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Kallarakal MA, Cohen G, Ibukun FI, Krummey SM. Marginal Zone B Cells Are Necessary for the Formation of Anti-donor IgG After Allogeneic Sensitization. Transplantation 2024; 108:1357-1367. [PMID: 38361235 PMCID: PMC11136604 DOI: 10.1097/tp.0000000000004931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The formation of anti-major histocompatibility complex (MHC) antibodies is a significant barrier for many patients awaiting organ transplantation. Patients with preformed anti-MHC antibodies have limited options for suitable donors, and the formation of donor-specific anti-MHC antibodies after transplantation is a harbinger of graft rejection. Despite the recognized importance of anti-MHC antibodies, the mechanisms responsible for the differentiation of B cells after exposure to allogeneic antigens are poorly understood. METHODS To evaluate the differentiation of B cells in response to allogeneic antigen, we used a model of H-2 b C57Bl/6 sensitization with H-2 d antigen. We used a class I MHC tetramer-based approach to identify allogeneic B cells and flow cytometric crossmatch to identify allogeneic IgM and IgG. RESULTS We found that although the formation of anti-H-2 d IgG was robust, few class-switched B cells and germinal center B cells were formed. Antigen-specific B cells did not express classical memory B-cell markers after sensitization but had an IgM + CD21 + marginal zone B-cell phenotype. The frequency of marginal zone B cells increased after sensitization. Depletion of marginal zone B cells before sensitization or skin grafting resulted in a significant diminution of anti-H-2 d IgG and fewer germinal center B cells. Adoptive transfer experiments revealed that marginal zone B cells more efficiently differentiated into germinal center B cells and anti-donor IgG-producing cells than follicular B cells. CONCLUSIONS These results demonstrate an important role for marginal zone B cells as a reservoir of alloreactive B cells that are activated by allogeneic antigens.
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Affiliation(s)
| | - Gregory Cohen
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Francis I. Ibukun
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Scott M. Krummey
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
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2
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Eid R, Scemla A, Giral M, Arzouk N, Bertrand D, Peraldi MN, Mesnard L, Longuet H, Maanaoui M, Desbuissons G, Lefevre E, Snanoudj R. Use of a Belatacept-based Immunosuppression for Kidney Transplantation From Donors After Circulatory Death: A Paired Kidney Analysis. Transplant Direct 2024; 10:e1615. [PMID: 38617465 PMCID: PMC11013701 DOI: 10.1097/txd.0000000000001615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 04/16/2024] Open
Abstract
Background Efficacy and safety of belatacept have not been specifically reported for kidney transplantations from donors after circulatory death. Methods In this retrospective multicenter paired kidney study, we compared the outcome of kidney transplantations with a belatacept-based to a calcineurin inhibitor (CNI)-based immunosuppression. We included all kidney transplant recipients from donors after uncontrolled or controlled circulatory death performed in our center between February 2015 and October 2020 and treated with belatacept (n = 31). The control group included the recipients of the contralateral kidney that were treated with CNI in 8 other centers (tacrolimus n = 29, cyclosporine n = 2). Results There was no difference in the rate of delayed graft function. A higher incidence of biopsy-proven rejections was noted in the belatacept group (24 versus 6 episodes). Estimated glomerular filtration rate (eGFR) was significantly higher in the belatacept group at 3-, 12-, and 36-mo posttransplant, but the slope of eGFR was similar in the 2 groups. During a mean follow-up of 4.1 y, 12 patients discontinued belatacept and 2 patients were switched from CNI to belatacept. For patients who remained on belatacept, eGFR mean value and slope were significantly higher during the whole follow-up. At 5 y, eGFR was 80.7 ± 18.5 with belatacept versus 56.3 ± 22.0 mL/min/1.73 m2 with CNI (P = 0.003). No significant difference in graft and patient survival was observed. Conclusions The use of belatacept for kidney transplants from either uncontrolled or controlled donors after circulatory death resulted in a better medium-term renal function for patients remaining on belatacept despite similar rates of delayed graft function and higher rates of cellular rejection.
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Affiliation(s)
- Rita Eid
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Anne Scemla
- Department of Nephrology and Transplantation, Necker University Hospital for Sick Children, AP-HP, Paris, France
| | - Magali Giral
- Department of Nephrology and Transplantation, Nantes University Hospital Centre, Nantes, France
| | - Nadia Arzouk
- Department of Nephrology and Transplantation, Pitié Salpêtrière University Hospital, AP-HP, Paris, France
| | - Dominique Bertrand
- Department of Nephrology and Transplantation, Rouen University Hospital Centre, Rouen, France
| | - Marie-Noëlle Peraldi
- Department of Nephrology and Transplantation, Saint-Louis Hospital, AP-HP, Paris, France
| | - Laurent Mesnard
- Department of Nephrology and Transplantation, Tenon Hospital, AP-HP, Paris, France
| | - Helene Longuet
- Department of Nephrology and Transplantation, Tours University Hospital Centre, Tours, France
| | - Mehdi Maanaoui
- Department of Nephrology and Transplantation, Lille University Hospital Centre, Lille, France
| | - Geoffroy Desbuissons
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Edouard Lefevre
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Renaud Snanoudj
- Department of Nephrology and Transplantation, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
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3
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Knight SR, O’Callaghan JM. Transplant Trial Watch. Transpl Int 2024; 37:12711. [PMID: 38389709 PMCID: PMC10883077 DOI: 10.3389/ti.2024.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Simon R. Knight
- Oxford Transplant Centre, Churchill Hospital, Oxford, United Kingdom
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - John M. O’Callaghan
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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4
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Johnson AC, Zhang J, Karadkhele G, Gragert L, Hertzberg V, Larsen CP. Belatacept with time-limited tacrolimus coimmunosuppression modifies the 3-year risk of eplet mismatch in kidney transplantation. Am J Transplant 2024; 24:260-270. [PMID: 37778459 PMCID: PMC10842047 DOI: 10.1016/j.ajt.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
Solid organ transplant donor-recipient eplet mismatch has been correlated with donor-specific antibody (DSA) formation, antibody-mediated rejection, and overall rejection rates. However, studies have been predominantly in patients on tacrolimus-based immunosuppression regimens and have not fully explored differences in ethnically and racially diverse populations. Evidence indicates that patients on belatacept have lower rates of DSA formation, suggesting mediation of the immunogenicity of mismatched human leukocyte antigen polymorphisms. We performed a retrospective, single-center analysis of class II eplet disparity in a cohort of kidney transplant recipients treated using belatacept with tacrolimus induction (Bela/TacTL) or tacrolimus regimens between 2016 and 2019. Bela/TacTL (n = 294) and tacrolimus (n = 294) cohorts were propensity score-matched with standardized difference <0.15. Single-molecule eplet risk level was associated with immune event rates for both groups. In Cox regression analysis stratified by eplet risk level, Bela/TacTL immunosuppression was associated with a decreased rate of DSA (hazard ratio [HR] = 0.4), antibody-mediated rejection (HR = 0.2), and rejection (HR = 0.45). In the low-risk group, cumulative graft failure was lower for patients on Bela/TacTL (P < .02). Analysis of eplet mismatch burden may be a useful adjunct in identifying high-risk populations with increased immunosuppression requirements and should encourage the design of allocation rules to incentivize lower-risk pairings without negatively impacting equity in access.
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Affiliation(s)
- Aileen C Johnson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joan Zhang
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Geeta Karadkhele
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Loren Gragert
- Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Vicki Hertzberg
- Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Christian P Larsen
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
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5
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Bredewold OW, van Oeveren-Rietdijk AM, Florijn B, Rotmans JI, de Fijter JW, van Kooten C, van Zonneveld AJ, de Boer HC. Conversion from calcineurin inhibitors to belatacept-based immunosuppressive therapy skews terminal proliferation of non-classical monocytes and lowers lymphocyte counts. Transpl Immunol 2024; 82:101976. [PMID: 38199271 DOI: 10.1016/j.trim.2023.101976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/26/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024]
Abstract
Belatacept, a modified form of CTLA-Ig that blocks CD28-mediated co-stimulation of T cells, is an immune-suppressant that can be used as an alternative to calcineurin inhibitors (CNIs). In kidney transplant recipients, belatacept has been associated with improved renal function and reduced cardiovascular toxicity. Monocytes as well as T-lymphocytes play causal roles in the pathophysiology of atherosclerotic disease. We hypothesized that the beneficial impact of the use of belatacept over CNIs on cardiovascular risk could be partly explained by the impact of belatacept therapy on these circulating leukocytes. Hence, we phenotyped circulating leukocytes in transplanted patients with a stable renal function that were randomized between either continuation of CNI or conversion to belatacept in two international studies in which we participated. In 41 patients, we found that belatacept-treated patients consistently showed lower numbers of B-lymphocytes, T-lymphocytes as well as CD14-negative monocytes (CD14NM), especially in non-diabetic patients. Our observation that this decrease was associated to plasma concentrations of TNFα is consistent with a model where CD14NM-production of TNFα is diminished by belatacept-treatment, due to effects on the antigen-presenting cell compartment.
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Affiliation(s)
- O W Bredewold
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands..
| | - A M van Oeveren-Rietdijk
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - B Florijn
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - J I Rotmans
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - J W de Fijter
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - C van Kooten
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - A J van Zonneveld
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - H C de Boer
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
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6
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DiToro D, Murakami N, Pillai S. T-B Collaboration in Autoimmunity, Infection, and Transplantation. Transplantation 2024; 108:386-398. [PMID: 37314442 DOI: 10.1097/tp.0000000000004671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We have attempted here to provide an up-to-date review of the collaboration between helper T cells and B cells in response to protein and glycoprotein antigens. This collaboration is essential as it not only protects from many pathogens but also contributes to a litany of autoimmune and immune-mediated diseases.
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Affiliation(s)
- Daniel DiToro
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, MA
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Naoka Murakami
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Shiv Pillai
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, MA
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7
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Fida N, Eagar TN, Yun AN, Rogers AW, Nguyen DT, Graviss EA, Ishaq F, DiPaola NR, Kim J, Janardhana G, Kassi M, Yousefzai R, Suarez EE, Bhimaraj A, Krisl JC, Guha A. Effectiveness of combined plasma cell therapy and costimulation blockade based desensitization regimen in heart transplant candidates. Clin Transplant 2024; 38:e15249. [PMID: 38369810 DOI: 10.1111/ctr.15249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Desensitization is one of the strategies to reduce antibodies and facilitate heart transplantation in highly sensitized patients. We describe our center's desensitization experience with combination of plasma cell (PC) depletion therapy (with proteasome inhibitor or daratumumab) and costimulation blockade (with belatacept). METHODS We reviewed five highly sensitized patients who underwent desensitization therapy with plasma cell depletion and costimulation blockade. We evaluated the response to therapy by measuring the changes in cPRA, average MFI, and number of positive beads > 5000MFI. RESULTS Five patients, mean age of 56 (37-66) years with average cPRA of 98% at 5000 MFI underwent desensitization therapy. After desensitization, mean cPRA decreased from 98% to 70% (p = .09), average number of beads > 5000 MFI decreased from 59 to 37 (p = .15), and average MFI of beads > 5000 MFI decreased from 16713 to 13074 (p = .26). CONCLUSION Combined PC depletion and CoB could be a reasonable strategy for sustained reduction in antibodies in highly sensitized patients being listed for heart transplantation.
