyclosporine-treated patients. Seven-year outcomes were examined by race post hoc in each study. The effect of race and treatment on time to death or graft loss was compared using Cox regression. The interaction between treatment and race was also considered. Glomerular filtration rate (GFR) was estimated from months 1 to 84 using a repeated-measures model. In total, 8.3% (55/666) and 13.1% (71/543) of patients in BENEFIT and BENEFIT-EXT, respectively, were black. Time to death or graft loss was similar in blacks and nonblacks. For both subgroups, estimated mean GFR increased over 7 years for belatacept, but declined for cyclosporine. Outcomes were similar in belatacept-treated black and nonblack patients. Due to the small number of black patients, these results must be interpreted with caution.
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Affiliation(s)
- Sander Florman
- Recanati/Miller Transplant Institute, Mount Sinai Medical Center, New York, NY, USA
| | - Flavio Vincenti
- Departments of Medicine and Surgery, University of California, San Francisco, CA, USA
| | - Antoine Durrbach
- Department of Nephrology, University Hôpital of Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Barbara Bresnahan
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Valter Duro Garcia
- Renal and Pancreas Transplant Department, Hospital Dom Vicente Scherer, Porto Alegre, Brazil
| | - Laura Mulloy
- Department of Medicine, Georgia Regents University, Augusta, GA, USA
| | - Kim Rice
- Baylor University Medical Center, Dallas, TX, USA
| | - Lionel Rostaing
- Department of Nephrology and Organ Transplantation, University Hospital and INSERM U563, IFR-BMT, Toulouse, France
| | - Carlos Zayas
- Department of Surgery, Piedmont Hospital, Atlanta, GA, USA
| | | | | | | | | | | | - Christian P Larsen
- Department of Surgery, Emory University Transplant Center, Atlanta, GA, USA
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Jones-Hughes T, Snowsill T, Haasova M, Coelho H, Crathorne L, Cooper C, Mujica-Mota R, Peters J, Varley-Campbell J, Huxley N, Moore J, Allwood M, Lowe J, Hyde C, Hoyle M, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model. Health Technol Assess 2018; 20:1-594. [PMID: 27578428 DOI: 10.3310/hta20620] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect(®), Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin(®), Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport(®), Sandoz; Capexion(®), Mylan; Modigraf(®), Astellas Pharma; Perixis(®), Accord Healthcare; Prograf(®), Astellas Pharma; Tacni(®), Teva; Vivadex(®), Dexcel Pharma), prolonged-release tacrolimus (Advagraf(®) Astellas Pharma), belatacept (BEL) (Nulojix(®), Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip(®), Zentiva; CellCept(®), Roche Products; Myfenax(®), Teva), mycophenolate sodium (MPS) (Myfortic(®), Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune(®), Pfizer) and everolimus (EVL) (Certican(®), Novartis) as maintenance therapy in adult renal transplantation. METHODS Clinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association's electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time-state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Eighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY. LIMITATIONS For included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled. FUTURE WORK High-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome. CONCLUSION Only a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000-30,000 per QALY. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013189. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jason Moore
- Exeter Kidney Unit, Royal Devon and Exeter Foundation Trust Hospital, Exeter, UK
| | - Matt Allwood
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
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Lemoine M, Guerrot D, Bertrand D. [Focusing on kidney transplantation in the elderly]. Nephrol Ther 2018; 14:71-80. [PMID: 29173815 DOI: 10.1016/j.nephro.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 02/06/2023]
Abstract
Due to the increase in life expectancy and the ageing of end-stage renal disease patients, the number of patients older than 65 years receiving a kidney transplant has been continuously growing over the last fifteen years. The benefits of renal transplantation compared to dialysis in terms of survival and quality of life have been shown in selected recipients over 65, or 70 years. However, the age remains the main limiting factor for the access to the waiting list, and the reluctance of the clinicians can be explained by the multiple comorbidities of these candidates, their limited life expectancy or the shortage of grafts. The challenge is to select the candidates who can benefit from renal transplantation, thanks to rigorous cardiovascular and neoplastic evaluation before enrolment and by taking into account the specific characteristics of elderly patients. The living donor appears to be the ideal option for elderly recipients, the alternative being the extended criteria donor, allowing waiting times to be limited. The choice of immunosuppressive therapy is also crucial in these patients at high risk of infectious and cardiovascular complications in whom the occurrence of acute rejection can have severe consequences. There are currently no specific recommendations for immunosuppression in elderly recipients, and we would need large-scale randomized studies to improve the prognosis of renal transplantation in this population.
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17
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Newell KA, Mehta AK, Larsen CP, Stock PG, Farris AB, Mehta SG, Ikle D, Armstrong B, Morrison Y, Bridges N, Robien M, Mannon RB. Lessons Learned: Early Termination of a Randomized Trial of Calcineurin Inhibitor and Corticosteroid Avoidance Using Belatacept. Am J Transplant 2017; 17:2712-2719. [PMID: 28556519 PMCID: PMC5623170 DOI: 10.1111/ajt.14377] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/26/2017] [Accepted: 05/21/2017] [Indexed: 01/25/2023]
Abstract
The intent of this National Institutes of Health-sponsored study was to compare a belatacept-based immunosuppressive regimen with a maintenance regimen of tacrolimus and mycophenolate. Nineteen primary, Epstein-Barr virus-immune renal transplant recipients with a negative cross-match were randomized to one of three groups. All patient groups received perioperative steroids and maintenance mycophenolate mofetil. Patients in groups 1 and 2 were induced with alemtuzumab and maintained on tacrolimus or belatacept, respectively. Patients in group 3 were induced with basiliximab, received 3 mo of tacrolimus, and maintained on belatacept. There was one death with a functioning allograft due to endocarditis (group 1). There were three graft losses due to vascular thrombosis (all group 2) and one graft loss due to glomerular disease (group 1). Biopsy-proven acute cellular rejection was more frequent in the belatacept-treated groups, with 10 treated episodes in seven participants compared with one episode in group 1; however, estimated GFR was similar between groups at week 52. There were no episodes of posttransplant lymphoproliferative disorder or opportunistic infections in any group. Protocol enrollment was halted prematurely because of a high rate of serious adverse events. Such negative outcomes pose challenges to clinical investigators, who ultimately must weigh the risks and benefits in randomized trials.
