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Clazakizumab for the treatment of chronic active antibody-mediated rejection (AMR) in kidney transplant recipients: Phase 3 IMAGINE study rationale and design. Trials 2022; 23:1042. [PMID: 36550562 PMCID: PMC9772593 DOI: 10.1186/s13063-022-06897-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chronic active antibody-mediated rejection (AMR) is a major cause of graft loss with no approved drugs for its treatment. Currently, off-label regimens are used, reflecting the high unmet need for effective therapies based on well-controlled trials. Clazakizumab is a high-affinity, humanized monoclonal antibody that binds interleukin-6 and decreases donor-specific antibody (DSA) production and inflammation. Phase 2 pilot studies of clazakizumab in kidney transplant recipients with chronic active AMR suggest modulation of DSA, stabilization of glomerular filtration rate (GFR), and a manageable safety profile. We report the design of the Phase 3 IMAGINE study (NCT03744910) to evaluate the safety and efficacy of clazakizumab for the treatment of chronic active AMR. METHODS IMAGINE is a multicenter, double-blind trial of approximately 350 kidney transplant recipients with chronic active AMR (Banff chronic glomerulopathy [cg] >0 with concurrent positive human leukocyte antigen DSA) randomized 1:1 to receive clazakizumab or placebo (12.5 mg subcutaneous once every 4 weeks). The event-driven trial design will follow patients until 221 occurrences of all-cause graft loss are observed, defined as return to dialysis, graft nephrectomy, re-transplantation, estimated GFR (eGFR) <15 mL/min/1.73m2, or death from any cause. A surrogate for graft loss (eGFR slope) will be assessed at 1 year based on prior modeling validation. Secondary endpoints will include measures of pharmacokinetics/pharmacodynamics. Recruitment is ongoing across North America, Europe, Asia, and Australia. DISCUSSION IMAGINE represents the first Phase 3 clinical trial investigating the safety and efficacy of clazakizumab in kidney transplant recipients with chronic active AMR, and the largest placebo-controlled trial in this patient population. This trial includes prognostic biomarker enrichment and uniquely utilizes the eGFR slope at 1 year as a surrogate endpoint for graft loss, which may accelerate the approval of a novel therapy for patients at risk of graft loss. The findings of this study will be fundamental in helping to address the unmet need for novel therapies for chronic active AMR. TRIAL REGISTRATION ClinicalTrials.gov NCT03744910 . Registered on November 19, 2018.
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Yilmaz VT, Dandin O, Kisaoglu A, Avanaz A, Kamaci D, Toru HS, Demiryilmaz I, Koksoy S, Aydinli B, Kocak H. Prognosis and Treatment for Active and Chronic Antibody-Mediated Rejection in Renal Transplant Recipients; Single Center Experience. Transplant Proc 2022; 54:1809-1815. [PMID: 35907695 DOI: 10.1016/j.transproceed.2022.03.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/01/2022] [Accepted: 03/26/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the prognostic factors and treatment alternatives of antibody-mediated rejection (ABMR) in renal transplant patients. METHODS Three thousand renal transplant patients were included in the study. The patients were first divided into 2 groups. Group 1: ABMR [-] recipients (n = 2871), Group 2: ABMR (+) recipients (n = 129). ABMR patients were compared among themselves by dividing them into 3 subgroups (early-active, late-active, chronic-active). The study was performed retrospectively. Different combinations of methylprednisolone, intravenous immunoglobulin (IVIG), rituximab, plasmapheresis (PP), anti-thymocyte globulin (ATG) were used in the treatment and the results were compared. RESULTS Graft survival and functions were worse and the rates of CAD, delayed graft function, BK virus, and cytomegalovirus higher in patients with ABMR. Also, graft survival was lower in patients with serum creatinine ≥3 (P = 0.001), GFR <30 (P <0.001), and spot urine protein to creatinine ratio ≥1 (P = 0.042) at the time of diagnosis. High interstitial fibrosis and tubular atrophy scores in chronic ABMR cases and high intimal arteritis scores in active ABMR cases were poor prognostic factors. CONCLUSIONS The study showed that ABMR has a poor prognosis in terms of clinical parameters, and treatment should be individualized according to pathologic findings and graft functions at the time of diagnosis. Pulse methylprednisolone and IVIG should be used in the treatment of all ABMR patients, but PP, rituximab, and ATG should be used in selected cases. ABMR has a poor prognosis and treatment should be individualized.
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Affiliation(s)
- Vural Taner Yilmaz
- Department of Internal Medicine, Division of Nephrology, Akdeniz University Medical School, Antalya, Turkey.