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Affiliation(s)
- Nadia Fida
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Todd N Eagar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Allison N Yun
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Alex W Rogers
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Institute for Academic Medicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Farhan Ishaq
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Nicholas R DiPaola
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Ju Kim
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Gorthi Janardhana
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Rayan Yousefzai
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Eric E Suarez
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Jill C Krisl
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
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8
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Schrezenmeier E, Dörner T, Halleck F, Budde K. Cellular Immunobiology and Molecular Mechanisms in Alloimmunity-Pathways of Immunosuppression. Transplantation 2024; 108:148-160. [PMID: 37309030 DOI: 10.1097/tp.0000000000004646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Current maintenance immunosuppression commonly comprises a synergistic combination of tacrolimus as calcineurin inhibitor (CNI), mycophenolic acid, and glucocorticoids. Therapy is often individualized by steroid withdrawal or addition of belatacept or inhibitors of the mechanistic target of rapamycin. This review provides a comprehensive overview of their mode of action, focusing on the cellular immune system. The main pharmacological action of CNIs is suppression of the interleukin-2 pathway that leads to inhibition of T cell activation. Mycophenolic acid inhibits the purine pathway and subsequently diminishes T and B cell proliferation but also exerts a variety of effects on almost all immune cells, including inhibition of plasma cell activity. Glucocorticoids exert complex regulation via genomic and nongenomic mechanisms, acting mainly by downregulating proinflammatory cytokine signatures and cell signaling. Belatacept is potent in inhibiting B/T cell interaction, preventing formation of antibodies; however, it lacks the potency of CNIs in preventing T cell-mediated rejections. Mechanistic target of rapamycin inhibitors have strong antiproliferative activity on all cell types interfering with multiple metabolic pathways, partly explaining poor tolerability, whereas their superior effector T cell function might explain their benefits in the case of viral infections. Over the past decades, clinical and experimental studies provided a good overview on the underlying mechanisms of immunosuppressants. However, more data are needed to delineate the interaction between innate and adaptive immunity to better achieve tolerance and control of rejection. A better and more comprehensive understanding of the mechanistic reasons for failure of immunosuppressants, including individual risk/benefit assessments, may permit improved patient stratification.
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Affiliation(s)
- Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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9
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Kitchens WH, Larsen CP, Badell IR. Costimulatory Blockade and Solid Organ Transplantation: The Past, Present, and Future. Kidney Int Rep 2023; 8:2529-2545. [PMID: 38106575 PMCID: PMC10719580 DOI: 10.1016/j.ekir.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/01/2023] [Accepted: 08/28/2023] [Indexed: 12/19/2023] Open
Abstract
Belatacept is the first costimulatory blockade agent clinically approved for transplant immunosuppression. Although more than 10 years of study have demonstrated that belatacept offers superior long-term renal allograft and patient survival compared to conventional calcineurin inhibitor (CNI)-based immunosuppression regimens, the clinical adoption of belatacept has continued to lag because of concerns of an early risk of acute cellular rejection (ACR) and various logistical barriers to its administration. In this review, the history of the clinical development of belatacept is examined, along with the findings of the seminal BENEFIT and BENEFIT-EXT trials culminating in the clinical approval of belatacept. Recent efforts to incorporate belatacept into novel CNI-free immunosuppression regimens are reviewed, as well as the experience of the Emory Transplant Center in using a tapered course of low-dose tacrolimus in belatacept-treated renal allograft patients to garner the long-term outcome benefits of belatacept without the short-term increased risks of ACR. Potential avenues to increase the clinical adoption of belatacept in the future are explored, including surmounting the logistical barriers of belatacept administration through subcutaneous administration or more infrequent belatacept dosing. In addition, belatacept conversion strategies and potential expanded clinical indications of belatacept are discussed for pediatric transplant recipients, extrarenal transplant recipients, treatment of antibody-mediated rejection (AMR), and in patients with failed renal allografts. Finally, we discuss the novel immunosuppressive drugs currently in the development pipeline that may aid in the expansion of costimulation blockade utilization.
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Affiliation(s)
- William H. Kitchens
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - I. Raul Badell
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Moein M, Dvorai RH, Li BW, Fioramonti PJ, Schilsky JB, Thankachan R, Yang C, Saidi RF, Shahbazov R. Early conversion to belatacept-based immunosuppression regimen promotes improved long-term renal graft function in kidney transplant recipients. Transpl Immunol 2023; 80:101882. [PMID: 37392898 DOI: 10.1016/j.trim.2023.101882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Belatacept has been demonstrated as an effective alternative immunosuppressant in kidney transplant recipients. This study focuses on outcomes of early and late conversion to Belatacept-based immunosuppression after kidney transplant. MATERIALS AND METHODS This retrospective analysis of a prospectively collected database included all adult kidney transplants patients at SUNY Upstate Medical Hospital from 1 January 2014 to 30 December 2022. Early conversion was defined as all conversions done at <6 months after kidney transplantation, and late conversion to belatacept was defined as conversion at >6 months after kidney transplantation. RESULTS Out of 61 patients included in this study, 33 patients (54%) were in the early conversion group, and 28 patients (46%) were in the late conversion group. The mean eGFR in the early conversion group was 26.73 ± 16.26 ml/min/1.73 m2 before conversion to belatacept, which improved to 45.3 ± 21.01 ml/min/1.73 m2 at one-year post-conversion (p = 0.0006). Furthermore, eGFR changes in the late conversion group were insignificant, with 46.30 ± 15.65 ml/min/1.73 m2 before conversion to belatacept, and 44.76 ± 22.91 ml/min/1.73 m2 after one year of follow-up (p = 0.72). All four biopsy-proven allograft rejections in the early conversion group were acute T-cell-mediated rejections (ATMR). In the late conversion group, out of three biopsy-proven rejections, one was chronic antibody-mediated rejection (CAMR), one was ATMR, and one was mixed ATMR/CAMR. All four patients with ATMR rejection received mycophenolic acid (MPA) as part of their immunosuppressive regimen, and none received tacrolimus. The one-year post-conversion allograft survival rate in early and late conversion groups was 100%. However, the one-year post-conversion patient survival rate was 90.9% in the early conversion group and 100% in the late conversion group (P = 0.11). CONCLUSIONS Early post-transplant conversion to belatacept can improve the eGFR more meaningful when compared to late conversion. Patients who receive belatacept and MPA rather than tacrolimus may have increased rates of T-cell-mediated rejection.
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Affiliation(s)
- Mahmoudreza Moein
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Reut Hod Dvorai
- Department of Pathology and Laboratory Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Benson W Li
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - P J Fioramonti
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Juliana B Schilsky
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Reeba Thankachan
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Christine Yang
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Reza F Saidi
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Rauf Shahbazov
- Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, NY, USA.
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11
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Zeng S, Crichton ES, Ford ML, Badell IR. Memory T follicular helper cells drive donor-specific antibodies independent of memory B cells and primary germinal center and alloantibody formation. Am J Transplant 2023; 23:1511-1525. [PMID: 37302575 DOI: 10.1016/j.ajt.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
Human leukocyte antigen antibodies are important immunologic mediators of renal allograft loss and are difficult to control. The inability to permanently eliminate donor-specific antibodies (DSA) is partly due to an incomplete understanding of the cellular mechanisms driving alloantibody formation, recurrence, and maintenance. Memory T follicular helper (mTfh) cells rapidly interact with memory B cells upon antigen re-exposure for anamnestic humoral responses, but little is known about Tfh memory in transplantation. We hypothesized that alloreactive mTfh cells form after transplantation and play a critical role in DSA formation following alloantigen re-encounter. To test this hypothesis, we utilized murine skin allograft models to identify and characterize Tfh memory and interrogate its ability to mediate alloantibody responses. We identified alloreactive Tfh memory as a mediator of accelerated humoral alloresponses independent of memory B cells and primary germinal center, or DSA, formation. Furthermore, we demonstrate that mTfh-driven alloantibody formation is susceptible to CD28 costimulation blockade. These findings provide novel insight into a pathologic role for memory Tfh in alloantibody responses and strongly support shifting therapeutic focus from the singular targeting of B cell lineage cells and alloantibodies themselves to multimodal strategies that include inhibition of mTfh cells to treat DSA.
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Affiliation(s)
- Shan Zeng
- Emory Transplant Center, Atlanta, Georgia, USA
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12
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Anwar IJ, Berman DM, DeLaura I, Gao Q, Willman MA, Miller A, Gill A, Gill C, Perrin S, Ricordi C, Ruiz P, Song M, Ladowski JM, Kirk AD, Kenyon NS. The anti-CD40L monoclonal antibody AT-1501 promotes islet and kidney allograft survival and function in nonhuman primates. Sci Transl Med 2023; 15:eadf6376. [PMID: 37647390 PMCID: PMC10990482 DOI: 10.1126/scitranslmed.adf6376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
Prior studies of anti-CD40 ligand (CD40L)-based immunosuppression demonstrated effective prevention of islet and kidney allograft rejection in nonhuman primate models; however, clinical development was halted because of thromboembolic complications. An anti-CD40L-specific monoclonal antibody, AT-1501 (Tegoprubart), was engineered to minimize risk of thromboembolic complications by reducing binding to Fcγ receptors expressed on platelets while preserving binding to CD40L. AT-1501 was tested in both a cynomolgus macaque model of intrahepatic islet allotransplantation and a rhesus macaque model of kidney allotransplantation. AT-1501 monotherapy led to long-term graft survival in both islet and kidney transplant models, confirming its immunosuppressive potential. Furthermore, AT-1501-based regimens after islet transplant resulted in higher C-peptide, greater appetite leading to weight gain, and reduced occurrence of cytomegalovirus reactivation compared with conventional immunosuppression. These data support AT-1501 as a safe and effective agent to promote both islet and kidney allograft survival and function in nonhuman primate models, warranting further testing in clinical trials.
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Affiliation(s)
- Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Dora M. Berman
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Qimeng Gao
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | | | - Allison Miller
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Alan Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | - Cindy Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | | | - Camillo Ricordi
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
- Department of Medicine, University of Miami; Miami, FL 33136, USA
| | - Philip Ruiz
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Joseph M Ladowski
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Allan D. Kirk
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
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Petrossian G, Ortiz J, Ortiz AC, Addonizio K, Hsiao A, James R, Koizumi N, Patel S, Plews R. Increased CMV disease and "severe" BK viremia with belatacept vs. sirolimus three-drug maintenance immunosuppression. Transpl Immunol 2023; 79:101857. [PMID: 37201797 DOI: 10.1016/j.trim.2023.101857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/09/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Belatacept may provide benefit in delayed graft function, but its association with infectious complications is understudied. We aim to assess the incidence of CMV and BK viremia in patients treated with sirolimus or belatacept as part of a three-drug immunosuppression regimen after kidney transplantation. MATERIALS AND METHODS Kidney transplant recipients from 01/01/2015 to 10/01/2021 were retrospectively reviewed. Maintenance immunosuppression was either tacrolimus, mycophenolate and sirolimus (B0) or tacrolimus, mycophenolate, and belatacept (5.0 mg/kg monthly) (B1). Primary outcomes of interest were BK and CMV viremia which were followed until the end of the study period. Secondary outcomes included graft function (serum creatinine, eGFR) and acute rejection through 12 months. RESULTS Belatacept was initiated in patients with a higher mean kidney donor profile index (B0:0.36 vs. B1:0.44, p = .02) with more delayed graft function (B0:6.1% vs. B1:26.1%, p < .001). Belatacept therapy was associated with more "severe" CMV viremia >25,000 copies/mL (B0:1.2% vs. B1:5.9%, p = .016) and CMV disease (B0:0.41% vs. B1:4.2%, p = .015). However, there was no difference in the overall incidence of CMV viremia >200 IU/mL (B0:9.4% vs. B1:13.5%, p = .28). There was no difference in the incidence of BK viremia >200 IU/mL (B0:29.7% vs. B1:31.1%, p = .78) or BK-associated nephropathy (B0:2.4% vs. B1:1.7%, p = .58), but belatacept was associated with "severe" BK viremia, defined as >10,000 IU/mL (B0:13.0% vs. B1:21.8%, p = .03). The mean serum Cr was significantly higher with belatacept therapy at 1-year follow up (B0:1.24 mg/dL vs. B1:1.43 mg/dL, p = .003). Biopsy-proven acute rejection (B0:1.2% vs. B1:2.6%, p = .35) and graft loss (B0:1.2% vs. B1:0.84%, p = .81) were comparable at 12 months. CONCLUSIONS Belatacept therapy was associated with an increased risk of CMV disease and "severe" CMV and BK viremia. However, this regimen did not increase the overall incidence of infection and facilitated comparable acute rejection and graft loss at 12-month follow up.