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Affiliation(s)
- Kenneth A. Newell
- Department of Surgery, Emory University School of Medicine, Atlanta GA
| | - Aneesh K. Mehta
- Department of Surgery, Emory University School of Medicine, Atlanta GA,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta GA
| | | | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
| | - A. Bradley Farris
- Department of Surgery, Emory University School of Medicine, Atlanta GA
| | - Shikha G. Mehta
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Yvonne Morrison
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Nancy Bridges
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark Robien
- Transplantation Branch, National Institute Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
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18
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Schulte K, Vollmer C, Klasen V, Bräsen JH, Püchel J, Borzikowsky C, Kunzendorf U, Feldkamp T. Late conversion from tacrolimus to a belatacept-based immuno-suppression regime in kidney transplant recipients improves renal function, acid-base derangement and mineral-bone metabolism. J Nephrol 2017; 30:607-615. [PMID: 28540602 DOI: 10.1007/s40620-017-0411-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/12/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-induced nephrotoxicity and chronic graft dysfunction with deteriorating glomerular filtration rate (GFR) are common problems of kidney transplant recipients. The aim of this study was to analyze the role of belatacept as a rescue therapy in these patients. METHODS In this retrospective, observational study we investigated 20 patients (10 females, 10 males) who were switched from a CNI (tacrolimus) to a belatacept-based immunosuppression because of CNI intolerance or marginal transplant function. Patient follow-up was 12 months. RESULTS Patients were converted to belatacept in mean 28.8 months after transplantation. Reasons for conversion were CNI intolerance (14 patients) or marginal transplant function (6 patients). Mean estimated GFR (eGFR) before conversion was 22.2 ± 9.4 ml/min at baseline and improved significantly to 28.3 ± 10.1 ml/min at 4 weeks and to 32.1 ± 12.6 ml/min at 12 months after conversion. Serum bicarbonate significantly increased from 24.4 ± 3.2 mmol/l at baseline to 28.7 ± 2.6 mmol/l after 12 months. Conversion to belatacept decreased parathyroid hormone and phosphate concentrations significantly, whereas albumin levels significantly increased. In 6 cases an acute rejection preceded clinically relevant CNI toxicity; only two patients suffered from an acute rejection after conversion. Belatacept was well tolerated and there was no increase in infectious or malignant side effects. CONCLUSION A late conversion from a tacrolimus-based immunosuppression to belatacept is safe, effective and significantly improves renal function in kidney transplant recipients. Additionally, the conversion to belatacept has a beneficial impact on acid-base balance, mineral-bone and protein metabolism, independently of eGFR.
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Affiliation(s)
- Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany.
| | - Clara Vollmer
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Vera Klasen
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Jan Hinrich Bräsen
- Nephropathology, Institute for Pathology, Hannover Medical School, Hanover, Germany
| | - Jodok Püchel
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Christian-Albrechts University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
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Pérez-Sáez MJ, Montero N, Redondo-Pachón D, Crespo M, Pascual J. Strategies for an Expanded Use of Kidneys From Elderly Donors. Transplantation 2017; 101:727-45. [PMID: 28072755 DOI: 10.1097/TP.0000000000001635] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.
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20
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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21
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Snanoudj R, Timsit M, Rabant M, Tinel C, Lazareth H, Lamhaut L, Martinez F, Legendre C. Dual Kidney Transplantation: Is It Worth It? Transplantation 2017; 101:488-97. [DOI: 10.1097/tp.0000000000001508] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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22
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Abstract
Tacrolimus, a calcineurin inhibitor, has been the cornerstone of immunosuppressive regimens in renal transplant over 2 decades. This has significantly improved the outcomes of renal transplant, including reduction of acute rejection episodes, improvement of renal function and graft survival, and reduction of some of the adverse effects associated with cyclosporine. However, use of tacrolimus is associated with a number of undesirable effects, such as nephrotoxicity, posttransplant diabetes mellitus, neurotoxicity, and cosmetic and electrolyte disturbances. To alleviate these effects, several strategies have been adopted to minimize or eliminate tacrolimus from maintenance regimens of immunosuppression, with some success. This review focuses on advancements in the understanding of the basic science related to tacrolimus and the clinical evidences that have examined the efficacy and safety of tacrolimus in renal transplant over the past 2 decades and highlights the future directions.
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Affiliation(s)
- Badri Man Shrestha
- From the Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
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23
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Durrbach A, Pestana JM, Florman S, del Carmen Rial M, Rostaing L, Kuypers D, Matas A, Wekerle T, Polinsky M, Meier‐Kriesche HU, Munier S, Grinyó JM. Long-Term Outcomes in Belatacept- Versus Cyclosporine-Treated Recipients of Extended Criteria Donor Kidneys: Final Results From BENEFIT-EXT, a Phase III Randomized Study. Am J Transplant 2016; 16:3192-3201. [PMID: 27130868 PMCID: PMC5516151 DOI: 10.1111/ajt.13830] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 04/01/2016] [Accepted: 04/08/2016] [Indexed: 01/25/2023]
Abstract
In the Belatacept Evaluation of Nephroprotection and Efficacy as First-Line Immunosuppression Trial-Extended Criteria Donors (BENEFIT-EXT), extended criteria donor kidney recipients were randomized to receive belatacept-based (more intense [MI] or less intense [LI]) or cyclosporine-based immunosuppression. In prior analyses, belatacept was associated with significantly better renal function compared with cyclosporine. In this prospective analysis of the intent-to-treat population, efficacy and safety were compared across regimens at 7 years after transplant. Overall, 128 of 184 belatacept MI-treated, 138 of 175 belatacept LI-treated and 108 of 184 cyclosporine-treated patients contributed data to these analyses. Hazard ratios (HRs) comparing time to death or graft loss were 0.915 (95% confidence interval [CI] 0.625-1.339; p = 0.65) for belatacept MI versus cyclosporine and 0.927 (95% CI 0.634-1.356; p = 0.70) for belatacept LI versus cyclosporine. Mean estimated GFR (eGFR) plus or minus standard error at 7 years was 53.9 ± 1.9, 54.2 ± 1.9, and 35.3 ± 2.0 mL/min per 1.73 m2 for belatacept MI, belatacept LI and cyclosporine, respectively (p < 0.001 for overall treatment effect). HRs comparing freedom from death, graft loss or eGFR <20 mL/min per 1.73 m2 were 0.754 (95% CI 0.536-1.061; p = 0.10) for belatacept MI versus cyclosporine and 0.706 (95% CI 0.499-0.998; p = 0.05) for belatacept LI versus cyclosporine. Acute rejection rates and safety profiles of belatacept- and cyclosporine-based treatment were similar. De novo donor-specific antibody incidence was lower for belatacept (p ≤ 0.0001). Relative to cyclosporine, belatacept was associated with similar death and graft loss and improved renal function at 7 years after transplant and had a safety profile consistent with previous reports.