| | - Ozgur Dandin
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - Abdullah Kisaoglu
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - Ali Avanaz
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - Davut Kamaci
- Department of Urology, Ankara City Hospital, Ankara, Turkey
| | - Havva Serap Toru
- Department of Pathology, Akdeniz University Medical School, Antalya, Turkey
| | - Ismail Demiryilmaz
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - Sadi Koksoy
- Department of Microbiology and Clinical Immunology, Akdeniz University Medical School, Antalya, Turkey
| | - Bulent Aydinli
- Department of General Surgery, Akdeniz University Medical School, Antalya, Turkey
| | - Huseyin Kocak
- Department of Internal Medicine, Division of Nephrology, Akdeniz University Medical School, Antalya, Turkey
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Kim MY, Brennan DC. Therapies for Chronic Allograft Rejection. Front Pharmacol 2021; 12:651222. [PMID: 33935762 PMCID: PMC8082459 DOI: 10.3389/fphar.2021.651222] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/10/2021] [Indexed: 12/14/2022] Open
Abstract
Remarkable advances have been made in the pathophysiology, diagnosis, and treatment of antibody-mediated rejection (ABMR) over the past decades, leading to improved graft outcomes. However, long-term failure is still high and effective treatment for chronic ABMR, an important cause of graft failure, has not yet been identified. Chronic ABMR has a relatively different phenotype from active ABMR and is a slowly progressive disease in which graft injury is mainly caused by de novo donor specific antibodies (DSA). Since most trials of current immunosuppressive therapies for rejection have focused on active ABMR, treatment strategies based on those data might be less effective in chronic ABMR. A better understanding of chronic ABMR may serve as a bridge in establishing treatment strategies to improve graft outcomes. In this in-depth review, we focus on the pathophysiology and characteristics of chronic ABMR along with the newly revised Banff criteria in 2017. In addition, in terms of chronic ABMR, we identify the reasons for the resistance of current immunosuppressive therapies and look at ongoing research that could play a role in setting better treatment strategies in the future. Finally, we review non-invasive biomarkers as tools to monitor for rejection.
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Affiliation(s)
| | - Daniel C. Brennan
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Gibson IW. Transplant Glomerulopathy: Importance of Ultrastructural Examination. GLOMERULAR DISEASES 2021; 1:68-81. [PMID: 36751426 PMCID: PMC9677739 DOI: 10.1159/000513522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/29/2020] [Indexed: 11/19/2022]
Abstract
Background Transplant glomerulopathy (TG) is a morphologic alteration in glomeruli of renal allografts, characterized by glomerular basement membrane reduplications. Summary TG is associated with progressive chronic allograft dysfunction and proteinuria and is a diagnostic feature of chronic antibody-mediated rejection (ABMR) in patients positive for donor-specific antibodies, according to the Banff schema for renal allograft pathology. It is a definitive endpoint in clinical trials and interventional studies for ABMR, but the lesion can also occur in the absence of definitive alloimmune injury, as a consequence of chronic thrombotic microangiopathy, and in some cases in association with hepatitis C infection. This review discusses the pathophysiology and clinical presentation of TG, the diagnostic features by light microscopy, and focuses on the sequential ultrastructural stages of the lesion. The differential diagnosis of TG, and Banff grading of the lesion, are reviewed. Clinicopathological indications for performing routine ultrastructural examination of renal allograft biopsies are discussed. Key Messages TG can be diagnosed at an early stage by electron microscopy, before histological features are apparent, emphasizing the importance of ultrastructural examination of renal allograft biopsies for an early diagnosis, when therapeutic intervention may be beneficial.
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Affiliation(s)
- Ian W. Gibson
- *Ian W. Gibson, Department of Pathology, MS-336C Electron Microscopy Lab, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9 (Canada),
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Lavacca A, Presta R, Gai C, Mella A, Gallo E, Camussi G, Abbasciano I, Barreca A, Caorsi C, Fop F, Messina M, Rossetti M, Biancone L. Early effects of first-line treatment with anti-interleukin-6 receptor antibody tocilizumab for chronic active antibody-mediated rejection in kidney transplantation. Clin Transplant 2020; 34:e13908. [PMID: 32415711 DOI: 10.1111/ctr.13908] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/09/2020] [Accepted: 05/09/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Chronic active antibody-mediated rejection (cAMR) is a major determinant of late allograft failure. Rituximab/immunoglobulins (IVIg) + plasma exchange (PLEX) showed controversial results in cAMR treatment. Tocilizumab (TCZ), a humanized anti-interleukin 6 receptor antibody, has been recently used as rescue therapy in patients non-responsive to rituximab/IVIg/PLEX with favorable outcomes. Whether TCZ acts "per se" or requires a priming effect from previous treatments is currently unknown. METHODS Fifteen patients with cAMR were treated with TCZ as a first-line therapy and followed for a median time of 20.7 months. RESULTS Despite the majority of patients experiencing advanced transplant glomerulopathy (TG) at diagnosis (60% with cg3), glomerular filtration rate and proteinuria stabilized during the follow-up, with a significant reduction in donor-specific antibodies. Protocol biopsies after 6 months demonstrated significant amelioration of microvascular inflammation and no TG, C4d deposition, or IF/TA progression. Gene-expression and immunofluorescence analysis showed upregulation of three genes (TJP-1, AKR1C3, and CASK) involved in podocyte, mesangial, and tubular restoration. CONCLUSION Tocilizumab adopted as a first-line approach in cAMR was associated with early serological and histological improvements and functional stabilization even in advanced TG, suggesting a role for the use of TCZ alone with the avoidance of unnecessary previous immunosuppressants.