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Affiliation(s)
| | - Jorge Ortiz
- Eerie County Medical Center, Buffalo, NY, United States of America
| | | | | | | | - Rosy James
- George Mason University, Fairfax, VA, United States of America
| | - Naoru Koizumi
- George Mason University, Fairfax, VA, United States of America
| | - Sunil Patel
- University Medical Center of Southern Nevada, Las Vegas, NV, United States of America
| | - Robert Plews
- University of Cincinnati, Cincinnati, OH, United States of America
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Herr F, Dekeyser M, Le Pavec J, Desterke C, Chiron AS, Bargiel K, Mercier O, Vernochet A, Fadel E, Durrbach A. mTOR Inhibition Impairs the Activation and Function of Belatacept-Resistant CD4 +CD57 + T Cells In Vivo and In Vitro. Pharmaceutics 2023; 15:pharmaceutics15041299. [PMID: 37111784 PMCID: PMC10142381 DOI: 10.3390/pharmaceutics15041299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Calcineurin inhibitors have improved graft survival in solid-organ transplantation but their use is limited by toxicity, requiring a switch to another immunosuppressor in some cases. Belatacept is one option that has been shown to improve graft and patient survival despite being associated with a higher risk of acute cellular rejection. This risk of acute cellular rejection is correlated with the presence of belatacept-resistant T cells. We performed a transcriptomic analysis of in vitro-activated cells to identify pathways affected by belatacept in belatacept-sensitive cells (CD4+CD57-) but not in belatacept-resistant CD4+CD57+ T cells. mTOR was significantly downregulated in belatacept-sensitive but not belatacept-resistant T cells. The inhibition of mTOR strongly decreases the activation and cytotoxicity of CD4+CD57+ cells. In humans, the use of a combination of mTOR inhibitor and belatacept prevents graft rejection and decreases the expression of activation markers on CD4 and CD8 T cells. mTOR inhibition decreases the functioning of belatacept-resistant CD4+CD57+ T cells in vitro and in vivo. It could potentially be used in association with belatacept to prevent acute cellular rejection in cases of calcineurin intolerance.
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Affiliation(s)
- Florence Herr
- Institut Gustave Roussy, Inserm, Immunologie Intégrative des Tumeurs et Immunothérapie des Cancers, Université Paris-Saclay, 94805 Villejuif, France
| | - Manon Dekeyser
- Institut Gustave Roussy, Inserm, Immunologie Intégrative des Tumeurs et Immunothérapie des Cancers, Université Paris-Saclay, 94805 Villejuif, France
- Hôpital Henri Mondor, Service de Néphrologie, Assistance Publique-Hôpitaux de Paris, 94010 Creteil, France
| | - Jerome Le Pavec
- Inserm, Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique, Université Paris-Saclay, 92350 Le Plessis Robinson, France
- Centre Hospitalier Marie Lannelongue, 92350 Le Plessis Robinson, France
| | - Christophe Desterke
- Inserm, Modèles de Cellules Souches Malignes et Thérapeutiques, Université Paris-Saclay, 94805 Villejuif, France
| | - Andrada-Silvana Chiron
- Unité des Technologies Chimiques et Biologiques pour la Santé, CNRS, INSERM, UTCBS, Université de Paris, 75006 Paris, France
- Clinical Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, 94270 Le Kremlin-Bicetre, France
| | - Karen Bargiel
- Institut Gustave Roussy, Inserm, Immunologie Intégrative des Tumeurs et Immunothérapie des Cancers, Université Paris-Saclay, 94805 Villejuif, France
| | - Olaf Mercier
- Inserm, Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique, Université Paris-Saclay, 92350 Le Plessis Robinson, France
- Centre Hospitalier Marie Lannelongue, 92350 Le Plessis Robinson, France
| | - Amelia Vernochet
- Institut Gustave Roussy, Inserm, Immunologie Intégrative des Tumeurs et Immunothérapie des Cancers, Université Paris-Saclay, 94805 Villejuif, France
| | - Elie Fadel
- Inserm, Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique, Université Paris-Saclay, 92350 Le Plessis Robinson, France
- Centre Hospitalier Marie Lannelongue, 92350 Le Plessis Robinson, France
| | - Antoine Durrbach
- Institut Gustave Roussy, Inserm, Immunologie Intégrative des Tumeurs et Immunothérapie des Cancers, Université Paris-Saclay, 94805 Villejuif, France
- Hôpital Henri Mondor, Service de Néphrologie, Assistance Publique-Hôpitaux de Paris, 94010 Creteil, France
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15
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Three-year Outcomes After Conversion From Monthly to Every 2-month Belatacept Maintenance Therapy in Kidney Transplant Recipients: Results From a Randomized Controlled Trial. Transplant Direct 2023; 9:e1449. [PMID: 36875938 PMCID: PMC9977481 DOI: 10.1097/txd.0000000000001449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/14/2022] [Accepted: 01/07/2023] [Indexed: 02/11/2023] Open
Abstract
Maintenance immunosuppression with belatacept following kidney transplantation results in improved long-term graft function as compared with calcineurin inhibitors. However, broad application of belatacept has been limited, in part related to logistical barriers surrounding a monthly (q1m) infusion requirement. Methods To determine whether every 2-mo (q2m) belatacept is noninferior to standard q1m maintenance, we conducted a prospective, single-center randomized trial in low-immunologic-risk, stable renal transplant recipients. Here, post hoc analysis of 3-y outcomes, including renal function and adverse events, are reported. Results One hundred sixty-three patients received treatment in the q1m control group (n = 82) or q2m study group (n = 81). Renal allograft function as measured by baseline-adjusted estimated glomerular filtration rate was not significantly different between groups (time-averaged mean difference of 0.2 mL/min/1.73 m2; 95% confidence interval: -2.5, 2.9). There were no statistically significant differences in time to death or graft loss, freedom from rejection, or freedom from donor-specific antibodies (DSAs). During the extended 12- to 36-mo follow-up, 3 deaths, 1 graft loss occurred in the q1m group, compared with 2 deaths, and 2 graft losses in the q2m group. In the q1m group, 1 patient developed DSAs and acute rejection. In the q2m group, 3 patients developed DSAs and 2 associated with acute rejection. Conclusions Based on the similar renal function and survival at 36 mo compared with q1m, q2m belatacept is a potentially viable maintenance immunosuppressive strategy in low immunologic risk kidney transplant recipients that may facilitate increased clinical utilization of costimulation blockade-based immunosuppression.
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16
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Bertrand D, Matignon M, Morel A, Ludivine L, Lemoine M, Hanoy M, Roy FL, Nezam D, Hamzaoui M, de Nattes T, Moktefi A, François A, Laurent C, Etienne I, Guerrot D. Belatacept rescue conversion in kidney transplant recipients with vascular lesions (Banff cv score >2): a retrospective cohort study. Nephrol Dial Transplant 2023; 38:481-490. [PMID: 35544123 DOI: 10.1093/ndt/gfac178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Immunosuppression in kidney transplant recipients with decreased graft function and histological vascular changes can be particularly challenging. The impact of a late rescue conversion to belatacept on kidney graft survival in this context has never been studied. METHODS We report a bicentric retrospective cohort study comparing a calcineurin inhibitor (CNI) to belatacept switch versus CNI continuation in 139 kidney transplant recipients with histological kidney vascular damage (cv ≥2, g + cpt ≤1, i + t ≤1) and low estimated glomerular filtration rate (≤40 mL/min/1.73 m²). Primary outcome was death-censored graft survival. RESULTS During the study follow-up, 10 graft losses (14.5%) occurred in the belatacept group (n = 69) versus 26 (37.1%) in the matched CNI group (n = 70) (P = .005). Death-censored graft survival was significantly higher in the belatacept group (P = .001). At 3 years, graft survival was 84.0% in the belatacept group compared with 65.1% in the control group. Continuing CNI was an independent risk factor for graft loss [hazard ratio (HR) 3.46; P < .005]. The incidence of cellular rejection after the conversion was low (4.3% in both groups) and not significantly different between groups (P = .84). Patients switched to belatacept developed significantly less donor-specific antibodies de novo. Belatacept was an independent risk factor for the occurrence of opportunistic infections (HR 4.84; P < .005). CONCLUSION The replacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in graft survival and represents a valuable option in a context of organ shortage. Caution should be exercised regarding the increased risk of opportunistic infection.
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Affiliation(s)
- Dominique Bertrand
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Marie Matignon
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - Antoine Morel
- Nephrology and Transplantation Department, Cancerology-Immunity-Transplantation-Infectiology, Clinical Investigation Center-Biotherapies, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U955, Paris-Est-Créteil University, Paris, France
| | - Lebourg Ludivine
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mathilde Lemoine
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mélanie Hanoy
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Frank Le Roy
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Dorian Nezam
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mouad Hamzaoui
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Tristan de Nattes
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Anissa Moktefi
- Department of Pathology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est-Créteil University, Paris, France
| | | | - Charlotte Laurent
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Isabelle Etienne
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Dominique Guerrot
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France.,INSERM U1096, Normandie Univ, UNIROUEN, Rouen, France
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17
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Abstract
Access to kidney transplantation is limited by HLA-specific sensitization. Desensitization strategies enable crossmatch-positive kidney transplantation. In this review, we describe clinical experience gained over the last 20 y using desensitization strategies before kidney transplantation and describe the different tools used (both drugs and apheresis options), including IVIg, rituximab, apheresis techniques, interleukin-6 interference, proteasome inhibition, enzymatic degradation of HLA antibodies, complement inhibition, and B cytokine interference. Although access to transplantation for highly sensitized kidney transplantation candidates has been vastly improved by desensitization strategies, it remains, however, limited by the recurrence of HLA antibodies after transplantation and the occurrence of antibody-mediated rejection.
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18
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Peddi VR, Marder B, Gaite L, Oberholzer J, Goldberg R, Pearson T, Yang H, Allamassey L, Polinsky M, Formica RN. Treatment of De Novo Renal Transplant Recipients With Calcineurin Inhibitor-free, Belatacept Plus Everolimus-based Immunosuppression. Transplant Direct 2023; 9:e1419. [PMID: 36700062 PMCID: PMC9820789 DOI: 10.1097/txd.0000000000001419] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/03/2022] [Indexed: 01/27/2023] Open
Abstract
Compared with calcineurin inhibitor-based immunosuppression, belatacept (BELA)-based treatment has been associated with better renal function but higher acute rejection rates. This phase 2 study (NCT02137239) compared the antirejection efficacy of BELA plus everolimus (EVL) with tacrolimus (TAC) plus mycophenolate mofetil (MMF), each following lymphocyte-depleting induction and rapid corticosteroid withdrawal. Methods Patients who were de novo renal transplant recipients seropositive for Epstein-Barr virus were randomized to receive BELA+EVL or TAC+MMF maintenance therapy after rabbit antithymocyte globulin induction and up to 7 d of corticosteroids. The primary endpoint was the rate of biopsy-proven acute rejection at month 6. Results Because of an unanticipated BELA supply constraint, enrollment was prematurely terminated at 68 patients, of whom 58 were randomized and transplanted (intention-to-treat [ITT] population: n = 26, BELA+EVL; n = 32, TAC+MMF). However, 25 patients received BELA+EVL' and 33 received TAC+MMF (modified ITT population). In the ITT population, the 6-mo biopsy-proven acute rejection rates were 7.7% versus 9.4% in the BELA+EVL versus TAC+MMF group. The corresponding 24-mo biopsy-proven acute rejection rates were 19.2% versus 12.5% in the ITT population and 16.0% versus 15.2% in the mITT population; all events were Banff severity grade ≤IIA and similar between groups. One patient in each group experienced graft loss unrelated to acute rejection. The 24-mo mean unadjusted estimated glomerular filtration rates were 71.8 versus 68.7 mL/min/1.73 m2 in the BELA+EVL versus TAC+MMF groups. Posttransplant lymphoproliferative disorder was reported for 1 patient in each group. No deaths or unexpected adverse events were observed. Conclusions A steroid-free maintenance regimen of BELA+EVL may be associated with biopsy-proven acute rejection rates comparable to TAC+MMF.