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Affiliation(s)
- A. Durrbach
- University Hôpital of BicêtreLe Kremlin‐BicêtreFrance,Université Paris‐SaclayPlateau de SaclayFrance
| | | | | | | | | | - D. Kuypers
- University Hospitals LeuvenLeuvenBelgium
| | - A. Matas
- University of MinnesotaMinneapolisMN
| | - T. Wekerle
- Medical University of ViennaViennaAustria
| | | | | | - S. Munier
- Bristol‐Myers SquibbBraine‐l'AlleudBelgium
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Brakemeier S, Kannenkeril D, Dürr M, Braun T, Bachmann F, Schmidt D, Wiesener M, Budde K. Experience with belatacept rescue therapy in kidney transplant recipients. Transpl Int 2016; 29:1184-1195. [PMID: 27514317 DOI: 10.1111/tri.12822] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/16/2016] [Accepted: 07/27/2016] [Indexed: 12/18/2022]
Abstract
In kidney transplant recipients with chronic graft dysfunction, long-term immunosuppression with calcineurin inhibitors (CNIs) or mTOR inhibitors (mTORi) can be challenging due to adverse effects, such as nephrotoxicity and proteinuria. Seventy-nine kidney transplant recipients treated with CNI-based or mTORi-based maintenance immunosuppression who had CNI-induced nephrotoxicity or severe adverse events were switched to belatacept. Mean time from transplantation to belatacept conversion was 69.0 months. Mean estimated glomerular filtration rate (eGFR) ± standard deviation at baseline was 26.1 ± 15.0 ml/min/1.73 m2 , increasing to 34.0 ± 15.2 ml/min/1.73 m2 at 12 months postconversion (P < 0.0005). Renal function improvements were also seen in patients with low eGFR (<25 ml/min/1.73 m2 ) or high proteinuria (>500 mg/l) at conversion. The Kaplan-Meier estimates for patient and graft survival at 12 months were 95.0% and 85.6%, respectively. The discontinuation rate due to adverse events was 7.9%. One case of post-transplant lymphoproliferative disorder occurred at 17 months postconversion. For comparison, a historical control group of 41 patients converted to mTORi-based immunosuppression because of biopsy-confirmed CNI-induced toxicity was examined; eGFR increased from 27.6 ± 7.2 ml/min/1.73 m2 at baseline to 31.1 ± 11.9 ml/min/1.73 m2 at 12 months (P = 0.018). Belatacept-based immunosuppression may be an alternative regimen for kidney transplant recipients with CNI- or mTORi-induced toxicity.
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Affiliation(s)
- Susanne Brakemeier
- Division of Nephrology, Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany.
| | - Dennis Kannenkeril
- Department of Nephrology and Hypertension, University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Dürr
- Division of Nephrology, Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany
| | - Tobias Braun
- Department of Nephrology and Hypertension, University Erlangen-Nürnberg, Erlangen, Germany
| | - Friederike Bachmann
- Division of Nephrology, Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany
| | - Danilo Schmidt
- Division of Nephrology, Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany
| | - Michael Wiesener
- Department of Nephrology and Hypertension, University Erlangen-Nürnberg, Erlangen, Germany
| | - Klemens Budde
- Division of Nephrology, Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany
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Le Meur Y, Aulagnon F, Bertrand D, Heng AE, Lavaud S, Caillard S, Longuet H, Sberro-Soussan R, Doucet L, Grall A, Legendre C. Effect of an Early Switch to Belatacept Among Calcineurin Inhibitor-Intolerant Graft Recipients of Kidneys From Extended-Criteria Donors. Am J Transplant 2016; 16:2181-6. [PMID: 26718625 DOI: 10.1111/ajt.13698] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/14/2015] [Accepted: 12/12/2015] [Indexed: 01/25/2023]
Abstract
Transplant recipients receiving a kidney from an extended-criteria donor (ECD) are exposed to calcineurin inhibitor (CNI) nephrotoxicity, as demonstrated by severe delayed graft function and/or a low GFR. Belatacept is a nonnephrotoxic drug that is indicated as an alternative to CNIs. We reported 25 cases of conversion from a CNI to belatacept due to CNI intolerance within the first 6 mo after transplantation. The mean age of the recipients was 59 years, and 24 of 25 patients received ECD kidneys. At the date of the medication switch, 12 of 25 patients displayed a calculated GFR (cGFR) <15 mL/min, six patients remained on dialysis, and the biopsies showed evidence of acute tubular damage associated with severe vascular or tubulointerstitial chronic lesions. Three patients did not recover renal function, and three patients died during the follow-up period. Among the remaining patients, renal function improved: The cGFR was 18.28 ± 12.3 mL/min before the medication switch compared with 34.9 ± 14.5 mL/min at 1 year after conversion to belatacept (p = 0.002). Tolerance of and compliance with belatacept were good, and only one patient experienced acute rejection. Belatacept is an effective therapy that preserves renal function in kidney transplant patients who are intolerant of CNIs.