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Affiliation(s)
- Antonio Lavacca
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Roberto Presta
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Chiara Gai
- Stem Cell Laboratory, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Mella
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Ester Gallo
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Giovanni Camussi
- Stem Cell Laboratory, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Isabella Abbasciano
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Cristiana Caorsi
- Department of Medical Sciences, Immunogenetic and Transplant Biology Center, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Fabrizio Fop
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Maria Messina
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Maura Rossetti
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center "A. Vercellone", Nephrology, Dialysis and Renal Transplant Division, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
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Chiu HF, Wen MC, Wu MJ, Chen CH, Yu TM, Chuang YW, Huang ST, Tsai SF, Lo YC, Ho HC, Shu KH. Treatment of chronic active antibody-mediated rejection in renal transplant recipients - a single center retrospective study. BMC Nephrol 2020; 21:6. [PMID: 31906890 PMCID: PMC6945538 DOI: 10.1186/s12882-019-1672-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/25/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Chronic active antibody-mediated rejection is a major etiology of graft loss in renal transplant recipients. However, there is no consensus on the optimal treatment strategies. METHODS Computerized records from Taichung Veterans General Hospital were collected to identify renal transplant biopsies performed in the past 7 years with a diagnosis of chronic active antibody-mediated rejection. The patients were divided into two groups according to treatment strategy: Group 1 received aggressive treatment (double filtration plasmapheresis and one of the followings: rituximab, intravenous immunoglobulin, antithymogycte globulin, bortezomib, or methylprednisolone pulse therapy); and group 2 received supportive treatment. RESULTS From February 2009 to December 2017, a total of 82 patients with biopsy-proven chronic antibody mediated rejection were identified. Kaplan-Meier analysis of death-censored graft survival showed a worse survival in group 2 (P = 0.015 by log-rank test). Adverse event-free survival was lower in group 1, whereas patient survival was not significantly different. Proteinuria and supportive treatment were independent risk factors for graft loss in multivariate analysis. CONCLUSIONS Aggressive treatment was associated with better graft outcome. However, higher incidence of adverse events merit personalized treatment, especially for those with higher risk of infection. Appropriate prophylactic antibiotics are recommended for patients undergoing aggressive treatment.
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Affiliation(s)
- Hsien-Fu Chiu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mei-Chin Wen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tung-Min Yu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Wen Chuang
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Ting Huang
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying-Chih Lo
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hao-Chung Ho
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Hsiung Shu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan. .,Division of Nephrology, Department of Internal Medicine, Lin Shin Hospital, No.36, Sec. 3, Hueijhong Rd., Nantun District, Taichung City, 40867, Taiwan.
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7
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Banff lesions and renal allograft survival in chronic-active antibody mediated rejection. Transpl Immunol 2019; 56:101213. [DOI: 10.1016/j.trim.2019.101213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 01/05/2023]
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8
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Treatment with intravenous immunoglobulins and methylprednisolone may significantly decrease loss of renal function in chronic-active antibody-mediated rejection. BMC Nephrol 2019; 20:218. [PMID: 31200654 PMCID: PMC6567552 DOI: 10.1186/s12882-019-1385-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/15/2019] [Indexed: 02/06/2023] Open
Abstract
Background Chronic-active antibody mediated rejection (c-aABMR) is a major contributor to long-term kidney allograft loss. We conducted a retrospective analysis to establish the efficacy of treatment with intravenous immunoglobulins (IVIG) and pulse methylprednisolone (MP) of patients with c-aABMR. Methods Sixty-nine patients, in the period 2005–2017, with the diagnosis (suspicious for) c-aABMR that were treated with IVIG and MP were included. Patients were administered three doses of 1 g intravenous MP combined with a single dose of IVIG (1 g/kg body weight). Primary outcome was the decline in allograft function one year post treatment. Responders to IVIG-MP therapy were defined by an eGFR one year after treatment which was at least 25% above the projected allograft function. Results Patients showed an average decline in eGFR of 9.8 ml/min/1.73m2 the year prior to treatment. Following treatment, a significant reduction (p < 0.001) in eGFR decline was observed (6.3 ml/min/1.73m2). Furthermore, a significant improvement in proteinuria was observed upon treatment (p < 0.001). Sixty-two percent (n = 43) of the patients were considered a responder and showed considerable slowing of graft function deterioration in the year after treatment (p < 0.001). Three and 5-year graft survival was significantly superior in responders. Conclusions More than 60% of patients with c-aABMR with a progressive decline in eGFR respond favorably to treatment with IVIG-MP resulting in a significant improvement of graft survival (Sablik, Am J Transplant 18, 2018). Electronic supplementary material The online version of this article (10.1186/s12882-019-1385-z) contains supplementary material, which is available to authorized users.
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Lubetzky M, Hayde N, Ó Broin P, Ajaimy M, Bao Y, Mohammed O, Schwartz D, Pullman J, Akalin E. Molecular signatures and clinical outcomes of transplant glomerulopathy stratified by microvascular inflammation and donor-specific antibody. Clin Transplant 2019; 33:e13469. [PMID: 30578675 DOI: 10.1111/ctr.13469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated clinical outcomes and molecular signatures of transplant glomerulopathy (TG) stratified by microvascular inflammation (MVI) and donor-specific antibody (DSA) status. METHODS We performed a retrospective review of 749 kidney transplant patients who received a for-cause kidney biopsy from 2009 to 2014. We classified TG as MVI positive (MVI+) or MVI negative (MVI-), and with or without DSA. We obtained gene expression profiles for 44 biopsies by Affymetrix HuGene 1.0 ST expression arrays. RESULTS A total of 100 patients had TG; 49 were MVI+, and 51 were MVI-. After a median post-biopsy follow-up of 2.08 years (range 0.43-4.59), Kaplan-Meier survival analysis demonstrated worse allograft survival in MVI+ TG patients compared with MVI- TG patients (P = 0.01), and time to graft failure was significantly shorter in MVI+ patients (1.08 ± 1.01 years vs 2.3 ± 1.8 years; P = 0.002). DSA status did not affect graft survival within MVI+ or MVI- groups. Analysis of pathogenesis-based transcripts (PBT) showed that MVI+ TG biopsies had increased expression of gamma interferon and rejection (GRIT) and DSA-associated transcripts (DSAST), as observed in antibody-mediated rejection. MVI- TG biopsies had increased expression of cytotoxic and regulatory T cell- and B cell-associated transcripts but not GRIT or DSAST. DSA status had no effect on expression of any PBTs studied in MVI- TG biopsies. CONCLUSIONS Graft survival in TG is significantly worse in the presence of MVI. Gene expression profiles of MVI+ TG resemble antibody-mediated rejection while gene expression profiles of MVI- TG resemble cell-mediated rejection regardless of DSA status.