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Affiliation(s)
- V. Ram Peddi
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA
| | - Bradley Marder
- Division of Transplant Research, Colorado Kidney Care, Denver, CO
| | - Luis Gaite
- Sección Hepatología, Clinica de Nefrología, Santa Fe, Argentina
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Ryan Goldberg
- Renal and Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ
| | - Thomas Pearson
- Emory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Harold Yang
- Department of Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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20
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Unger LW, Muckenhuber M, Mahr B, Schwarz C, Pilat N, Granofszky N, Regele H, Wekerle T. Chronic CD40L blockade is required for long-term cardiac allograft survival with a clinically relevant CTLA4-Ig dosing regimen. Front Immunol 2022; 13:1060576. [PMID: 36569922 PMCID: PMC9773869 DOI: 10.3389/fimmu.2022.1060576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction In de-novo kidney transplantation, the CTLA4-Ig fusion protein belatacept is associated with improved graft function but also an increased risk of acute rejection compared to calcineurin inhibitor therapy. The combination with a second costimulation blocker could potentially improve outcome while avoiding calcineurin inhibitor toxicity. The aim of this study was to define the conditions under which the combination of CTLA4-Ig and CD40L blockade leads to rejection-free permanent graft survival in a stringent murine heart transplantation model. Methods Naïve wild-type or CD40L (CD154) knock-out mice received a fully mismatched BALB/c cardiac allograft. Selected induction and maintenance protocols for CTLA4-Ig and blocking αCD40L monoclonal antibodies (mAB) were investigated. Graft survival, rejection severity and donor-specific antibody (DSA) formation were assessed during a 100-day follow-up period. Results and Discussion Administering αCD40L mAb as monotherapy at the time of transplantation significantly prolonged heart allograft survival but did not further improve the outcome when given in addition to chronic CTLA4-Ig therapy (which prolongs graft survival to a median of 22 days). Likewise, chronic αCD40L mAb therapy (0.5mg) combined with perioperative CTLA4-Ig led to rejection in a proportion of mice and extensive histological damage, despite abrogating DSA formation. Only the permanent interruption of CD40-CD40L signaling by using CD40L-/- recipient mice or by chronic αCD40L administration synergized with chronic CTLA4-Ig to achieve long-term allograft survival with preserved histological graft integrity in all recipients without DSA formation. The combination of α-CD40L and CTLA4-Ig works most effectively when both therapeutics are administered chronically.
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Affiliation(s)
- Lukas W. Unger
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria,Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Moritz Muckenhuber
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Benedikt Mahr
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Christoph Schwarz
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria,Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Nina Pilat
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Nicolas Granofszky
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Thomas Wekerle
- Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria,*Correspondence: Thomas Wekerle,
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21
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Kervella D, Blancho G. New immunosuppressive agents in transplantation. Presse Med 2022; 51:104142. [PMID: 36252821 DOI: 10.1016/j.lpm.2022.104142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
Immunosuppressive agents have enabled the development of allogenic transplantation during the last 40 years, allowing considerable improvement in graft survival. However, several issues remain such as the nephrotoxicity of calcineurin inhibitors, the cornerstone of immunosuppressive regimens and/or the higher risk of opportunistic infections and cancers. Most immunosuppressive agents target T cell activation and may not be efficient enough to prevent allo-immunization in the long term. Finally, antibody mediated rejection due to donor specific antibodies strongly affects allograft survival. Many drugs have been tested in the last decades, but very few have come to clinical use. The most recent one is CTLA4-Ig (belatacept), a costimulation blockade molecule that targets the second signal of T cell activation and is associated with a better long term kidney function than calcineurin inhibitors, despite an increased risk of acute cellular rejection. The research of new maintenance long-term immunosuppressive agents focuses on costimulation blockade. Agents inhibiting CD40-CD40 ligand interaction may enable a good control of both T cells and B cells responses. Anti-CD28 antibodies may promote regulatory T cells. Agents targeting this costimulation pathways are currently evaluated in clinical trials. Immunosuppressive agents for ABMR treatment are scarce since anti-CD20 agent rituximab and proteasome inhibitor bortezomib have failed to demonstrate an interest in ABMR. New drugs focusing on antibodies removal (imlifidase), B cell and plasmablasts (anti-IL-6/IL-6R, anti-CD38…) and complement inhibition are in the pipeline, with the challenge of their evaluation in such a heterogeneous pathology.
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Affiliation(s)
- Delphine Kervella
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Gilles Blancho
- CHU Nantes, Nantes Université, Service de Néphrologie et d'immunologie clinique, ITUN, Nantes, France; Nantes Université, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France.
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22
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Bharadwaj P, Shrestha S, Pongracz T, Concetta C, Sharma S, Le Moine A, de Haan N, Murakami N, Riella LV, Holovska V, Wuhrer M, Marchant A, Ackerman ME. Afucosylation of HLA-specific IgG1 as a potential predictor of antibody pathogenicity in kidney transplantation. Cell Rep Med 2022; 3:100818. [PMID: 36384101 PMCID: PMC9729883 DOI: 10.1016/j.xcrm.2022.100818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/23/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022]
Abstract
Antibody-mediated rejection (AMR) is the leading cause of graft failure. While donor-specific antibodies (DSAs) are associated with a higher risk of AMR, not all patients with DSAs develop rejection, suggesting that the characteristics of alloantibodies determining their pathogenicity remain undefined. Using human leukocyte antigen (HLA)-A2-specific antibodies as a model, we apply systems serology tools to investigate qualitative features of immunoglobulin G (IgG) alloantibodies including Fc-glycosylation patterns and FcγR-binding properties. Levels of afucosylated anti-A2 antibodies are elevated in seropositive patients, especially those with AMR, suggesting potential cytotoxicity via FcγRIII-mediated mechanisms. Afucosylation of both glycoengineered monoclonal and naturally glycovariant polyclonal serum IgG specific to HLA-A2 drives potentiated binding to, slower dissociation from, and enhanced signaling through FcγRIII, a receptor widely expressed on innate effector cells, and greater cytotoxicity against HLA-A2+ cells mediated by natural killer (NK) cells. Collectively, these results suggest that afucosylated DSA may be a biomarker of AMR and contribute to pathogenesis.
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Affiliation(s)
- Pranay Bharadwaj
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA
| | - Sweta Shrestha
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA
| | - Tamas Pongracz
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Catalano Concetta
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium,Department of Nephrology, Dialysis and Renal Transplantation, Hôpital Erasme, Université libre de Bruxelles, Bruxelles, Belgium
| | - Shilpee Sharma
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium
| | - Alain Le Moine
- Department of Nephrology, Dialysis and Renal Transplantation, Hôpital Erasme, Université libre de Bruxelles, Bruxelles, Belgium
| | - Noortje de Haan
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Naoka Murakami
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Vanda Holovska
- HLA Laboratory, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB), Hôpital Erasme ULB, Brussels, Belgium
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, the Netherlands
| | - Arnaud Marchant
- Institute for Medical Immunology, Université Libre de Bruxelles, Charleroi, Belgium
| | - Margaret E. Ackerman
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03755, USA,Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA,Corresponding author
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23
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Schaenman J, Rossetti M, Pickering H, Sunga G, Wilhalme H, Elashoff D, Zhang Q, Hickey M, Reddy U, Danovitch G, Reed EF, Bunnapradist S. Preservation of Antiviral Immunologic Efficacy Without Alloimmunity After Switch to Belatacept in Calcineurin Inhibitor-Intolerant Patients. Kidney Int Rep 2022; 8:126-140. [PMID: 36644348 PMCID: PMC9832066 DOI: 10.1016/j.ekir.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Belatacept has shown potential for prevention of rejection after kidney transplantation, given its demonstration of reduced nephrotoxicity in combination with absence of significant incidence of rejection. However, concerns have been raised regarding increased risk of viral infection. Methods We set out to explore the impact of the switch to belatacept on alloimmune and antiviral immunity through the study of patients switched from calcineurin inhibitor (CNI) to belatacept within 3 months of kidney transplantation compared with a matched cohort of control patients on a CNI-based regimen. Results After the switch to belatacept, immune phenotyping demonstrated a decrease in naive and an increase in terminally differentiated effector memory (TMRA) T cells, with no significant difference compared with control patients. Donor-specific immune response, measured by intracellular cytokine staining (ICS), did not change significantly either by single or double cytokine secretion, but it was associated with the appearance of donor-specific antibody (DSA) in the control but not the belatacept cohort (P = 0.039 for naive and P = 0.002 for TMRA subtypes). Increased incidence of de novo DSA development was observed in the control group (P = 0.035). Virus-specific immune response, as measured by ICS in response to cytomegalovirus (CMV) or Epstein-Barr virus (EBV), was similar in both groups and stable over time. Conclusion We found that belatacept use was associated with an absence of alloreactivity without impact on immune phenotype, while preserving the antiviral immune response, for patients switched from a CNI-based regimen. In parallel, the antiviral immune response against CMV and EBV was preserved after the belatacept switch (clinicaltrials.gov: NCT01953120).
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Disease, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gemalene Sunga
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Holly Wilhalme
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - David Elashoff
- Department of Medicine Biostatistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Qiuheng Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Michelle Hickey
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Uttam Reddy
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gabriel Danovitch
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Suphamai Bunnapradist
- Division of Kidney Transplantation, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA,Correspondence: Suuphamai Bunnapradist, 200 UCLA Medical Plaza, Suite 565, Los Angeles, CA 90095, USA.
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24
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Schmitz R, Fitch ZW, Manook M, Schroder PM, Choi AY, Olaso D, Yoon J, Bae Y, Shaw BI, Song M, Kuchibhatla M, Farris AB, Kirk A, Kwun J, Knechtle SJ. Belatacept-Based Maintenance Immunosuppression Controls the Post-Transplant Humoral Immune Response in Highly Sensitized Nonhuman Primates. KIDNEY360 2022; 3:2116-2130. [PMID: 36591367 PMCID: PMC9802566 DOI: 10.34067/kid.0001732022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
Preexisting donor-specific antibodies (DSA) to MHC antigens increase the risk of antibody-mediated rejection (AMR) in sensitized transplant recipients and reduces graft survival. Pretransplant desensitization with costimulation blockade and proteasome inhibition has facilitated transplantation in our preclinical nonhuman primate (NHP) model. However, long-term graft survival is limited by rebound of DSA after transplantation. In this study, we performed kidney transplants between highly sensitized, maximally MHC-mismatched NHPs (n=14). At kidney transplantation, primates received T cell depletion with rhesus-specific anti-thymocyte globulin (rhATG; n=10) or monoclonal anti-CD4 and anti-CD8 antibodies (n=4). Maintenance immunosuppression consisted of belatacept and tacrolimus (n=5) or belatacept and rapamycin (n=9) with steroids. Rebound of DSA post-kidney transplantation was significantly reduced compared with maintenance immunosuppression with tacrolimus, mycophenolate, and steroids. Protocol lymph node biopsy specimens showed a decrease in germinal center activity, with low frequencies of T follicular helper cells and class-switched B cells after kidney transplantation. Combined belatacept and rapamycin was superior in controlling viral reactivation, enabling weaning of ganciclovir prophylaxis. Tacrolimus was associated with increased morbidity that included cytomegalovirus and parvovirus viremia and post-transplant lymphoproliferative disorder. All primates in the tacrolimus/belatacept group failed discontinuation of antiviral therapy. Overall, belatacept-based immunosuppression increased AMR-free graft survival by controlling post-transplant humoral responses in highly sensitized NHP recipients and should be further investigated in a human clinical trial.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Zachary W. Fitch
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Miriam Manook
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Paul M. Schroder
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Ashley Y. Choi
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Danae Olaso
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Janghoon Yoon
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Yeeun Bae
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Brian I. Shaw
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Mingqing Song
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Alton B. Farris
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Kirk
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Jean Kwun
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
| | - Stuart J. Knechtle
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
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25
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Chong AS, Habal MV. From bench to bedside: reversing established antibody responses and desensitization. Curr Opin Organ Transplant 2022; 27:376-384. [PMID: 35950890 PMCID: PMC9474614 DOI: 10.1097/mot.0000000000001009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Basic transplant immunology has primarily focused on the definition of mechanisms, but an often-stated aspirational goal is to translate basic mechanistic research into future therapy. Pretransplant donor-specific antibodies (DSA) mediate hyperacute as well as early antibody-mediated rejection (AMR), whereas DSA developing late posttransplantation may additionally mediate chronic rejection. Although contemporary immunosuppression effectively prevents early cellular rejection after transplant in nonsensitized patients, it is less effective at controlling preexisting HLA antibody responses or reversing DSA once established, thus underscoring a need for better therapies. RECENT FINDINGS We here review the development of a bench-to-bedside approach involving transient proteasome inhibition to deplete plasma cells, combined with maintenance co-stimulation blockade, with CTLA-4Ig or belatacept, to prevent the generation of new antibody-secreting cells (ASCs). SUMMARY This review discusses how this treatment regimen, which was rationally designed and validated to reverse established DSA responses in mouse models, translated into reversing active AMR in the clinic, as well as desensitizing highly sensitized patients on the transplant waitlist.