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Affiliation(s)
- Y Le Meur
- Department of Nephrology and Transplantation, University Hospital La Cavale Blanche, European University of Brittany, Brest, France
| | - F Aulagnon
- Department of Renal Transplantation, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - D Bertrand
- Department of Nephrology, University Hospital, Rouen, France
| | - A E Heng
- Department of Nephrology, University Hospital, Clermont-Ferrand, France
| | - S Lavaud
- Department of Nephrology and Transplantation, University Hospital, Reims, France
| | - S Caillard
- Department of Nephrology and Renal Transplantation, Hospices Civils, Strasbourg, France
| | - H Longuet
- Department of Nephrology and Clinical Immunology-EA4245, Bretonneau Hospital, University Hospital, Tours, France
| | - R Sberro-Soussan
- Department of Renal Transplantation, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - L Doucet
- Department of Anatomy and Pathology, University Hospital, Brest, France
| | - A Grall
- Department of Nephrology and Transplantation, University Hospital La Cavale Blanche, European University of Brittany, Brest, France
| | - C Legendre
- Department of Renal Transplantation, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
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Hardinger KL, Sunderland D, Wiederrich JA. Belatacept for the prophylaxis of organ rejection in kidney transplant patients: an evidence-based review of its place in therapy. Int J Nephrol Renovasc Dis 2016; 9:139-50. [PMID: 27307759 PMCID: PMC4888760 DOI: 10.2147/ijnrd.s88816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Belatacept is a novel immunosuppressive therapy designed to improve clinical outcomes associated with kidney transplant recipients while minimizing use of calcineurin inhibitors (CNIs). Methods We searched for clinical trials related to administration of belatacept to kidney transplant patients compared to various immunosuppression regimens, as well as for studies that utilized data from belatacept trials to validate new surrogate measures. The purpose of this review is to consolidate the published evidence of belatacept’s effectiveness and safety in renal transplant recipients to better elucidate its place in clinical practice. Results Analysis of the results from the Belatacept Evaluation of Nephroprotection and Effi-cacy as First-Line Immunosuppressive Trial (BENEFIT) study, a de novo trial that compared cyclosporine (CsA)-based therapy to belatacept-based therapy in standard criteria donors, found a significant difference in mean estimated glomerular filtration rate (eGFR) of 13–15 mL/min/1.73 m2 and 23–27 mL/min/1.73 m2 at 1 year and 7 years, respectively. The BENEFIT-EXT study was similarly designed with the exception that it included extended criteria donors. Renal function improved significantly for the more intensive belatacept group in all years of the BENEFIT-EXT study; however, it was not significant in the less intensive group until 5 years after transplant. Belatacept regimens resulted in lower blood pressure, cholesterol levels, and incidence of new-onset diabetes after transplant compared to CsA-based regimens. Results from conversion of CNIs to belatacept therapy, dual therapy of belatacept with sirolimus, and belatacept with corticosteroid avoidance therapy are also included in this article. Conclusion The evidence reviewed in this article suggests that belatacept is an effective alternative in kidney transplant recipients. Compared to CNI-based therapy, belatacept-based therapy results in superior renal function and similar rates of allograft survival. In terms of safety, belatacept was shown to have lower incidence of hypertension, hyperlipidemia, and diabetes; however, incidence of posttransplantation lymphoproliferative disorder and the cost of belatacept may hinder use of this medication.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel Sunderland
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jennifer A Wiederrich
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
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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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Huber M, Kemmner S, Renders L, Heemann U. Should belatacept be the centrepiece of renal transplantation? Nephrol Dial Transplant 2016; 31:1995-2002. [DOI: 10.1093/ndt/gfw226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/04/2016] [Indexed: 12/28/2022] Open
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Trimarchi H, Rengel T, Andrews J, Paulero M, Iotti A, Forastiero A, Lombi F, Pomeranz V, Forrester M, Iriarte R, Agorio I. Belatacept and mediastinal histoplasmosis in a kidney transplant patient. J Nephropathol 2016; 5:84-7. [PMID: 27152295 PMCID: PMC4844914 DOI: 10.15171/jnp.2016.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 03/08/2016] [Indexed: 12/30/2022] Open
Abstract
Background: In transplantation immunosuppression enhances the appearance of opportunist infections. An ideal balance between the prevention of rejection, the lowest risk of infections and the highest rates of graft survival is a continuous challenge. Lower doses of immunosuppression may diminish the risk of infections, metabolic and hemodynamic complications or even of malignancy, but may expose patients to episodes of acute rejection. New drugs are being developed to improve graft survival at the lowest risk of side effects. Belatacept has recently been introduced in kidney transplantation to inhibit the co-ligand signal of T cell stimulation. It is a drug with a safe profile, is well-tolerated and appears to improve long-term survival of kidney grafts. However, there may be an increase in opportunistic infections which may be facilitated by T cell depression, as Aspergillus sp., Cryptococcus neoformans or tuberculosis.
Case Presentation: We describe a 59-year-old female who developed fever, clinical wasting and a mediastinal mass 31 months after receiving a living non-related kidney transplant while on belatacept therapy. A mediastinal node biopsy disclosed the presence of Histoplasma capsulatum. Infection successfully resolved after appropriate antifungal treatment.
Conclusions: To our knowledge, this is the first reported case of Histoplasma capsulatum in a kidney transplanted patient on belatacept therapy
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Affiliation(s)
- Hernán Trimarchi
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Tatiana Rengel
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - José Andrews
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Matías Paulero
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Alejandro Iotti
- Pathology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Agustina Forastiero
- Microbiology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Lombi
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Vanesa Pomeranz
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Mariano Forrester
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Romina Iriarte
- Nephrology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Iris Agorio
- Microbiology Services, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Casiraghi F, Cortinovis M, Perico N, Remuzzi G. Recent advances in immunosuppression and acquired immune tolerance in renal transplants. Am J Physiol Renal Physiol 2016; 310:F446-53. [DOI: 10.1152/ajprenal.00312.2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 01/19/2016] [Indexed: 01/03/2023] Open
Affiliation(s)
- Federica Casiraghi
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Transplant Research Center “Chiara Cucchi de Alessandri e Gilberto Crespi,” Ranica, Bergamo, Italy
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” Ranica, Bergamo, Italy
| | - Monica Cortinovis
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Transplant Research Center “Chiara Cucchi de Alessandri e Gilberto Crespi,” Ranica, Bergamo, Italy
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” Ranica, Bergamo, Italy
| | - Norberto Perico
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” Ranica, Bergamo, Italy
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Transplant Research Center “Chiara Cucchi de Alessandri e Gilberto Crespi,” Ranica, Bergamo, Italy
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri,” Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” Ranica, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; and
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Krenzien F, ElKhal A, Quante M, Rodriguez Cetina Biefer H, Hirofumi U, Gabardi S, Tullius SG. A Rationale for Age-Adapted Immunosuppression in Organ Transplantation. Transplantation 2015; 99:2258-68. [PMID: 26244716 DOI: 10.1097/TP.0000000000000842] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Demographic changes are associated with a steady increase of older patients with end-stage organ failure in need for transplantation. As a result, the majority of transplant recipients are currently older than 50 years, and organs from elderly donors are more frequently used. Nevertheless, the benefit of transplantation in older patients is well recognized, whereas the most frequent causes of death among older recipients are potentially linked to side effects of their immunosuppressants.Immunosenescence is a physiological part of aging linked to higher rates of diabetes, bacterial infections, and malignancies representing the major causes of death in older patients. These age-related changes impact older transplant candidates and may have significant implications for an age-adapted immunosuppression. For instance, immunosenescence is linked to lower rates of acute rejections in older recipients, whereas the engraftment of older organs has been associated with higher rejection rates. Moreover, new-onset diabetes mellitus after transplantation is more frequent in the elderly, potentially related to corticosteroids, calcineurin inhibitors, and mechanistic target of rapamycin inhibitors.This review presents current knowledge for an age-adapted immunosuppression based on both, experimental and clinical studies in and beyond transplantation. Recommendations of maintenance and induction therapy may help to improve graft function and to design future clinical trials in the elderly.