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Affiliation(s)
- Michelle Lubetzky
- Weill Cornell-NY Presbyterian, Division of Nephrology, New York City, New York
| | - Nicole Hayde
- Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, New York City, New York
| | - Pilib Ó Broin
- School of Mathematics, Statistics & Applied Mathematics, National University of Ireland Galway, Galway, Ireland
| | - Maria Ajaimy
- Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, New York City, New York
| | - Yi Bao
- Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, New York City, New York
| | - Omar Mohammed
- Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, New York City, New York
| | - Daniel Schwartz
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York
| | - James Pullman
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York
| | - Enver Akalin
- Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, New York City, New York
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Piñeiro GJ, De Sousa-Amorim E, Solé M, Ríos J, Lozano M, Cofán F, Ventura-Aguiar P, Cucchiari D, Revuelta I, Cid J, Palou E, Campistol JM, Oppenheimer F, Rovira J, Diekmann F. Rituximab, plasma exchange and immunoglobulins: an ineffective treatment for chronic active antibody-mediated rejection. BMC Nephrol 2018; 19:261. [PMID: 30309322 PMCID: PMC6182805 DOI: 10.1186/s12882-018-1057-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/24/2018] [Indexed: 12/20/2022] Open
Abstract
Background Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants. Methods To determine the efficacy and safety of combined therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF’17 classification, was identified. Results We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively. Conclusions Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications. Trial registration Agencia Española de Medicametos y Productos Sanitarios (AEMPS): 14566/RG 24161. Study code: UTR-INM-2017-01. Electronic supplementary material The online version of this article (10.1186/s12882-018-1057-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gastón J Piñeiro
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - Erika De Sousa-Amorim
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Manel Solé
- Department of Pathology, Hospital Clinic, Barcelona, Spain
| | - José Ríos
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Frederic Cofán
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Pedro Ventura-Aguiar
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - David Cucchiari
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain
| | - Ignacio Revuelta
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Eduard Palou
- Department of Immunology, Hospital Clinic, Barcelona, Spain
| | - Josep M Campistol
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Federico Oppenheimer
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain. .,Red de Investigación Renal (REDinREN), Madrid, Spain.
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain. .,Laboratori Experimental de Nefrologia i Trasplantament (LENIT), IDIBAPS, Barcelona, Spain. .,Red de Investigación Renal (REDinREN), Madrid, Spain.
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11
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Mella A, Gallo E, Messina M, Caorsi C, Amoroso A, Gontero P, Verri A, Maletta F, Barreca A, Fop F, Biancone L. Treatment with plasmapheresis, immunoglobulins and rituximab for chronic-active antibody-mediated rejection in kidney transplantation: Clinical, immunological and pathological results. World J Transplant 2018; 8:178-187. [PMID: 30211026 PMCID: PMC6134268 DOI: 10.5500/wjt.v8.i5.178] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/14/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the role of a therapeutic regimen with plasma exchange, intravenous immunoglobulins and rituximab in chronic-active antibody-mediated rejection (cAMR) settings.
METHODS We compared 21 kidney transplant recipients (KTRs) with a diagnosis of cAMR in a retrospective case-control analysis: nine KTRs treated with plasmapheresis, intravenous immunoglobulins and rituximab (PE-IVIG-RTX group) vs 12 patients (control group) not treated with antibody-targeted therapies. We examined kidney survival and functional outcomes 24 mo after diagnosis. Histological features and donor-specific antibody (DSA) characteristics (MFI and C1q-fixing ability) were also investigated.
RESULTS No difference in graft survival between the two groups was noted: three out of nine patients in the PE-IVIG-RTX group (33.3%) and 4/12 in the control group (33.3%) experienced loss of allograft function at a median time after diagnosis of 14 mo (min 12-max 18) and 15 mo (min 7-max 22), respectively. Kidney functional tests and proteinuria 24 mo after cAMR diagnosis were also similar in both groups. Only microvascular inflammation (glomerulitis + peritubular capillaritis score) was significantly reduced after PE-IVIG-RTX in seven out of eight patients (87.5%) in the PE-IVIG-RTX group (median score 3 in pre-treatment biopsy vs 1.5 in post-treatment biopsy; P = 0.047), without any impact on kidney survival and/or DSA characteristics. No functional or histological parameter at diagnosis was predictive of clinical outcome.
CONCLUSION Our data showed no difference in the two year post-treatment outcome of kidney grafts treated with PE-IVIG-RTX for cAMR diagnosis, however there were notable improvements in microvascular inflammation in post-therapy protocol biopsies. Further studies, especially involving innovative therapeutic approaches, are required to improve the management and long-term results of this severe condition.