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Affiliation(s)
- Anita S. Chong
- Department of Surgery, The University of Chicago, Chicago, Illinois, USA
| | - Marlena V. Habal
- Department of Medicine, Columbia University College of Medicine, New York, NY, USA
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26
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Rodriguez-Ramirez S, Al Jurdi A, Konvalinka A, Riella LV. Antibody-mediated rejection: prevention, monitoring and treatment dilemmas. Curr Opin Organ Transplant 2022; 27:405-414. [PMID: 35950887 PMCID: PMC9475491 DOI: 10.1097/mot.0000000000001011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Antibody-mediated rejection (AMR) has emerged as the leading cause of late graft loss in kidney transplant recipients. Donor-specific antibodies are an independent risk factor for AMR and graft loss. However, not all donor-specific antibodies are pathogenic. AMR treatment is heterogeneous due to the lack of robust trials to support clinical decisions. This review provides an overview and comments on practical but relevant dilemmas physicians experience in managing kidney transplant recipients with AMR. RECENT FINDINGS Active AMR with donor-specific antibodies may be treated with plasmapheresis, intravenous immunoglobulin and corticosteroids with additional therapies considered on a case-by-case basis. On the contrary, no treatment has been shown to be effective against chronic active AMR. Various biomarkers and prediction models to assess the individual risk of graft failure and response to rejection treatment show promise. SUMMARY The ability to personalize management for a given kidney transplant recipient and identify treatments that will improve their long-term outcome remains a critical unmet need. Earlier identification of AMR with noninvasive biomarkers and prediction models to assess the individual risk of graft failure should be considered. Enrolling patients with AMR in clinical trials to assess novel therapeutic agents is highly encouraged.
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Affiliation(s)
- Sonia Rodriguez-Ramirez
- Department of Medicine, Division of Nephrology
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana Konvalinka
- Department of Medicine, Division of Nephrology
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network
- Institute of Medical Science, University of Toronto
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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27
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Iglesias M, Brennan DC, Larsen CP, Raimondi G. Targeting inflammation and immune activation to improve CTLA4-Ig-based modulation of transplant rejection. Front Immunol 2022; 13:926648. [PMID: 36119093 PMCID: PMC9478663 DOI: 10.3389/fimmu.2022.926648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
For the last few decades, Calcineurin inhibitors (CNI)-based therapy has been the pillar of immunosuppression for prevention of organ transplant rejection. However, despite exerting effective control of acute rejection in the first year post-transplant, prolonged CNI use is associated with significant side effects and is not well suited for long term allograft survival. The implementation of Costimulation Blockade (CoB) therapies, based on the interruption of T cell costimulatory signals as strategy to control allo-responses, has proven potential for better management of transplant recipients compared to CNI-based therapies. The use of the biologic cytotoxic T-lymphocyte associated protein 4 (CTLA4)-Ig is the most successful approach to date in this arena. Following evaluation of the BENEFIT trials, Belatacept, a high-affinity version of CTLA4-Ig, has been FDA approved for use in kidney transplant recipients. Despite its benefits, the use of CTLA4-Ig as a monotherapy has proved to be insufficient to induce long-term allograft acceptance in several settings. Multiple studies have demonstrated that events that induce an acute inflammatory response with the consequent release of proinflammatory cytokines, and an abundance of allograft-reactive memory cells in the recipient, can prevent the induction of or break established immunomodulation induced with CoB regimens. This review highlights advances in our understanding of the factors and mechanisms that limit CoB regimens efficacy. We also discuss recent successes in experimentally designing complementary therapies that favor CTLA4-Ig effect, affording a better control of transplant rejection and supporting their clinical applicability.
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Affiliation(s)
- Marcos Iglesias
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christian P. Larsen
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Giorgio Raimondi
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
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28
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Wiedemann A, Pellaton C, Dekeyser M, Guillaumat L, Déchenaud M, Krief C, Lacabaratz C, Grimbert P, Pantaleo G, Lévy Y, Durrbach A. Longitudinal evaluation of the impact of immunosuppressive regimen on immune responses to COVID-19 vaccination in kidney transplant recipients. Front Med (Lausanne) 2022; 9:978764. [PMID: 36072955 PMCID: PMC9441691 DOI: 10.3389/fmed.2022.978764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/03/2022] [Indexed: 12/01/2022] Open
Abstract
Immunocompromised patients have a high risk of death from SARS-CoV-2 infection. Vaccination with an mRNA vaccine may protect these patients against severe COVID-19. Several studies have evaluated the impact of immune-suppressive drug regimens on cellular and humoral responses to SARS-CoV-2 variants of concern in this context. We performed a prospective longitudinal study assessing specific humoral (binding and neutralizing antibodies against spike (S) and T-lymphocyte (cytokine secretion and polyfunctionality) immune responses to anti-COVID-19 vaccination with at least two doses of BNT162b2 mRNA vaccine in stable kidney transplant recipients (KTR) on calcineurin inhibitor (CNI)- or belatacept-based treatment regimens. Fifty-two KTR−31 receiving CNI and 21 receiving belatacept—were enrolled in this study. After two doses of vaccine, 46.9% of patients developed anti-S IgG. Anti-spike IgG antibodies were produced in only 21.4% of the patients in the belatacept group, vs. 83.3% of those in the CNI group. The Beta and Delta variants and, more importantly, the Omicron variant, were less well neutralized than the Wuhan strain. T-cell functions were also much weaker in the belatacept group than in the CNI group. Renal transplant patients have an impaired humoral response to BNT162b2 vaccination. Belatacept-based regimens severely weaken both humoral and cellular vaccine responses. Clinically, careful evaluations of at least binding IgG responses, and prophylactic or post-exposure strategies are strongly recommended for transplant recipients on belatacept-based regimens.
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Affiliation(s)
- Aurélie Wiedemann
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Céline Pellaton
- Service of Immunology and Allergy, Department of Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Manon Dekeyser
- Department of Nephrology, Assistance Publique Hopitaux de Paris (APHP), Creteil, France
- Paris-Saclay University, Gustave Roussy Institut, Institut National de la Santé et de la Recherche Médicale (INSERM) - Unité Mixte de Recherche (UMR) 1186, Integrative Tumor Immunology and Immunotherapy, Villejuif, France
| | - Lydia Guillaumat
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Marie Déchenaud
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Corinne Krief
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Christine Lacabaratz
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Philippe Grimbert
- Department of Nephrology, Assistance Publique Hopitaux de Paris (APHP), Creteil, France
- Paris-Saclay University, Gustave Roussy Institut, Institut National de la Santé et de la Recherche Médicale (INSERM) - Unité Mixte de Recherche (UMR) 1186, Integrative Tumor Immunology and Immunotherapy, Villejuif, France
- Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
| | - Giuseppe Pantaleo
- Service of Immunology and Allergy, Department of Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Swiss Vaccine Research Institute, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Yves Lévy
- Vaccine Research Institute, Université Paris-Est Créteil, Faculté de Médecine, INSERM U955, Créteil, France
- Groupe Henri-Mondor Albert-Chenevier, Service Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Antoine Durrbach
- Department of Nephrology, Assistance Publique Hopitaux de Paris (APHP), Creteil, France
- Paris-Saclay University, Gustave Roussy Institut, Institut National de la Santé et de la Recherche Médicale (INSERM) - Unité Mixte de Recherche (UMR) 1186, Integrative Tumor Immunology and Immunotherapy, Villejuif, France
- *Correspondence: Antoine Durrbach
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29
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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30
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Pernin V, Meneghini M, Torija A, Jouve T, Del Bello A, Sanz-Muñoz I, Eiros J, Donadeu L, Polo C, Morandeira F, Navarro S, Masuet C, Favà A, LeQuintrec M, Kamar N, Crespo E, Bestard O. Impaired antigen-specific B-cell responses after Influenza vaccination in kidney transplant recipients receiving co-stimulation blockade with Belatacept. Front Immunol 2022; 13:918887. [PMID: 35967428 PMCID: PMC9374104 DOI: 10.3389/fimmu.2022.918887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/04/2022] [Indexed: 01/14/2023] Open
Abstract
Emerging data suggest that costimulation blockade with belatacept effectively controls humoral alloimmune responses. However, whether this effect may be deleterious for protective anti-infectious immunity remains poorly understood. We performed a mechanistic exploratory study in 23 kidney transplant recipients receiving either the calcineurin-inhibitor tacrolimus (Tac, n=14) or belatacept (n=9) evaluating different cellular immune responses after influenza vaccination such as activated T follicular Helper (Tfh), plasmablasts and H1N1 hemagglutinin (HA)-specific memory B cells (HA+mBC) by flow-cytometry, and anti-influenza antibodies by hemagglutination inhibition test (HI), at baseline and days 10, 30 and 90 post-vaccination. The proportion of CD4+CD54RA-CXCR5+ Tfh was lower in belatacept than Tac patients at baseline (1.86%[1.25-3.03] vs 4.88%[2.40-8.27], p=0.01) and remained stable post-vaccination. At M3, HA+mBc were significantly higher in Tac-treated patients (0.56%[0.32-1.49] vs 0.27%[0.13-0.44], p=0.04) and correlated with activated Tfh numbers. When stratifying patients according to baseline HA+mBc frequencies, belatacept patients with low HA+mBC displayed significantly lower HA+mBc increases after vaccination than Tac patients (1.28[0.94-2.4] vs 2.54[1.73-5.70], p=0.04). Also, belatacept patients displayed significantly lower seroprotection rates against H1N1 at baseline than Tac-treated patients (44.4% vs 84.6%) as well as lower seroconversion rates at days 10, 30 and 90 after vaccination (50% vs 0%, 63.6% vs 0%, and 63.6% vs 0%, respectively). We show the efficacy of belatacept inhibiting T-dependent antigen-specific humoral immune responses, active immunization should be highly encouraged before starting belatacept therapy.