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Vincenti F, Rostaing L, Grinyo J, Rice K, Steinberg S, Gaite L, Moal MC, Mondragon-Ramirez GA, Kothari J, Polinsky MS, Meier-Kriesche HU, Munier S, Larsen CP. Belatacept and Long-Term Outcomes in Kidney Transplantation. N Engl J Med 2016; 374:333-43. [PMID: 26816011 DOI: 10.1056/nejmoa1506027] [Citation(s) in RCA: 485] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In previous analyses of BENEFIT, a phase 3 study, belatacept-based immunosuppression, as compared with cyclosporine-based immunosuppression, was associated with similar patient and graft survival and significantly improved renal function in kidney-transplant recipients. Here we present the final results from this study. METHODS We randomly assigned kidney-transplant recipients to a more-intensive belatacept regimen, a less-intensive belatacept regimen, or a cyclosporine regimen. Efficacy and safety outcomes for all patients who underwent randomization and transplantation were analyzed at year 7 (month 84). RESULTS A total of 666 participants were randomly assigned to a study group and underwent transplantation. Of the 660 patients who were treated, 153 of the 219 patients treated with the more-intensive belatacept regimen, 163 of the 226 treated with the less-intensive belatacept regimen, and 131 of the 215 treated with the cyclosporine regimen were followed for the full 84-month period; all available data were used in the analysis. A 43% reduction in the risk of death or graft loss was observed for both the more-intensive and the less-intensive belatacept regimens as compared with the cyclosporine regimen (hazard ratio with the more-intensive regimen, 0.57; 95% confidence interval [CI], 0.35 to 0.95; P=0.02; hazard ratio with the less-intensive regimen, 0.57; 95% CI, 0.35 to 0.94; P=0.02), with equal contributions from the lower rates of death and graft loss. The mean estimated glomerular filtration rate (eGFR) increased over the 7-year period with both belatacept regimens but declined with the cyclosporine regimen. The cumulative frequencies of serious adverse events at month 84 were similar across treatment groups. CONCLUSIONS Seven years after transplantation, patient and graft survival and the mean eGFR were significantly higher with belatacept (both the more-intensive regimen and the less-intensive regimen) than with cyclosporine. (Funded by Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00256750.).
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Affiliation(s)
- Flavio Vincenti
- From the University of California, San Francisco, San Francisco (F.V.), and Sharp Memorial Hospital, San Diego (S.S.) - both in California; University Hospital and INSERM Unité 563, IFR-BMT, Toulouse (L.R.), and Hôpital de La Cavale Blanche, Brest (M.-C.M.) - both in France; University Hospital Bellvitge, Barcelona (J.G.); Baylor University Medical Center, Dallas (K.R.); Clínica de Nefrología, Santa Fe, Argentina (L.G.); Instituto Mexicano de Trasplantes, Morelos, Mexico (G.A.M.-R.); Hinduja Hospital, Hinduja Health Care and Apex Kidney Foundation, Mumbai, India (J.K.); Bristol-Myers Squibb, Princeton, NJ (M.S.P., H.-U.M.-K.); Bristol-Myers Squibb, Braine-l'Alleud, Belgium (S.M.); and Emory University Transplant Center, Atlanta (C.P.L.)
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Ghanta M, Kozicky M, Jim B. Pathophysiologic and treatment strategies for cardiovascular disease in end-stage renal disease and kidney transplantations. Cardiol Rev. 2014;23:109-118. [PMID: 25420053 DOI: 10.1097/crd.0000000000000044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The inextricable link between the heart and the kidneys predestines that significant cardiovascular disease ensues in the face of end-stage renal disease (ESRD). As a point of fact, the leading cause of mortality of patients on dialysis is still from cardiovascular etiologies, albeit differing in particular types of disease from the general population. For example, sudden cardiac death outnumbers coronary artery disease in patients with ESRD, which is the reverse for the general population. In this review, we will focus on the pathophysiology and treatment options of important traditional and nontraditional risk factors for cardiovascular disease in ESRD patients such as hypertension, anemia, vascular calcification, hyperparathyroidism, uremia, and oxidative stress. The evidence of erythropoietin-stimulating agents, phosphate binders, calcimimetics, and dialysis modalities will be presented. We will then discuss how these risk factors may be changed and perhaps exacerbated after renal transplantation. This is largely due to the immunosuppressive agents that are both crucial yet potentially detrimental in the posttransplant state. Calcineurin inhibitors, corticosteroids, and mammalian target of rapamycin inhibitors, the mainstay of transplant immunosuppression, are all known to increase the risks of developing new onset diabetes as well as the metabolic syndrome. Thus, we need to carefully negotiate between patients' cardiovascular profile and their risks of rejection. Finally, we end by considering strategies by which we may minimize cardiovascular disease in the transplant population, as this modality still confers the highest chance of survival in patients with ESRD.
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Del Bello A, Marion O, Milongo D, Rostaing L, Kamar N. Belatacept prophylaxis against organ rejection in adult kidney-transplant recipients. Expert Rev Clin Pharmacol 2015; 9:215-27. [PMID: 26691282 DOI: 10.1586/17512433.2016.1112736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
End-stage renal disease is a major health problem worldwide, with kidney transplantation being the treatment of choice. Calcineurin inhibitors are still the cornerstone of immunosuppressive therapy. However, they have well-known nephrotoxic affects and increase the risk of cardiovascular disease and cancer. In contrast, belatacept is a biological immunosuppressive agent that inhibits the T-cell co-stimulation. It is approved by the US Food and Drug Administration and the European Medicine Agency for use in adult kidney-transplant recipients to prevent acute rejection. Developmental studies show that belatacept is as efficient as calcineurin inhibitors at preventing acute rejection. In addition, kidney function is better and cardiovascular risk factors are reduced in patients given belatacept. Herein, the authors review the published evidence concerning the efficacy and safety of belatacept and discuss its potential specific indications.