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Affiliation(s)
- Alberto Mella
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Ester Gallo
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Maria Messina
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Cristiana Caorsi
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Antonio Amoroso
- Immunogenetics and Transplant Biology Service, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Aldo Verri
- Division of Vascular Surgery, Department of Thoracic-Vascular Surgery, Città della Salute e della Scienza Hospital, Turin 10126, Italy
| | - Francesca Maletta
- Division of Pathology Transplantation, Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Antonella Barreca
- Division of Pathology Transplantation, Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Fabrizio Fop
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
| | - Luigi Biancone
- Renal Transplantation Center “A. Vercellone”, Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città della Salute e della Scienza Hospital and University of Turin, Turin 10126, Italy
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12
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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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13
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Parajuli S, Mandelbrot DA, Muth B, Mohamed M, Garg N, Aziz F, Redfield RR, Zhong W, Astor BC, Djamali A. Rituximab and Monitoring Strategies for Late Antibody-Mediated Rejection After Kidney Transplantation. Transplant Direct 2017; 3:e227. [PMID: 29536028 PMCID: PMC5828696 DOI: 10.1097/txd.0000000000000746] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is limited information on treatment strategies and monitoring strategies for late antibody-mediated rejection (ABMR) after kidney transplantation. METHODS In this observational and nonrandomized study, we compared 78 patients diagnosed with late ABMR (>3 months after transplant) who were treated with standard of care steroids/IVIG (n = 38) ± rituximab (n = 40) at our center between March 1, 2013 and December 31, 2016. All patients had follow-up biopsy and donor-specific antibodies (DSA) monitoring within 3 to 12 weeks. RESULTS Patients had biopsy 7.3 ± 7 years after transplant and were followed for 15.9 ± 9.6 months after ABMR was diagnosed. Both treatment strategies were associated with a significant decline in DSA, microvascular inflammation (peritubular capillaritis + glomerulitis), and C4d Banff scores. In univariate regression analyses, rituximab, estimated glomerular filtration rate (eGFR), Banff i, t, v, chronicity (interstitial fibrosis + tubular atrophy + fibrous intimal thickening + allograft glomerulopathy) scores on the first biopsy, and eGFR and Banff v score on follow-up biopsy were associated with graft loss. Multivariate analyses retained only rituximab (hazard ratio, 0.23; 95% confidence interval, 0.06-0.84; P = 0.03) and eGFR at follow-up biopsy (0.84; 95% confidence interval, 0.76-0.92; P < 0.001) as significant predictors of graft loss. Kaplan-Meier analyses demonstrated that the benefit associated with rituximab was apparent after 1 year (15% vs 32% graft loss, P = 0.02). CONCLUSION Treatment of late ABMR with steroids/IVIG ± rituximab was effective in reducing DSA and microcirculation inflammation. The addition of rituximab was associated with better graft survival. Follow-up biopsies could be considered in the management of acute rejection to monitor the effect of therapy. Randomized studies on the best therapeutic options for ABMR are needed.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier A. Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brenda Muth
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert R. Redfield
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brad C. Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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14
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Seija M, Nin M, Astesiano R, Coitiño R, Santiago J, Ferrari S, Noboa O, González-Martinez F. Rechazo agudo del trasplante renal: diagnóstico y alternativas terapéuticas. NEFROLOGÍA LATINOAMERICANA 2017. [DOI: 10.1016/j.nefrol.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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15
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Haas M, Mirocha J, Reinsmoen NL, Vo AA, Choi J, Kahwaji JM, Peng A, Villicana R, Jordan SC. Differences in pathologic features and graft outcomes in antibody-mediated rejection of renal allografts due to persistent/recurrent versus de novo donor-specific antibodies. Kidney Int 2017; 91:729-737. [DOI: 10.1016/j.kint.2016.10.040] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/06/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
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16
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Abreu R, Carvalho F, Viana H, Mesquita I, Possante M, Aires I, Caeiro F, Silva C, Cotovio P, Ferreira A, Remédio F, Nolasco F. Morphologic patterns and treatment of transplant glomerulopathy: A retrospective analysis. Clin Transplant 2017; 31. [PMID: 28135784 DOI: 10.1111/ctr.12915] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2017] [Indexed: 11/29/2022]
Abstract
Transplant glomerulopathy is mainly due to chronic antibody-mediated rejection and actually represents a major cause of long-term allograft failure. The lack of effective treatment remains a serious problem in transplantation. A retrospective and uni-center study was performed in 48 kidney allograft recipients with transplant glomerulopathy between January 2010 and December 2015. Median time for diagnosis was 7.1 (3.6-11.8) years post-transplant. Light microscopy showed severity of transplant glomerulopathy in the majority of patients (cg1=10.4%; cg2=20.8%; cg3=68.8%). Moderate microvascular inflammation was present in 56.3% (g+ptc≥2), and almost half of recipients (51.1%) were C4d positive in immunofluorescence. Female gender (P=.001), age (P=.043), renal dysfunction (P=.002), acute rejection episodes (P=.026), and anti-HLA class II antibodies (P=.004) were associated with kidney allograft failure. Treatment of transplant glomerulopathy was performed in 67.6% of patients. The histologic and laboratory features that led to a therapeutic intervention were score ptc (P=.021), C4d (P=.03), and the presence of anti-HLA antibodies (P=.029), whereas score ah (P=.005) was associated with conservative measure. The overall cumulative kidney allograft survival at 10 years was 75%. Treatment of transplant glomerulopathy was ineffective to improve long-term kidney allograft survival.