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Affiliation(s)
- Vincent Pernin
- Kidney Transplant Unit, Nephrology Department. Montpellier University Hospital, Montpellier, France
| | - Maria Meneghini
- Kidney transplant Unit. Nephrology Department. Vall d’Hebron Hospital Universitari, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alba Torija
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Thomas Jouve
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Kidney transplant Unit, Nephrology Department. Grenoble University Hospital, Grenoble, France
| | - Arnaud Del Bello
- Centro Nacional de Gripe de Valladolid, Universidad de Valladolid, Valladolid, Spain
| | - Iván Sanz-Muñoz
- Centro Nacional de Gripe, Valladolid Universidad de Valladolid, Valladolid, Spain
| | - Jose Maria Eiros
- Department of Microbiology and Parasitology, Rio Hortega University Hospital, University of Valladolid, Valladolid, Spain
| | - Laura Donadeu
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carol Polo
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain
| | | | - Sergio Navarro
- Immunology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Cristina Masuet
- Department of Preventive Medicine, Bellvitge University Hospital, Barcelona, Spain
| | - Alexandre Favà
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, Barcelona, Spain
| | - Moglie LeQuintrec
- Kidney Transplant Unit, Nephrology Department. Montpellier University Hospital, Montpellier, France
| | - Nassim Kamar
- Kidney transplant Unit, Nephrology Department. Grenoble University Hospital, Grenoble, France
| | - Elena Crespo
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Bestard
- Kidney transplant Unit. Nephrology Department. Vall d’Hebron Hospital Universitari, Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Laboratoryof Nephrology and Transplantation. Vall d’Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Oriol Bestard,
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Mayer KA, Budde K, Jilma B, Doberer K, Böhmig GA. Emerging drugs for antibody-mediated rejection after kidney transplantation: a focus on phase II & III trials. Expert Opin Emerg Drugs 2022; 27:151-167. [PMID: 35715978 DOI: 10.1080/14728214.2022.2091131] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Antibody-mediated rejection (ABMR) is a leading cause of kidney allograft failure. Its therapy continues to be challenge, and no treatment has been approved for the market thus far. AREAS COVERED In this article, we discuss the pathophysiology and phenotypic presentation of ABMR, the current level of evidence to support the use of available therapeutic strategies, and the emergence of tailored drugs now being evaluated in systematic clinical trials. We searched PubMed, Clinicaltrials.gov and Citeline's Pharmaprojects for pertinent information on emerging anti-rejection strategies, laying a focus on phase II and III trials. EXPERT OPINION Currently, we rely on the use of apheresis for alloantibody depletion and intravenous immunoglobulin (referred to as standard of care), preferentially in early active ABMR. Recent systematic trials have questioned the benefits of using the CD20 antibody rituximab or the proteasome inhibitor bortezomib. However, there are now several promising treatment approaches in the pipeline, which are being trialed in phase II and III studies. These include interleukin-6 antagonism, CD38-targeting antibodies, and selective inhibitors of complement. On the basis of the information that has emerged so far, it seems that innovative treatment strategies for clinical use in ABMR may be available within the next 5-10 years.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Anwar IJ, DeLaura IF, Gao Q, Ladowski J, Jackson AM, Kwun J, Knechtle SJ. Harnessing the B Cell Response in Kidney Transplantation - Current State and Future Directions. Front Immunol 2022; 13:903068. [PMID: 35757745 PMCID: PMC9223638 DOI: 10.3389/fimmu.2022.903068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 01/21/2023] Open
Abstract
Despite dramatic improvement in kidney transplantation outcomes over the last decades due to advent of modern immunosuppressive agents, long-term outcomes remain poor. Antibody-mediated rejection (ABMR), a B cell driven process, accounts for the majority of chronic graft failures. There are currently no FDA-approved regimens for ABMR; however, several clinical trials are currently on-going. In this review, we present current mechanisms of B cell response in kidney transplantation, the clinical impact of sensitization and ABMR, the B cell response under current immunosuppressive regimens, and ongoing clinical trials for ABMR and desensitization treatment.
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Affiliation(s)
| | | | | | | | | | | | - Stuart J. Knechtle
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
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33
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Naesens M, Budde K, Hilbrands L, Oberbauer R, Bellini MI, Glotz D, Grinyó J, Heemann U, Jochmans I, Pengel L, Reinders M, Schneeberger S, Loupy A. Surrogate Endpoints for Late Kidney Transplantation Failure. Transpl Int 2022; 35:10136. [PMID: 35669974 PMCID: PMC9163814 DOI: 10.3389/ti.2022.10136] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022]
Abstract
In kidney transplant recipients, late graft failure is often multifactorial. In addition, primary endpoints in kidney transplantation studies seek to demonstrate the short-term efficacy and safety of clinical interventions. Although such endpoints might demonstrate short-term improvement in specific aspects of graft function or incidence of rejection, such findings do not automatically translate into meaningful long-term graft survival benefits. Combining many factors into a well-validated model is therefore more likely to predict long-term outcome and better reflect the complexity of late graft failure than using single endpoints. If conditional marketing authorization could be considered for therapies that aim to improve long-term outcomes following kidney transplantation, then the surrogate endpoint for graft failure in clinical trial settings needs clearer definition. This Consensus Report considers the potential benefits and drawbacks of several candidate surrogate endpoints (including estimated glomerular filtration rate, proteinuria, histological lesions, and donor-specific anti-human leukocyte antigen antibodies) and composite scoring systems. The content was created from information prepared by a working group within the European Society for Organ Transplantation (ESOT). The group submitted a Broad Scientific Advice request to the European Medicines Agency (EMA), June 2020: the request focused on clinical trial design and endpoints in kidney transplantation. Following discussion and refinement, the EMA made final recommendations to ESOT in December 2020 regarding the potential to use surrogate endpoints in clinical studies that aim to improving late graft failure.
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Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | | | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
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Jehn U, Siam S, Wiening V, Pavenstädt H, Reuter S. Belatacept as a Treatment Option in Patients with Severe BK Polyomavirus Infection and High Immunological Risk—Walking a Tightrope between Viral Control and Prevention of Rejection. Viruses 2022; 14:v14051005. [PMID: 35632747 PMCID: PMC9143364 DOI: 10.3390/v14051005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 12/16/2022] Open
Abstract
Balancing the immune system with immunosuppressive treatment is essential in kidney transplant recipients to avoid allograft rejection on the one hand and infectious complications on the other. BK polyomavirus nephropathy (BKPyVAN) is a viral complication that seriously threatens kidney allograft survival. Therefore, the main treatment strategy is to reduce immunosuppression, but this is associated with an increased rejection risk. Belatacept is an immunosuppressant that acts by blocking the CD80/86-CD28 co-stimulatory pathway of effector T-cells with marked effects on the humoral response. However, when compared with calcineurin-inhibitors (CNI), the cellular rejection rate is higher. With this in mind, we hypothesized that belatacept could be used as rescue therapy in severely BKPyV-affected patients with high immunological risk. We present three cases of patients with BKPyVAN-associated complications and donor-specific antibodies (DSA) and one patient who developed T-cell-mediated rejection after a reduction in immunosuppression in response to BKPyVAN. Patients were switched to a belatacept-based immunosuppressive regimen and showed significantly improved viral control and stabilized graft function. The cases presented here suggest that belatacept is a potential treatment option in the complicated situation of refractory BKPyV infection in patients with high immunological risk.
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35
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Morel A, Hoisnard L, Dudreuilh C, Moktefi A, Kheav D, Pimentel A, Sakhi H, Mokrani D, Attias P, El Sakhawi K, Champy CM, Remy P, Sbidian E, Grimbert P, Matignon M. Three-Year Outcomes in Kidney Transplant Recipients Switched From Calcineurin Inhibitor-Based Regimens to Belatacept as a Rescue Therapy. Transpl Int 2022; 35:10228. [PMID: 35497889 PMCID: PMC9043102 DOI: 10.3389/ti.2022.10228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/18/2022] [Indexed: 01/05/2023]
Abstract
Background: The long-term benefits of conversion from calcineurin inhibitors (CNIs) to belatacept in kidney transplant recipients (KTr) are poorly documented. Methods: A single-center retrospective work to study first-time CNI to belatacept conversion as a rescue therapy [eGFR <30 ml/min/1.73 m2, chronic histological lesions, or CNI-induced thrombotic microangiopathy (TMA)]. Patient and kidney allograft survivals, eGFR, severe adverse events, donor-specific antibodies (DSA), and histological data were recorded over 36 months after conversion. Results: We included N = 115 KTr. The leading cause for switching was chronic histological lesions with non-optimal eGFR (56.5%). Three years after conversion, patient, and death-censored kidney allograft survivals were 88% and 92%, respectively, eGFR increased significantly from 31.5 ± 17.5 to 36.7 ± 15.7 ml/min/1.73 m2 (p < 0.01), the rejection rate was 10.4%, OI incidence was 5.2 (2.9–7.6) per 100 person-years. Older age was associated with death, eGFR was not associated with death nor allograft loss. No patient developed dnDSA at M36 after conversion. CNI-induced TMA disappeared in all cases without eculizumab use. Microvascular inflammation and chronic lesions remained stable. Conclusion: Post-KT conversion from CNIs to belatacept, as rescue therapy, is safe and beneficial irrespective of the switch timing and could represent a good compromise facing organ shortage. Age and eGFR at conversion should be considered in the decision whether to switch.
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Affiliation(s)
- Antoine Morel
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Léa Hoisnard
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Centre d'Investigation Clinique and Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), Créteil, France.,Université Paris Est Créteil (UPEC), EpiDermE (Epidemiology in Dermatology and Evaluation of therapeutics), Créteil, France
| | - Caroline Dudreuilh
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Anissa Moktefi
- Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Pathology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris-Est Créteil, Créteil, France
| | - David Kheav
- AP-HP (Assistance Publique-Hôpitaux de Paris), Laboratoire Régional d'histocompatibilité, Hôpital Saint Louis, Vellefaux, Paris
| | - Ana Pimentel
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Hamza Sakhi
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - David Mokrani
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Philippe Attias
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Karim El Sakhawi
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Cécile Maud Champy
- Groupe Hospitalier Henri-Mondor/Albert Chenevier, Urology department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Philippe Remy
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris-Est Créteil, Créteil, France
| | - Emilie Sbidian
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Centre d'Investigation Clinique and Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), Créteil, France.,Université Paris Est Créteil (UPEC), EpiDermE (Epidemiology in Dermatology and Evaluation of therapeutics), Créteil, France.,Department of Dermatology, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France.,INSERM, Centre d'Investigation Clinique 1430, Créteil, France
| | - Philippe Grimbert
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Centre d'Investigation Clinique and Fédération Hospitalo-Universitaire TRUE (InnovaTive theRapy for immUne disordErs), Créteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris-Est Créteil, Créteil, France.,AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, CIC biotherapy, Créteil, France
| | - Marie Matignon
- Nephrology and Renal Transplantation Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris-Est Créteil, Créteil, France
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Polymorphisms in CTLA-4 predict de novo donor specific antibody formation after kidney transplantation. Hum Immunol 2022; 83:494-498. [PMID: 35365357 DOI: 10.1016/j.humimm.2022.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 11/20/2022]
Abstract
The post-transplant development of donor-specific antibodies (DSAs) initiates the antibody-mediated rejection, which is associated with an increased rate of graft loss. Therefore, risk prediction of de novo DSA (dnDSA) is important for understanding long-term prognostic implications for kidney transplantation outcomes. Cytotoxic T lymphocyte antigen-4 (CTLA-4), a cell surface molecule, suppresses T cell responses. Single-nucleotide polymorphisms (SNPs) in CTLA-4 are known to be associated with acute rejection; however, their association with dnDSA formation is not established. In the present study, we investigated the impact of CTLA-4 SNPs on dnDSA formation after kidney transplantation (KT) by analyzing three CTLA-4 SNPs (rs231775, rs3087243, and rs5742909) in 88 recipients. Patients with the GG genotype of CTLA-4 SNPs rs231775 and rs3087243 had higher rates of dnDSA formation than patients with the AA genotype or heterozygous genotypes. In conclusion, our findings indicate that CTLA-4 SNPs are predisposing factors for dnDSA formation after KT.
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37
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Ohm B, Jungraithmayr W. B Cell Immunity in Lung Transplant Rejection - Effector Mechanisms and Therapeutic Implications. Front Immunol 2022; 13:845867. [PMID: 35320934 PMCID: PMC8934882 DOI: 10.3389/fimmu.2022.845867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
Allograft rejection remains the major hurdle in lung transplantation despite modern immunosuppressive treatment. As part of the alloreactive process, B cells are increasingly recognized as modulators of alloimmunity and initiators of a donor-specific humoral response. In chronically rejected lung allografts, B cells contribute to the formation of tertiary lymphoid structures and promote local alloimmune responses. However, B cells are functionally heterogeneous and some B cell subsets may promote alloimmune tolerance. In this review, we describe the current understanding of B-cell-dependent mechanisms in pulmonary allograft rejection and highlight promising future strategies that employ B cell-targeted therapies.