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Affiliation(s)
- Arnaud Del Bello
- a Department of Nephrology and Organ Transplantation , CHU Rangueil , Toulouse , France.,b Faculte de Medecine , Université Paul Sabatier , Toulouse , France
| | - Olivier Marion
- a Department of Nephrology and Organ Transplantation , CHU Rangueil , Toulouse , France
| | - David Milongo
- a Department of Nephrology and Organ Transplantation , CHU Rangueil , Toulouse , France
| | - Lionel Rostaing
- a Department of Nephrology and Organ Transplantation , CHU Rangueil , Toulouse , France.,b Faculte de Medecine , Université Paul Sabatier , Toulouse , France.,c INSERM U1043, IFR-BMT, CHU Purpan , Toulouse , France
| | - Nassim Kamar
- a Department of Nephrology and Organ Transplantation , CHU Rangueil , Toulouse , France.,b Faculte de Medecine , Université Paul Sabatier , Toulouse , France.,c INSERM U1043, IFR-BMT, CHU Purpan , Toulouse , France
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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de Graav GN, Bergan S, Baan CC, Weimar W, van Gelder T, Hesselink DA. Therapeutic Drug Monitoring of Belatacept in Kidney Transplantation. Ther Drug Monit 2015; 37:560-7. [DOI: 10.1097/ftd.0000000000000179] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zsom L, Wagner L, Fülöp T. Minimization vs tailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015? World J Transplant 2015; 5:73-80. [PMID: 26421259 PMCID: PMC4580929 DOI: 10.5500/wjt.v5.i3.73] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 06/13/2015] [Accepted: 07/14/2015] [Indexed: 02/05/2023] Open
Abstract
The introduction of novel immunosuppressive agents over the last two decades and the improvement of our diagnostic tools for early detection of antibody-mediated injury offer us an opportunity, if not a mandate, to better match the immunosuppression needs of the individual patients with side effects of the therapy. However, immunosuppressive regimens in the majority of programs remain mostly protocol-driven, with relatively little inter-program heterogeneity in certain areas of the world. Emerging data showing different outcomes with a particular immunosuppressive strategy in populations with varying immunological risks underscore a real potential for “personalized medicine” in renal transplantation. Studies demonstrating marked differences in the adverse-effect profiles of individual drugs including the risk for viral infections, malignancy and renal toxicity call for a paradigm shift away from a “one size fits all” approach to an individually tailored immunosuppressive therapy for renal transplant recipients, assisted by both screening for predictors of graft loss and paying close attention to dose or class-related adverse effects. Our paper explores some of the opportunities during the care of these patients. Potential areas of improvements may include: (1) a thorough assessment of immunological and metabolic risk profile of each renal transplant recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen. Altogether, these considerations may enable the most effective use of the drugs we already have.
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Le Meur Y. What immunosuppression should be used for old-to-old recipients? Transplant Rev (Orlando) 2015; 29:231-6. [PMID: 26409505 DOI: 10.1016/j.trre.2015.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 12/18/2022]
Abstract
Elderly patients receiving a kidney from old donors (old-to-old) are a growing population of transplant recipients. This population cumulates risks of complications due to the co-morbidities and the immunodeficiency state and the frailty of the recipients together with the kidney senescence of the donors. In this context, the choice of immunosuppression is complicated and must take into account some contradictory principles explaining why no consensus exists today.
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Affiliation(s)
- Yannick Le Meur
- Department of Nephrology, University Hospital La Cavale Blanche, European University of Brittany, Brest, France.
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Langsford D, Dwyer K. Dysglycemia after renal transplantation: Definition, pathogenesis, outcomes and implications for management. World J Diabetes 2015; 6:1132-51. [PMID: 26322159 PMCID: PMC4549664 DOI: 10.4239/wjd.v6.i10.1132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 07/06/2015] [Accepted: 08/16/2015] [Indexed: 02/05/2023] Open
Abstract
New-onset diabetes after transplantation (NODAT) is major complication following renal transplantation. It commonly develops within 3-6 mo post-transplantation. The development of NODAT is associated with significant increase in risk of major cardiovascular events and cardiovascular death. Other dysglycemic states, such as impaired glucose tolerance are also associated with increasing risk of cardiovascular events. The pathogenesis of these dysglycemic states is complex. Older recipient age is a consistent major risk factor and the impact of calcineurin inhibitors and glucocorticoids has been well described. Glucocorticoids likely cause insulin resistance and calcineurin inhibitors likely cause β-cell toxicity. The impact of transplantation in incretin hormones remains to be clarified. The oral glucose tolerance test remains the best diagnostic test but other tests may be validated as screening tests. Possibly, NODAT can be prevented by administering insulin early in patients identified as high risk for NODAT. Once NODAT has been diagnosed altering immunosuppression may be acceptable, but creates the difficulty of balancing immunological with metabolic risk. With regard to hypoglycemic use, metformin may be the best option. Further research is needed to better understand the pathogenesis, identify high risk patients and to improve management options given the significant increased risk of major cardiovascular events and death.
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Talawila N, Pengel LHM. Does belatacept improve outcomes for kidney transplant recipients? A systematic review. Transpl Int 2015; 28:1251-64. [PMID: 25965549 DOI: 10.1111/tri.12605] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Belatacept was intended to provide better outcomes for kidney transplant (KT) recipients by allowing minimization/withdrawal of calcineurin inhibitors (CNI) and steroids. METHODS We searched for randomized controlled trials (RCTs) in adult KT comparing belatacept with CNIs. Methodological quality was assessed. Meta-analyses were performed to calculate odds ratios (OR) and mean differences (MD). RESULTS Six RCTs were included. Pooled analyses found no differences for acute rejection at any time point. Renal function [Calculated glomerular filtration rate (cGFR)] was better with belatacept at 12 and 24 months (MD = 11.7 and 13.7 ml/min/1.73 m(2) ). New onset diabetes after transplantation was lower with belatacept at 12 months (OR = 0.43). Systolic and diastolic blood pressures were lower at 12 months (MD -7.2 and -3.1 mmHg) as were triglycerides at 12 and 24 months (MD = -32.9 and -41.7 mg/dl). Total and low-density lipoprotein cholesterol were lower with belatacept at 24 months (MD = -19.8 and -10.6 mg/dl). There were no differences for other outcomes. CONCLUSION Limited available data suggest a potential benefit for belatacept by reducing the risk of CNI toxicity, especially renal function, without evidence of increased acute rejection. There were no safety issues apart from a possible risk of post-transplant lymphoproliferative disorder in Epstein-barr virus-seronegative recipients. Further studies are required to confirm this benefit.
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Affiliation(s)
- Nishanthi Talawila
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW Calcineurin inhibitors (CNIs) play a major role in long-term renal allograft dysfunction because of their nephrotoxic side-effects. Belatacept, a selective costimulation blockade agent, is the first biological agent approved for maintenance immunosuppression in renal transplantation. RECENT FINDINGS Studies have shown better preservation of glomerular filtration rate and improved metabolic end points with belatacept when compared with CNIs. More recent studies have shown that belatacept can be an effective first-line immunosuppressive agent with complete avoidance of CNIs and corticosteroids. SUMMARY Newer biological agents like belatacept may replace CNIs/corticosteroids in renal transplant recipients, with a benefit of better short-term and long-term renal function, better compliance, and ultimately a possible improvement in long-term renal allograft survival.