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Affiliation(s)
- Rui Abreu
- Nephrology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - Helena Viana
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
| | - Isabel Mesquita
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
| | | | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
| | | | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, Lisboa, Portugal
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Patri P, Seshan SV, Matignon M, Desvaux D, Lee JR, Lee J, Dadhania DM, Serur D, Grimbert P, Hartono C, Muthukumar T. Development and validation of a prognostic index for allograft outcome in kidney recipients with transplant glomerulopathy. Kidney Int 2017; 89:450-8. [PMID: 26422505 PMCID: PMC4814368 DOI: 10.1038/ki.2015.288] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/05/2015] [Accepted: 07/31/2015] [Indexed: 01/29/2023]
Abstract
We studied 92 patients with transplant glomerulopathy to develop a prognostic index based on the risk factors for allograft failure within five years of diagnosis (Development cohort). During 60 months (median) follow up, 64 patients developed allograft failure. A chronic-inflammation score generated by combining Banff ci, ct and ti scores, serum creatinine and proteinuria at biopsy, were independent risk factors for allograft failure. Based on the Cox model, we developed a prognostic index and classified patients into risk groups. Compared to the low risk group (median allograft survival over 60 months from diagnosis), patients in the medium risk group had a hazard ratio of 2.83 (median survival 25 months), while those in the high risk group had a hazard ratio of 5.96 (median survival 3.7 months). We next evaluated the performance of the prognostic index in an independent external cohort of 47 patients with transplant glomerulopathy (Validation cohort). The hazard ratios were 2.18 (median survival 19 months) and 16.27 (median survival 1.6 months), respectively, for patients in the medium and high risk groups, compared to the low risk group (median survival 47 months). Our prognostic index model did well in measures of discrimination and calibration. Thus, risk stratification of transplant glomerulopathy based on our prognostic index may provide informative insight for both the patient and physician regarding prognosis and treatment.
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18
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Loupy A, Haas M, Solez K, Racusen L, Glotz D, Seron D, Nankivell BJ, Colvin RB, Afrouzian M, Akalin E, Alachkar N, Bagnasco S, Becker JU, Cornell L, Drachenberg C, Dragun D, de Kort H, Gibson IW, Kraus ES, Lefaucheur C, Legendre C, Liapis H, Muthukumar T, Nickeleit V, Orandi B, Park W, Rabant M, Randhawa P, Reed EF, Roufosse C, Seshan SV, Sis B, Singh HK, Schinstock C, Tambur A, Zeevi A, Mengel M. The Banff 2015 Kidney Meeting Report: Current Challenges in Rejection Classification and Prospects for Adopting Molecular Pathology. Am J Transplant 2017; 17:28-41. [PMID: 27862883 PMCID: PMC5363228 DOI: 10.1111/ajt.14107] [Citation(s) in RCA: 506] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/25/2016] [Accepted: 10/28/2016] [Indexed: 01/25/2023]
Abstract
The XIII Banff meeting, held in conjunction the Canadian Society of Transplantation in Vancouver, Canada, reviewed the clinical impact of updates of C4d-negative antibody-mediated rejection (ABMR) from the 2013 meeting, reports from active Banff Working Groups, the relationships of donor-specific antibody tests (anti-HLA and non-HLA) with transplant histopathology, and questions of molecular transplant diagnostics. The use of transcriptome gene sets, their resultant diagnostic classifiers, or common key genes to supplement the diagnosis and classification of rejection requires further consensus agreement and validation in biopsies. Newly introduced concepts include the i-IFTA score, comprising inflammation within areas of fibrosis and atrophy and acceptance of transplant arteriolopathy within the descriptions of chronic active T cell-mediated rejection (TCMR) or chronic ABMR. The pattern of mixed TCMR and ABMR was increasingly recognized. This report also includes improved definitions of TCMR and ABMR in pancreas transplants with specification of vascular lesions and prospects for defining a vascularized composite allograft rejection classification. The goal of the Banff process is ongoing integration of advances in histologic, serologic, and molecular diagnostic techniques to produce a consensus-based reporting system that offers precise composite scores, accurate routine diagnostics, and applicability to next-generation clinical trials.
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19
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Kahwaji J, Jordan SC, Najjar R, Wongsaroj P, Choi J, Peng A, Villicana R, Vo A. Six-year outcomes in broadly HLA-sensitized living donor transplant recipients desensitized with intravenous immunoglobulin and rituximab. Transpl Int 2016; 29:1276-1285. [PMID: 27529314 DOI: 10.1111/tri.12832] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/15/2016] [Accepted: 08/02/2016] [Indexed: 11/29/2022]
Abstract
Desensitization with intravenous immunoglobulin (IVIG) and rituximab can improve transplantation rates in broadly sensitized kidney transplant recipients. However, long-term outcomes are lacking. Here we analyze long-term outcomes in living donor kidney transplant recipients desensitized with this regimen and compare them to low-risk recipients. Living donor kidney transplants that took place between July 2006 and December 2010 were considered retrospectively. The primary end point of the study was death-censored allograft survival at last follow-up. Secondary end points included patient survival, incidence of rejection, glomerular filtration rate (GFR), and proteinuria. There were 66 sensitized and 111 low-risk patients included. Average follow-up was 68 months. There was no difference in long-term patient or graft survival. The rate of rejection was similar in the groups with more early rejection in the sensitized group and more late rejection in the low-risk group. There was more antibody-mediated rejection in the sensitized group. Estimated GFR was similar during the follow-up period. Risk factors for rejection included a positive cross-match (HR: 2.4 CI: 1.35-4.40) and age (HR: 0.97 CI: 0.95-0.99). Desensitization with IVIG and rituximab has good long-term results with graft outcomes similar to non-HLA-sensitized patients despite higher immunologic risk.