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Affiliation(s)
- Birte Ohm
- Department of Thoracic Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Jungraithmayr
- Department of Thoracic Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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38
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Herr F, Desterke C, Bargiel K, Vernochet A, Vanhove B, Vadanici R, Ye F, Dekeyser M, Durrbach A. The proliferation of belatacept-resistant T cells requires early IFNα pathway activation. Am J Transplant 2022; 22:489-503. [PMID: 34431219 DOI: 10.1111/ajt.16811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/20/2021] [Accepted: 08/14/2021] [Indexed: 01/25/2023]
Abstract
Belatacept was developed to replace calcineurin inhibitors in kidney transplantation. Its use is associated with better kidney transplant function, a lower incidence of anti-donor antibodies and higher graft survival. However, it is also associated with a higher risk of cellular rejection. We studied the activation and proliferation mechanisms of belatacept-resistant T lymphocytes (TLs), to identify new pathways for control. We performed a transcriptomic analysis on CD4+ CD57+ PD1- memory TLs, which are responsible for a higher incidence of graft rejection, after allogeneic stimulation with activated dendritic cells (aDCs) in the presence or absence of belatacept. After six hours of contact with aDCs, the (CD4+ CD57+ PD1- ) (CD4+ CD57+ PD1+ ) and (CD4+ CD57- ) lymphocytes had different transcriptional profiles with or without belatacept. In the CD4+ CD57+ PD1- population, the IFNα-dependent activation pathway was positively overrepresented, and IRF7 transcript levels were high. IRF7 was associated with IFNα/β and IL-6 regulation. The inhibition of both these cytokines in a context of belatacept treatment inhibited the proliferation of CD4+ CD57+ PD1- T cells. Our results show that IRF7 is rapidly upregulated in belatacept-resistant CD4+ CD57+ PD1- TLs. The inhibition of type I IFN or IL-6 in association with belatacept treatment reduces the proliferation of belatacept-resistant TLs, paving the way for new treatments for use in organ transplantation.
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Affiliation(s)
- Florence Herr
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France.,Université Paris-Saclay, Orsay, France
| | | | - Karen Bargiel
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France.,Université Paris-Saclay, Orsay, France
| | - Amelia Vernochet
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France.,Université Paris-Saclay, Orsay, France
| | | | | | - Fan Ye
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France
| | - Manon Dekeyser
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France.,Université Paris-Saclay, Orsay, France.,Henri Mondor Hospital, APHP, Creteil, France
| | - Antoine Durrbach
- INSERM UMR1186, Gustave Roussy Institute, Villejuif, France.,Université Paris-Saclay, Orsay, France.,Henri Mondor Hospital, APHP, Creteil, France
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39
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Nikolova A, Patel JK. Induction Therapy and Therapeutic Antibodies. Handb Exp Pharmacol 2022; 272:85-116. [PMID: 35474024 DOI: 10.1007/164_2021_570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Prevention of allograft rejection is one of the crucial goals in solid organ transplantation to ensure durability of the graft and is chiefly mediated by cellular and humoral pathways targeting cell surface alloantigens. The risk of rejection is highest in the first post-transplant year and wanes with time albeit the risk always exists and varies with the type of organ transplanted. Induction therapies refer to the use of high-intensity immunosuppression in the immediate post-operative period to mitigate the highest risk of rejection. This term encompasses chiefly the use of antibody therapies directed against one of the key pathways in T-cell activation or abrogating effects of circulating alloantibodies. These antibodies carry more potent immunomodulatory effect than maintenance immunosuppressive therapy alone and many of them lead to durable immune cell depletion. A variety of monoclonal and polyclonal antibodies have been utilized for use not only for induction therapy, but also for treatment of allograft rejection when it occurs and as components of desensitization therapy before and after transplantation to modulate circulating alloantibodies.
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40
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Budde K, Prashar R, Haller H, Rial MC, Kamar N, Agarwal A, de Fijter JW, Rostaing L, Berger SP, Djamali A, Leca N, Allamassey L, Gao S, Polinsky M, Vincenti F. Conversion from Calcineurin Inhibitor- to Belatacept-Based Maintenance Immunosuppression in Renal Transplant Recipients: A Randomized Phase 3b Trial. J Am Soc Nephrol 2021; 32:3252-3264. [PMID: 34706967 PMCID: PMC8638403 DOI: 10.1681/asn.2021050628] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/16/2021] [Accepted: 10/07/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Calcineurin inhibitors (CNIs) are standard of care after kidney transplantation, but they are associated with nephrotoxicity and reduced long-term graft survival. Belatacept, a selective T cell costimulation blocker, is approved for the prophylaxis of kidney transplant rejection. This phase 3 trial evaluated the efficacy and safety of conversion from CNI-based to belatacept-based maintenance immunosuppression in kidney transplant recipients. METHODS Stable adult kidney transplant recipients 6-60 months post-transplantation under CNI-based immunosuppression were randomized (1:1) to switch to belatacept or continue treatment with their established CNI. The primary end point was the percentage of patients surviving with a functioning graft at 24 months. RESULTS Overall, 446 renal transplant recipients were randomized to belatacept conversion ( n =223) or CNI continuation ( n =223). The 24-month rates of survival with graft function were 98% and 97% in the belatacept and CNI groups, respectively (adjusted difference, 0.8; 95.1% CI, -2.1 to 3.7). In the belatacept conversion versus CNI continuation groups, 8% versus 4% of patients experienced biopsy-proven acute rejection (BPAR), respectively, and 1% versus 7% developed de novo donor-specific antibodies (dnDSAs), respectively. The 24-month eGFR was higher with belatacept (55.5 versus 48.5 ml/min per 1.73 m 2 with CNI). Both groups had similar rates of serious adverse events, infections, and discontinuations, with no unexpected adverse events. One patient in the belatacept group had post-transplant lymphoproliferative disorder. CONCLUSIONS Switching stable renal transplant recipients from CNI-based to belatacept-based immunosuppression was associated with a similar rate of death or graft loss, improved renal function, and a numerically higher BPAR rate but a lower incidence of dnDSA.Clinical Trial registry name and registration number: A Study in Maintenance Kidney Transplant Recipients Following Conversion to Nulojix® (Belatacept)-Based, NCT01820572.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rohini Prashar
- Division of Nephrology, Henry Ford Hospital, Detroit, Michigan
| | - Hermann Haller
- Department of Nephrology and Hypertension, The Hannover Medical School, Hannover, Germany
| | - Maria C. Rial
- Department of Nephrology, Dialysis and Organ Transplantation, Instituto de Nefrologia, Nephrology SA, Buenos Aires, Argentina
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Université de Toulouse, Toulouse, France
| | - Avinash Agarwal
- Department of Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Johan W. de Fijter
- Department of Nephrology; Leiden University Medical Center, Leiden, The Netherlands
| | - Lionel Rostaing
- Department of Nephrology, Université Grenoble Alpes, Saint-Martin-d'Hères, France
| | - Stefan P. Berger
- Division of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Arjang Djamali
- Division of Nephrology, University of Wisconsin, Madison, Wisconsin
| | - Nicolae Leca
- Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | | | - Sheng Gao
- Bristol-Myers Squibb, Princeton, New Jersey
| | | | - Flavio Vincenti
- Department of Surgery, Kidney Transplant Service, University of California, San Francisco, California
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41
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Nakamura T, Shirouzu T. Antibody-Mediated Rejection and Recurrent Primary Disease: Two Main Obstacles in Abdominal Kidney, Liver, and Pancreas Transplants. J Clin Med 2021; 10:5417. [PMID: 34830699 PMCID: PMC8619797 DOI: 10.3390/jcm10225417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023] Open
Abstract
The advances in acute phase care have firmly established the practice of organ transplantation in the last several decades. Then, the next issues that loom large in the field of transplantation include antibody-mediated rejection (ABMR) and recurrent primary disease. Acute ABMR is a daunting hurdle in the performance of organ transplantation. The recent progress in desensitization and preoperative monitoring of donor-specific antibodies enables us to increase positive outcomes. However, chronic active ABMR is one of the most significant problems we currently face. On the other hand, recurrent primary disease is problematic for many recipients. Notably, some recipients, unfortunately, lost their vital organs due to this recurrence. Although some progress has been achieved in these two areas, many other factors remain largely obscure. In this review, these two topics will be discussed in light of recent discoveries.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takayuki Shirouzu
- Molecular Diagnositcs Division, Wakunaga Pharmaceutical Co., Ltd., 13-4 Arakicho, shinjyuku-ku, Tokyo 160-0007, Japan;
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42
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Karadkhele G, Duneton C, Garro R, Badell IR, Pearson TC, Larsen CP, Hogan J. Temporal trends and current use of de novo belatacept in kidney transplant recipients in the United States. Clin Transplant 2021; 36:e14531. [PMID: 34757651 DOI: 10.1111/ctr.14531] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 12/20/2022]
Abstract
The adoption of de novo belatacept in kidney transplant (kTx) recipients was hampered by an increased risk of acute cellular rejection (ACR) with variation in adopted belatacept based immunosuppressive therapies across centers. We used data from the Scientific Registry of Transplant Recipients (SRTR) to evaluate the temporal trends in belatacept use and describe the associated induction and maintenance regimens in US adult kTx recipients transplanted between June 2011 and December 2018. The number of patients receiving de novo-belatacept based immunosuppressive therapy increased from .74% in 2011 to 3.11% in 2016. In 2016, 66/207 centers used de novo belatacept-based regimen with 3.03% using it in over 50% of their patients. The use of T-cell depleting agents increased with time. Since 2012, the rate of calcineurin inhibitor (CNI) use in combination with belatacept remained stable around 50% and ∼30% remained under belatacept/CNI combination at 1-year post-transplantation. The adoption of belatacept as de novo immunosuppressive regimen has been slow and its use remains low in the United States. Various regimens have been used to modulate the risk of ACR. Further studies evaluating the long-term outcomes of these regimens and assessing their safety especially with regard to the risk of infection are needed.
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Affiliation(s)
- Geeta Karadkhele
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA
| | - Charlotte Duneton
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA.,Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Rouba Garro
- Pediatric Nephrology Division, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Idelberto Raul Badell
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA
| | - Thomas C Pearson
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA
| | - Christian P Larsen
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA
| | - Julien Hogan
- Emory Transplant Center, Department of Surgery, Emory School of medicine, Atlanta, Georgia, USA.,Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
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43
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Mujtahedi SS, Yigitbilek F, Ozdogan E, Schinstock CA, Stegall MD. Antibody-Mediated Rejection: the Role of Plasma Cells and Memory B Cells. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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44
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El Hennawy H, Safar O, Al Faifi AS, El Nazer W, Kamal A, Mahedy A, Zaitoun M, Fahmy AE. Belatacept rescue therapy of CNI-induced nephrotoxicity, meta-analysis. Transplant Rev (Orlando) 2021; 35:100653. [PMID: 34597943 DOI: 10.1016/j.trre.2021.100653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/28/2021] [Accepted: 09/15/2021] [Indexed: 01/03/2023]
Abstract
There is growing evidence about the potential favorable effects that can be obtained from converting the administration of calcineurin inhibitors (CNIs) to Belatacept in kidney transplantation recipients. We conducted a meta-analysis to formulate strong evidence from the current literature about this effect on kidney functions, as measured by the estimated glomerular filtration rate (eGFR). Our search was conducted on the following databases: PubMed, Web of Science, Scopus, Embase, Google Scholar, Cochrane library, the clinical trials, and the International Standard Randomized Controlled Trial Number registries to obtain all studies that investigated the effect of post-transplantation CNIs conversion to Belatacept on kidney functions. Thirteen studies were finally included in the current study. The results showed a significant improvement in the eGFR following the conversion as compared to its value prior to it (MD = 10.41; 95% CI = 6.93, 13.90; P-value < 0.001). Although, there was no risk of bias among the pooled studies (P-value = 0.391), there was a significant heterogenity (I 2 = 80%; P value < 0.001). Serum creatinine levels showed no significant change following the conversion as compared to its value prior to it (MD = -1.22; 95% CI = -2.61, 0.16; P-value = 0.083). Nevertheless, a significant heterogeneity among the included studies was observed (I 2 = 87%; P-value = 0.005). Belatacept can be a good alternative to the CNI-based regimens following the kidney transplantation. The conversion to Belatacept resulted in an improvement in eGFR.