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Snanoudj R, Tinel C, Legendre C. Immunological risks of minimization strategies. Transpl Int 2015; 28:901-10. [DOI: 10.1111/tri.12570] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 12/17/2014] [Accepted: 03/19/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Renaud Snanoudj
- Université Sorbonne Paris Cité; Paris France
- Service de Néphrologie - Transplantation; Hôpital Necker; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Claire Tinel
- Université Sorbonne Paris Cité; Paris France
- Service de Néphrologie - Transplantation; Hôpital Necker; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Christophe Legendre
- Université Sorbonne Paris Cité; Paris France
- Service de Néphrologie - Transplantation; Hôpital Necker; Assistance Publique-Hôpitaux de Paris; Paris France
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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: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Rossi AP, Vella JP. Hypertension, living kidney donors, and transplantation: where are we today? Adv Chronic Kidney Dis 2015; 22:154-64. [PMID: 25704353 DOI: 10.1053/j.ackd.2015.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
Hypertension is a prevalent problem in kidney transplant recipients that is known to be a "traditional" risk factor for atherosclerotic cardiovascular disease leading to premature allograft failure and death. Donor, peritransplant, and recipient factors affect hypertension risk. Blood pressure control after transplantation is inversely associated with glomerular filtration rate (GFR). Calcineurin inhibitors, the most commonly used class of immunosuppressives, cause endothelial dysfunction, increase vascular tone, and sodium retention via the renin-angiotensin-aldosterone system resulting in systemic hypertension. Steroid withdrawal seems to have little impact on blood pressure control. Newer agents like belatacept appear to be associated with less hypertension. Transplant renal artery stenosis is an important, potentially treatable cause of hypertension. Dihydropyridine calcium channel blockers mitigate calcineurin inhibitor nephrotoxicity and may be associated with improved estimated GFR. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not recommended in the first 3 to 6 months given their effects on reduced estimated GFR, anemia, and hyperkalemia. The use of ß-blockers may be associated with improved patient survival, even for patients without cardiovascular disease. Living donation may increase blood pressure by 5 mm Hg or more. Some transplant centers accept Caucasian living donors with well-controlled hypertension on a single agent if they agree to close follow-up.
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Weissenbacher A, Oberhuber R, Cardini B, Weiss S, Ulmer H, Bösmüller C, Schneeberger S, Pratschke J, Öllinger R. The faster the better: anastomosis time influences patient survival after deceased donor kidney transplantation. Transpl Int 2015; 28:535-43. [DOI: 10.1111/tri.12516] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/17/2014] [Accepted: 12/30/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Sascha Weiss
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics; Innsbruck Medical University; Innsbruck Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
| | - Johann Pratschke
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
- Department of General Visceral and Transplant Surgery; Charité Campus Virchow-Klinikum; Berlin Germany
| | - Robert Öllinger
- Department of Visceral, Transplant and Thoracic Surgery; Center of Operative Medicine; Innsbruck Medical University; Innsbruck Austria
- Department of General Visceral and Transplant Surgery; Charité Campus Virchow-Klinikum; Berlin Germany
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Abstract
PURPOSE OF REVIEW Although the scarcity of clinical trials with de-novo immunosuppression has been typical over the last 2 years, several attempts have been made in drug conversion, dosing optimization, and bioequivalence. On the basis of recent clinical and animal studies, future directions of management and treatment are outlined. RECENT FINDINGS Studies with new tacrolimus formulations showed better bioavailability and lower doses, which might translate into less toxicity. The long-term results of studies with costimulation blockade confirmed their safety and efficacy. Calcineurin inhibitor (CNI)-free regimens based on mTOR inhibitors were shown to be associated with increased risk of the humoral response. Therefore, ongoing trials are predominantly designed to minimize calcineurin inhibitor dose only. Biologics, such as B-cell-specific agents (bortezomib and rituximab) and complement inhibitors (eculizumab) used to treat antibody-mediated rejection, recurrence of glomerulonephritis, are shifted to more preventive applications. The pretransplant quantification of alloreactive memory/effector T cell response may help to better stratify a patient's immunologic risk and allow for drug minimization. SUMMARY Despite clinical trials with innovative protocols with already established agents, tacrolimus-based and induction-based protocols have been shown to be the mainstay of immunosuppressive regimens. In the future, research aims to focus on biomarker-driven immunosuppression and cell therapy approaches.
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Salvadori M, Bertoni E. What's new in clinical solid organ transplantation by 2013. World J Transplant 2014; 4:243-66. [PMID: 25540734 PMCID: PMC4274595 DOI: 10.5500/wjt.v4.i4.243] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/11/2014] [Accepted: 07/27/2014] [Indexed: 02/05/2023] Open
Abstract
Innovative and exciting advances in the clinical science in solid organ transplantation continuously realize as the results of studies, clinical trials, international conferences, consensus conferences, new technologies and discoveries. This review will address to the full spectrum of news in transplantation, that verified by 2013. The key areas covered are the transplantation activity, with particular regards to the donors, the news for solid organs such as kidney, pancreas, liver, heart and lung, the news in immunosuppressive therapies, the news in the field of tolerance and some of the main complications following transplantation as infections and cancers. The period of time covered by the study starts from the international meetings held in 2012, whose results were published in 2013, up to the 2013 meetings, conferences and consensus published in the first months of 2014. In particular for every organ, the trends in numbers and survival have been reviewed as well as the most relevant problems such as organ preservation, ischemia reperfusion injuries, and rejections with particular regards to the antibody mediated rejection that involves all solid organs. The new drugs and strategies applied in organ transplantation have been divided into new way of using old drugs or strategies and drugs new not yet on the market, but on phase Ito III of clinical studies and trials.
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Cicora F, Mos F, Petroni J, Casanova M, Reniero L, Roberti J. Belatacept-based, ATG-Fresenius-induction regimen for kidney transplant recipients: a proof-of-concept study. Transpl Immunol 2014; 32:35-9. [PMID: 25448417 DOI: 10.1016/j.trim.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 12/28/2022]
Abstract
Belatacept provides effective immunosuppression while avoiding the nephrotoxicities associated with calcineurin inhibitors (CNIs). However, existing belatacept-based regimens still have high rates of acute rejection. We hypothesized that therapy with belatacept, mycophenolic acid (MMA), steroids and induction therapy with rabbit anti-thymocyte globulin Fresenius (ATGF), rejection rate could be reduced. Prospective, single center, proof-of-concept study including males and females aged ≥18years, Epstein-Barr virus (EBV)-seropositive recipients of a first, HLA non-identical, live or deceased donor kidney allograft. Only patients with a calculated panel reactive antibody score of 0% were included. Three donors were positive for Chagas disease. Six of twelve patients had at least one infection and five were readmitted to the hospital for treatment. One patient had a Trypanosoma cruzi infection via the graft treated successfully. Median cold ischemia time for the transplant patients with a deceased donor was 21.5h. Mean serum creatinine levels at 1, 3 and 6months were 1.76±0.59, 1.55±0.60 and 1.49±0.60mg/dl, respectively. Two of twelve patients experienced clinical, biopsy-proven rejection, successfully treated with methylprednisolone. No patient developed post-transplant lymphoproliferative disorder (PTLD) or any other malignancy and no patient lost their graft or died during follow-up. The potential of this approach makes it worthy of further investigation.