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Affiliation(s)
- Joseph Kahwaji
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Stanley C Jordan
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Reiad Najjar
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Patarapha Wongsaroj
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Jua Choi
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Alice Peng
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Rafael Villicana
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
| | - Ashley Vo
- Cedars-Sinai Medical Center, Comprehensive Transplant Center, Los Angeles, CA, USA
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20
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De Serres SA, Noël R, Côté I, Lapointe I, Wagner E, Riopel J, Latulippe E, Agharazii M, Houde I. 2013 Banff Criteria for Chronic Active Antibody-Mediated Rejection: Assessment in a Real-Life Setting. Am J Transplant 2016; 16:1516-25. [PMID: 26602055 DOI: 10.1111/ajt.13624] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/05/2015] [Accepted: 11/07/2015] [Indexed: 01/25/2023]
Abstract
Significant changes in the criteria for chronic active antibody-mediated rejection (CAABMR) were made in the Banff 2013 classification. These modifications expanded the number of patients diagnosed with CAABMR, with undetermined clinical significance. We compared the 2007 and 2013 criteria for the composite end point of death-censored graft failure or doubling of serum creatinine in 123 patients meeting the criterion related to the morphologic evidence of chronic tissue injury. In all, 18% and 36% of the patients met the 2007 and 2013 criteria, respectively. For the criterion related to antibody interaction with endothelium, only 25% were positive based on the 2007 definition compared with 82% using the 2013 definition. Cox modeling revealed that a 2013 but not a 2007 diagnosis was associated with the composite end point (adjusted hazard ratio 2.5 [95% confidence interval (CI) 1.2-5.2] vs. 1.6 [95% CI 0.7-3.8], respectively). The 2013 criterion based on both the C4d score and the glomerulitis plus peritubular capillaritis score (g+ptc) was more strongly associated with the end point than the 2007 criterion based only on C4d; however, when dissected by component, only the C4d component was significant. The association with clinical outcomes improved with the 2013 criteria. This is related to the new C4d threshold but not to the g+ptc ≥2 component.
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Affiliation(s)
- S A De Serres
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - R Noël
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - I Côté
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - I Lapointe
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - E Wagner
- Immunology and Histocompatibility Laboratory, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - J Riopel
- Department of Pathology, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - E Latulippe
- Department of Pathology, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - M Agharazii
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - I Houde
- Transplantation Unit, Renal Division, Department of Medicine, University Health Center of Quebec, Faculty of Medicine, Laval University, Québec, QC, Canada
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22
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Clinical, Histological, and Molecular Markers Associated With Allograft Loss in Transplant Glomerulopathy Patients. Transplantation 2015; 99:1912-8. [PMID: 25675205 DOI: 10.1097/tp.0000000000000598] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND We aimed to investigate the clinical, histopathological, and molecular factors associated with allograft loss in transplant glomerulopathy (TGP) patients. METHODS Of the 525 patients who underwent clinically indicated kidney biopsies, 52 (10%) had diagnosis of TGP. Gene expression profiles of 28 TGP and 11 normal transplant kidney biopsy samples were analyzed by Affymetrix HuGene 1.0 ST expression arrays. RESULTS Over a median follow up of 23 months (1-46 months) after the diagnosis of TGP by biopsy, 17 patients (32%) lost their allografts at a median of 16 months (1-44 months). There was no difference between the 2 groups in terms of any demographic variables, serum creatinine, panel reactive antibody levels, donor-specific antibody frequency, or mean fluorescence intensity values. Patients who lost their allograft had a significantly higher median spot protein to creatinine ratio 2.81 (1.20-6.00) compared to no graft loss patients 1.16 (0.15-2.53), (P < 0.01), and a trends toward a higher mean chronic glomerulopathy (cg) score (1.65 ± 0.93 vs 1.11 ± 0.93) (P = 0.05). There was also no difference in microvascular inflammation or any other Banff injury scores between the 2 groups. Although 117 gene transcripts were upregulated in both groups, 86 and 57 were upregulated in graft loss and functioning allograft groups, respectively. There were significantly increased levels of intragraft endothelial cell-associated transcripts, gene transcripts associated with complement cascade, interleukins and their receptors and granulysin in graft loss patients compared to patients with a functioning allograft. CONCLUSION Our results demonstrate differential intragraft gene expression profiles in TGP patients with allograft loss.
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Abstract
BACKGROUND Desensitization, a term loosely referring to a collection of antibody reduction and B-cell depletional therapies aimed at improving rates of transplantation in highly HLA and ABO-incompatible transplant recipients, has seen significant growth in the last decade. Advancements relate to an increasing unmet medical need for FDA-approved therapies, advancements in antibody detection methodologies and improved renal pathological assessments of antibody-mediated rejection (ABMR). SOURCES OF DATA, AREAS OF AGREEMENT AND CONTROVERSY Data reviewed include collective summaries of experience with high-dose intravenous immunoglobulin (IVIG), B-cell depletion with rituximab and the use of plasma exchange with low-dose IVIG. Consensus suggests that these protocols are the most commonly used while experiences with other agents (i.e. bortezomib) are evolving. Controversy exists as to the extent of resources required, expense and outcomes of desensitization protocols. GROWING POINTS OR AREAS TIMELY FOR DEVELOPING RESEARCH Here we review and synthesize data from evolving protocols and summarize developments of novel biologics aimed at modification of B-cells, antibodies and complement activation which will likely improve desensitization and treatment of ABMR.