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Affiliation(s)
- Hany El Hennawy
- Surgery Department, Section of Transplantation, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia.
| | - Omar Safar
- Urology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Abdullah S Al Faifi
- Surgery Department, Section of Transplantation, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed Kamal
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed Mahedy
- Nephrology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Mohammad Zaitoun
- Pharmacy Department, Armed Forces Hospitals Southern Region, Khamis Mushayte 101, Saudi Arabia
| | - Ahmed E Fahmy
- Transplant Surgery Department, North Shore University Hospital, Northwell Health, Manhasset, NY, United States of America
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45
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Habal MV. Current Desensitization Strategies in Heart Transplantation. Front Immunol 2021; 12:702186. [PMID: 34504489 PMCID: PMC8423343 DOI: 10.3389/fimmu.2021.702186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 01/03/2023] Open
Abstract
Heart transplant candidates sensitized to HLA antigens wait longer for transplant, are at increased risk of dying while waiting, and may not be listed at all. The increasing prevalence of HLA sensitization and limitations of current desensitization strategies underscore the urgent need for a more effective approach. In addition to pregnancy, prior transplant, and transfusions, patients with end-stage heart failure are burdened with unique factors placing them at risk for HLA sensitization. These include homograft material used for congenital heart disease repair and left ventricular assist devices (LVADs). Moreover, these risks are often stacked, forming a seemingly insurmountable barrier in some cases. While desensitization protocols are typically implemented uniformly, irrespective of the mode of sensitization, the heterogeneity in success and post-transplant outcomes argues for a more tailored approach. Achieving this will require progress in our understanding of the immunobiology underlying the innate and adaptive immune response to these varied allosensitizing exposures. Further attention to B cell activation, memory, and plasma cell differentiation is required to establish methods that durably abrogate the anti-HLA antibody response before and after transplant. The contribution of non-HLA antibodies to the net state of sensitization and the potential implications for graft longevity also remain to be comprehensively defined. The aim of this review is to first bring forth select issues unique to the sensitized heart transplant candidate. The current literature on desensitization in heart transplantation will then be summarized providing context within the immune response. Building on this, newer approaches with therapeutic potential will be discussed emphasizing the importance of not only addressing the short-term pathogenic consequences of circulating HLA antibodies, but also the need to modulate alloimmune memory.
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Affiliation(s)
- Marlena V. Habal
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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46
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Wojciechowski D, Wiseman A. Long-Term Immunosuppression Management: Opportunities and Uncertainties. Clin J Am Soc Nephrol 2021; 16:1264-1271. [PMID: 33853841 PMCID: PMC8455033 DOI: 10.2215/cjn.15040920] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The long-term management of maintenance immunosuppression in kidney transplant recipients remains complex. The vast majority of patients are treated with the calcineurin inhibitor tacrolimus as the primary agent in combination with mycophenolate, with or without corticosteroids. A tacrolimus trough target 5-8 ng/ml seems to be optimal for rejection prophylaxis, but long-term tacrolimus-related side effects and nephrotoxicity support the ongoing evaluation of noncalcineurin inhibitor-based regimens. Current alternatives include belatacept or mammalian target of rapamycin inhibitors. For the former, superior kidney function at 7 years post-transplant compared with cyclosporin generated initial enthusiasm, but utilization has been hampered by high initial rejection rates. Mammalian target of rapamycin inhibitors have yielded mixed results as well, with improved kidney function tempered by higher risk of rejection, proteinuria, and adverse effects leading to higher discontinuation rates. Mammalian target of rapamycin inhibitors may play a role in the secondary prevention of squamous cell skin cancer as conversion from a calcineurin inhibitor to an mammalian target of rapamycin inhibitor resulted in a reduction of new lesion development. Early withdrawal of corticosteroids remains an attractive strategy but also is associated with a higher risk of rejection despite no difference in 5-year patient or graft survival. A major barrier to long-term graft survival is chronic alloimmunity, and regardless of agent used, managing the toxicities of immunosuppression against the risk of chronic antibody-mediated rejection remains a fragile balance.
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Affiliation(s)
- David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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47
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Kaufman D, Woodle ES, Shields A, Leone J, Matas A, Wiseman A, West-Thielke P, Sa T, King E, Alloway R. Belatacept for Simultaneous Calcineurin Inhibitor and Chronic Corticosteroid Immunosuppression Avoidance. Clin J Am Soc Nephrol 2021; 16:1387-1397. [PMID: 34233921 PMCID: PMC8729588 DOI: 10.2215/cjn.13100820] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 06/23/2021] [Indexed: 11/23/2022]
Abstract
Immunosuppressive therapy in kidney transplantation is associated with numerous toxicities. CD28-mediated T cell costimulation blockade using belatacept may reduce long-term nephrotoxicity, compared with calcineurin inhibitor-based immunosuppression. The efficacy and safety of simultaneous calcineurin inhibitor avoidance and rapid steroid withdrawal were tested in a randomized, prospective, multi-center study. Methods All kidney transplants were performed using rapid steroid withdrawal immunosuppression. Recipients were randomized to 1:1:1 to receive belatacept with alemtuzumab induction, belatacept with rabbit antithymocyte globulin (rATG) induction, or tacrolimus with rATG induction. The composite endpoint consisted of death, kidney allograft loss, or an MDRD calculated eGFR of <45 ml/min/1.73m2 at 2 years. Results The composite endpoint was observed for 11/107 (10%) participants assigned to belatacept/alemtuzumab, 13/104 (13%) assigned to belatacept /rATG, and 21/105 (21%) assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.99: belatacept/rATG vs tacrolimus/rATG p = 0.66). Patient and graft survival rates were similar between all groups. eGFR <45 ml/min/1.73m2 was observed for 9/107 (8%) participants assigned to belatacept/alemtuzuab, 8/104 (8%) participants assigned to belatacept/rATG, and 20/105 (19%) participants assigned to tacrolimus/rATG (p<0.05 for each belatacept group vs tacrolimus/rATG). Biopsy-proven acute rejection was observed for 20/107 (19%) participants assigned to belatacept/alemtuzuab, 26/104 (25%) participants assigned to belatacept/rATG, and 7/105 (7%) participants assigned to tacrolimus/rATG (belatacept/alemtuzumab vs tacrolimus/rATG p = 0.006: belatacept/rATG vs tacrolimus/rATG p < 0.001). Gastrointestinal and neurologic adverse events were less frequent with belatacept versus calcineurin based immunosuppression. Conclusions Overall two-year outcomes were similar comparing maintenance immunosuppression based on belatacept versus tacrolimus, each protocol with rapid steroid withdrawal. The incidence of eGFR <45 ml/min/1.73m2 was significantly lower but the incidence of biopsy proven acute rejection significantly higher with belatacept compared with tacrolimus.
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Affiliation(s)
- Dixon Kaufman
- D Kaufman, University of Wisconsin-Madison, Madison, United States
| | - E Steve Woodle
- E Woodle, University of Cincinnati College of Medicine, Cincinnati, United States
| | - Adele Shields
- A Shields, University of Cincinnati College of Medicine, Cincinnati, United States
| | - John Leone
- J Leone, Tampa General Hospital, Tampa, United States
| | - Arthur Matas
- A Matas, University of Minnesota, Minneapolis, United States
| | | | | | - Ting Sa
- T Sa, Biostastics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Eileen King
- E King, University of Cincinnati College of Medicine, Cincinnati, United States
| | - Rita Alloway
- R Alloway, University of Cincinnati College of Medicine, Cincinnati, United States
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48
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Coemans M, Senev A, Van Loon E, Lerut E, Sprangers B, Kuypers D, Emonds MP, Verbeke G, Naesens M. The evolution of histological changes suggestive of antibody-mediated injury, in the presence and absence of donor-specific anti-HLA antibodies. Transpl Int 2021; 34:1824-1836. [PMID: 34197662 DOI: 10.1111/tri.13964] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 06/27/2021] [Indexed: 11/26/2022]
Abstract
The interplay between donor-specific anti-HLA antibodies (HLA-DSA), histology of active antibody-mediated rejection (aABMRh ), transplant glomerulopathy (cg) and graft failure in kidney transplantation remains insufficiently understood. We performed a single-center cohort study (n=1000) including 2761 protocol and 833 indication biopsies. Patients with pre-transplant HLA-DSA were more prone to develop aABMRh (OR 22.7, 95% CI, 11.8 - 43.7, p<0.001), cg (OR 5.76, 95% CI, 1.67 - 19.8, p=0.006) and aABMRh/cg (OR 19.5, 95% CI, 10.6 - 35.9, p<0.001). The negative impact of pre-transplant HLA-DSA on graft survival (HR 2.12, 95% CI, 1.41 - 3.20, p<0.001) was partially mediated through aABMRh and cg occurrence. When adjusted for time-dependent HLA-DSA (HR 4.03, 95% CI, 2.21 - 7.15, p=0.002), graft failure was only affected by aABMRh when cg was evident. In HLA-DSA negative patients, aABMRh was associated with impaired graft outcome only when evolving to cg (HR 1.32, 95% CI, 1.07 - 1.61, p=0.008). We conclude that the kinetics of HLA-DSA are important to estimate the rate of graft failure, and that histological follow-up is necessary to discover, often subclinical, ABMR and cg. In the absence of HLA-DSA, patients experience similar histological lesions and the evolution to transplant glomerulopathy associates with impaired graft outcome.
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Affiliation(s)
- Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Imaging & Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Geert Verbeke
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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49
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Sakhi H, Chavarot N, Attias P, El Karoui K, Anglicheau D. [COVID-19 vaccination in dialysis and kidney transplant patients]. Nephrol Ther 2021; 17:208-213. [PMID: 34305020 PMCID: PMC8245347 DOI: 10.1016/j.nephro.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 01/04/2023]
Abstract
Au cours de la COVID-19, la dialyse et la transplantation rénale ont été identifiées comme d’importants facteurs de risque de développer une forme sévère de la maladie. La réponse immunitaire humorale post-infection est durable. Cependant, après vaccination, celle-ci apparaît plus limitée, tant en termes de taux de réponse (séropositivité post-vaccination) qu’en termes de taux quantitatif d’anticorps. Alors que les patients dialysés ont un taux de réponse de 80–95 % en fonction des études, la réponse est particulièrement faible chez les patients transplantés rénaux, avec des taux de séropositivité de 30–50 %, et notamment s’ils sont traités par bélatacept (environ 5 % de réponse). Ces éléments ont poussé à proposer des schémas vaccinaux alternatifs en France, avec notamment l’utilisation d’une 3e injection de vaccin ARNm. Malgré ces résultats, de nombreuses questions sur la vaccination des insuffisants rénaux restent en suspens, concernant notamment la qualité des réponses cellulaires (encore peu étudiées), la durabilité des réponses post-vaccinales, et surtout l’efficacité clinique des vaccins.
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Affiliation(s)
- Hamza Sakhi
- Service de néphrologie et transplantation, fédération hospitalo-universitaire « Innovative therapy for immune disorders », centre de référence maladie rare « syndrome néphrotique idiopathique », hôpitaux universitaires Henri-Mondor, Créteil, France; Équipe 21, institut national de la santé et de la recherche médicale (Inserm) U955, institut Mondor de recherche biomédicale (IMRB), université Paris-Est-Créteil, Créteil, France
| | - Nathalie Chavarot
- Service de néphrologie et transplantation, centre de référence Maladie rare MAREHA, hôpitaux universitaires Necker-Enfants malades, Paris, France
| | - Philippe Attias
- Department of nephrology and dialysis, hôpital privé Nord Parisien, Sarcelles, France
| | - Khalil El Karoui
- Service de néphrologie et transplantation, fédération hospitalo-universitaire « Innovative therapy for immune disorders », centre de référence maladie rare « syndrome néphrotique idiopathique », hôpitaux universitaires Henri-Mondor, Créteil, France; Équipe 21, institut national de la santé et de la recherche médicale (Inserm) U955, institut Mondor de recherche biomédicale (IMRB), université Paris-Est-Créteil, Créteil, France.
| | - Dany Anglicheau
- Service de néphrologie et transplantation, centre de référence Maladie rare MAREHA, hôpitaux universitaires Necker-Enfants malades, Paris, France
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50
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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] [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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