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Affiliation(s)
- Federico Cicora
- Renal Transplantation, Hospital Alemán, Buenos Aires, Argentina; Foundation for Research and Assistance of Kidney Disease (FINAER), Buenos Aires, Argentina
| | - Fernando Mos
- Renal Transplantation, Hospital Alemán, Buenos Aires, Argentina
| | | | - Matías Casanova
- Renal Transplantation, Hospital Alemán, Buenos Aires, Argentina
| | - Liliana Reniero
- Renal Transplantation, Hospital Alemán, Buenos Aires, Argentina
| | - Javier Roberti
- Foundation for Research and Assistance of Kidney Disease (FINAER), Buenos Aires, Argentina.
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Abstract
BACKGROUND Most people who receive a kidney transplant die from either cardiovascular disease or cancer before their transplant fails. The most common reason for someone with a kidney transplant to lose the function of their transplanted kidney necessitating return to dialysis is chronic kidney transplant scarring. Immunosuppressant drugs have side effects that increase risks of cardiovascular disease, cancer and chronic kidney transplant scarring. Belatacept may provide sufficient immunosuppression while avoiding unwanted side effects of other immunosuppressant drugs. However, high rates of post-transplant lymphoproliferative disease (PTLD) have been reported when belatacept is used in particular kidney transplant recipients at high dosage. OBJECTIVES 1) Compare the relative efficacy of belatacept versus any other primary immunosuppression regimen for preventing acute rejection, maintaining kidney transplant function, and preventing death. 2) Compare the incidence of several adverse events: PTLD; other malignancies; chronic transplant kidney scarring (IF/TA); infections; change in blood pressure, lipid and blood sugar control. 3) Assess any variation in effects by study, intervention and recipient characteristics, including: differences in pre-transplant Epstein Barr virus serostatus; belatacept dosage; and donor-category (living, standard criteria deceased, or extended criteria deceased). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 1 September 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCT) that compared belatacept versus any other immunosuppression regimen in kidney transplant recipients were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently extracted data for study quality and transplant outcomes and synthesized results using random effects meta-analysis, expressed as risk ratios (RR) and mean differences (MD), both with 95% confidence intervals (CI). Subgroup analyses and univariate meta-regression were used to investigate potential heterogeneity. MAIN RESULTS We included five studies that compared belatacept and calcineurin inhibitors (CNI) that reported data from a total of 1535 kidney transplant recipients. Of the five studies, three (478 participants) compared belatacept and cyclosporin and two (43 recipients) compared belatacept and tacrolimus. Co-interventions included basiliximab (4 studies, 1434 recipients); anti-thymocyte globulin (1 study, 89 recipients); alemtuzumab (1 study, 12 recipients); mycophenolate mofetil (MMF, 5 studies, 1509 recipients); sirolimus (1 study, 26 recipients) and prednisone (5 studies, 1535 recipients).Up to three years following transplant, belatacept and CNI-treated recipients were at similar risk of dying (4 studies, 1516 recipients: RR 0.75, 95% CI 0.39 to 1.44), losing their kidney transplant and returning to dialysis (4 studies, 1516 recipients: RR 0.91, 95% CI 0.61 to 1.38), and having an episode of acute rejection (4 studies, 1516 recipients: RR 1.56, 95% CI 0.85 to 2.86). Belatacept-treated kidney transplant recipients were 28% less likely to have chronic kidney scarring (3 studies, 1360 recipients: RR 0.72, 95% CI 0.55 to 0.94) and also had better graft function (measured glomerular filtration rate (GFR) (3 studies 1083 recipients): 10.89 mL/min/1.73 m², 95% CI 4.01 to 17.77; estimated GFR (4 studies, 1083 recipients): MD 9.96 mL/min/1.73 m², 95% CI 3.28 to 16.64) than CNI-treated recipients. Blood pressure was lower (systolic (2 studies, 658 recipients): MD -7.51 mm Hg, 95% CI -10.57 to -4.46; diastolic (2 studies, 658 recipients): MD -3.07 mm Hg, 95% CI -4.83 to -1.31, lipid profile was better (non-HDL (3 studies 1101 recipients): MD -12.25 mg/dL, 95% CI -17.93 to -6.57; triglycerides (3 studies 1101 recipients): MD -24.09 mg/dL, 95% CI -44.55 to -3.64), and incidence of new-onset diabetes after transplant was reduced by 39% (4 studies (1049 recipients): RR 0.61, 95% CI 0.40 to 0.93) among belatacept-treated versus CNI-treated recipients.Risk of PTLD was similar in belatacept and CNI-treated recipients (4 studies, 1516 recipients: RR 2.79, 95% CI 0.61 to 12.66) and was no different among recipients who received different belatacept dosages (high versus low dosage: ratio of risk ratios (RRR) 1.06, 95% CI 0.11 to 9.80, test of difference = 0.96) or among those who were Epstein Barr virus seronegative compared with those who were seropositive before their kidney transplant (seronegative versus seropositive; RRR 1.49, 95% CI 0.15 to 14.76, test for difference = 0.73).The belatacept dose used (high versus low), type of donor kidney the recipient received (extended versus standard criteria) and whether the kidney transplant recipient received tacrolimus or cyclosporin made no difference to kidney transplant survival, incidence of acute rejection or estimated GFR. Selective outcome reporting meant that data for some key subgroup comparisons were sparse and that estimates of the effect of treatment in these groups of recipients remain imprecise. AUTHORS' CONCLUSIONS There is no evidence of any difference in the effectiveness of belatacept and CNI in preventing acute rejection, graft loss and death, but treatment with belatacept is associated with less chronic kidney scarring and better kidney transplant function. Treatment with belatacept is also associated with better blood pressure and lipid profile and a lower incidence of diabetes versus treatment with a CNI. Important side effects (particularly PTLD) remain poorly reported and so the relative benefits and harms of using belatacept remain unclear. Whether short-term advantages of treatment with belatacept are maintained over the medium- to long-term or translate into better cardiovascular outcomes or longer kidney transplant survival with function remains unclear. Longer-term, fully reported and published studies comparing belatacept versus tacrolimus are needed to help clinicians decide which patients might benefit most from using belatacept.
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Affiliation(s)
- Philip Masson
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Lorna Henderson
- Royal Infirmary of EdinburghDepartment of Renal MedicineEdinburghUK
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadAustralia2145
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