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Affiliation(s)
- Stanley C Jordan
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jua Choi
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Kidney Transplant Program and Transplant Immunotherapy Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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24
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Haas M. Molecular diagnostics in renal allograft biopsy interpretation: potential and pitfalls. Kidney Int 2015; 86:461-4. [PMID: 25168495 DOI: 10.1038/ki.2014.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Application of molecular techniques, particularly gene expression microarrays, to the study of T cell-mediated rejection, antibody-mediated rejection (ABMR), and other changes in renal allografts has grown. While studies of gene expression within renal allograft biopsies have elucidated the pathogenesis of rejection and helped lead to recognition of C4d-negative ABMR, the use of molecular studies to achieve greater diagnostic accuracy and precision, guide therapy, and decrease the need for biopsies still remains a hope for the future.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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25
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Bachelet T, Nodimar C, Taupin JL, Lepreux S, Moreau K, Morel D, Guidicelli G, Couzi L, Merville P. Intravenous immunoglobulins and rituximab therapy for severe transplant glomerulopathy in chronic antibody-mediated rejection: a pilot study. Clin Transplant 2015; 29:439-46. [PMID: 25739833 DOI: 10.1111/ctr.12535] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 12/28/2022]
Abstract
Outcome of patients with transplant glomerulopathy (TG) is poor. Using B-cell targeting molecules represent a rational strategy to treat TG during chronic antibody-mediated rejection. In this pilot study, 21 patients with this diagnosis received four doses of intravenous immunoglobulins and two doses of rituximab (IVIG/RTX group). They were retrospectively compared with a untreated control group of 10 patients. At 24 months post-biopsy, graft survival was similar and poor between the treated and the untreated group, 47% vs. 40%, respectively, p = 0.69. This absence of response of IVIG/RTX treatment was observed, regardless the phenotype of TG. Baseline estimated glomerular filtration rate (eGFR) and decline in eGFR during the first six months after the treatment were risk factors associated with 24-month graft survival. The IVIG/RTX therapy had a modest effect on the kinetics of donor-specific alloantibodies at M24, compared to the untreated group, not associated with an improvement in graft survival. The mean number of adverse events per patient was higher in the IVIG/RTX group than in the control group (p = 0.03). Taken together, IVIG/RTX treatment for severe TG during chronic antibody-mediated rejection does not seem to change the natural history of TG and is associated with a high incidence of adverse events.
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Affiliation(s)
- Thomas Bachelet
- Unité de Transplantation, Service de Néphrologie, Transplantation, Dialyse, CHU de Bordeaux, Bordeaux, France; UMR 5164, CNRS, Bordeaux, France; Université de Bordeaux, Bordeaux, France
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Higgins RM, Daga S, Mitchell DA. Antibody-incompatible kidney transplantation in 2015 and beyond. Nephrol Dial Transplant 2014; 30:1972-8. [PMID: 25500804 DOI: 10.1093/ndt/gfu375] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/11/2014] [Indexed: 01/18/2023] Open
Abstract
Rejection caused by donor-specific antibodies (principally ABO and HLA antibodies) has become one of the major barriers to successful long-term transplantation. This review focuses on clinical outcomes in antibody-incompatible transplantation, the current state of the science underpinning clinical observations, and how these may be translated into further novel therapies. The clinical outcomes for allografts facing donor-specific antibodies are at present determined largely by the use of agents developed in the 20th century for the treatment of T-lymphocyte-mediated cellular rejection, such as interleukin-2 agents and anti-thymocyte globulin. These treatments are partially effective, because acute antibody-mediated rejection is mediated to a considerable extent by T lymphocytes. However these treatments are essentially ineffective in chronic antibody-mediated rejection. Future therapies for the prevention and treatment of antibody-mediated rejection are likely to fall into the categories of those that reduce antibody production, extracorporeal antibody removal and disruption of the effector arms of antibody-mediated tissue damage.
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Affiliation(s)
- Rob M Higgins
- Renal Unit, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Sunil Daga
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dan A Mitchell
- Warwick Medical School, University of Warwick, Coventry, UK
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Shiu KY, Dorling A. Optimising long-term graft survival: establishing the benefit of targeting B lymphocytes. Clin Med (Lond) 2014; 14 Suppl 6:s84-8. [PMID: 25468927 DOI: 10.7861/clinmedicine.14-6-s84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Kidney transplants do not last for the natural lifespan of most recipients. Of the reasons why transplants fail, damage by the immune system is the commonest cause. Understanding how the immune system recognises transplanted organs has increased significantly in recent years, but there is little insight into how organs are damaged, and no still no way of suppressing immune-mediated damage without exposing patients to the detrimental effects of long-term immunosuppression. In this article, we review the role of antibodies and B cells in immune-mediated damage of kidney transplants, and discuss the potential for manipulation of B cells to improve clinical outcomes.
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Affiliation(s)
- Kin Yee Shiu
- Royal Free London NHS Foundation Trust, London, UK
| | - Anthony Dorling
- MRC Centre for Transplantation, King's College London, and honorary consultant nephrologist, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Haas M. Transplant glomerulopathy: the view from the other side of the basement membrane. J Am Soc Nephrol 2014; 26:1235-7. [PMID: 25388221 DOI: 10.1681/asn.2014090945] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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